2008;389:259-269. Contributed by Jessica Dwyer, MD and Octavia Peck Palmer, PhD, http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm. The Data on Cobalt Poisoning and Neuropsychiatric Complications. For example, a notable historical example of cobalt toxicity is the cohorts of patients given cobalt chloride nearly 40 years ago to treat refractory anemia. At least two test-confirmed symptoms that are consistent with cobalt toxicity, i.e comprehensive neuro-cognitive testing, EMG, and/or formal ophthalmologic evaluation. Instead, the toxicologist alluded to the fact that the patient was not taking his pain medication and was endorsing symptoms of worsening anxiety and depression, medical conditions he was diagnosed with prior to his bilateral hip replacements in 2008. Learmonth ID, Case CP (2007) Metallic debris from orthopaedic implants. Queally JM, Devitt BM, Butler JS, et al. 3. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. Health Phys.1972;22:359-367. 2010;92(17):2847-2851. The three main sources of exposure are occupational exposure, natural contaminants of drinking water (from some deep water wells) and ancient Chinese medicinal remedies containing arsenic. A few studies have been conducted regarding the role of chelation therapy in arthroprosthetic cobaltism, but there is no reliable data to suggest its efficacy[1]. What is Arthroplasty Cobalt Encephalopathy (ACE)? An individual is exposed to this chemical element via inhalation, ingestion, or dermal exposure and, in general, chronic exposure is required for most of the adverse effects to develop.. The effects of the cobalt alloy hips were life-altering for Frances. Severe exposures to Cr (VI) compounds are usually accidental or intentional (suicide), and are rarely occupational or environmental. Therefore, there are no current definitive conclusions regarding the association of suspected arthroprosthetic cobaltism with specific clinical, physical, imaging, or laboratory findings. There are three basic ways that cobalt can cause poisoning. Inhalation - Pulmonary toxicity following chronic cobalt exposure is associated typically with the hard metal (tungsten carbide) industry. In addition, he noted that the patient lacked other symptoms of systemic cobalt toxicity including hypothyroidism and cardiomyopathy. However, there have been recent safety concerns regarding these prostheses, including excessive revision rates, local reactions to the prosthetic device, and high circulating metal ion levels in patients, which have led to product recalls, a medical device alert, and issuance of clinical guidelines by the United States' Food and Drug Administration (FDA). These questions usually arise after clients get blood work done and the test reveals abnormally high metal levels. J Bone Joint Surg Br 2007; 89: 567-573. Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. The neurological symptoms that occur with cobalt metal poisoning include: To this day, it is unclear whether elevated cobalt metal ion levels should be considered toxic in patients with cobalt alloy-containing metal-on-metal prostheses, especially if they are asymptomatic, since no clear correlation has even been made between cobalt concentration and physiologic effects (to be discussed later)[12]. Untreated chronic pain and depression are both known to contribute to cognitive changes and somatic symptoms. cobalt levels, it is likely that they may represent previously undescribed complications of cobalt toxicity. 09: Signs Your Artificial Hip May Be Defective, Aqueous Film-Forming Foam (AFFF) and Cancer: What You Need to Know, Physical Therapist: Problems with Metal-on-Metal Hip Failures (Part 3), Physical Therapist: What It Feels Like When Artificial Hips Fail (Part 2), Physical Therapist Discusses Hip Replacement Surgery, Recovery (Part 1). This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. Br Med J. What is the Prognosis of Cobalt Poisoning? Lancet 369:542-544. Cobalt is also component of cyanocobalamin also known as vitamin B12, which is widely consumed. J Arthroplasty. Chronic Toxic Encephalopathy . According to some sources, hypothyroidism is also considered to be the most sensitive indicator of cobalt toxicity. The patient described in the preceding clinical vignette is an excellent example of a concerning medical topic emerging in the current news. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. Symptoms of cobalt poisoning can include neurological damages, irregularities of the heart and even seizures. The United Sates Food and Drug Administration (2013). You get this after contact with a low dose over a long time. Contrastingly, if a patient has subjective and objective clinical evidence of systemic cobalt toxicity, has elevated cobalt metal ion concentrations, and no history of a cobalt alloy-containing metal-on-metal prostheses, a diagnosis of cobalt toxicity may be more straightforward. Serum concentrations >1 mcg/L indicate possible environmental or occupational exposure, and concentrations >5 mcg/L are considered toxic. An individual is exposed to this chemical element via inhalation, ingestion, or dermal exposure and, in general, chronic exposure is required for most of the adverse effects to develop.. Cobalt-induced myocardial injury was also implicated in a study of hard metal workers chronically exposed to cobalt, and another study of Finnish cobalt workers revealed that cumulative cobalt exposure was associated with subclinical echocardiographic changes[6]. There is no consensus regarding the treatment of patients with systemic symptoms of cobalt toxicity, and clinical response to these treatments is inconsistently documented in the current literature[1]. Based on the most recent level, which is really only about 2-3 times the normal limit, the toxicologist was not convinced that this was consistent with cobalt toxicity. You can check out that article here. One issue Dr. Tower discovered was that ACE could occur with lower readings of cobalt in the body. It’s caused when the metal wears and introduces cobalt into the bloodstream. The neurological symptoms that occur with cobalt metal poisoning include: tremors Most of what is known about cobalt toxicity comes from cases of ingestion or inhalation of excess cobalt. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. During this appointment, he reported symptoms of intermittent confusion, short-term memory loss, difficulty concentrating, poor attention, dysthymia, increased falling episodes, fatigue, and chronic headaches since his bilateral hip replacements in 2008. The diagnosis of cobalt toxicity is based on the combination of clinical history and laboratory confirmation. But we need to start looking much more closely at the things we put into our bodies, whether it’s a Twinkie, a sleeping pill, or a metal artificial hip. The preferred method of testing is inductively coupled mass spectrometry for metal ion value determination, and the typical patient specimens tested include serum, whole blood, or urine. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. Toxins include organic solvents (with high blood-brain permeability) and metals (with sometimes poorly understood mechanisms of neural uptake). 1999;37(7):839-844. Cobalt poisoning is a common problem in patients with artificial hips. When these criteria are applied to the currently published cases of arthroprosthetic cobaltism secondary to cobalt alloy-containing metal-on-metal hip prostheses, the circulating serum cobalt metal ion concentrations are typically very high, usually approaching 100 �g/L, before systemic cobalt toxicity is objectively identified. Others suggest that whole blood values provide a more accurate assessment of systemic exposure[1, 6]. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. November 3, 2016: (National Institute of Health) Seven substances added to 14th Report on Carcinogens Cobalt and cobalt compounds that release cobalt ions* in the body are being listed as reasonably anticipated to be a human carcinogen. When metal components grind together, as they naturally do when a MoM artificial hip is implanted in a person, very small metal particles can be released into the tissue and the bloodstream. It has generally been accepted that cobalt readings below 4 ppb was not cause for concern, and some surgeons would not order further testing until the cobalt readings exceeded 7 ppb or even 10 ppb. The most worrisome form of cobalt poisoning occurs when you breathe too much into your lungs. BMJ 1967; 1: 544-545. Schirrmacher UO. 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