Serum concentrations >1 mcg/L indicate possible environmental or occupational exposure, and concentrations >5 mcg/L are considered toxic. He has even given it a name: Arthroplasty Cobalt Encephalopathy, or ACE. It is a very small part of our environment and very small amounts are needed for many animals and humans to stay healthy.Cobalt poisoning can occur when you are exposed to large amounts of cobalt. It is an integral part of vitamin B12, and is required for oxygen transport in metabolism. Yet, even if a patient is symptomatic and highly suspicious for arthroprosthetic cobaltism, there is inadequate information provided by the FDA to guide clinical decision making because no consensus has been reached in regard to treatment of these patients. Coleman RF, Herrington J, Scales JT. The biokinetics of inorganic cobalt in the human body. A deficiency of cobalt, which is very rare, is also potentially lethal, leading to pernicious anemia. When the metal parts rub against each other, they release microscopic metal particles into the blood and surrounding tiss… Cardiovascular dysfunction: A notable toxic effect of cobalt exposure is a severe and often fatal cardiomyopathy. Pritchett JW. You can swallow too much of it, breathe too much into your lungs, or have it come in constant contact with your skin. Does this settle the questions regarding artificial hip implants and metallosis? Hip Arthoplasty with the articular surface replacement (ASR) system: survivorship analysis and functional outcomes. What is the Prognosis of Cobalt Poisoning? Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. Health risks of chronic exposure . Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. However, caution must be applied when testing and interpreting cobalt levels in patients with cobalt alloy-containing metal-on-metal prostheses since these patients tend to have incidentally higher circulating cobalt metal ion concentrations, sometimes greater than 5 �g/L, but may not have symptoms of cobalt toxicity. Others suggest that whole blood values provide a more accurate assessment of systemic exposure[1, 6]. 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. Health Phys. According to some sources, hypothyroidism is also considered to be the most sensitive indicator of cobalt toxicity. These devices are made from a blend of several different metals, including chromium, cobalt, nickel, titanium and molybdenum. 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). Hard metal workers (involved, for example, in grinding metals) and soldiers with embedded shrapnel may be exposed to the risk of long-term tungsten exposure. Therefore the 7 �g/L threshold was derived from a population reference range, and indicates a potential for periprosthetic soft tissue reaction/metallosis and a need for closer surveillance[1]. Cobalt poisoning is an intoxication brought on by having too much cobalt in the body. So, does the patient described in the previous clinical vignette have arthroprosthetic cobaltism secondary to his bilateral cobalt alloy-containing metal-on-metal hip prostheses? Tower SS. It’s caused when the metal wears and introduces cobalt into the bloodstream. Letourneau EG, McCullough RS, Hollins JG. The more commonly reported value for cobalt metal ion concentration is the serum value, which is considered to be reflective of the extracellular fluid levels. The patient described in the preceding clinical vignette is an excellent example of a concerning medical topic emerging in the current news. The most worrisome form of cobalt poisoning occurs when you breathe too much into your lungs. Sometimes, metal particles (cobalt) are released … Sci Total Environ. Exposure to chromium, cobalt, and molybdenum from metal-on-metal total hip replacement and hip resurfacing arthroplasty. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. Health risks of chronic exposure . The neurological symptoms that occur with cobalt metal poisoning include: tremors Cobalt poisoning through chronic exposure may result in pulmonary fibrosis, cough, and dyspnea. The patient’s vision loss was attributed by ophthalmology to optic neuropathy and possible retinal toxicity from cobalt. 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). The toxicologist evaluating the patient mentioned that the patient exhibited tangential speech, and that it was extremely difficult to elucidate a clear clinical history and progression of symptoms from the patient. The contact form sends information by non-encrypted email, which is not secure. Chronic persistent diffuse injury to the brain with clinical manifestations involving cognitive impairment. 7. Instead, government authorities in the United States and United Kingdom have released recommendations for management of both symptomatic and asymptomatic patients with cobalt alloy-containing metal-on-metal hip prostheses and elevated circulating cobalt metal ion concentrations. 2011;194:649-651. When the patient was discharged from the hospital in February 2013, he was evaluated in an outpatient toxicology clinic. 2008;389:259-269. According to one reference, a serum cobalt metal ion concentration greater than 1 �g/L is suggestive of excessive cobalt exposure, and a value greater than 5 �g/L is considered likely toxic[11]. J Med Toxicol. The metabolism of cobalt by the normal human male: whole body retention and radiation dosimetry. Signs and symptoms of cobalt poisoning can include visual Total hip replacement using implantable metal components is a common medical surgery that has been performed in North America for more than 50 years. Acta Orthop. Chronic Toxic Encephalopathy . This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. This would include products such as the DePuy ASR hip and the Zimmer Durom hip (and several other metal-on-metal hip products, about which I have written often on this website). The prognosis of Cobalt Poisoning is dependent on the amount of substance consumed, time between consumption and treatment, severity of the symptoms, as well as general health status of the patient. Oral intake of Cr (VI) compound may cause Cobalt toxicity - an emerging clinical problem in patients with metal-on-metal hip prostheses? 2013 Jul 11 (ahead of print). In these patients, they advise to consider serial cobalt metal ion testing, but also strongly advise interpretation of these levels in the context of the patient's clinical symptoms, baseline renal function, and potential alternative sources of cobalt. Devlin JJ, Pomerleau AC, Brent J, Morgan BW, et al. Cobalt(II) may become cobalt chloride or bind to proteins. Breathing in this cobalt dust can lead to chronic lung problems. Absorption and retention of cobalt in man by whole-body counting. J Bone Joint Surg Br 2007; 89: 567-573. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … Br Med J. Chronic Toxic Encephalopathy . You can check out that article here. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. Recently in November 2013, Pizon et al. occurred. It is used by the body in small amounts as part of vitamin B-12, to help make red blood cells and maintain the nervous system. The neurological symptoms that occur with cobalt metal poisoning include: Dr. Tower did a post-surgical study of his patients with artificial hips containing at least one component made from chromium/cobalt. Cobalt or chromium poisoning can occur from the wear and tear of cobalt/chromium metal-on-metal hip implants. Cobalt metal ion values are typically reported in units of micrograms/liter (�g/L). Nearly 400,000 hip arthroplasty procedures are performed annually in the United States, and over the past decade, there has been an increasing trend of utilizing cobalt alloy-containing metal-on-metal prosthetic hip joints[1]. He notes that the onset of symptoms with metal on plastic or ceramic occurs more slowly, but the symptoms themselves can be just as severe. In general, improved case definitions, controlled studies, and improved surveillance are needed to fully elucidate the course of this relatively new disease and direct further investigations. 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. Metal-on-metal hip resurfacing: advantages and disadvantages. The diagnosis of cobalt toxicity is based on the combination of clinical history and laboratory confirmation. The Data on Cobalt Poisoning and Neuropsychiatric Complications. Smith T, Edmonds CJ, Barbaby CF. These patients also presented with severe neurologic and cardiac symptoms, hip pain resulting from periprosthetic metallosis, and elevated serum cobalt concentrations, up to 122 �g/L. (1) 1 Chronic exposure to cobalt by inhalation … ACE symptoms usually occurred one year before hip symptoms (pain, weakness, clicking, loosening, etc.) J Bone Joint Surg Am. If you are reading this article, you probably already know that cobalt and chromium are two metals used in the construction of most metal-on-metal (MoM) artificial hip systems. BMJ 1967; 1: 544-545. We are finding cobalt poisoning in too many patients with metal-on-plastic and metal-on-ceramic hips. 1989;7(3):307-315. Chronic persistent diffuse injury to the brain with clinical manifestations involving cognitive impairment. When ingested, cobalt is rapidly absorbed from the small intestine, but the bioavailability is incomplete and variable[6]. While elevated levels of chromium do not appear to result in heart problems, they can wreak havoc with the reproductive system. I am a product liability lawyer with many clients who were injured by artificial hips containing cobalt and chromium. Cobalt is acutely toxic in large doses, and in cumulative long-term, low level exposure, i.e occupational exposure from cobalt processing plants, hard metal industry, diamond polishing, and the ceramic industry. 1988;43:299-303. BMJ 1967; 1: 544-545. (1) 1 Chronic exposure to cobalt by inhalation … 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. Med J Aust. Therefore, the final recommendations for this patient were that he be re-evaluated by his pain specialist, undergo extensive psychiatric testing, and have his hips re-assessed by orthopedic surgery. Mao X, Wong AA, Crawford RW. I wrote about the health effects of metallosis on the body over a year ago. A precise, unifying mechanism of cobalt toxicity remains unclear. Studies following patients with arthroprosthetic cobaltism have demonstrated symptom improvement and declining circulating cobalt metal ion levels after removal of the implanted hardware, especially in patients with endocrinopathies and cardiomyopathy. Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. The friction releases tiny metal particles into your bloodstream that could trigger a hypersensitive immune response in your body. Acute poisoning is likely to occur through the oral route, whereas chronic poisoning is mainly from inhalation or skin contact [Meditext 2005]. Adverse reaction to metal debris: metallosis of the resurfaced hip. Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. Dr. Tower has concluded that this approach is wrong, or at least incomplete, and he has seen that often the first signs of trouble with hip replacement patients are neurological symptoms. As the metal builds up in your body, you can get sick. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. The benefits touted by metal-on-metal prostheses is that there is less device wear since cobalt-alloy containing metal prostheses have a higher resistance to wear than polyethylene, a decreased risk of dislocation because of new designs and engineering modifications, and a decreased risk of device fracture[2-3]. If the whole blood cobalt metal ion concentration in these patients is greater than 7 �g/L, a second metal ion test should be performed three months later and the patient should be assessed for cardiac and neurologic symptoms[1]. 3. 2008 Oct 23:69-73. Therefore, the cobalt metal ion concentration value of concern is unknown. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. Queally JM, Devitt BM, Butler JS, et al. Essentially, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological, cardiac, and endocrine function. Unfortunately, no. from the Division of Toxicology at the University of Pittsburgh School of Medicine (Pittsburgh, PA, USA) proposed diagnostic criteria for arthroprosthetic cobaltism secondary to cobalt alloy-containing metal hip prostheses[18]. The signs and symptoms of Chromium Toxicity depend on whether the exposure occurred through oral ingestion, chronic inhalation, or skin contact. Studies comparing the symptoms of patients pre-exposure, during exposure, at the point of maximal symptoms, and following hardware removal would be the most helpful in defining the clinical course of arthroprosthetic cobaltism, but these have not been performed. Cobalt has also been used as a treatment for anemia, because it stimulates red blood cell production. Arsenic is a type of carcinogen that’s gray, silver, or white in color. Common signs and symptoms of Chromium Toxicity ingested orally include: Severe gastrointestinal … 2006;77(5):697-704. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. 2013 Nov 13 [Epub ahead of print]. Chronic tungsten poisoning. Yet, more importantly, these patients with cobalt alloy-containing metal-on-metal hip prostheses that require revision surgeries due to metallosis have elevated circulating cobalt levels and may be at risk for systemic cobalt toxicity. Unfortunately, most neurologic symptoms are highly subjective, but some can be proven objectively, including optic nerve atrophy, audiometry-confirmed hearing loss, and abnormal neurologic function illustrated by electrodiagnostic studies such as an electroencephalograms (EEG) or electromyograms (EMG). J Toxicol Clin Toxicol. Following a single dose of cobalt, the concentration in the blood and serum is initially high, but rapidly decreases to a low level within 24 hours due to the combination of tissue uptake, primarily in the liver and kidney, and urinary excretion. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. 8. Witzleb WC, Ziegler J, Krummenauer F, Neumeister V, et al. Toxins include organic solvents (with high blood-brain permeability) and metals (with sometimes poorly understood mechanisms of neural uptake). Skin Malady: Exposure to cobalt can occasionally produce dermatitis, but typically hypersensitivity reactions are less commonly associated with cobalt than other metals, such as nickel. Cobalt poisoning symptoms may include: The biggest concern is that corrosion, wear, and other mechanical factors of the cobalt alloy-containing metal-on-metal prosthetic produce metal debris in the form of wear particles, which subsequently release soluble cobalt metal ions into the joint space and into the systemic circulation[4]. Case of cobalt poisoning. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. Since 2006, there have been increasing reports in the literature of patients with cobalt alloy-containing metal prostheses developing systemic symptoms of cobalt toxicity, termed athroprosthetic cobaltism[13]. The concentration of cobalt, in particular, was remarkably high. Cobalt poisoning from hip prosthesis is rare but debilitating. Queally JM, Devitt BM, Butler JS, et al. Further studies validating these new proposed criteria are not currently available. Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. Leavelle DE, editor. In his assessment, the toxicologist noted that in the documented cases of arthroprosthetic cobaltism secondary to cobalt alloy-containing metal-on-metal hip prostheses, the serum cobalt metal ion concentration is often close to, if not greater than, 100 �g/L. Arsenic poisoning, or arsenicosis, occurs after the ingestion or inhalation of high levels of arsenic. Cobalt(II) may become cobalt chloride or bind to proteins. And clouded judgment hurts people. It has, however, been noted that tungsten carbide appears to modify the toxicity of cobalt and that cobalt alone does not have the same potent toxic effects. Post-mortem studies of the heart in these patients confirmed accumulation of cobalt within the myocardium. 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. J Orthop Res. The risk to the patient occurs with any artificial hip containing a cobalt component.” Conventional wisdom has been that eliminating the metal on metal contact should eliminate the risk of metallosis, but Dr. Tower at least does not accept this thinking. There are no established indications for chelation therapy[1]. 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.. Treatment options in cases with chronic cobalt poisoning include chelation therapy with EDTA or BAL/DMPS. cobalt toxicity . Symptoms usually arise after several years and may manifest as pneumoconiosis (with dyspnoea and cough secondary to interstitial fibrosis), an allergic alveolitis or occupational asthma. As recently as five years ago, the medical community mostly believed that metallosis derived from metal-on-metal artificial hips. Therefore, elevated cobalt metal ion levels should always be interpreted within the context of the patient's clinical history. At least two test-confirmed symptoms that are consistent with cobalt toxicity, i.e comprehensive neuro-cognitive testing, EMG, and/or formal ophthalmologic evaluation. J Arthroplasty. It has been proposed that many of the adverse effects of cobalt are secondary to its high affinity for sulfhydryl groups. Eur J Orthop Surg Traumatol. Sometimes, metal particles (cobalt) are released … It happens when there’s friction between metal surfaces. In the United Kingdom, the Medicines and Healthcare Products Regulatory Agency (MHRA) recommends following patients with cobalt alloy-containing metal-on-metal hip prostheses for cobalt toxicity symptoms at least annually for five years post-implantation[1]. This finding, if true, could be a game changer. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. 2012;23(1):50-58. Cobalt ions induce chemokine secretion in primary human osteoblasts. In fact, cobalt and chromium are used to make artificial hips that are not metal-on-metal but instead use polyethylene liners, or ceramic heads, or other non-metal components. Of course not. Cobalt and chromium can be released as the metal ball grinds against the metal cup when a person walks or moves. Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases. Health Phys.1972;22:359-367. Untreated chronic pain and depression are both known to contribute to cognitive changes and somatic symptoms. Remember I am not a doctor and this is not medical advice. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … Mayo Medical Laboratories interpretive handbook: interpretive data for diagnostic laboratory tests. It happens when there’s friction between metal surfaces. Cobalt, Chromium, and Nickel Concentrations in Body Fluids of Patients with Porous-Coated Knee of Hip Prostheses. The symptoms of cobalt toxicity documented in the literature are variable, but typically involve derangements of endocrine, cardiac, and neurological function[1]: Endocrinopathy: The classic endocrinopathy associated with cobalt toxicity is hypothyroidism. Studies of whole-body retention of inorganic cobalt in physiologically normal adult human males after intravenous injection demonstrated that approximately 40% of the dose was eliminated within the first 24 hours, 70% by one week, after one month 20% was retained, and after one year 10% was retained[7-8]. Arch Environ Health. Cobalt is an essential, transition group metal present in trace amounts in the human diet, notably in fish, vegetables, and drinking water. Sci Total Environ. Symptoms come on slowly and can include: This usually will only happen in industrial settings where large amounts of drilling, polishing, or other processes release fine particles containing cobalt into the air. Following cessation of the chronic exposure, the concentration of cobalt decreases by 51�21% and 66�29% in the blood and urine, respectively[10]. 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. 3. 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]. Cobalt is a chemical element with the symbol Co and atomic number 27. Alexandersson R. Blood and urinary concentrations as estimators of cobalt exposure. For some unclear reason, cobalt salts stimulate the production of erythropoietin, and before the availability of recombinant human erythropoietin, cobalt salts were regularly used in clinical practice for the treatment of anemia[6]. 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]. Cobalt is an essential element for health in animals in minute amounts as a component of Vitamin B12. The medical community has (slowly) accepted that MoM hips were a health problem and have moved away from their use. Dr. Tower found that patients could have serious neurological issues caused by cobalt with readings of 1 ppb. You get this after contact with a low dose over a long time. These criteria were created as an objective approach to making the diagnosis of arthroprosthetic cobaltism since the evaluation of systemic cobalt toxicity in patients with metal hip prostheses is often complicated by limited published data, subjective patient symptoms, comorbid conditions, or secondary financial gain. However, other studies have demonstrated persistence of neurologic symptoms even after the hardware is removed[1]. 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. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. Most of what is known about cobalt toxicity comes from cases of ingestion or inhalation of excess cobalt. There have been concerns, especially among younger patients, that the plastic cup in conventional hip prostheses undergo more wear and tear with time, and are more likely to require revision. Concentration of Wear Products in Hair, Blood, and Urine after Total Hip Replacement. After 20 days of hospitalization, the patient’s decreased visual acuity and hearing were only mildly improved, her This is a known risk with metal-on-metal implants, but newer data are showing that it is also a risk with metal-on-polyethylene implants. 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. ELEVATED BLOOD COBALT LEVELS IN A PATIENT WITH BILATERAL METAL-ON-METAL HIP PROSTHESES. But Dr. Tower has observed neurological problems in several patients with metal-on-plastic hips, or hips utilizing a ceramic ball with a metal cup. In addition, he noted that the patient lacked other symptoms of systemic cobalt toxicity including hypothyroidism and cardiomyopathy. The friction releases tiny metal particles into your bloodstream that could trigger a hypersensitive immune response in your body. 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]. In fact, if any part of an artificial hip contains chrome or cobalt materials, the patient is at risk for higher metal levels in the blood and neurological symptoms as a result. What is Arthroplasty Cobalt Encephalopathy (ACE)? Rochester, MN: The Laboratories; 2001. 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