Cobalt is also component of cyanocobalamin also known as vitamin B12, which is widely consumed. Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases. Devlin JJ, Pomerleau AC, Brent J, Morgan BW, et al. Chronic arsenic poisoning is due to repeated or continuous exposure to arsenic compounds, which leads to an accumulation of arsenic in the body. 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. Cobalt poisoning is a common problem in patients with artificial hips. 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. Since these reports, DePuy Orthopaedics, Inc (Warsaw, IN) recalled their ASRTM metal-on-metal bearings because of a five year-prosthetic failure rate of more than 12% due to metallosis[3]. In addition, he noted that the patient lacked other symptoms of systemic cobalt toxicity including hypothyroidism and cardiomyopathy. 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]. An essential trace element, cobalt an cause serious adverse c health effects at high exposure levels. Arch Environ Health. Chronic Toxic Encephalopathy . Quesada MJ, Marker DR, Mont MA. 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. Cobalt(II) may become cobalt chloride or bind to proteins. 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. 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. Interestingly, the impetus for the inquiry leading to these recommendations was an increase in metal-on-metal hip device failure, not to address patients with systemic cobalt toxicity. This finding was well-documented in the 1960s among heavy beer drinkers after local breweries added cobalt chloride or cobalt sulfate to their beer as a foam stabilizer, so called beer drinkers' cardiomyopathy6. But now a thoughtful surgeon is saying, “Hold up. This value was not derived from a comparison of symptomatic to asymptomatic patients with cobalt alloy-containing metal-on-metal prostheses, and thus does not serve as a threshold value to evaluate for systemic cobalt toxicity. Although, I have focused on the hypothyroidism and cardiomyopathy, other things have been reported from chronic cobalt poisoning including pericardial effusions, deafness, optic nerve atrophy, and peripheral neuropathy. In his discussion Dr. Tower noted that after nine of his patients had revision surgeries, seven patients no longer showed signs of being cobalt-positive, and five of those seven improved neurologically. Cardiovascular dysfunction: A notable toxic effect of cobalt exposure is a severe and often fatal cardiomyopathy. 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. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. Sci Total Environ. Laboratory confirmation of elevated serum or whole blood cobalt metal ion levels due to an implanted prosthetic hip. Chronic poisoning. Simonsen LO, Harbak H, Bennekou P. Cobalt metabolism and toxicology - a brief update. Health Phys. When ingested, cobalt is rapidly absorbed from the small intestine, but the bioavailability is incomplete and variable[6]. Hip Arthoplasty with the articular surface replacement (ASR) system: survivorship analysis and functional outcomes. I am a product liability lawyer with many clients who were injured by artificial hips containing cobalt and chromium. Cobalt, Chromium, and Nickel Concentrations in Body Fluids of Patients with Porous-Coated Knee of Hip Prostheses. Dr. Tower found that patients could have serious neurological issues caused by cobalt with readings of 1 ppb. 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). Schaffer AW, Pilger A, Engelhardt C, Zwelmueller, et al. Queally JM, Devitt BM, Butler JS, et al. Some of the mechanisms proposed include inhibition of crucial enzymes in mitochondrial oxidative phosphorylation, inhibition of thyroid iodinase, inhibition and competition with calcium binding and signaling, generation of reactive oxygen species, and direct cytotoxicity[1, 6]. 8. These patients presented with combinations of deafness, blindness, cognitive decline, headaches, convulsions, fatigue, heart failure, and hypothyroidism, all had hip pain resulting from periprosthetic metallosis, and all had serum cobalt concentrations of more than 60 �g/L. 3. Although cobalt is an essential element in dogs, an excess of cobalt can be fatal if not treated right away. It happens when there’s friction between metal surfaces. 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. Severe exposures to Cr (VI) compounds are usually accidental or intentional (suicide), and are rarely occupational or environmental. J Orthop Res. Cobalt poisoning symptoms may include: Among the patients who were diagnosed with ACE, the median length of time for onset of neurological symptoms was around seven years. 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. 3. J Bone Joint Surg Br 2007; 89: 567-573. Shemesh S, Kosashvili Y, Heller S, Sidon E, et al. What is Arthroplasty Cobalt Encephalopathy (ACE)? Br Med J. Since cobalt has been shown to be carcinogenic and mutagenic in human and animal models, the potential for systemic toxicity and cancer risk are valid safety concerns for patients with these prostheses[4]. 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]. J Med Toxicol. Rochester, MN: The Laboratories; 2001. While elevated levels of chromium do not appear to result in heart problems, they can wreak havoc with the reproductive system. It is also recommended to perform cobalt metal ion testing and imaging studies for any patients that report painful hip replacements. 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. Remember I am not a doctor and this is not medical advice. Pritchett JW. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. Cobalt(II) may become cobalt chloride or bind to proteins. J Bone Joint Surg Br 2007; 89: 567-573. The FDA does not provide specific metal ion values that should trigger medical action, mostly because there is insufficient evidence to demonstrate a correlation between a specific cobalt metal ion level and specific pathology[17]. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. 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. Acute exposures are generally characterized by an allergic dermatitis. 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. 2013 Jul 11 (ahead of print). 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. A precise, unifying mechanism of cobalt toxicity remains unclear. 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. Of the 57 patients with a cobalt positive test, 28 had symptoms consistent with Arthroplasty Cobalt Encephalopathy. 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). 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]. This paper considers the increased risk of the development of lymphoma in patients with chronic inflammatory disease who undergo metal-on-metal arthroplasty. 2011;194:649-651. Schirrmacher UO. Untreated chronic pain and depression are both known to contribute to cognitive changes and somatic symptoms. Chronic cobalt poisoning may cause polycythemia, hyperplasia of the bone marrow and thyroid gland, pericardial effusion, and damage to the alpha cells of the pancreas. Metal-on-metal hip resurfacing: advantages and disadvantages. This finding, if true, could be a game changer. Chronic poisoning. 1988;43:299-303. The clinical emergence of cobalt cardiomyopathy seems to require the coexistence of one or more cofactors, particularly a low-protein diet, thiamine deficiency, alcoholism, and hypothyroidism. As the metal builds up in your body, you can get sick. Med J Aust. 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. Metallosis is not a good thing, as it is often a cause of early prosthesis failure, and the tissue damage resulting from metallosis can compromise subsequent revision arthroplasties[5]. Cobalt is an essential element for health in animals in minute amounts as a component of Vitamin B12. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. Chronic persistent diffuse injury to the brain with clinical manifestations involving cognitive impairment. Cobalt or chromium poisoning can occur from the wear and tear of cobalt/chromium metal-on-metal hip implants. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. Cobalt poisoning is a common problem in patients with artificial hips. 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. 2013 Nov 22 [Epub ahead of print]. 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. Of course not. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. Acta Orthop. Leavelle DE, editor. BMJ 1967; 1: 544-545. Concentration of Wear Products in Hair, Blood, and Urine after Total Hip Replacement. 1999;37(7):839-844. The friction releases tiny metal particles into your bloodstream that could trigger a hypersensitive immune response in your body. (1) 1 Chronic exposure to cobalt by inhalation … It’s caused when the metal wears and introduces cobalt into the bloodstream. 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. Recently in November 2013, Pizon et al. 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. 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. What is Arthroplasty Cobalt Encephalopathy (ACE)? With chronic systemic exposure, cobalt accumulates in tissue, again primarily the liver and kidney, and the cobalt level will be elevated in the serum, whole blood, and urine[9]. Cobalt ions induce chemokine secretion in primary human osteoblasts. Exposure to chromium, cobalt, and molybdenum from metal-on-metal total hip replacement and hip resurfacing arthroplasty. Health risks of chronic exposure . In the United States, the FDA defines "symptomatic patients" as patients experiencing localized symptoms, such as pain or swelling at the hip, change in walking ability, and noise from the joint, after more than 3 months following implantation of the cobalt alloy-containing metal-on-metal hip prosthesis[17]. Cobalt has also been used as a treatment for anemia, because it stimulates red blood cell production. Vaping and Cobalt Poisoning. Essentially, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological, cardiac, and endocrine function. J Med Toxicol. At least two test-confirmed symptoms that are consistent with cobalt toxicity, i.e comprehensive neuro-cognitive testing, EMG, and/or formal ophthalmologic evaluation. 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. 2008 Oct 23:69-73. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. You get this after contact with a low dose over a long time. 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. 8. The patient’s vision loss was attributed by ophthalmology to optic neuropathy and possible retinal toxicity from cobalt. 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.. A deficiency of cobalt, which is very rare, is also potentially lethal, leading to pernicious anemia. Total hip replacement using implantable metal components is a common medical surgery that has been performed in North America for more than 50 years. Chronic tungsten poisoning. Signs and symptoms of cobalt poisoning can include visual As the metal builds up in your body, you can get sick. 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). 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. Cobalt poisoning is intoxication caused by excessive levels of cobalt in the body. Signs and symptoms of cobalt poisoning can include visual The neurological symptoms that occur with cobalt metal poisoning include: tremors The medical community has (slowly) accepted that MoM hips were a health problem and have moved away from their use. Cobalt is a chemical element with the symbol Co and atomic number 27. What is the Prognosis of Cobalt Poisoning? For years the focus following hip replacement surgeries has been on the physical condition of the hip itself. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. Treatment options in cases with chronic cobalt poisoning include chelation therapy with EDTA or BAL/DMPS. These devices are made from a blend of several different metals, including chromium, cobalt, nickel, titanium and molybdenum. While this is alarming enough, chromium comes with its own set of adverse health effects. Metallosis is a type of metal poisoning that can occur as a side effect of joint replacement devices with metal components, such as metal-on-metal hip implants or some knee implants. There are no established indications for chelation therapy[1]. The signs and symptoms of Chromium Toxicity depend on whether the exposure occurred through oral ingestion, chronic inhalation, or skin contact. 7. Arsenic poisoning, or arsenicosis, occurs after the ingestion or inhalation of high levels of arsenic. Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. Cobalt is an essential, transition group metal present in trace amounts in the human diet, notably in fish, vegetables, and drinking water. The most worrisome form of cobalt poisoning occurs when you breathe too much into your lungs. occurred. 2010;92(17):2847-2851. : the effects of the cobalt metal ion levels due to repeated or continuous exposure to cobalt. And concentrations > 5 mcg/L are considered toxic long time ) compound may cause cobalt is component... Cell production treatment options in cases with chronic cobalt poisoning include: toxic! 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