Abstract
Cobalt-induced cardiomyopathy is a well-known but uncommon disease, and the physician must maintain a high index of suspicion in order to make a timely diagnosis. We report two patients with cobalt-induced cardiomyopathy. Both patients developed progressively worsening symptoms of cobalt toxicity following revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. In both patients, echocardiography showed LV hypertrophy, biventricular systolic dysfunction, and a large amount of pericardial effusion. Due to decompensated heart failure, both patients were initially considered candidates for heart transplantation. One patient was diagnosed with cobalt-induced cardiomyopathy before transplantation. He received cobalt chelation therapy and revision surgery, which led to complete recovery of heart function. In the other patient, the diagnosis was not made until the time of heart transplantation. The gross examination of the explanted heart revealed typical features of cobalt cardiotoxicity, which was then diagnosed as cobalt-induced cardiomyopathy. These cases emphasise the importance of early diagnosis and prompt treatment of cobalt intoxication.
Similar content being viewed by others
References
Gilbert, C. J., et al. (2013). Hip pain and heart failure: The missing link. Canadian Journal of Cardiology, 29(5), 639e1–e2.
Machado, C., Appelbe, A., & Wood, R. (2012). Arthroprosthetic cobaltism and cardiomyopathy. Heart, Lung and Circulation, 21(11), 759–760.
van Lingen, C. P., et al. (2013). Clinical manifestations in ten patients with asymptomatic metal-on-metal hip arthroplasty with very high cobalt levels. Hip International, 23(5), 441–444.
Oldenburg, M., Wegner, R., & Baur, X. (2009). Severe cobalt intoxication due to prosthesis wear in repeated total hip arthroplasty. The Journal of Arthroplasty, 24(5), 825 e15–e20.
Cheung, A. C., et al. (2016). Systemic cobalt toxicity from total hip arthroplasties: Review of a rare condition Part 1—History, mechanism, measurements, and pathophysiology. The Bone & Joint Journal, 98-b(1), 6–13.
Gessner, B. D., et al. (2015). A systematic review of systemic cobaltism after wear or corrosion of chrome-cobalt hip implants. Journal of Patient Safety, 0, 1–8
Tower, S. S. (2010). Arthroprosthetic cobaltism: Neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: A case report. The Journal of Bone and Joint Surgery, 92(17), 2847–2851.
Catalani, S., et al. (2012). Neurotoxicity of cobalt. Human & Experimental Toxicology, 31(5), 421–437.
Mosier, B. A., Maynard, L., Sotereanos, N. G., Sewecke, J. J. (2016). Progressive cardiomyopathy in a patient with elevated cobalt ion levels and bilateral metal-on-metal hip arthroplasties. The American Journal of Orthopedics, 45(3), E132–E135.
Zywiel, M. G., et al. (2013). Fatal cardiomyopathy after revision total hip replacement for fracture of a ceramic liner. The Bone & Joint Journal, 95(1), 31–37.
Allen, L. A., et al. (2014). Clinical problem-solving. Missing elements of the history. The New England Journal of Medicine, 370(6), 559–566.
Samar, H. Y., et al. (2015). Novel use of cardiac magnetic resonance imaging for the diagnosis of cobalt cardiomyopathy. JACC Cardiovasc Imaging, 8(10), 1231–1232.
Kempf, I., & Semlitsch, M. (1990). Massive wear of a steel ball head by ceramic fragments in the polyethylene acetabular cup after revision of a total hip prosthesis with fractured ceramic ball. Archives of Orthopaedic and Trauma Surgery, 109(5), 284–287.
Morin, Y., Tetu, A., & Mercier, G. (1971). Cobalt cardiomyopathy: Clinical aspects. British Heart Journal, 33(p. Suppl), 175–178.
Morin, Y., Tetu, A., & Mercier, G. (1969). Quebec beer-drinkers’ cardiomyopathy: Clinical and hemodynamic aspects. Annals of the New York Academy of Sciences, 156(1), 566–576.
Alexander, C. S. (1972). Cobalt-beer cardiomyopathy. A clinical and pathologic study of twenty-eight cases. The American Journal of Medicine, 53(4), 395–417.
Tilney, R., Burg, M. R., & Sammut, M. A., (2017). Cobalt cardiomyopathy secondary to hip arthroplasty: An increasingly prevalent problem. Case Reports in Cardiology, 2017, 5434571.
Pandit, H., et al. (2008). Pseudotumours associated with metal-on-metal hip resurfacings. The Journal of Bone and Joint Surgery British, 90(7), 847–851.
Polyzois, I., et al. (2012). Local and systemic toxicity of nanoscale debris particles in total hip arthroplasty. Journal of Applied Toxicology, 32(4), 255–269.
Gill, H. S., et al. (2012). Molecular and immune toxicity of CoCr nanoparticles in MoM hip arthroplasty. Trends in Molecular Medicine, 18(3), 145–155.
Papageorgiou, I., et al. (2007). The effect of nano- and micron-sized particles of cobalt-chromium alloy on human fibroblasts in vitro. Biomaterials, 28(19), 2946–2958.
Tower, S. (2010). Arthroprosthetic cobaltism: Identification of the at-risk patient. Alaska Medicine, 52, 28–32.
Sotos, J. G., & Tower, S. S. (2013). Systemic disease after hip replacement: Aeromedical implications of arthroprosthetic cobaltism. Aviation, Space, and Environmental Medicine, 84(3), 242–245.
Heggtveit, H. A., Grice, H. C., & Wiberg, G. S. (1970). Cobalt cardiomyopathy. Experimental basis for the human lesion. Pathologia et Microbiologia (Basel), 35(1), 110–113.
Dingle, J. T., et al. (1962). The biological action of cobalt and other metals. II. The mechanism of the respiratory inhibition produced by cobalt in mammalian tissues. Biochimica et Biophysica Acta, 65, 34–46.
Rona, G., (1971). Experimental aspects of cobalt cardiomyopathy. British Heart Journal, 33(Suppl), 171–174.
Harrow, J. A., Das, P. K., & Dhalla, N. S. (1978). Influence of some divalent cations on heart sarcolemmal bound enzymes and calcium binding. Biochemical Pharmacology, 27(22), 2605–2609.
Barceloux, D. G. (1999). Cobalt. Journal of Toxicology: Clinical Toxicology, 37(2), 201–206.
Unverferth, D. V., et al. (1984). The evolution of beta-adrenergic dysfunction during the induction of canine cobalt cardiomyopathy. Cardiovascular Research, 18(1), 44–50.
Seghizzi, P., et al. (1994). Cobalt myocardiopathy. A critical review of literature. Science of the Total Environment, 150(1–3), 105–109.
Tabel, G. M., et al. (2006). Collagen fiber morphology determines echogenicity of myocardial scar: Implications for image interpretation. Echocardiography, 23(2), 103–107.
Mohiuddin, S. M., et al. (1970). Experimental cobalt cardiomyopathy. American Heart Journal, 80(4), 532–543.
Giampreti, A., Lonati, D., & Locatelli, C. A. (2014). Chelation in suspected prosthetic hip-associated cobalt toxicity. Canadian Journal of Cardiology, 30(4), 465.e13.
Devlin, J. J., Schwartz, M., & Brent, J. (2013). Chelation in suspected prosthetic hip-associated cobalt toxicity. Canadian Journal of Cardiology, 29(11), 1533.e7.
Smith, S. W. (2013). The role of chelation in the treatment of other metal poisonings. Journal of Medical Toxicology, 9, 355–369.
Pazzaglia, U. E., et al. (2011). Cobalt, chromium and molybdenum ions kinetics in the human body: Data gained from a total hip replacement with massive third body wear of the head and neuropathy by cobalt intoxication. Archives of Orthopaedic and Trauma Surgery, 131(9), 1299–1308.
Repo, E., et al. (2011). Capture of Co(II) from its aqueous EDTA-chelate by DTPA-modified silica gel and chitosan. Journal of Hazardous Materials, 187(1–3), 122–132.
Giampreti, A., et al. (2016). N-acetyl-cysteine as effective and safe chelating agent in metal-on-metal hip-implanted patients: Two cases. Case Reports in Orthopedics, 2016, 8682737.
Asapoglu, N. K., Toprak, A. B.,M. S., Koseoglu, Y., & Bayrakdar, H. (2000). Synthesis and characterization of NiFe ~ 2O ~ 4 nano-octahedrons by EDTA-assisted hydro-thermal method. Turkish Journal of Chemistry, 30, 659–666.
Kwon, Y. M., et al. (2014). Risk stratification algorithm for management of patients with dual modular taper total hip arthroplasty: Consensus statement of the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons and the Hip Society. The Journal of Arthroplasty, 29(11), 2060–2064.
Author information
Authors and Affiliations
Corresponding author
Additional information
Handling Editor: Y. James Kang.
Rights and permissions
About this article
Cite this article
Choi, HI., Hong, J.A., Kim, MS. et al. Severe Cardiomyopathy Due to Arthroprosthetic Cobaltism: Report of Two Cases with Different Outcomes. Cardiovasc Toxicol 19, 82–89 (2019). https://doi.org/10.1007/s12012-018-9480-0
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12012-018-9480-0