Review: cobalt toxicity and artificial metal hips

metal-hip-300x181

4.5 out of 5 stars

Systemic toxicity related to metal hip prostheses. Bradberry SM et al. Clin Toxicol 2014;52:837-847.

Abstract

As TPR has reported before, cobalt poisoning can cause hypothyroidism, cardiomyopathy, and neurotoxicity. Neurological manifestations include:

  • optic nerve damage and retinopathy with reduced visual acuity
  • bilateral nerve deafness and tinnitus
  • polyneuropathy (sensory and motor)
  • cognitive impairment and memory loss

A number of papers and case reports have described clinical cobalt toxicity related to metal-on-metal hip prostheses or revision of a failed ceramic prosthesis with metal parts. Although these cases are somewhat rare, missing the association can be catastrophic. Recently, a report in theNew England Journal of Medicine described a 59-year-old woman with bilateral metal-on-metal hip prostheses who received a heart transplant for severe progressive cardiomyopathy. She also developed hypothyroidism, initially attributed to previous treatment with amiodarone. Cobalt toxicity was not diagnosed until months after transplant surgery.

This superb paper describes and critically reviews that 18 cases in the medical literature of systemic toxicity in patients with metal hip prostheses. The authors — using somewhat vague criteria — determined that i 10 of these cases the systemic manifestations were probably related to cobalt exposure.

Some key take-home points from the paper.

  • metal ions released from hip prostheses impair osteocyte function and may contribute to implant failure
  • cobalt decreases uptake of iodine by the thyroid, leading to hypothyroidism and goiter
  • patients with hip implants at highest risk for cobalt toxicity are those whose failed ceramic prostheses have been revised using cobalt-containing metal parts
  • there is scant evidence supporting treating these patients with chelation

This is important reading. You’re not likely to see a case of this, but if you do you don’t want to miss the diagnosis. Bottom line: think cobalt toxicity if you see a patient with a metal hip and hypothyroidism, heart failure, and/or neurologic deficits.

Related posts:

You don’t need Dr. House to suspect cobalt toxicity in a patient with an artificial hip

Case report: cobalt toxicity following implantation of a metal hip prosthesis

Cognitive decline in patients with metal-on-metal hips: think cobalt toxicity

Neurological changes and hip prosthesis: consider cobalt toxicity

Avoid couchlock! Four things to know about cannabis pharmacology

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With medical marijuana now legal in 23 states and the District of Columbia — and recreational weed available in Colorado and Washington State — knowing the pharmacokinetics of THC has never been more important, both for consumers and the physicians who must counsel and treat them. Recently, the New York Times’ Pulitzer Prize-winning columnist Maureen Dowd got into trouble in Denver when she overdosed on a cannabis candy bar and experienced 8 hours of paranoia and couchlock. My recent Emergency Medicine News column describing 4 things Maureen should have known about weed before venturing to the “mile high city” has been posted online. You can read it here.

Tox on the Web: sarin, lithium, strychnine, and much more!

 

Toxicologist as Man on Couch with Laptop: This video shows a short presentation by Larissa Laskowski a first year fellow at the NYC Poison Control Center, describing the work of Eliot Higgins and the Brown Moses blog. Higgins — an unemployed finance worker several years ago with no knowledge about weapons of warfare — started blogging about the use of different weapons in Syria, and posting online videos appearing on sites such as YouTube that demonstrated use of these weapons. He is now an acknowledge expert in the field. His work led to the identification of sarin as the agent used in the Ghouta chemical attack on August 21, 2013. Dr. Laskowski ends by challenging toxicologists to make use of their knowledge to effect positive change in the outside world. Inspiring stuff. For more on Higgins and Brown Moses, read this story in the Guardian (U.K.). [HT @acmt]

Would you like some lithium with that? In a New York Times opinion piece, psychiatrist Anna Fels reviews the evidence suggesting that we’d all be better off if a little lithium were added to our water, soda, and beer.

All white powders look alike: The Los Angeles Times reports that a 14-year-old boy in the town of Anderson may be charged after he allegedly gave a white powder to another youth, say it was cocaine. The other youth died after snorting the powder. Subsequent analysis revealed that it was actually strychnine.

Must-read: Lake Erie and the Toxic Bloom: In a long story that’s both extremely informative and amazingly well-written, Dan Egan of the Milwaukee Journal Sentinel explains how the “toxic algae cocktail brew” that poisoned and shut town the Toledo OH water system last year was possibly the harbinger of much worse to come. BTW, it’s become ever clearer that the J-S is one of the best papers in the country when it comes to coverage of science, medicine and the environment. (HT @deborahblum)

Murder by nicotine? People Magazine has a brief update on the case of nuclear engineer Paul Curry, who is on trial in Santa Ana, CA charged with killing his wife Linda 20 years ago by injecting her with nicotine. Prosecution expert Dr. Neal Benowitz testified that he had “never seen levels like this in any blood sample.” Curry’s public defender argued that the nicotine might have been present because his wife may have been using it to treat irritable bowel syndrome.

The discovery of LSD: The Atlantic Magazine has an excerpt from Tom Shroder’s new book Acid Test: LSD, Ecstasy, and the Power to Heal. The piece describes the accidental discovery of LSD by chemist Albert Hofmann in April 1943. Shroder quotes Hofmann’s own description of the experience:

The dizziness and sensation of fainting became so strong at times that I could no longer hold myself erect, and had to lie down on a sofa … Everything in the room spun around, and the familiar objects and pieces of furniture assumed grotesque, threatening forms. They were in continuous motion, animated, as if driven by an inner relentlessness. The lady next door, whom I scarcely recognized, brought me milk—in the course of the evening I drank more than two liters. She was no longer Mrs. R, but rather a malevolent, insidious witch with a colored mask … Every exertion of my will, every attempt to put an end to the disintegration of the outer world and the dissolution of my ego, seemed to be a wasted effort. A demon had invaded me, had taken possession of my body, mind, and soul … I was seized by the dreadful fear of going insane. I was taken to another world, another place, another time. My body seemed to be without sensation, lifeless, strange. Was I dying?

The excerpt made me want to read the entire book.

Case Report: Synthetic Cannabinoid K2 and Myocardial Infarction

K2-Weed-thumb-300x20012.5 out of 5 stars

K2—Not the Spice of Life; Synthetic Cannabinoids and ST Elevation Myocardial Infarction: A Case Report. McKeever RG et al. J Med Toxicol 2014 Aug 26 [Epub ahead of print]

Abstract

Use of synthetic cannabinoids has been associated with a broad range of adverse effects, including tachycardia, hypertension, seizures, psychosis, renal injury, and cyclic vomiting.

This article describes 16-year-old male who presented to hospital with 1 day of substernal chest pressure associated with nausea, vomiting, and dyspnea that started 2 hours after he smoked the synthetic cannabinoid K2. Workup revealed elevated ST segments in the inferolateral leads and elevated troponin that peaked at 8.29 ng/ml (normal 0-0.3 ng/ml). Echocardiogram and cardiac catheterization were unremarkable. Urine drug screen was positive only for opiates and benzodiazepines, both of which the patient received in the hospital before the specimen was obtained. Specimens for additional toxicology tests were sent to an outside lab but never arrived.

The authors claim that this is “the first report of ST-elevation myocardial infarction (STEMI) in the setting of synthetic cannabinoid use without concomitant marijuana use.” To my mind this claim is a bit disingenuous. A 2011 paper by Mir et al — cited in this article — described several teenagers who presented with chest pain and STEMI after smoking K2 but had no history of proximate marijuana use.

Conservative treatment for asymptomatic body packers?

Body packer

Body packer

2 out of 5 stars

Asymptomatic body packers should be treated conservatively. Glovinski PV et al. Dan Med J 2013 Nov;60:A4723

Abstract

Kudos to the authors for putting their general conclusion in the title. Unfortunately, there’ s less here than meets the eye.

This is a retrospective review of 57 patients suspected of body packing, seen at Hvidovre Hospital in Denmark. However, actual body packing was confirmed in only a little over half of these cases, meaning this is really a study of only 29 patients.

All confirmed body packers were admitted, given a laxative and “monitored using a scope.” (I’m not quite sure what this means. After passing two stools not containing packets, they received a non-contrast CT to confirm that the GI tract was clear. The treatment protocol indicated surgery only for GI tract obstruction or evidence of drug intoxication suggesting packet rupture.

No patient developed signs or symptoms of obstruction or rupture, and none required surgery. One patient treated conservatively did not clear his GI tract until the 17th hospital day.

There is a consensus in recent literature that surgery in body packers is generally not required. Certainly, evidence of GI tract obstruction or packet rupture is an indication. The open question is whether delayed progression of drug packets calls for surgery. The authors note that some studies have recommended surgery for packets retained more that 5-7 days.

The authors conclude that, based on their study “Package retention per se is not an indication for emergency operation.” I think they are probably correct, but since their study included as few as a single patient with delayed passage and retention, it is not a conclusion that is ready for prime time.
Related posts:

Body packers: can CT determine the number of drug packets?

MRI for body packers?

Low-dose abdominal CT is superior to plain film for imaging suspected body packers

Cannabis body packers

Treatment protocol for symptomatic body packers (mules)

Cocaine mules: what to do with body packers

 

 

 

 

 

Do pediatric patients require endoscopy after ingesting a laundry pod?

Laundry_pod23 out of 5 stars

Laundry Detergent Pod Ingestions: Is There a Need for Endoscopy? Smith E et al. J Med Toxicol 2014 Sep;10(3):286-91

Abstract

The authors never answer their title question definitively, but you wouldn’t expect that they’d be able to on the basis of this small case series and the limited data published to date.

Ingestion of laundry detergent pod (LDP) ingredients can present with manifestations affecting a number of systems:

  • Gastrointestinal
  • Pulmonary
  • Neurological
  • Metabolic

The paper presents 3 cases of pediatric LDP ingestion in patients ages 13 months to 3 years. Presenting signs and symptoms included vomiting, stridor, respiratory distress, cyanosis, lethargy and decreased level of consciousness, and lactic acidosis. One child required intubation for respiratory distress. No child had visible oropharyngeal lesions but all had superficial esophageal erythema or sloughing. One child developed swallowing abnormality and evidence of silent aspiration on a barium swallow study.

In their discussion, the authors note that the contents of LDPs are in fact less alkaline than the corresponding loose detergents. They do contain propylene glycol, which may be responsible for the drowsiness and lactic acidosis often seen in these patients.

The authors conclude:

If a patient presents with significant gastrointestinal symptoms, including persistent vomiting, dysphagia, drooling, or oral aversion, it is reasonable to evaluate with an upper endoscopy.

They do note, however, that they were unable to find any reported cases of esophageal stricture after LDP ingestion.

 

Related posts:

Laundry ‘pods’: more toxic than your mom’s detergent

Just when you thought it was safe to go back to the laundry room . . .

Look-alike tox: is it a laundry detergent, or a piece of candy?