• SGPath Slide Seminar 2015/11

Case 6

• Rosmarie Caduff, Institut für Klinische Pathologie, UniversitätsSpital Zürich

Clinics • 67-year old women

• Bilateral hip replacement, right two years after left side, prostheses ceramic-on-ceramic

• Broken prosthesis at the left side, 5 years after primary surgery, replacemnt with metal-

on-polyethylene

• 8 years well. General malaise, hypothyreoidism, progressive visual and hearing loss,

hypertension, low output, elevated serum lipid levels, obesity

• Outside hospitalisation, MRI edema right N.opticus, transfer to the Neurological Clinic

USZ. MRI progression of cerebral lesions

• No conclusive diagnosis. DD: mitochondriopathy, cobalt intoxication

• Unexpected detoriation, MOF

• Serum cobalt 18885 nmol/L (no <119 nmol/L). Death one day later

• Clinical question: metal analysis of the left hip prosthesis

Your diagnoses 62

• Cobalt metallosis, cobalt intoxication 6

• toxic metallosis, systemic metallosis, metallosis with

polyneuropathy 15

• Metallosis, metal debris, black particles 36

• Alkapturia/oochronosis 2

• Interstitial sclerosis/acute PML/ no diagnosis 3

Diagnosis

• Metallosis, cobalt-metallosis (cobalt-intoxication)

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Additional major findings

• Heart: weight 680g (normal upper limit 280g), biventricular hypertrophy.

Sclerosis of the coronary arteries without stenosis.

• Lungs: edema, bronchopneumonia. Bilateral pleural effusions.

• Pigmentations in liver, pancreas and spleen

• Shock necroses of the liver, shock kidneys

• Cerebral demyelinisation

Cobalt level

Normal blood and urin levels < 17nmol/L (< 119nmol/L)

Toxicity > 12000nmol/L (patient 13885)

Cobalt is Albumin bound

Free ions toxic

Neuro-ocular toxicity, cardiotoxicity, thyroidtoxicity

Toxic mechanisms

Positive correlation between CO ion amount and tissue damage

Different pathways: oxydative damage by Co induced ROS,

induction of apoptosis,

interaction with ion channels and receptors,

Co displace other ions in tissue

Therapy: Removal of the prosthesis

Clinical Diagnosis of cobalt intoxication

Typical clinical features known as asocciated with cobalt toxicit

Cobalt prosthesis

Tissue metallosis

Decreasing concentration and recovering after removal of prosthesis

Pathological Diagnosis

Cobalt metallosis