A 55-year-old man with severe heart failure was referred to a hospital in Marburg, Germany, to rule out coronary artery disease, a common cause of heart failure. He was almost deaf and almost blind, with fever of unknown cause, hypothyroidism and several other symptoms. Both his hips had been replaced but otherwise his medical history was uneventful.
"Searching for the cause combining these symptoms — and remembering an episode of the TV series House, which we used for teaching medical students — we suspected cobalt intoxication as the most likely reason," wrote Dr. Juergen Schaefer of Marburg University Clinic Center for Undiagnosed Diseases and his co-authors in Thursday’s online issue of the medical journal The Lancet.
Schaefer’s team took X-rays of the hip and found high levels of two heavy metals, cobalt and chromium, in his urine. The diagnosis? Cobalt intoxication from metal hip replacements.
One of the first published reports on cobalt intoxication was in 1967. Called "Quebec beer drinkers’ cardiomyopathy," doctors described 44 men in their 40s to 60s who were heavy drinkers who died unexpectedly.
"There was a suspense element to the story," recalled cardiologist Dr. Yves Morin of Quebec City. "It took a lot of time and effort to find a cause of the disease."
It turned out the men all drank beer made at the Dow brewery in Quebec City. The brewery had added cobalt to stabilize the beer's foam.
Morin said autopsies were carefully conducted but pathologists in Canada and the U.S. weren’t familiar with the lesions. Investigations of similar outbreaks in other beer-brewing towns led to diagnoses of cobalt poisoning.
"At that point, the addition of cobalt was suspended throughout the world but you can't imagine the number of patients everywhere who died from that disease because it was 40 per cent mortality," Morin said.
In the German case, after the man received a new left ceramic hip prosthesis, the cobalt and chromium concentrations in his blood decreased, he stabilized and recovered slightly. His cardiac function improved after a defibrillator was implanted but the vision and hearing recovered only slightly.