Sunday, February 9, 2014

As Seen on TV, a medical mystery involving hip implants is solved...cobalt Poisoning

New York Times
Feb 6th, 2014

By a strange coincidence, two leading medical journals on Thursday published case studies of the same arcane medical mystery. In one, doctors solved the riddle only after the patient, a middle-aged woman, got so sick she had to have a heart transplant. But in the other, a physician who teaches at the University of Marburg in Germany found the clues in Season 7, Episode 11, of the Fox television show “House.”

It turned out that Dr. Gregory House, the cantankerous, fictional diagnostician modeled on Sherlock Holmes, had used his powers of deduction to diagnose the very same ailment in a woman played by the actress Candice Bergen on an episode that first aired in 2011.

In this case of life imitating art — or at least television — a paper in The Lancet, a London-based medical publication, described how an ailing man in Germany had gone from doctor to doctor, seeking a diagnosis as his condition worsened.

His problems began about three years ago. He had low thyroid hormone levels, inflammation of his esophagus and fever of unknown origin. His loss of vision was so profound he was almost blind, and his loss of hearing so severe he was almost deaf. Most perilous of all, his heart had weakened so much it could not pump hard enough to supply blood to his body.
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Two case studies published on Thursday traced high levels of cobalt in patients in Colorado and Germany to metal-on-metal hip implants. Joshua Borough for The New York Times
Heart failure usually follows coronary artery disease, but this man’s arteries were fine. Doctor after doctor was stumped.

Finally, in May 2012, the man, then 55, arrived at a University of Marburg clinic run by Dr. Juergen R. Schaefer, who specializes in puzzling cases and happens to be a major fan of “House.” In fact, Dr. Schaefer uses “House” in teaching medicine, and he realized his patient’s symptoms were eerily similar to those of Ms. Bergen’s character on the show. In that episode, she, too, had heart failure. Dr. House’s diagnosis: cobalt poisoning from her artificial metal hip.

Dr. Schaefer’s patient had had an artificial ceramic hip that failed, and it was replaced with a metal one in November 2010, shortly before his symptoms began. So Dr. Schaefer tested the man’s cobalt level and discovered it was a thousand times the level considered normal.

A scan showed the metal in his hip was eroded. The reason, Dr. Schaefer speculated, was that when the man’s doctor removed the broken ceramic hip, he inadvertently left behind tiny particles of ceramic. Those particles, Dr. Schaefer said, acted like sandpaper: “You destroy the metal part with each movement.”

The man had his metal hip replaced with another ceramic one, after which his cobalt level plunged. His heart function improved, but he still needed a defibrillator implanted. His fever and esophagus problems went away. But his hearing and eyesight barely got any better.

Needless to say, the doctors in the other case, published in The New England Journal of Medicine, had not seen that episode of “House.”

The patient, a woman in Denver who asked not to be named to protect her privacy, said she began feeling ill on a vacation in Hawaii a few years ago.

“I was tired all the time,” she said. When she returned from her travels, she discovered she had gained 10 pounds on her 4-foot-10, 95-pound frame, for no apparent reason. Her abdomen was swollen, as were her arms and legs.

Her doctor ordered a CT scan, which showed fluid accumulating around her heart. He drained the fluid, but she still felt ill. Normally, someone with such a condition, cardiomyopathy, has an enlarged heart, but hers was a normal size.

“It was kind of a puzzle to my first cardiologist,” she said.
By 2011, her heart was failing. She went to the Anschutz Medical Campus of the University of Colorado, Denver, where her doctor, Larry A. Allen, a heart failure and transplant specialist, confessed he was baffled.

“We did a work-up looking at possible causes and even rare causes,” he said. “Nothing showed up.”
On Sept. 10, 2011, she underwent a heart transplant.
Sometime later, the orthopedist who had replaced her hips with metal implants took some routine blood tests and found something curious. Her cobalt level was more than 300 times normal. Cobalt poisoning can seriously damage organs, particularly the heart. The cause of her problems was suddenly clear.

About a year after her heart transplant, she had both artificial hips replaced with ones that had a polyethylene liner. Her postoperative course was rocky, but her cobalt level declined.
“I have much of my old energy back,” she said in an interview.

In their article describing the case, Dr. Allen and his colleagues wrote that cobalt poisoning was first described in the 1960s in people who had been drinking beer that had foam stabilizers that contained cobalt.

But its link to metal-on-metal hip implants leaves questions, they said. Their patient had nothing obviously wrong with her prosthetic hips. And, Dr. Allen said, “literally tens of thousands of people had these hips without her problems.”

But Dr. Allen said the patient’s case was a good reminder. However rare cobalt poisoning might be, it is something to consider when people with metal-on-metal hip implants have symptoms suggestive of it.

And, yes, he said, maybe if he had just seen Dr. House in action he would have considered it.
“Unfortunately,” he said, “I have seen about two half-episodes of ‘House.’ ”

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