An arcane cardiomyopathy

Last February, the Lancet and the New England Journal of Medicine almost simultaneously published two interesting case reports on an arcane cardiomyopathy [1, 2]. The New York Times drew attention to these papers in their Health Section as ‘A Medical Mystery Solved’. A 55-year-old man is described. He was hospitalised for severe heart failure after he had gone from doctor to doctor seeking a diagnosis for his many puzzling ailments. His left ventricular ejection fraction was 25 % and his coronary arteriogram normal. In 2010 his ceramic artificial hip was replaced by a metal-on-metal type, which to the doctors had seemed unrelated to his many symptoms (heart failure, deafness, almost blind, hypothyroidism, and fever). However, a doctor of the team in Marburg (Germany) remembered an episode of Dr. House that he watched on the Fox TV show (also broadcast in Germany and in the Netherlands), on a mysterious illness caused bymetal poisoning from an artificial metal hip. When they measured the patient’s blood serum cobalt level it was 1000 times higher than normal. Radiography showed metal debris near his metal hip. After chelation therapy and replacement of his metal hip with a ceramic type, his condition improved and his ejection fraction rose from 25 to 40 %. Cobalt intoxication was the most likely cause of the heart failure and the many other ailments of this patient [1]. The other report describes a 59-year-old woman who underwent heart transplantation for severe heart failure, also after a few years of puzzling complaints and symptoms. In her work-up all rare causes of her medical history were considered but none showed up. She had undergone right total hip replacement 4 years previously and left total hip replacement 3 years previously, both with a metal prosthesis. Sometime after her heart transplantation her orthopaedist unexpectedly found her blood serum cobalt level to be 300 times higher than normal on a routine check-up. A year later both artificial hips were replaced with prostheses with a polyethylene liner. Her cobalt levels decreased and her condition improved. The most likely cause of her symptoms and unexplained heart failure was cobalt intoxication [2]. Since 2006, there is an increasing number of publications on patients with problems after a metal-on-metal hip arthroplasty. As a result of the wear over time at the bearing surfaces, chromium and cobalt are commonly found in the blood and urine of these patients. In the vicinity of the prosthesis, the metal ions can cause metallosis resulting in giant cell infiltration, fibrosis and solid pseudotumours [3–6] In 2010, Tower was the first to draw attention to the neurological and cardiac adverse effects of chronic systemic cobaltism [7]. Subsequently, a few case reports have been published on cobalt cardiomyopathy, one with fatal outcome [1, 2, 8–10]. When I was starting my fellowship in cardiology at the University of Leuven (B) in 1966, my mentor, Professor H. Kesteloot published a series of patients with severe heart failure. All were heavy beer drinkers. Strangely enough, these patients had a large pericardial effusion and polycythaemia, two findings which had not been reported before in alcoholic cardiomyopathy. Also, after tapping the fluid, their heart size was not significantly enlarged. The syndrome was presented as a new form of cardiomyopathy in chronic beer drinkers [11]. Early in 1967, there was a request from the FDA as to whether they could come to Leuven to examine the files of these patients. After studying the data, they told us the story of Prof. dr. Jos R.T.C. Roelandt suddenly passed away on Sunday, August,31th, 2014. Please send correspondence concerning the article to Professor F. Zijlstra at the below address.