Prepared for the Scientific Guidance Panel Biomonitoring California November 8, 2021
A 75 year old retired female federal accountant requested “heavy metal testing” after attending a homeowners meeting where the topic of human biomonitoring was discussed by residents living adjacent to a federal Superfund site in southeast San Francisco.
Concerned about her worsening fatigue, memory loss and cognitive decline, she tried a range of memory supplements, vitamins and fish oil. She walked with cane assistance and lived with chronic pain in her hips and low back. She relied on paratransit services and her adult son for transport to the shopping center and church. She was no longer able to enjoy weekly swim sessions because the pain in her hips had become unbearable.
In 2011 and 2013 she underwent bilateral total hip arthroplasty performed by an orthopedic surgeon at UCSF Medical Center but was lost to follow up when more serious medical problems took front and center. She developed heart failure, atrial fibrillation and her blood pressure became difficult to control. She suffered from urinary retention alternating with brisk uncontrollable bouts of incontinence due to the potent diuretics prescribed for blood pressure and heart failure control. Her disabling hip pain and loss of urinary control restricted her to the nearest bathroom.
During the months of the 2020 COVID -19 shut in she gained an enormous amount of weight and at 5'4" and 234# and a BMI of 40, her hip pain became even more unbearable. Imprisoned in the inlaw unit of her Hunters Point hilltop home and unable to climb the stairs to the kitchen to prepare a healthy meal, she was confined to a cluttered downstairs unit stocked with processed high carbohydrate snacks and beverages.
Her medical history is highly significant in that in 2000 she underwent ENT surgery for excision of an acoustic neuroma in her left ear that requires follow up MRI scan every five years. Gadolinium would have been used as a head and neck soft tissue enhancing contrast agent for scans performed in this era.
Additionally, she is plagued by chronic allergies to dust and pollens and during the 2020 California wildfire season required a rescue inhaler for asthmatic bronchitis triggered on days when the overhead sky turned orange from smoke particulates. Her home is located near the India Basin entry to the federal Superfund site on Evans Avenue southeast to the shipyard’s Innes Avenue north gate. This is the region the Bay Area Air Monitoring District identifies in its interactive mappings as being exceedingly high in toxic air contaminants.[https://www.baaqmd.gov/about-air-quality/interactive-data-maps]
EPA EJ Screen mappings of diesel particulates and fine particulates in the region of her Hunters Point hilltop home confirm PM 2.5 detections exceeding the 100th percentile based on national standards at [https://www.epa.gov/ejscreen].
The urinary toxic exposure screening was remarkable for the detection of cobalt in concentrations almost 9 times greater than maximum allowable levels and elevated chromium levels for the reference range. This is metallosis! [Metallosis: A diagnosis not only in patients with metal-on-metal prostheses. https://www.ncbi.lnl.nih.gov/pmc/articles/PMC4750564]
Metallosis is a life threatening complication of metal on metal hip (MoM) replacements. Hip replacements with metal on metal bearing surfaces were introduced in the late 1990’s . Heavy metal toxicity is triggered by release of cobalt and chromium ions into supporting tissues of the prosthetic joint and into the human blood stream. Over time charged metal particles from the toxic heavy metals cobalt and chromium damage bone and tissue. Symptoms of metal poisoning include a metallic taste in the mouth, nausea, depression and popping, squeaking, unstable hips. Cobalt is toxic to heart muscle and may have contributed to the patient’s history of heart failure and refractory high blood pressure. Cobalt can increase red blood cell mass to cause polycythemia. Chromium can suppress the immune system during a global pandemic.
The spectrum of symptoms of metallosis include skin rashes, heart failure, hearing and visual disturbances, weakness, fatigue and cognitive decline. Harris et al report cobalt toxicity in a 57 year old woman who presented with progressively worsening hip pain, tachycardia, fatigue, memory loss, lower extremity sensory loss and ocular changes. A cobalt level of 788 ppb and chromium level of 140 ppb were detected on serum screening. Both levels declined two weeks after total hip revision using a ceramic on polyethylene arthroplasty and her symptoms improved. [https://www.arthroplastytoday.org/article/S2352–3441%2815%2900069–2/fulltext]
Elevated cobalt levels can be detected in blood, urine, hair or joint fluid in patients who may or may not have symptoms. Populations at highest risk of developing metallosis include females, patients with bilateral hip implants, men and women who are obese, physically active or have renal insufficiency. [https://www.drug.awcenter.org/metallosis/]
In the United States MoM implants are no longer used for total hip replacement and, as of 2019, none are approved for use by the FDA. Metal on metal (MoM) implants often fail after five years. The Stryker Rejuvenate and ABD II are two MoM prosthetic devices whose modular necks and stems were found by post marketing data prone to corrosion and excessive release of metal ionic debris.
Since 2012 the Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended those with MoM hip replacements undergo screening that includes clinical review, gait assessment, blood metal ion testing for cobalt and chromium, X -rays to identify signs of implant failure as well as ultrasound or MRI to detect muscle damage and soft tissue fibrosis. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5697529]
Our patient was immediately referred to her primary care physician and orthopedic surgeon for revision and to a national law firm for medico- legal counseling. Additionally, she received nutritional counseling and referral for weight loss services.
The Hunters Point Biomonitoring Foundation welcomes James Dahlgren, MD Environmental Toxicologist and Expert Witness in the historic settlement of the Erin Brokovich case against PG&E in California.