Protect…Detect…Prevent!

Prepared for the Scientific Guidance Panel Biomonitoring California November 8, 2021

Metallosis is a potentially fatal complication seen in metal on metal hip replacements caused by erosion and release of metallic debris triggering a massive discharge of cytokines from inflammatory cells. The systemic absorption of metal ions like cobalt and chromium can cause a spectrum of clinical diseases.[https://www.ejropen.com/article/S2352–0477%2814%2900011–2/fulltext]

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.

EPA Map of Particulate Emissions in tons per year shows >20 (red) in the India Basin north entry to the federal Superfund site adjacent to the Hunters Point hilltop where she has owned a home for over 20 years.

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]

The Evans street route to the federal Superfund site traveling southeast toward the Innes street north gate is a region exceeding the 100th percentile in PM 2.5 detections according to the EPA EJSCREEN map. The patient’s son uses a home particulate monitor.

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].

Innes Avenue north entry federal Superfund site Hunters Point Shipyard

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]

Urinary toxic exposure screening detects elevations in gadolinium, cobalt and high normal levels of chromium. Global nutrient deficiencies are evident in this physically impaired senior whose hip and back pain interferes with her ability to prepare meals and climb stairs in her home. Gadolinium is used in contrast agents to visualize soft tissues. It is also used for neutron shielding in nuclear submarines and occurs naturally in serpentinite bedrock.

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.

https://www.drugwatch.com/hip-replacement/metallosis/

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]

Metal on Metal (MoM) hip replacements were sold in the US from 2002 to 2014. None of the models received FDA approval and none were subjected to clinical trials. [https://westernjusticelaw.com/metal-on-metal-hip-replacements]

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/]

Extensive fibrosis and metallosis in a prosthetic knee. Metal particles deposit in tissue causing necrosis and excite an inflammatory response when cobalt, chromium and stainless steel are used in joint prosthesis. {https://ispub.com/IJPA/4/2/10194]
Radiological features of osteoarthritis, metallosis and aseptic loosening of the right hip. [https://www.researchgate.net/figure/Radiological-and-macroscropic-tissue-features-of-OA-AL-and-metallosis-a-Anteroposterior_fig6_304998344]

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.

Dr. Dahlgren can be contacted at dahlgren@envirotoxicology.com
https://www.sfexaminer.com/features/doing-no-harm-ahimsa-sumchai/

Ahimsa Porter Sumchai MD, PD - Medical Director & PI. Founding Chair- Radiological Committee Hunters Point Shipyard RAB Attending MD VA Toxic Registry and SFDPH