Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. An individual is exposed to this chemical element via inhalation, ingestion, or dermal exposure and, in general, chronic exposure is required for most of the adverse effects to develop.

The manifestations originating from the respiratory tract are traditionally linked to toxicity due to cobalt inhalation and comprise asthma, fibrosis, pneumonia, decreased lung function, and bronchospasm [1] [2] [3]. Cardiovascular manifestations are generally limited to cardiomyopathy accompanied with cardiomegaly and cardiac failure, while anemia with an approximate 5% decrease in hemoglobin has also been reported [4] [5] [6] [7]. Also documented are the effects of cobalt poisoning on the endocrine system, and specifically on the thyroid gland: even though reports evince a certain dissent, increased serum thyroxine (T4) or decreased concentrations of triiodothyronine (T3) have been observed [8]. In addition to the aforementioned symptomatology, persisting occupational exposure to cobalt may also lead to conjunctival congestion, weight loss in patients with the cobalt-associated pulmonary disease, and neurological sequelae which include nerve deafness, as well as memory and visual acuity impairment [9] [10] [11].

Ingesting cobalt is an important way of exposure to the element's toxic effects, with lethal cardiomyopathy having been reported as the most detrimental manifestation [12]. It develops abruptly with a clinical picture that resembles beriberi or alcoholic cardiomyopathy. Sinus tachycardia, left ventricular failure, and cardiogenic shock are some of the main manifestations, which may be preceded by nausea, diarrhea, and vomiting [13]. Ingestion of cobalt has also shown to result in polycythemia, increased hemoglobin levels, goiter, and histological changes of the thyroid gland [14].

Cobalt is known to cause dermatitis, should it come into contact with an individual's skin [15] [16].

An additional way in which cobalt poisoning is induced is metal-on-metal hip arthroplasty (MoM) [17]. The phenomenon is known as prosthetic hip-associated cobalt toxicity (PHACT) and leads to some of the manifestations that inhaled and ingested cobalt does, including cardiac, neurologic, and thyroid impairment [18]. Depression, lack of orientation and concentration, as well as aphasia, are also results of PHACT-related cobalt poisoning [19].

• Fatigue

  She had regained a normal appetite and gained weight, the metallic taste in her mouth was gone, and she had less fatigue and greater energy. Additionally, her hip pain was gone and her cobalt levels had come back down to normal. [schmidtandclark.com]

  Cobalt-60 emits radiation, causing long-lasting symptoms like fatigue and hairloss, and even loss of consciousness. [environmentalpollutioncenters.org]

  She had regained a normal appetite and gained weight, the metallic taste in her mouth had gone, and she had less fatigue and greater energy. The hip pain had completely resolved and she was walking up to 2 km a day. [mja.com.au]

  Symptoms of cobaltism include: Irritability Fatigue Tinnitus Hearing loss Headaches Loss of coordination Cognitive decline Depression Metal-on-Metal Hip Implants Can Shed Cobalt and Chromium Debris A hip implant that uses all-metal components is known [yourlawyer.com]

  Two years after the hip implantation, the patients in the study experienced even more symptoms of cobaltism, which can include irritability, fatigue, tinnitus, hearing loss, headaches, loss of coordination, cognitive decline, and depression. [cobalt-poisoning.com]

• Difficulty Walking

  If you have experienced symptoms of chromium and cobalt toxicity, which include pain, inflammation, tumors and difficulty walking, it is imperative that you seek medical attention immediately. [sullolaw.com]

  Swelling, Extreme Pain & Discomfort Dislocation of Implant Clicking, Popping or Grinding Loosening of the Implant Unexplained Hip Pain Thigh Pain or Groin Pain Pain with Walking Pain Rising from a Seated Position Pain with Weight Bearing Difficulty walking [earlsview.com]

  Persons who suffer pain, inflammation, difficulty walking, or develop cysts after receiving a metal-on-metal hip implant may have cobalt poisoning. Cobalt poisoning is extremely serious if left untreated. [thelawfirm.com]

• Poor Growth

  This in turn leads to poor growth of the plant as well as leaf loss which overall decreases the amount of oxygen produced by plants during photosynthesis. Eventually the deficiency would lead to plant death. [en.wikipedia.org]

• Soft Tissue Mass

  Pseudotumors Pseudotumor from a metal on metal hip implant A pseudotumor (SUE-dough-two-mur) is a large soft tissue mass that forms around the hip. [mctlawyers.com]

• Aspiration

  At the time of surgery, 30 mL of turbid fluid was aspirated from the joint and debridement of metal stained tissue was undertaken. The concentration of cobalt in the joint fluid was 4218 nmol/L and chromium was 217 000 nmol/L. [mja.com.au]

• Nausea

  Sinus tachycardia, left ventricular failure, and cardiogenic shock are some of the main manifestations, which may be preceded by nausea, diarrhea, and vomiting. [symptoma.com]

  In some rare cases, Cobalt-57 may also generate the Acute Radiation Syndrome, with symptoms like bleeding, diarrhea, nausea, vomiting, coma and even sudden death. [environmentalpollutioncenters.org]

  It may cause nausea and vomiting. [nlm.nih.gov]

  In July 2010, the woman suffered a severe cerebrovascular episode whose symptoms were similar to that of a stroke: dizziness, disorientation, nausea, vomiting, and being ‘off balance on the left side.’ [schmidtandclark.com]

  Side effects of chelation therapy include a burning sensation at the injection site, fever, a sudden drop in blood pressure, headache, nausea, vomiting, inability to create new blood cells, and mineral deficiencies. [sullolaw.com]

• Abdominal Pain

  The signs and symptoms may include: Nausea and vomiting from ingesting large amounts of cobalt compounds Abdominal pain Exposure of the compound to the eye may result in pain, irritation, redness, and watery eyes Contact dermatitis from direct contact [dovemed.com]

  Gastrointestinal symptoms include a flu-like illness (gastroenteritis) that is characterized by vomiting; abdominal pain; fever; and diarrhea, which, in some cases, may be bloody. [rarediseases.org]

  pain (ingestion) Copper deficiency: anemia, neurologic degeneration, osteoporosis Normal range: 0.6-1.1 mg/L (plasma) 10-14 mg/L (red cells) * *No accepted chelation regimen; contact a medical toxicologist regarding treatment plan. [emedicine.medscape.com]

• Cardiomegaly

  Cardiovascular manifestations are generally limited to cardiomyopathy accompanied with cardiomegaly and cardiac failure, while anemia with an approximate 5% decrease in hemoglobin has also been reported. [symptoma.com]

  Little JA,Sunico R (1958) Cobalt-induced goiter with cardiomegaly and congestive failure. J Pediatr 52: 284-288 Sederholm T,Kouvalainen K,Lamberg BA (1968) Cobalt-induced hypothyroidism and polycythemia in lipoid nephrosis. [toxicology.imedpub.com]

• Axillary Rash

  At 3 months post-op, he complained of bilateral axillary rashes. At 8 months post-op, he reported unaccustomed shortness of breath. Pulmonary function tests and allergy testing for metals were normal. [earlsview.com]

• Cerebellar Sign

  The patient reported difficulty in remembering names and registering information, headaches and cerebellar signs (ataxia and dysdiadochokinesis). [schmidtandclark.com]

  She had particularly noted difficulty in remembering names and registering information (both written and aural), headaches and cerebellar signs (ataxia and dysdiadochokinesis). [mja.com.au]

The diagnosis of cobalt poisoning initially requires a thorough medical history, including a history of potential exposure to toxic metals. This chemical element can be detected in the blood or urine [20] [21]. On average, an individual that has not been exposed to an excessive amount of cobalt is expected to exhibit values of the element less than 0.19 μg/dL and 2 μg/dL in the serum and urine, respectively [22]. A patient believed to have been exposed to a dangerous amount of cobalt should undergo laboratory evaluation of cobalt concentration in the urine and blood as soon as possible upon presentation, as the excretion rate is maximized within 24 hours after an occasion of exposure. Cobalt-associated allergic reactions can lead to elevated levels of IgE and IgA in the serum, which can be used both for diagnostic and monitoring purposes [23].

• Hepatic Necrosis

  Gastrointestinal PO 0.04 mgCo/kg/day [27,28] Nausea Vomiting Diarrhea Hepatic effects [26,27] PO 0.04 mgCo/kg/day Central hepatic necrosis Increased Serum Bilirubin Increase AST,ALT,LDH Increase Creatine Phosphokinase Increase Ornithine CarbamylTransferase [toxicology.imedpub.com]

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