Makindo Medical Notes.com

Related Subjects: |Dilated Cardiomyopathy |Hypertrophic cardiomyopathy (HCM - HOCM) |Peripartum cardiomyopathy |Restrictive Cardiomyopathy |Takotsubo Cardiomyopathy

Cobalt can cause a distinctive, rapidly progressive and reversible depression of cardiac systolic function

Heart failure outbreaks
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About

• Was also known as Beer-drinker’s Cardiomyopathy
• Causes a subacute and possible reversible form of heart failure
• The heart involvement usually mimics a hypertrophic or restrictive cardiomyopathy

Aetiology

• Cobalt is a trace metal element that is essential for the production of cobalamin permitting normal cellular function
• In excess levels it may cause cellular damage: apoptosis, necrosis, and oxidative damage to DNA

Risks which help support diagnosis

• Low-protein diet
• Thiamine deficiency
• Alcoholism
• Hypothyroidism.
• Cobalt-alloy hip prosthesis
• Misuse by athletes
• Cobalt has been used to increase foam stability in beer so affects heavy drinkers

Clinical

• Lethargy, anorexia, and weight loss in the months preceding the illness
• Subacute onset of severe heart failure
• Hypotension and cyanosis, Pericardial effusion
• Goitre may be present, tender hepatomegaly
• Sensorineural hearing loss

Investigations

• FBC: polycythaemia
• ECG: low voltage on the electrocardiogram
• VBG: lactic acidosis
• TFT: hypothyroid
• Echocardiogram
• Cardiac MRI: may show myocardial oedema and thickened walls and LV dysfunction
• Cobalt levels difficult to interpret but suggest measurement of the concentration of cobalt in serum or whole blood, but such levels are not necessarily predictive of or correlate with clinical cardiotoxicity

Differential

• Wet Beri-Beri
• Sarcoidosis
• Amyloidosis
• Haemochromatosis
• Mitochondrial syndromes
• Fabry disease

Management

• ABC and standard management of heart failure. Avoidance of cobalt. The role of chelation therapy is not clear.
• The course of cobalt-related cardiomyopathy may be progressive and fatal, but those who survive and cease exposure generally demonstrate complete resolution of symptoms and recovery of cardiac function. Most deaths occurred within days of hospital admission, but in those who did not die, recovery was generally rapid and complete with normalization of cardiac function and exercise tolerance, even in patients who continued heavy beer consumption
• If due to a hip prosthesis then removal of the metal hip prosthesis is mandatory. After the surgery, even when the levels of cobalt in the blood decrease, the cardiac condition can either improve or get worse quickly, leading to acute heart failure or cardiogenic shock. Mechanical circulatory support as a bridge to heart transplant is feasible in this scenario

References

• Review article
• Case study involving hip