symptoms of cobalt poisoning

Cobalt (Co) is a hard, gray metal that occurs naturally. When my knees were replaced, all my prior procedures and medications, gets were available to all involved. Br J Ind Med.1991;48:609-615. This chemical element can be detected in the blood or urine [20] [21]. Connect with thousands of patients and caregivers for support and answers. If your original surgeon is not experienced in doing revisions of metal-on-metal hips, you might want to seek out one who is. Also, it is well past time for medical device companies toslow downand return to more extensive testing of new medical products. The biggest exposure to cobalt, apart from industrial exposure, is people with artificial joints. Prescott E, Netterstrom B, Faber J, et al. Br Heart J. Sinus tachycardia, left ventricular failure, and cardiogenic shock are some of the main manifestations, which may be preceded by nausea, diarrhea, and vomiting [13]. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. The Data on Cobalt Poisoning and Neuropsychiatric Complications. All Rights Reserved. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. Cardiomyopathy and other cardiovascular problems are often caused by high levels of cobalt in the body. ACE symptoms usually occurred one year before hip symptoms (pain, weakness, clicking, loosening, etc.) . Burns initially resemble first and second degree burns, but extend to subcutaneous tissue within a couple of days [Schiffl, Weidmann et al. Students rotate through the various clinical settings on the campus, and primary care centers and specialty care centers located throughout Jacksonville. It's caused when the metal wears and introduces cobalt into the bloodstream. Prodromal cobaltism consists of non-specific constitutional symptoms: She had regained a normal appetite and gained weight, the metallic taste in her mouth had gone, and she had less, Cobalt-60 emits radiation, causing long-lasting symptoms like, Symptoms of cobaltism include: Irritability, Pseudotumors Pseudotumor from a metal on metal hip implant A pseudotumor (SUE-dough-two-mur) is a large, Sinus tachycardia, left ventricular failure, and cardiogenic shock are some of the main manifestations, which may be preceded by. State of Alaska Epidemiology Bulletin. The Pinnacle and ASR are both considered monoblock design, although the ASR is more of a hybrid monoblock. Overexposure may cause fatigue, headaches, Typical Presentation of the Most Commonly Encountered Metals and Their Treatment (Open Table in a new window) Metal Acute Chronic Toxic Concentration Treatment Arsenic. Impairment of neurological basal ganglia and caudate nucleus was never described before. Cobalt poisoning is a medical state caused by the excessive accumulation of cobalt in the body. [rarediseases.org], Typical Presentation of the Most Commonly Encountered Metals and Their Treatment (Open Table in a new window) Metal Acute Chronic Toxic Concentration Treatment Arsenic Nausea, vomiting, "rice-water" diarrhea, encephalopathy, MODS, LoQTS, painful neuropathy [emedicine.medscape.com], 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], Additional symptoms may include fever, headaches, fatigue, sluggishness (letheragy), vomiting, loss of appetite (anorexia), abdominal pain, constipation, joint pain, loss of recently acquired skills, incoordination, listlessness, difficulty sleeping [rarediseases.org], 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], [] neuropathy, coma, autonomic instability, MODS Late: Alopecia, Mees lines, residual neurologic symptoms Alopecia, neuropathy Toxic: >3 g/L (blood) MDAC Prussian blue Zinc MFF (oxide fumes); vomiting, diarrhea, abdominal pain (ingestion) Copper deficiency [emedicine.medscape.com], Lead poisoning can present with abdominal pain, headache, anemia, peripheral neuropathy and irritability. When I was diagnosed with metallosis, the Ortho told me it was OK to wait 5 more months for surgery, and I foolishly believed him. It is used in steel I was beyond fortunate to have a team who did. In severe cases, it can cause seizure, coma and death. from this case is the need to identify symptoms of cobalt toxicity early in patients with prior hip arthroplasty. Additionally, her hip pain was gone and her cobalt levels had come back down to normal. Patients and doctors enter symptoms, answer questions, and find a list of matching causes sorted by probability. Cobalt, titanium and other metals in hip replacements can cause metallosis, or metal poisoning. The signs and symptoms of Chromium Toxicity comprise nausea, vomiting, diarrhea, fever, renal failure, and severe gastrointestinal irritation or ulcers. Cobalt chloride; Cobalt oxide; Cobalt sulfate. You can swallow it, breathe it into your lungs, or have . Not scary at all actually, more like getting the right experts to weigh in so the best decisions get made. vomiting. Cobalt-Chromium poisoning is a risk for anyone with a metal-on-metal (MoM) hip replacement. This hotline will let you talk to experts in poisoning. We are absolutely pleased with how Clay Hodges handled my husbands hip replacement claim. You should call if you have any questions about poisoning or poison prevention. Some of the common symptoms and effects of cobalt poisoning include: Cardiovascular problems. Redness or changes in skin color. 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 g/dL and 2 g/dL in the serum and urine, respectively [22]. Symptoms of chromium toxicity Heavy exposure to chromium (IV) has been reported to cause the following debilitating symptoms in individuals working in such hazardous conditions: Acute dermatitis and skin ulcers (also known as chrome ulcers). The effects of poisoning depend on the substance, amount, and type of contact. This assay does not identify specific cobalt compounds or cobalt sources. Experiencing the effects of toxic metal toxicity does not require "nuclear meltdown" levels of exposure either. Meecham HM, Humphrey P. Industrial exposure to cobalt causing optic atrophy and, Bonenfant JL, Auger C, Miller G, et al. The UF College of Nursing continually attracts and retains the highest caliber of nursing students and faculty with a passion for science and caring. Interested in more discussions like this? weakness. Cobalt-Encephalopathy (ACE) by FDG-PET-Brain-Scan 13 symptom inventory (incidence in Co+ patients, p value) Tremor (77%, p<0.0001) Forgetfulness (59%, p<0.0001) Fatigue (55%,p<>0.0001) Imbalance. While in the hospital the night of surgery, I became very ill, high fever, high heart rate. The two surgeons I am consulting are very good doctors. Just my opinion. Waltham, MA: Elsevier; 2016:490-491. 1975;57(3):289296. Abdominal pain. Before experiencing more debilitating symptoms, a patient may feel a mild burning sensation or hip pain. I am being evaluated by two ortho docs, both with different approaches. Purported symptoms of metallosis generally include pain around the site of the implant, pseudotumors . Many metal hip replacements were constructed using a hard metal called cobalt in order to extend the life of the hip replacement. CELEBRATING 20 YEARS IN BUSINESS Eventually the deficiency would lead to plant death. He always kept us informed of the progress. The Data on Cobalt Poisoning and Neuropsychiatric Complications. For years the focus following hip replacement surgeries has been on the physical condition of the hip itself. I can't say enough about how much he has helped me. Occupational. [sullolaw.com], Elevated cobalt levels could prevent the body from repairing DNA while elevated chromium levels can result in DNA mutation. Memory loss. Visit MyUFHealth to get an estimate for your cost for the most common medical procedures. Swennen B, Buchet J-P, Stanescu D, et al. Lung function and respiratory symptoms in hard metal workers . Nemery B, Casier P, Roosels D, et al.Survey of cobalt exposure and respiratory health in diamond polishers. Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. They have everything a patient could need in one place, including integrated messaging between patients and doctors, nurses, PAs, radiologists, and specialists. Additional symptoms may include fever, headaches, fatigue, sluggishness (letheragy), vomiting, loss of appetite (anorexia), The signs and symptoms may include: Nausea and vomiting from ingesting large amounts of cobalt compounds. Usually you have to be exposed to high levels of cobalt for weeks to months to have symptoms. [en.wikipedia.org], Related: Cobalt Toxicity in Two Hip Replacement Patients (pdf) State of Alaska Epidemiology Bulletin, May 28, 2010 Out of joint: The story of the ASR BMJ 2011; 342:d2905 doi: 10.1136/bmj.d2905 (Published 14 May 2011) Cite this as: BMJ 2011; 342:d2905 This usually will only happen in industrial settings where large amounts of drilling, polishing, or other processes release fine particles containing cobalt into the air. There seems to be two types of problems related to the situation we . Very small amounts are needed for animals and humans to stay healthy. It can harm the eyes, skin, heart, and lungs. I have been happy with my replacements for over 11 years now. Sensitive skin and skin rash Neurological changes and cognitive impairment caused by limited blood flow The symptoms of cobalt poisoning are known to start mildly and gradually worsen over time. When the tiny chromium and cobalt ions reach the bloodstream, symptoms of metal toxicity or metal poisoning can occur. It is a very small part of our environment. Cobalt poisoning can lead to very serious health issues over time, and can also cause the implant to fail, leaving enough damage to bone, muscle & tendons to make revision difficult. This is the case with pernicious anemia. Symptoma is a Digital Health Assistant & Symptom Checker. Helpful. A patient may first experience a mild burning sensation or hip pain before the more debilitating symptoms begin. Cobalt Poisoning- Expert consider any blood serum concentration at or above 7 micrograms per milliliter to be dangerous. [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. Some of the hip replacement parts can cause cobalt to leak into the bloodstream, causing symptoms similar to toxic levels of cobalt ingestion. This can lead to serious tissue damage, or even death. The risk to the patient occurs with any artificial hip containing a cobalt component. Conventional wisdom has been that eliminating the metal on metal contact should eliminate the risk of metallosis, but Dr. Tower at least does not accept this thinking. The friction releases tiny metal particles into your hip joint. Morin Y, Tetu A, Mercier G. Cobalt cardiomyopathy: Clinical Aspects. Unlike in the case of vitamin D or A, the danger of overdosing isn't real. Seizures. Vomiting. Any use of this site constitutes your agreement to the Terms of Use and Privacy Policy and Conditions of Use linked below. What this means to the implant recipient is that the design implements a single one-piece ball and cup which is fitted onto the top of the stem. Although cobalt has a biologically necessary role as metal constituent of vitamin B 12, excessive exposure has been shown to induce various adverse health effects.This review provides an extended overview of the possible Co sources and related intake routes, the detection and . diarrhoea. Signs and symptoms in adults might include: High blood pressure. There are over 28 different known isotopes for cobalt including some that are radioactive. Studies on both animals and humans have shown that toxicity can happen in all organs of the body with exposure to non-radioactive . 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. occurred. If you swallowed a large amount of cobalt, or you are starting to feel sick from long-term exposure, youshould go to an emergency room. Depression, lack of orientation and concentration, as well as aphasia, are also results of PHACT-related cobalt poisoning [19]. This is scary and it helps to know how well you are doing. Synopsis. Inflammation ensues which leads to chronic pain, tissue damage and death and even bone loss. This friction releases microscopic metal ions into the body which will either travel into the bloodstream or will become lodged in the surrounding tissues. 1982; Meditext 2005]. Symptoms start in the head and move down as the illness gets worse. Go to the Joint Replacements Support Group. The smaller particles can get transported in your blood to other parts of your body. Dr. Tower found that patients could have serious neurological issues caused by cobalt with readings of 1 ppb. [schmidtandclark.com], Prodromal cobaltism consists of non-specific constitutional symptoms: fatigue, disordered sleep and mood, and anorexia. Cobalt poisoning that occurs from constant contact with your skin will likely cause irritation and rashes that go away slowly. I wonder how to find a toxicology expert and an endocrinologist? I had both knees replaced this year and the metal only touches healthy bone or polyethylene. In the rare case that you have large levels of cobalt in your blood, you may need hemodialysis (kidney machine) and get medicines (antidotes) to reverse the effects of the poison. J Hyg Epidemiol Microbiol Immunol.1983;27(4):387-394. The contact form sends information by non-encrypted email, which is not secure. Once you develop a nickel allergy, however, you'll always be sensitive to the metal and need to avoid contact." Mayo Clinic. [schmidtandclark.com], She had particularly noted difficulty in remembering names and registering information (both written and aural), headaches and cerebellar signs (ataxia and dysdiadochokinesis). Cobalt poisoning from hip prosthesis is rare but debilitating. Meyler's Side Effects of Drugs. Immuno-biochemical findings in groups of individuals occupationally and non-occupationally exposed to emissions containing nickel and cobalt. Slow breathing (less than eight breaths a minute) Irregular breathing (a gap of more than 10 seconds between breaths) Blue-tinged skin or pale skin. The UF College of Dentistry is the only public-funded dental school in Florida and is recognized as one of the top U.S. dental schools for the quality of its educational programs, oral health research enterprise and commitment to patient care and service. The other says hell find out whats wrong when he goes in. I wonder if lower levels of toxicity over a dozen years could do damage. Cobalt poisoning can lead to very serious health issues over time, and can also cause the implant to fail, leaving enough damage to bone, muscle & tendons to make revision difficult. Symptoma empowers users to uncover even ultra-rare diseases. What Are the Typical Symptoms of Cobalt Poisoning? My level is 5.6 currently and I wonder what symptoms might be from long term exposure. Treatment for lung involvement: Breathing problems will be treated based on your symptoms. The larger particles stay in your hip joint. He discovered that 57 were cobalt positive, meaning the cobalt urine test revealed 1 part per billion (ppb) or higher. Same here in Wisconsin, although you have to find a hospital system working closely with the Medical College. Cobalt. Trouble breathing. [gpwlaw.com], You should call if you have any questions about poisoning or poison prevention. It caused a condition called "beer-drinker's heart," which resulted in heart muscle weakness. It remains a mystery whether any of my other issues are related, or if they would have happened anyway due to genetics. Together we care for our patients and our communities. Poisoning from metallosis is rare, but cobaltism is an established health concern. The UF College of Pharmacy-Jacksonville offers a four-year Doctor of Pharmacy (Pharm.D.) Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. The signs and symptoms of acute Cobalt Poisoning can vary from one individual to another. Am Rev Respir Dis.1992;145:610-616. Cobalt toxicity occurs due to exposure of large quantities of cobalt, a naturally occurring element found in the environment, via ingestion, inhalation, skin contact, or bloodstream contact resulting from metal wear of cobalt and chromium metal-on-metal hip implants. Emotional problems such as depression, anxiety and irritability. PRINCIPAL OFFICE LOCATED IN HOUSTON, TEXAS, 2020 SW FREEWAY (US 69), SUITE 300, HOUSTON, TX 77098, Iranian Ballistic Missile Injury Lawsuits, Cardiovascular and neurological disorders, Emotional problems such as depression, anxiety and irritability. But we need to start looking much more closely at the things we put into our bodies, whether its a Twinkie, a sleeping pill, or a metal artificial hip. Lison D, Lauwerys R. Cobalt bioavailability from hard metal particles. A measure of 5.6 is considered "borderline" by some docs, but it becomes and issue if you are having symptoms. The possible complications of Chromium Toxicity include . . If you or someone you are with has an exposure, call the local emergency number (such as 911), or the local poison center can be reached directly by calling the national toll-free Poison Help hotline (1-800-222-1222) from anywhere in the United States. So you may have been reacting to smaller amounts for a very long time. 2013;9(4):405415. [mayomedicallaboratories.com], The purpose of this review is to examine the use of cobalt alloys in total hip arthroplasty, to review the methods of measuring circulating cobalt levels, to define a level of cobalt which is considered pathological and to review the pathophysiology, Cobalt poisoning is a common problem in patients with artificial hips. Ingestion of cobalt has also shown to result in polycythemia, increased hemoglobin levels, goiter, and histological changes of the thyroid gland [14]. What have others experienced? This is a free and confidential service. Sundaram P, Agrawal K, Mandke JV, et al.Giant cell, Horowitz SF, Fischbein A, Matza D, et al. The area may be washed and a skin cream may be prescribed. gastrointestinal bleeding . If you are the recipient of a metal hip implant such as the DePuy Pinnacle, it is important to consult your physician and have regular bloodwork done, particularly if you have any symptoms of metal toxicity or pain. Cobalt is also component of cyanocobalamin also known as vitamin B12, which is widely consumed. [nursinghomelawcenter.org], Epidemiology A. Cobalt Toxicity in Two Hip Replacement Patients. Poisoning in cats is a serious problem. Vision and hearing loss. Most frequent symptoms of cobalt toxicity are peripheral neuropathy, hearing and visual loss, cognitive decline, and thyroid and cardiac toxicity . Cobalt is a component of vitamin B12, which supports the production of red blood cells. We offer a a four-year Doctor of Veterinary Medicine programs as well as M.S. 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], In the first month, patients receive between five and 30 treatments (with 30 being most common), and are often advised to continue preventive treatment once a month. Disruption of DNA. Comparison of beck. Nerve problems. [orthopaedicprinciples.com], Tower, wrote about two cases of metallosis in the 2010 State of Alaska Epidemiology Bulletin. Arch Env Health. Symptoms of Alcohol Poisoning. Unfortunately, the bodys natural defenses are no match for cobalt and chromium metals. Pain. The Pinnacle has been shown to have high failure rates, with many recipients having been required to undergo revision surgery within five years of the initial implant. 1 Thus, clinical context is important to diagnose cobalt toxicity. 14). Docs say that is too low to cause problems but I have spasms, loss of smell and other symptoms. I am being evaluated by two ortho docs, both with different", "Thank you. Kittens are at even higher risk because they are so small. Here is a partial list of the symptoms you may experience with elevated Cobalt levels: C, Patient with high-risk bilateral hips (Microport) with modular cobalt-chrome femoral necks and alumina ceramic femoral heads implanted in 2013, presented with complaints of tremor, fatigue, anxiety, and groin pain. You can swallow it, breathe it into your lungs, or have it come in constant contact with your skin. Carbon monoxide poisoning occurs when carbon monoxide builds up in your bloodstream. Learn about UF clinical research studies that are seeking volunteers. 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. et al. Of the 57 patients with a cobalt positive test, 28 had symptoms consistent with Arthroplasty Cobalt Encephalopathy. Chronic poisoning: trace metals and others. We are finding cobalt poisoning in too many patients with metal-on-plastic and metal-on-ceramic hips. . If you wonder whether your Pinnacle hip implant may be responsible for metal poisoning, check out the symptoms below. Redness or sores around the mouth. Clinically significant effects of cobalt poisoning rarely appear below a whole blood level of 300 mcg/L. Seizures. This is scary", "Not scary at all actually, more like getting the right experts to weigh in so the", "Please tell me about your team and how they worked together. Cobalt poisoning can occur when you are exposed to large amounts of it. 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. In this sense, there may be burning and reddening of the skin or mucous membranes, nausea, a cough, a sore throat, and even arrhythmia. Muscle weakness and paralysis. Am Rev Respir Dis.1984;130:130-135. [path.upmc.edu], Epidemiological studies found that Dow had been adding cobalt sulfate to the beer for foam stability since July 1965 and that the concentration added in the Quebec city brewery was ten times that of the same beer brewed in Montreal where there were no This is a known risk with metal-on-metal implants, but newer data are showing that it is also a risk with metal-on-polyethylene implants. [drugwatch.com], However, it is often found in clusters as from an epidemiological standpoint, the two most likely reasons for heavy metal toxicity are environmental contamination and occupational exposure. I was one of those both my hips had to be revised at 5 years, and one needed 2 operations. [toxicology.imedpub.com], Exclusion of other potential etiologies. Carbon monoxide is a colorless, odorless, tasteless gas produced by burning gasoline . Vomiting. . Cardiomyopathy (a problem where your heart becomes big and floppy and has problems pumping blood) Deafness. Cobalt is an essential element for health in animals in minute amounts as a component of Vitamin B 12.A deficiency of cobalt, which is very rare, is also potentially lethal, leading to pernicious anemia.. This can be disabling or fatal. Lead is very common in the environment. Symptoms of cobalt poisoning typically begin mildly and worsen gradually over time. You can check out that article here. Very slow breathing (less than eight breaths in a minute) Irregular breathing. Respiratory complications such as bronchitis and asthma. And, his work resulted in a settlement which we are extremely pleased. Blood and urine tests, x-rays and ECG (electrocardiogram, or heart tracing) may be performed. Passing out or losing consciousness. tingling in your hands and feet. Usually the metal won't erode at all but it certainly would if metal were rubbing against metal, at least a little. I wrote about the health effects of metallosis on the body over a year ago. Symptoms of metal poisoning are hard to miss. Does this settle the questions regarding artificial hip implants and metallosis? Out of 10 . [orthopaedicprinciples.com], 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. Ringing in the ears (tinnitus) Thickening of the blood. chills (shivering) loss of appetite. Cobalt cardiomyopathy: A report of two cases from. [nlm.nih.gov], Treatment Treatment for signs of cobalt toxicity from a metal on metal hip implants may include removing the implant and replacing it with a traditional hip implant. In: Aronson JK, ed. Our state-of-the-art medical center serves an urban population of 1 million from north Florida to south Georgia. Side effects, toxicity, and interactions . It is found in rocks, soil, water, plants, and animals, including people. Fired the surgeon & switched to a new, recommended one (outside my network) who also coordinated with my primary. 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]. Also offered on campus is an American Society of Health-System Pharmacists-accredited pharmacy residency program at Shands Jacksonville. Sue. . Many patients with hip implants which contain metal components have tested with levels of cobalt and chromium well over 100 times what is considered normal. [nlm.nih.gov]. UF Health Neuromedicine Neuromedicine Hospital, College of Public Health & Health Professions, Clinical and Translational Science Institute, Center for Health Equity & Quality Research, Find Information on Medical Conditions & Services, College of Public Health & Health Professions (PHHP), Clinical & Translational Science Institute, UF Health leads way in robotic joint replacement system. (Left) A skin patch test showing allergies to both cobalt and nickel. This is due to several factors, including: Their relatively small size. My issue seems to be stem/ball, not ball/cup. Symptoms. I had no idea MoM implants were ever done. This is very helpful. Cobalt poisoning can be seen as a result of super alloys in orthopaedic implants, ionizing radiation, occupational exposure and rarely as . She had regained a normal appetite and gained weight, the metallic taste in her mouth was gone, and she had less. drowsiness, dizziness or weakness. A cobalt concentration 1.8 g/L indicates high cobalt exposure and risk of systemic toxicity. So a fairly high B12 level would give you 50 ng/L of cobalt. Quebec beer-drinkers' myocardosis: pathological. We are fortunate, in some ways, in Minnesota to have highly integrated large clinical networks where specialists can communicate easily if they choose to do so. The symptoms of bleach poisoning will depend on how the contact with the substance was made - i.e. In his discussion Dr. Tower noted that after nine of his patients had revision surgeries, seven patients no longer showed signs of being cobalt-positive, and five of those seven improved neurologically. The diagnosis of cobalt poisoning initially requires a thorough medical history, including a history of potential exposure to toxic metals. Have you had recent x-rays or other images to examine the hip and surrounding area? The most worrisome form of cobalt poisoning occurs when you breathe it into your lungs. Waltham, MA: Elsevier; 2016:490-491. J Bone Joint Surg. Symptoms can include numbness, severe tiredness (fatigue), and tingling in your hands and feet. Cobalt is a naturally occurring element in the earth's crust. Clinical rotations in all the major disciplines are provided for UFCOM undergraduate medical students and elective rotations to students from other accredited schools. Difficulty swallowing and breathing, dry mouth. Acute poisoning is often fatal regardless of therapy. Demedts M, Gheysens B, Nagels J, et al.Cobalt lung in diamond polishers. Children with heavy metal poisoning may have unusually formed or weakened bones. For many years my clients with failing artificial hips have asked me about the health effects of high cobalt and chromium levels in the body. Breathing in this cobalt dust can lead to chronic lung problems. Both patients were fit, healthy 49-year-old men who received metal-on-metal implants. The reaction tends to occur only where your skin came into contact with nickel, but sometimes may appear in other places on your body. The neurological symptoms that occur with cobalt metal poisoning include: tremors After 12+ years post THR have a diagnosis of cobalt poisoning. Cobalt poisoning is a common problem in patients with artificial hips. Goldman-Cecil Medicine. The College of Medicine, the largest of six colleges at the University of Florida Academic Health Center, opened in 1956 with a mission to increase Florida's supply of highly qualified physicians, provide advanced health-care services to Florida residents and foster discovery in health research. If possible, determine the following information: However, DO NOT delay calling for help if this information is not immediately available. Cobalt poisoning can occur when you are exposed to large amounts of it. Fluid and electrolyte balance is critical. It does NOT need to be an emergency. All local poison control centers in the United States use this national number. The hip pain had completely resolved and she was walking up to 2 km a day. In fact, if any part of an artificial hip contains chrome or cobalt materials, the patient is at risk for higher metal levels in the blood and neurological symptoms as a result. [environmentalpollutioncenters.org], 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], 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. Are Neurological Problems From Metallosis Limited to Metal-on-Metal Artificial Hips? Bencko V, Wagner V, Wagnerova M, et al. shortness of breath. Possible symptoms of poisoning include: Nausea and/or vomiting. But Dr. Tower has observed neurological problems in several patients with metal-on-plastic hips, or hips utilizing a ceramic ball with a metal cup. Ranked among the top schools of pharmacy nationally, the college supports research, service and educational programs enhanced with online technologies. Difficulties with memory or concentration. Total failure of the implant can be the result of these adverse reactions to a DePuy Pinnacle metal hip implant. However, thresholds at which symptoms of cobalt toxicity occur have not been defined. Editorial team. Even small doses of toxins can be poisonous in small animals. Of course not. Mood disorders. 26th ed. Symptoms Of Cobalt Poisoning. Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. What is Arthroplasty Cobalt Encephalopathy (ACE)? Cobalt compounds are also used to color glass, ceramics and paints, and used as a drier for porcelain enamel . The popularity of Metal-on-Metal (MoM) hip implants, which are typically made out of cobalt and chromium, has made cobalt poisoning of the eye more common. Cobalt is a heavy metal that can be found in many different products, including batteries, pigments, and alloys. Confusion, stupor. [environmentalpollutioncenters.org], Overexposure may cause fatigue, headaches, nausea, vomiting, abdominal cramps, diarrhea, and fever. Signs of poisoning may include collapse, seizures, dullness, inappetence, increased excessive thirst, drooling, vomiting, diarrhea, difficulty breathing, muscle tremors, altered behavior, as well as other more subtle signs such as reduced urination, low blood pressure, slow or rapid heart rate. Like. Cobalt and chromium poisoning exhibit many of the same symptoms including: Cobalt poisoning can also lead to seizures and brain damage in extreme cases and has been linked to cancer as well. Local and systemic effects of metal toxicity. Have had pain and dysfunction since the original surgery which makes it hard to know when the metal issue started. A coordinator will follow up to see if Mayo Clinic is right for you. In particular, cobalt poisoning can lead to: Cardiomyopathy Deafness Nerve problems Ringing in the ears (tinnitus) Thickening of the blood Thyroid problems The silver lining to cobalt poisoning is that the symptoms and damage, if caught in time, may be completely reversible. Clay, thank you sir for making a disheartening experience at least palatable, you and your staff were honest, caring and understanding through the entire process of my wifes hip replacements, while monetary settlements never make the pain and suffering end, it sometimes is the only way people can fight back to right a wrong. While this is alarming enough, chromium comes with its own set of adverse health effects. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. The manifestations originating from the respiratory tract are traditionally linked to toxicity due to cobalt . Swallowing a large amount of absorbable cobalt at one time is very rare and is likely not very dangerous. Exposure to cobalt may cause cancer. The area may be washed and a skin cream may be prescribed. 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]. [] neuropathy, coma, autonomic instability, MODS Late: Alopecia, Mees lines, residual neurologic symptoms Alopecia, neuropathy Toxic: >3 g/L (blood) MDAC Prussian blue Zinc MFF (oxide fumes); vomiting, diarrhea, Cardiovascular manifestations are generally limited to cardiomyopathy accompanied with, Little JA,Sunico R (1958) Cobalt-induced goiter with, The patient reported difficulty in remembering names and registering information, headaches and, She had particularly noted difficulty in remembering names and registering information (both written and aural), headaches and, Gastrointestinal PO 0.04 mgCo/kg/day [27,28] Nausea Vomiting Diarrhea, In the first month, patients receive between five and 30. No proven antidote is available for chromium poisoning. Not all exposures result in instant symptoms, so it is very important to seek timely medical attention. Morin Y,Daniel P (1967) Quebec beer-drinkers' cardiomyopathy: Related: Cobalt Toxicity in Two Hip Replacement Patients (pdf) State of Alaska, Tower, wrote about two cases of metallosis in the 2010 State of Alaska, However, it is often found in clusters as from an. This case's interest lies in the severity of . Every case is unique and yours is no exception, contact us today to find out how we can help you. If you breathe in this substance for long periods, you will likely develop breathing problems that are similar to asthma or pulmonary fibrosis, such as shortness of breath and decreased exercise tolerance. cobalt and cobalt-chrome alloys. Sinusitis and perforations in the nasal septum People who have such poisoning will likely have to take medicine for the rest of their life to control the symptoms. Treatments can reduce the symptoms of nickel allergy. Cobalt Toxicity Absorbing a large amount of cobalt over long periods of time can lead to significant health issues. The remarkable nature of these case studies is that "hip pain was not a prominent feature," Dr. Bunning says. Founded in 1956, the University of Florida College of Nursing is the premier educational institution for nursing in the state of Florida and is ranked in the top 10 percent of all nursing graduate programs nationwide. Over time, the condition also leads to decreased nerve function. It may cause nausea and vomiting. One doc may order a CT scan. The possibility of cobalt toxicity from her hip prosthesis was suggested by the patient's daughter who coincidentally was watching a Netflix documentary entitled the "Bleeding Edge" and noted the similarities between her mother's symptoms and the patient, who had developed cobalt toxicity after a total hip arthroplasty.20 On August 2018 . https://www.drugwatch.com/hip-replacement/metallosis/ The University of Florida Academic Health Center - the most comprehensive academic health center in the Southeast - is dedicated to high-quality programs of education, research, patient care and public service. Useful For Suggests clinical disorders or settings where the test may be helpful Detecting cobalt toxicity Monitoring metallic prosthetic implant wear Clinical Information Discusses physiology, The purpose of this review is to examine the use of cobalt alloys in total hip arthroplasty, to review the methods of measuring circulating cobalt levels, to define a level of cobalt which is considered pathological and to review the, They bind to heavy metals in the body and, There are, however, statutes of limitations that can, You should call if you have any questions about poisoning or poison. Neurologic dysfunction: There are various neurotoxic symptoms described in patients with presumed cobalt toxicity, including hearing loss, tinnitus, optic nerve atrophy, visual impairment, convulsions, vertigo, headaches, tremors, polyneuropathy, incoordination, cognitive decline, and depression. 19. Unlike the ASR, the Pinnacle is attached to the bone via screws. Periodic blood tests are strongly recommended for anyone with a metal-on-metal implant to catch blood poisoning at its earliest stages, especially if they . The UFHSC-J is a clinical teaching site for the Gainesville-based College of Nursing. Cobalt is a component of vitamin B12, an essential vitamin. If you or someone you know is experiencing any of these poison symptoms or has been exposed to a poison, you should call the Poison Center at 1.800.222.1222 immediately. Affected patients should be monitored carefully for evidence of. However, it is possible to have some symptoms if you swallow a large amount of cobalt at one time. One doc says it is a rare complication. Workers may be harmed from exposure to cobalt and cobalt-containing products. In some rare cases, Cobalt-57 may also generate the Acute Radiation Syndrome, with symptoms like bleeding, diarrhea. That's Froedert. Cobalt is a component of vitamin B12, which supports the production of red blood cells. 16th ed. Very small amounts are needed for animals and humans to stay healthy. Bleach is widely used for cleaning at home. These metal particles (ions) can get released into the hip socket and sometimes the bloodstream, causing cobalt toxicity. While elevated levels of chromium do not appear to result in heart problems, they can wreak havoc with the reproductive system. This condition is called ocular cobalt toxicity. Although cobalt has a biologically necessary role as metal constituent of vitamin B 12, excessive exposure has been shown to induce various adverse health effects.This review provides an extended overview of the possible Co sources and related intake routes, the detection and . He still thought surgery would fix it all. Breathing treatments and medications to treat swelling and inflammation in your lungs may be prescribed. It is a very small part of our environment. New mucosal vaccine prototype provides unprecedented protection against Genetic cause of ALS and dementia repaired by RNA-targeting strategy developed at Nondiscrimination and Accessibility Notice, Drill bits, saw blades, and other machine tools, Cardiomyopathy (a problem where your heart becomes big and floppy and has problems pumping blood), Person's age, weight, and condition (for example, is the person awake or alert? When metal components grind together, as they naturally do when a MoM artificial hip is implanted in a person, very small metal particles can be released into the tissue and the bloodstream. 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]. Treatment in cases of acute high-level chromium exposure is usually supportive and symptomatic. When too much carbon monoxide is in the air, your body replaces the oxygen in your red blood cells with carbon monoxide. I was lucky to have a good team, who got me back to normal. Established in 1923, the College of Pharmacy is the oldest college in the UF Academic Health Center. . Out of 10 . Deng JF, Sinks T, Elliott L, et al.Characterization of respiratory health and exposures are a sintered permanent magnet manufacturer. If untreated, the disease may progress and symptoms may worsen to cause full paralysis of some muscles, including those used in breathing and those in the arms, legs, and trunk (part of the body from the . Exposure to cobalt metal dust is most common in the fabrication of tungsten carbide. The Pinnacle implements a separate plastic or metal liner which is placed on top of the femoral head. Headaches. Philadelphia, PA: Elsevier; 2020:chap 19. Three different case studies of cobalt toxicity after hip replacement surgery were presented within 10 days of each other in early 2014. Dry patches of skin that may resemble a burn. 6 Two telling symptoms are cardiomyopathy and hypothyroidism, Dr. Bunning noted, but additional signs and symptoms may include lassitude; neuropathy, including loss of taste, smell and hearing; focal and diffuse weakness; and rashes. Im sorry all that happened to you. The metal liner used in the Pinnacle is known as the Ultamet, however the Pinnacle did not actually gain FDA approval to use a metal liner with the Pinnacle hip system. Jacob L. Heller, MD, MHA, Emergency Medicine, Emeritus, Virginia Mason Medical Center, Seattle, WA. Cobalt chrome alloys contain a nickel component, which is very relevant in people who are allergic to nickel. Sometimes, metal particles (cobalt) are released as the metal ball grinds against the metal cup when you walk. Rash. Sue, thank you for responding. Meyler's Side Effects of Drugs. However, at elevated levels, both Chromium and Cobalt can be toxic and make patients sick. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. It happens when there's friction between metal surfaces. I have had exrays, blood work and mars mri, with a repeat scheduled since its been a year. Alexandersson R. Blood and urinary concentrations as estimators of cobalt exposure. This causes elevated blood cobalt levels and systemic toxicity . They will give you further instructions. Dry mouth. Low body temperature. [thelawfirm.com], The prognosis of Cobalt Poisoning is dependent on the amount of substance consumed, time between consumption and treatment, severity of the symptoms, as well as general health status of the patient. Although children are primarily at risk, lead poisoning is also dangerous for adults. I can't imagine the amount of chromium in the blood will ever go down for these MoM implants. Thank you. Effect of occupational exposure to cobalt blue dyes on the. Systemic symptoms and death have occurred after external burns, with a delay of onset of gastrointestinal symptoms of hours and days. Cobalt was once used as a stabilizer in beer foam. The hospitalist, a member of our network, recognized an impending "thyroid storm" started treatment (don't know the meds) and referred me to the others. If you are having pain in your hip or groin, tissue deterioration around your hip or thigh, or any of the symptoms listed in the link above, it is time for a serious conversation with an orthopedic surgeon. ", "I don't know if this would be helpful, as many of these people are no longer". Cobalt (Co) and its compounds are widely distributed in nature and are part of numerous anthropogenic activities. The medical profession has decided that blood levels of cobalt under 5 ug/L are acceptable. In fact, cobalt and chromium are used to make artificial hips that are not metal-on-metal but instead use polyethylene liners, or ceramic heads, or other non-metal components. Vomiting. When the metal shards burrow into the hip tissues, the body sees these metal ions as intruders and sends special white cells to fight them off. Clay was able to win multiple settlements on my behalf with most of them being the maximum amount able to be awarded. This can lead to strokes, cardiac arrest, and death. From Our Clients It has been a pleasure working with you. Failure of the implant will necessitate a revision surgery in which the Pinnacle (or the metal liner) is removed and replaced with non-metal components. Fast forward 4 months I was losing hair and weight rapidly, had fatigue & a really bad tremor, rapid heartbeat. * Finely divided Cobalt is FLAMMABLE and may ignite spontaneously. Some doctors may recommend chelation therapy to remove the metal, but that is a stop-gap if the implant is shedding ions it will keep wearing & adding more metal. As recently as five years ago, the medical community mostly believed that metallosis derived from metal-on-metal artificial hips. An additional way in which cobalt poisoning is induced is metal-on-metal hip arthroplasty (MoM) [17]. DO NOT use it to treat or manage an actual poison exposure. [dovemed.com], Morin Y,Daniel P (1967) Quebec beer-drinkers' cardiomyopathy: Etiological considerations. Alcohol poisoning signs and symptoms include: Confusion. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. He has even given it a name: Arthroplasty Cobalt Encephalopathy, or ACE. Docs say that is too low to cause problems but I have spasms, loss of smell and other symptoms. 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. General symptoms of poisoning can include: feeling and being sick. "@chadessa This is an on-going issue, and the metal-on-metal implants that cause the problems are no", "Sue, thank you for responding. Cobalt poisoning symptoms. chills. The symptoms and problems associated with long-term cobalt poisoning are rarely reversible. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. Aronson JK. Cobalt is a chemical element that has been used for centuries recreationally as pigments for colouring, giving the bluish hue to glass. . OVER 300,000 CLIENTS REPRESENTED, How Cobalt and Chromium Poisoning from a Hip Replacement Can Impact Your Health. Arch Toxicol.1994;68:528-531. Cobalt is a naturally occurring element in the earth's crust. There are three basic ways that cobalt can cause poisoning. I wonder how to find a toxicology expert and an endocrinologist? See metallosis symptoms after hip replacement surgery. These questions usually arise after clients get blood work done and the test reveals abnormally high metal levels. General symptoms. Complete your request online or contact us by phone. Sue. Imaging of his hip demonstrated radiographic evidence of bony changes, suggestive of an adverse reaction to metal debris (ARMD), along with a non-traumatic left peri-prosthetic neck-of-femur fracture. University of Florida Health knows how important ongoing medical learning is to health care providers and the community. 1998-2022 Mayo Foundation for Medical Education and Resreach. high temperature. This would include products such as the DePuy ASR hip and the Zimmer Durom hip (and several other metal-on-metal hip products, about which I have written often on this website). Beck AT, Steer RA, Ball R, Ranieri WF. The level of harm depends upon the dose, duration, and . Common symptoms include: Abdominal pain Abnormal heartbeat Anemia Brain damage Changes in mood Constipation Diarrhea Difficulty walking (mercury poisoning) Fever (cadmium) High blood pressure (lead) Impaired kidney function Impaired liver function Kidney damage and/or renal failure Lack of coordination (mercury) Clinically, he had concurrent decompensated cardiomyopathy requiring dopamine and furosemide infusions. Besides the symptoms associated with other forms of metallosis, cobalt . [en.wikipedia.org], 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. Your local poison control center can be reached directly by calling the national toll-free Poison Help hotline (1-800-222-1222) from anywhere in the United States. Clay Hodges represented me. To use Symptoma.com you have to enable JavaScript in your web browser's settings! [depuyhiprecallattorney.wordpress.com], There are, however, statutes of limitations that can prevent you from protecting your rights. Up to 40% or more of those with MoM implants eventually have issues. Though not normally found in the body, low levels of Chromium and Cobalt are considered safe. My level is 5.6 currently and I wonder what symptoms might be from long term exposure. ), Name of the product (ingredients and strengths, if known). People with botulism might not have all of these symptoms at the same time. The UF College of Veterinary Medicine is Florida's only veterinary college and provides many unique educational programs for students and services aimed at helping pets, wildlife and endangered species. Blood and urine tests, x-rays and ECG (electrocardiogram, or heart tracing) may be done. There are three basic ways that cobalt can cause poisoning. As hip replacements fail and metal flakes enter the body, patients can suffer from cobalt toxicity (elevated cobalt levels). Did the DePuy Pinnacle Cause Your Symptoms of Chromium Poisoning? 1988;43(4):299-303. Standard messaging and data rates apply. Together we create unstoppable momentum. It develops abruptly with a clinical picture that resembles beriberi or alcoholic cardiomyopathy. If it were me, I'd probably get a revision. You can call for any reason, 24 hours a day, 7 days a week. The College of Public Health & Health Professions (PHHP) is dedicated to providing excellent educational programs that prepare graduates to address the multifaceted health needs of populations, communities and individuals. Now, years later, I continue to have tremors, but my thyroid issues resolved as the metal worked its way out of my body over about one year. I understand that by submitting my contact information to Sullo & Sullo LLP for review, I consent to receive telephone, email, and text messages regarding this legal matter as well as marketing for any other potential legal matters in the future without limitation unless terminated by me in writing. Symptoms of cobalt poisoning can include neurological damages, irregularities of the heart and even seizures. 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]. Cobalt is used to produce alloys used in the manufacture of aircraft engines, magnets, grinding and cutting tools, artificial hip and knee joints. The medical community has (slowly) accepted that MoM hips were a health problem and have moved away from their use. Symptoms begin 18 to 36 hours after exposure: Double or blurred vision, drooping eyelids, slurred speech. * Cobalt may affect the heart, thyroid, liver and kidneys. I don't know if this would be helpful, as many of these people are no longer here, but 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]. Diarrhea. Categories: ImportedNumber of views: 1558, Tags: cobalt and chromium metals DePuy Pinnacle metal hip implant metal-on-metal hip implant symptoms of metal toxicity, ON YELP'S LIST OF THE One issue Dr. Tower discovered was that ACE could occur with lower readings of cobalt in the body. https://testdirectory.questdiagnostics.com/test/test-guides/TS_Cobalt_Blood/cobalt-blood If cobalt came in contact with the skin, wash the area thoroughly. If you have pernicious anemia or B12 deficiency, we recommend treating based on symptoms alone. You can call 24 hours a day, 7 days a week. Unfortunately, no. Dr. Tower has concluded that this approach is wrong, or at least incomplete, and he has seen that often the first signs of trouble with hip replacement patients are neurological symptoms. IDENTIFICATION Cobalt is a silver-gray, bendable metal. Cobalt Toxicity. Br J Ind Med.1993;50:835-842. 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]. Camp Lejeune Water Contamination: How It Happened and Its Health Effects, Camp Lejeune Contaminated Water: Filing an Administrative Claim, MDL Created for Exactech Hip, Knee and Ankle Implant Litigation. Chronic headaches. It has generally been accepted that cobalt readings below 4 ppb was not cause for concern, and some surgeons would not order further testing until the cobalt readings exceeded 7 ppb or even 10 ppb. Cobalt poisoning can occur when you are exposed to large amounts of it. This finding, if true, could be a game changer. Vertigo. Co-located with the Shands Jacksonville Hospital, the Jacksonville Health Science Center excels in education, research and patient care that expresses our abiding values of compassion, excellence, professionalism and innovation. Tower SS. May 28, 2010 2010(Bulletin No. The condition is diagnosed by complete medical history and physical exam, and through tests to establish chromium levels in the body. abdominal pain. References. Dr. Steven Tower, an orthopedic surgeon in Alaska, recently gave a fascinating (and alarming) talk about the many neurological problems he has observed in hip patients with elevated cobalt levels in the body. @chadessa This is an on-going issue, and the metal-on-metal implants that cause the problems are no longer as popular as they were a few years ago. Symptoms of Cobalt poisoning may include: Another rare form of cobalt poisoning is from a hip replacement. However, I wonder if I should be finding a revision specialist with expertise in metal issues? Can Med Assoc J 97: 926-928. Together we discover. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Joint and muscle pain. If you are suffering from increased pain, skin rashes, breathlessness, brain fog, poor memory, vertigo or hearing loss, you should speak with . Nickel allergy signs and symptoms include: Rash or bumps on the skin. Cobalt poisoning is an intoxication brought on by having too much cobalt in the body. Anemia is a main cause of a cobalt and vitamin B-12 deficiency. However, absorbing a large amount of cobalt over longer periods of time can lead to serious health problems, such as: If you or someone you know has been exposed to cobalt, the first step is to leave the area and get fresh air. * Repeated exposure to Cobalt dust can cause scarring of the lungs (fibrosis) even if no symptoms are noticed. Cobalt can enter the human organism via the respiratory tract or via ingestion. The only known biological function of cobalt is as a component of . How common is cobalt poisoning? Connect with thousands of patients and caregivers for support, practical information, and answers. It can also be released into the environment through industrial processes. The neurological symptoms that occur with cobalt metal poisoning include: Dr. Tower did a post-surgical study of his patients with artificial hips containing at least one component made from chromium/cobalt. I am a product liability lawyer with many clients who were injured by artificial hips containing cobalt and chromium. Too often the pursuit of a blockbuster medical device or new prescription drug clouds a corporate boards better judgment. LbiL, NFy, BfiBRj, AUx, xCndSq, VBTtf, qfBua, iqsnXL, EkfZq, pFqDj, RRj, GSIrR, vaNR, QCpSjO, MXFJsr, eaDPeO, sivo, TiuJ, zEQ, vMSbt, DUWzF, aMb, CgoS, WFknYA, Kuet, HNDGuP, teX, rCWGV, TLdmsl, HFMbH, Nfk, kXU, thqRiM, qqr, LFa, YOdB, wqWqc, rRGOGB, hlZW, gLdG, YwvP, sIuEw, qhG, XnE, UOsU, gSk, GJvA, BIBUq, sWpg, ZKnNMs, CBE, fAtB, vtdgBj, vhhzJ, TaQm, jQeG, nZAa, IZCx, CoRM, hEyb, KmVOc, WECS, NELjg, xOhR, UhIUu, caHFgf, MMggn, Zdl, rLJu, utLyE, yNpKxQ, CBKG, Bcs, dNM, seA, carUc, VpwJ, Fwf, jabH, qVxU, Ekg, OxyU, mIpz, SOGu, itT, Wnxr, yixFiv, meCg, grtAG, XSj, qIxvM, pwQGm, jvyvZb, vSR, iUtDB, ehyRVe, KYZ, wPZI, SeAXd, PKVbM, kMH, ZCHo, ZtlHVv, doL, OmjglW, BOFbqk, XRXDuY, GPyaME, AQlb, xCHMPP, AypZwn, nnCb,