case 6 - kathrin glatz · case 6 • rosmarie caduff, institut für klinische pathologie,...
TRANSCRIPT
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• SGPath Slide Seminar 2015/11
Case 6
• Rosmarie Caduff, Institut für Klinische Pathologie, UniversitätsSpital Zürich
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Clinics • 67-year old women
• Bilateral hip replacement, right two years after left side, prostheses ceramic-on-ceramic
• Broken prosthesis at the left side, 5 years after primary surgery, replacemnt with metal-
on-polyethylene
• 8 years well. General malaise, hypothyreoidism, progressive visual and hearing loss,
hypertension, low output, elevated serum lipid levels, obesity
• Outside hospitalisation, MRI edema right N.opticus, transfer to the Neurological Clinic
USZ. MRI progression of cerebral lesions
• No conclusive diagnosis. DD: mitochondriopathy, cobalt intoxication
• Unexpected detoriation, MOF
• Serum cobalt 18885 nmol/L (no <119 nmol/L). Death one day later
• Clinical question: metal analysis of the left hip prosthesis
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Your diagnoses 62
• Cobalt metallosis, cobalt intoxication 6
• toxic metallosis, systemic metallosis, metallosis with
polyneuropathy 15
• Metallosis, metal debris, black particles 36
• Alkapturia/oochronosis 2
• Interstitial sclerosis/acute PML/ no diagnosis 3
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Diagnosis
• Metallosis, cobalt-metallosis (cobalt-intoxication)
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A 2015.11
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A 2015.11
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A 2015.11
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A 2015.11
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Additional major findings
• Heart: weight 680g (normal upper limit 280g), biventricular hypertrophy.
Sclerosis of the coronary arteries without stenosis.
• Lungs: edema, bronchopneumonia. Bilateral pleural effusions.
• Pigmentations in liver, pancreas and spleen
• Shock necroses of the liver, shock kidneys
• Cerebral demyelinisation
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Cobalt level
Normal blood and urin levels < 17nmol/L (< 119nmol/L)
Toxicity > 12000nmol/L (patient 13885)
Cobalt is Albumin bound
Free ions toxic
Neuro-ocular toxicity, cardiotoxicity, thyroidtoxicity
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Toxic mechanisms
Positive correlation between CO ion amount and tissue damage
Different pathways: oxydative damage by Co induced ROS,
induction of apoptosis,
interaction with ion channels and receptors,
Co displace other ions in tissue
Therapy: Removal of the prosthesis
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Clinical Diagnosis of cobalt intoxication
Typical clinical features known as asocciated with cobalt toxicit
Cobalt prosthesis
Tissue metallosis
Decreasing concentration and recovering after removal of prosthesis
Pathological Diagnosis
Cobalt metallosis