Hearing and Vision Loss in an Older Man | Geriatrics | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Hearing and Vision Loss in an Older Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 63-year-old man with a history of well-controlled hypertension, lumbar stenosis, and hip arthroplasty with revisions presented with bilateral loss of vision and hearing for several weeks. He also reported a history of painful paresthesias at his feet beginning about 1 year prior.

On examination, his visual acuity was initially 20/80 OD and 20/200 OS; it deteriorated over the next 2 months to finger counting bilaterally. The Weber test gave a nonlateralizing result, and bone conduction hearing was absent bilaterally. There was length-dependent loss of vibratory sensation and absent reflexes at both lower extremities. Magnetic resonance imaging demonstrated abnormal enhancement of bilateral optic nerves (Figure, A). Optical coherence tomography and fluorescein angiogram were normal. Nerve conduction studies showed mild sensory axonal polyneuropathy. Laboratory tests were notable for elevated thyrotropin (63 mlU/ml), low levels of free thyroxine (T4) (0.2 ng/dL), and elevated levels of cerebrospinal fluid protein (94 mg/dL). Cerebrospinal fluid IgG index, oligoclonal bands, aquaporin 4 antibody, paraneoplastic panel, and protein electrophoresis test results were all normal. He was treated empirically with high-dose steroids and plasmapheresis, with no improvement in symptoms.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

D. Cobalt toxicity

The patient’s prior hip replacement surgeries raised the possibility of cobalt toxicity as a cause of his constellation of symptoms. The patient had his first hip replacement surgery 7 years prior to presentation with a ceramic-on-ceramic implant and had required 2 revision surgeries. During the revisions, which occurred 2 years prior to presentation, extensive soft-tissue metallosis was noted. Given this history of failed hip replacement, serum cobalt levels were checked and were consistently elevated, ranging between 280 to 779 ng/mL (a normal level is less than 1.5 ng/mL). A plain-film radiographic image of the hip showed that the hardware was intact, and there was heterotopic ossification in the surrounding soft tissue (not shown). Magnetic resonance imaging demonstrated a pseudotumor of metallosis (Figure, B). The patient was referred to orthopedic surgery for revision but died before surgical intervention.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: Perry B. Shieh, MD, PhD, Department of Neurology, University of California, Los Angeles, 710 Westwood Plaza, Los Angeles, CA 90095 (pshieh@mednet.ucla.edu).

Published Online: July 23, 2018. doi:10.1001/jamaneurol.2018.1868

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the family of the patient for granting permission to publish this information.

References
1.
Kesteloot  H, Roelandt  J, Willems  J, Claes  JH, Joossens  JV.  An enquiry into the role of cobalt in the heart disease of chronic beer drinkers.  Circulation. 1968;37(5):854-864. doi:10.1161/01.CIR.37.5.854PubMedGoogle ScholarCrossref
2.
Domingo  JL.  Cobalt in the environment and its toxicological implications.  Rev Environ Contam Toxicol. 1989;108:105-132. doi:10.1007/978-1-4613-8850-0_3PubMedGoogle ScholarCrossref
3.
Licht  A, Oliver  M, Rachmilewitz  EA.  Optic atrophy following treatment with cobalt chloride in a patient with pancytopenia and hypercellular marrow.  Isr J Med Sci. 1972;8(1):61-66.PubMedGoogle Scholar
4.
Cheung  AC, Banerjee  S, Cherian  JJ,  et al.  Systemic cobalt toxicity from total hip arthroplasties: review of a rare condition Part 1—history, mechanism, measurements, and pathophysiology.  Bone Joint J. 2016;98-B(1):6-13. doi:10.1302/0301-620X.98B1.36374PubMedGoogle ScholarCrossref
5.
Catalani  S, Rizzetti  MC, Padovani  A, Apostoli  P.  Neurotoxicity of cobalt.  Hum Exp Toxicol. 2012;31(5):421-437. doi:10.1177/0960327111414280PubMedGoogle ScholarCrossref
6.
Leyssens  L, Vinck  B, Van Der Straeten  C, Wuyts  F, Maes  L.  Cobalt toxicity in humans—a review of the potential sources and systemic health effects.  Toxicology. 2017;387:43-56. doi:10.1016/j.tox.2017.05.015PubMedGoogle ScholarCrossref
7.
Zywiel  MG, Cherian  JJ, Banerjee  S,  et al.  Systemic cobalt toxicity from total hip arthroplasties: review of a rare condition part 2—measurement, risk factors, and step-wise approach to treatment.  Bone Joint J. 2016;98-B(1):14-20. doi:10.1302/0301-620X.98B1.36712PubMedGoogle ScholarCrossref
8.
Maradit Kremers  H, Larson  DR, Crowson  CS,  et al.  Prevalence of total hip and knee replacement in the United States.  J Bone Joint Surg Am. 2015;97(17):1386-1397. doi:10.2106/JBJS.N.01141PubMedGoogle ScholarCrossref
9.
Devlin  JJ, Pomerleau  AC, Brent  J, Morgan  BW, Deitchman  S, Schwartz  M.  Clinical features, testing, and management of patients with suspected prosthetic hip-associated cobalt toxicity: a systematic review of cases.  J Med Toxicol. 2013;9(4):405-415. doi:10.1007/s13181-013-0320-0PubMedGoogle ScholarCrossref
10.
Dahms  K, Sharkova  Y, Heitland  P, Pankuweit  S, Schaefer  JR.  Cobalt intoxication diagnosed with the help of Dr House.  Lancet. 2014;383(9916):574. doi:10.1016/S0140-6736(14)60037-4PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close