Idiopathic Cardiomyopathy Following Metal-on-Metal Hip Arthroplasty: The New Face of “Beer Drinker’s Cardiomyopathy”

CASE REPORT, August 2013, VOL II ISSUE III, ISSN 2042-4884
10.5083/ejcm.20424884.101 , Cite or Link Using DOI
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Erik O’Connell, Nicolas Mead, Henry Fesniak,


In 1966, the “beer drinker’s cardiomyopathy” was described in Quebec City, Canada among heavy drinkers following the addition of cobalt by breweries for foam stabilisation. Almost half of those affected died. A similar process has been proposed for cardiovascular periprosthetic metallosis in patients receiving cobalt-containing hip prostheses. This case describes a young man with congenital osteonecrosis treated with cobalt containing prosthetic arthroplasty. Postoperatively, he developed pericardial effusion, dilated cardiomyopathy, polycythemia and lactic acidosis. His serum cobalt level was 156 mcg/L ( normal 0.1 – 0.4 mcg/L). Metal-on-metal hip implants have been associated with arthroprosthetic cobaltisim, a presentation indistinguishable from “beer drinker’s cardiomyopathy.” Up to 35% of hip replacements utilize metal-on-metal bearing surfaces, making this a potentially wide-spread and relatively underappreciated etiology of postoperative idiopathic cardiomyopathy. This clinical vignette emphasizes the importance of considering cobalt cardio-toxicity, or “beer drinker’s cardiomyopathy,” as a differential diagnosis of idiopathic cardiomyopathy following total hip arthroplasty.


In 1966, the “beer drinker’s cardiomyopathy” manifested in Quebec City, Canada as congestive heart failure, diastolic dysfunction, polycythemia, lactic acidosis, and pericardial effusion in heavy drinkers following the addition of cobalt to beer for foam stabilisation (1-3). Nearly 50% of those affected ultimately died from this epidemic. (4) A similar process was proposed for cardiovascular manifestations of periprosthetic metallosis when serum cobalt levels were > 7 mcg/L presenting postoperatively in cobalt-containing hip prostheses. (5) This case underscores the importance of considering the diagnosis of cobalt toxicity in a patient presenting with heart failure following hip replacement.