"Indeed..." Yang Ping muttered to himself. His reasoning was initially verified.
The combined effects of cobalt and cadmium could disrupt Ms. Lin’s bone health through various pathways: direct osteocyte toxicity, interference with mineral tabolism, especially affecting calcium, phosphorus, and magnesium reabsorption through kidney damage, and potential oxidative stress and mitochondrial dysfunction. High bone turnover ans bones are "busy for nothing," constantly tearing down one wall to build another, but the quality of new bone matrix may be poor, poorly mineralized or with abnormal collagen cross-linking, leading to reduced bone strength, microscopic damage, and pain at stress concentration sites. Tubular damage is a typical early manifestation of cadmium toxicity.
"This explains why her inflammation markers aren’t elevated, because it’s simply not a typical inflammatory disease," Li Min exclaid excitedly, "It’s a bone tabolic disorder caused by toxic tabolism. Professor Yang, can we diagnose ’Chronic cobalt and cadmium toxicity-related bone disease’?"
"There’s one more step," Yang Ping calmly said, "These markers suggest toxicity and tabolic disorder, explaining increased bone turnover and kidney damage, but we need more direct evidence proving damage to her bone microstructure and ruling out other diseases that could cause high bone turnover. Histomorphotry of the bone biopsy can give us the answer, to see if her trabeculae are thinner, fractured, if bone turnover units are abnormally increased, and if matrix mineralization is delayed or poor."
Li Min picked up the phone and directly dialed Ms. Lin’s number. The call was quickly answered, and Ms. Lin’s tense yet hopeful voice ca through: "Dr. Li?"
"Ms. Lin, the test results are out, and there are so important findings," Li Min said in a calm and clear tone, "The levels of cobalt and cadmium in your blood and urine are indeed beyond normal range, indicating chronic excessive exposure. Simultaneously, your bone tabolism is unusually active, and signs of early kidney damage are evident. These findings biologically correlate with your long-term exposure to cobalt and cadmium-containing pignts."
Silence ensued for a few seconds, followed by a sigh of relief from the other end: "After five years, finally... finally, sothing matches..." It wasn’t sadness but a sense of confirmation bordering on exhaustion.
"However," Li Min continued, "to finalize the diagnosis and guide precise treatnt, we need to conduct an invasive test—a iliac bone biopsy. This is the most direct way to obtain your bone microstructure insights, telling us what’s happening with your bones. This procedure requires local anesthesia, involves a small incision, and may cause slight pain, but the risk is controllable. You need to consider carefully."
"I’ll do it!" Ms. Lin replied without the slightest hesitation, "As long as we can figure it out and treat it, I’m willing to do anything. These five years, I’ve had enough of speculation and ineffective treatnt, please arrange it."
"Okay. Take so ti to co over, and I’ll discuss pre-operative preparations and risks with you in detail, arranging it as soon as possible," Li Min hung up.
The bone biopsy was scheduled two days later, with Li Min performing it, surrounded by many graduate students.
For accurate sampling, Li Min, under CT guidance, used a specialized needle to extract from Ms. Lin’s posterior superior iliac spine a cylindrical bone tissue sample about pencil lead thickness and over a centiter long. The process went smoothly, and besides a sense of soreness at the puncture site, Ms. Lin felt little discomfort.
The specin was promptly sent to the Pathology Departnt for non-decalcified bone tissue section processing. This is a specialized technique that preserves the bone’s original mineral components for bone histomorphotric analysis—to precisely asure trabecular thickness, number, separation under a microscope, calculate bone volu fraction, observe osteoblast and osteoclast activity, assess matrix mineralization degree.
The results would take a few days to process.
During these days, Yang Ping had Li Min systematically review literature on cobalt and cadmium toxicity, especially its impact on bones and kidneys. They found that while acute poisoning cases have been reported, cases like Ms. Lin’s, with such hidden and complex symptoms due to long-term low-level exposure to art materials, were extrely rare, scarcely recorded in the literature—emphasizing the importance of a clear diagnosis even more.
Simultaneously, Yang Ping started drafting an initial intervention plan based on the current results. If the bone biopsy confirms bone microstructure damage related to heavy tal load, the core of treatnt would be: thorough avoidance of further exposure: replace all cobalt and cadmium-containing painting materials, implent strict protective asures, and even consider pausing painting hobbies for a period.
He dictated, Li Min recorded treatnt, with all the graduate students opening their notebooks, starting to scribble notes.
Promote heavy tal excretion: For chronic, low-level poisoning, whether to use chelating agents like EDTA, DMSA, needs evaluation of benefit and risk, potentially burdening the kidneys or causing loss of other elents. However, nutritional support detoxification can be attempted: supplent zinc, selenium to counteract cadmium toxicity, antioxidants such as N-acetylcysteine, Vitamins C, E, and ample magnesium and B vitamins to support tabolism and nerve function.
Correct tabolic disorder: supplent Vitamin D to sufficient levels, optimize calcium and magnesium intake, ensure quality protein, as it is bone matrix raw material.
Bone support and pain managent: In high bone turnover state, whether to use anti-bone resorption drugs like bisphosphonates needs extre caution, must be based on bone biopsy results, as these drugs could interfere with bone’s self-repair.
Pain managent might need to combine nerve sensitization-regulating drugs but be cautious to avoid exacerbating fatigue.
"Did you record it all?" Yang Ping only realized he’d probably spoken too fast after he finished saying everything.
Li Min closed his notebook: "Recorded it all." He’s trained his shorthand skills during this internship period.
A week later, the pathology report of the bone biopsy finally ca out.
Li Min, holding the hefty report, went to Yang Ping imdiately. Yang Ping took it, carefully reading the pathological description and those series of precise asurent data: Bone volu fraction (BV/TV): slightly reduced. Trabecular thickness (Tb.Th): thinner. Trabecular separation (Tb.Sp): increased. Osteoblast surface (Ob.S/BS) and osteoclast surface (Oc.S/BS): both significantly increased, confirming high bone turnover state. Mineral apposition rate (MAR): normal to slightly low. Bone formation rate (BFR/BS): elevated. Locally observed widened osteoid tissue (unmineralized bone matrix), irregular mineralization front.
The pathological diagnostic conclusion was: consistent with high-turnover tabolic bone disease changes, with mildly delayed mineralization. The observed changes should be considered clinical, potentially related to tabolic disorders caused by chronic heavy tal exposure (cobalt/cadmium).
"The evidence is indisputable." Yang Ping exhaled deeply, handing the report to Li Min.
"The pathological examination results reaffird our hypothesis. Her bones are indeed ’busy for nothing,’ imbalanced in reconstruction, degraded in structure and quality, and affected in mineralization. Those migratory bone pains are precisely the distress signals from these compromised sites under normal activity."
Yang Ping personally explained the diagnosis and treatnt plan to Ms. Lin. Listening to those unfamiliar toxicology and bone tabolism terms, yet her eyes sparkled with a lightness she hadn’t felt in five years. It wasn’t the fear of the disease, but the relief of finally having the "enemy" unveiled.
"Professor Yang, thank you... thank you for finding it," Ms. Lin said chokingly, "Finally figured out what was going on."
"Your understanding and cooperation are crucial," Yang Ping said kindly, "From now on, we’ll treat this well, it’s completely curable, no need to worry too much."
"Had I known, I would’ve co to you directly, wouldn’t have struggled for those five years, I’ve beco depressed," Ms. Lin said excitedly.
Li Min imdiately comforted her: "It wasn’t all for nothing, you can’t deny the previous bread just because our last bread satiates you."
Ms. Lin found Dr. Li’s analogy unreasonable: "But if it wasn’t for this bread from you, I might never be full in this lifeti."
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