Manganese intoxication during total parenteral nutrition: report of two cases and review of the literature

doi:10.1016/S0022-510X(98)00289-5

Journal of the Neurological Sciences

Volume 162, Issue 1, 1 January 1999, Pages 102-105

https://doi.org/10.1016/S0022-510X(98)00289-5 Get rights and content

Abstract

We report two cases of manganese (Mn) intoxication during total parenteral nutrition including manganese (Mn). Both patients showed parkinsonism with psychiatric symptoms and elevated serum Mn levels. T1-weighted magnetic resonance images (MRI) revealed symmetrical high intensity lesions in the globus pallidus. Discontinuation of Mn supplementation and levodopa treatment improved the symptoms and MRI abnormalities in the both patients. Thus, careful attention should be paid to the long-term intravenous administration of Mn.

Introduction

In recent years, the medical professions has focused increasing attention on the importance of trace elements during nutritional management [1]. New information on the requirements and reports of trace element deficiencies in patients receiving intravenous nutrition emphasize the need for ensuring proper levels of trace elements in solutions for intravenous feeding. This is particularly true when the parenteral route is the sole or primary source of nutrients for a prolonged period. Because of the importance of trace elements in nutrition, commercially available trace element solution in multiple ingredient form for parenteral use has been widely used in recent years. However, risk of overdose of trace elements has not gained so much attention as the corresponding deficiency state. In this present study, we report two cases of chronic Mn intoxication due to long-term total parenteral nutrition (TPN).

Section snippets

Case 1

A 68-year-old woman was admitted to the hospital due to psychiatric symptoms and gait disturbance. She had been on TPN for 3 months because of ulcerative colitis. Essential trace elements (Elemenmic®) including Mn (20 μmol daily) had been added to the TPN solution for a total of 3 months. On admission, she was markedly confused in addition to manifestations of parkinsonism (dysarthria, marked rigidity, hypokinesia with masked facies, supranuclear vertical gaze palsy). Laboratory values were as

Discussion

These two patients had a unique combination of parkinsonism with psychiatric symptoms, a high signal intensity in globus pallidus on T1-weighted image, a history of intravenous Mn administration, and elevated serum Mn levels. Trace element solution that included zinc (60 μmol), copper (5 μmol), Mn (20 μmol), Fe (35 μmol), iodine (1 μmol) were added to the TPN in both cases. Mn is known to clinically induce parkinsonism 3, 7, and to radiologically show increased intensities on T1-weighted MR

Acknowledgements

We thank Dr. Raymond L. Rosales for critical reading of the manuscript.

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Citation Excerpt :
In addition, there is a growing concern about the potential health consequences of chronic low-level ambient manganese exposure in the general population due to increased industrial use of manganese containing compounds being released into the environment as well as commercial use of compounds like methylcyclopentadienyl manganese tricarbony (MMT), an antiknock gasoline additive (Kaiser, 2003). Human and animal studies have shown toxic manganese exposure results in metal accumulations in various areas of the basal ganglia and dysfunction of cells of both the striatum and the globus pallidus (Calne et al., 1994; Eriksson et al., 1987; Erikson et al., 2004a, b; Brenneman et al., 1999; Nagatomo et al., 1999; Newland, 1999; Pal et al., 1999; Baek et al., 2003). Although manganism has been recognized for some time, the primary mechanism underlying manganese neurotoxicity remains elusive.
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Manganese intoxication during total parenteral nutrition: report of two cases and review of the literature

Abstract

Introduction

Section snippets

Case 1

Discussion

Acknowledgements

Exp Neurol

Neurologic disorders due to brain manganese deposition in a jaundice patient receiving long-term parenteral nutrition

J Parenter Enter Nutr

Manganism and idiopathic parkinsonism: similarities and differences

Neurology

Manganese intoxication during total parenteral nutrition

Lancet

Extrapyramidal symptoms in a BMT recipient with hyperintense basal ganglia and elevated manganese

Bone Marrow Transplant