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Table of Contents    
Year : 2014  |  Volume : 62  |  Issue : 1  |  Page : 1-2

Neurological and neuroimaging signs of reversible Parkinsonism associated with manganese exposure

Department of Imaging, Hammersmith Hospital, London, United Kingdom

Date of Submission03-Feb-2014
Date of Decision03-Feb-2014
Date of Acceptance03-Feb-2014
Date of Web Publication7-Mar-2014

Correspondence Address:
Basant K Puri
Department of Imaging, Hammersmith Hospital, Du Cane Road, London W12 0HS
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.128210

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How to cite this article:
Puri BK. Neurological and neuroimaging signs of reversible Parkinsonism associated with manganese exposure. Neurol India 2014;62:1-2

How to cite this URL:
Puri BK. Neurological and neuroimaging signs of reversible Parkinsonism associated with manganese exposure. Neurol India [serial online] 2014 [cited 2022 Aug 7];62:1-2. Available from: https://www.neurologyindia.com/text.asp?2014/62/1/1/128210

In this month's issue of Neurology India, Han et al. present an unusual case entitled 'Reversal of pallidal magnetic resonance imaging (MRI) T1 hyperintensity in a welder presenting as reversible parkinsonism'. [1] Parkinsonism is a syndrome of multiple different etiologies and among the toxic causes of parkinsonism are alcohol (ethanol) withdrawal, methanol, 1-methyl-4-phenyl-1, 2, 3, 6-tetrahydropyrodine, inhalant abuse, metals (including manganese, iron and copper), cyanide poisoning, agricultural chemicals (including rotenone, paraquat, maneb and atrazine), isoquinoline derivatives, 6-hydroxydopamine, cycad seeds (which are associated with the amyotrophic lateral sclerosis-parkinsonism dementia complex of Guam), annonacin and carbon monoxide poisoning. [2],[3] In the case reported in this month's issue, the cause of parkinsonism was manganese intoxication as a result of working as a welder. The association of parkinsonism with manganese exposure, sometimes referred to as manganism, was noted in a paper published as early as 1837 by Couper in pyrolusite ore grinding workers. [4]

The heavy metal manganese (atomic number 25, relative atomic mass 54.938) lies in group 7 of the periodic table and has a natural abundance in the earth's crust that, among the heavy metals, is second only to that of iron, with which it is roughly similar in terms of many of its physical and chemical properties (although manganese is harder and more brittle but less refractory). [5] It has one of the highest industrial uses of all metals, being important in the production of steel and batteries, in water purification, the manufacture of bactericidal and fungicide compounds and as part of a knockout compound for petrol. [3] In commonly used welding methods, such as flux-cored arc welding and shielded manual metal arc welding, manganese may be present in the flux material and in the metal electrodes used. [6] Thus, as in the accompanying case report, those who perform routine welding jobs may be exposed to manganese-containing fumes, for example as mixed oxidation state oxides formed in the high temperature oxidizing environment in which this procedure takes place. [5],[6]

Racette et al. carried out a case-control study in which they compared the clinical features of parkinsonism in 15 career welders with two control groups of idiopathic Parkinson's disease, one of which was ascertained sequentially to compare the frequency of clinical features and the second age- and sex-matched to compare the frequency of motor fluctuations. [7] Parkinsonism in welders was distinguished clinically from idiopathic Parkinson's disease only by an earlier age of onset (mean 46 years compared with 63 years in the sequentially ascertained controls), with no significant differences being found in respect of frequency of tremor, bradykinesia, rigidity, asymmetric onset, postural instability, family history, clinical depression, dementia, drug-induced psychosis, response to levodopa, motor fluctuations or dyskinesias; furthermore, 6-[18F] fluorodopa positron emission tomography was carried out in two of the welders and showed findings typical of idiopathic Parkinson's disease. [7]

In the United States, the San Francisco/Oakland Bay Bridge was damaged by the 1989 earthquake and reconstruction of a vulnerable part of the bridge began to be carried out in 2003; this afforded Bowler et al. the opportunity to study the relationship between fume exposure in confined space welding and neurological and neuropsychological sequelae. [8] The researchers reported that '[In] 43 eligible welders, 11 cases of manganism were identified presenting with the following symptoms: Sleep disturbance, mood changes, bradykinesia, headaches, sexual dysfunction, olfaction loss, muscular rigidity, tremors, hallucinations, slurred speech, postural instability, monotonous voice and facial masking. Significant associations between outcome variables and cumulative exposure index (CEI) or blood Mn (MnB) were obtained with CEI for variables implicating attention and concentration, working and immediate memory, cognitive flexibility and verbal learning; and with MnB for executive function, cognitive flexibility, visuo-spatial construction ability and visual contrast sensitivity. This study strongly suggests that neuropsychological features contribute in a dose-effect related way to the portrait of manganism usually characterized by tremor, loss in balance, diminished cognitive performance and signs and symptoms of parkinsonism'. [8]

A key finding in the case report in this month's issue of Neurology India is that the manganism was found to be reversible, with respect to both neurological signs and neuroimaging findings. [1] I strongly recommend the reader to compare the before and after structural MRI figures provided in that report. This reversibility holds out some hope for potential treatment of manganism. Finally, this case emphasizes the important point made by Professor David Moore that, 'although Parkinson's disease is the most common cause of parkinsonism, it must always be kept in mind that this is but one of many possible causes and the physician must dutifully consider the other causes before deciding that a patient with parkinsonism has Parkinson's disease'. [2]

 » References Top

1.Han SH, Ahn SW, Youn YC, Shin HW. Reversal of pallidal MRI T1 hyperintensity in a welder presenting as reversible parkinsonism. Neurol India 2014;62:118-9.  Back to cited text no. 1
2.Moore DP, Puri BK. Textbook of Clinical Neuropsychiatry and Behavioral Neuroscience. 3 rd ed. London: Hodder Arnold; 2012.  Back to cited text no. 2
3.Lev N, Melamed E, Offen D. Toxic causes of parkinsonism. Handb Clin Neurol 2007;84:385-98.  Back to cited text no. 3
4.Couper J. On the effects of black oxide of manganese when inhaled into the lungs. Br Ann Med Pharmacol 1837;41-2.  Back to cited text no. 4
5.Cotton FA. Advanced Inorganic Chemistry. 6 th ed., Vol. xv. New York: Wiley; 1999. p. 1355.  Back to cited text no. 5
6.Dale Marcy A, Drake PL. Development of a field method for measuring manganese in welding fume. J Environ Monit 2007;9:1199-204.  Back to cited text no. 6
7.Racette BA, McGee-Minnich L, Moerlein SM, Mink JW, Videen TO, Perlmutter JS. Welding-related parkinsonism: Clinical features, treatment, and pathophysiology. Neurology 2001;56:8-13.  Back to cited text no. 7
8.Bowler RM, Nakagawa S, Drezgic M, Roels HA, Park RM, Diamond E, et al. Sequelae of fume exposure in confined space welding: A neurological and neuropsychological case series. Neurotoxicology 2007;28:298-311.  Back to cited text no. 8

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