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

Evaluating the risk of manganese-induced neurotoxicity of parenteral nutrition: review of the current literature

INTRODUCTION

Several diseases and clinical conditions can affect enteral nutrition and adequate gastrointestinal uptake. In this respect, parenteral nutrition (PN) is necessary for the provision of deficient trace elements. However, some essential elements, such as manganese (Mn) may be toxic to children and adults when parenterally administered in excess, leading to toxic, especially neurotoxic effects.

AREAS COVERED

Here, we briefly provide an overview on Mn, addressing its sources of exposure, the role of Mn in the etiology of neurodegenerative diseases, and focusing on potential mechanisms associated with Mn-induced neurotoxicity. In addition, we discuss the potential consequences of overexposure to Mn inherent to PN.

EXPERT OPINION

In this critical review, we suggest that additional research is required to safely set Mn levels in PN, and that eliminating Mn as an additive should be considered by physicians and nutritionists on a case by case basis in the meantime to avoid the greater risk of neurotoxicity by its presence. There is a need to better define clinical biomarkers for Mn toxicity by PN, as well as identify new effective agents to treat Mn-neurotoxicity. Moreover, we highlight the importance of the development of new guidelines and practice safeguards to protect patients from excessive Mn exposure and neurotoxicity upon PN administration.

Inherited Manganese Disorders and the Brain: What Neurologists Need to Know

Although acquired manganese neurotoxicity has been widely reported since its first description in 1837 and is popularly referred to as "manganism," inherited disorders of manganese homeostasis have received the first genetic signature as recently as 2012. These disorders, predominantly described in children and adolescents, involve mutations in three manganese transporter genes, i.e., SLC30A10 and SLC39A14 which lead to manganese overload, and SLC39A8, which leads to manganese deficiency. Both disorders of inherited hypermanganesemia typically exhibit dystonia and parkinsonism with relatively preserved cognition and are differentiated by the occurrence of polycythemia and liver involvement in the SLC30A10-associated condition. Mutations in SLC39A8 lead to a congenital disorder of glycosylation which presents with developmental delay, failure to thrive, intellectual impairment, and seizures due to manganese deficiency. Chelation with iron supplementation is the treatment of choice in inherited hypermanganesemia. In this review, we highlight the pathognomonic clinical, laboratory, imaging features and treatment modalities for these rare disorders.

Manganese in the Diet: Bioaccessibility, Adequate Intake, and Neurotoxicological Effects

Manganese (Mn) is an essential element that participates in several biological processes. Mn serves as a cofactor for several enzymes, such as glutamine synthetase and oxidoreductases, that have an important role in the defense of the organisms against oxidative stress. The diet is the main source of Mn intake for humans, and adequate daily intake levels for this metal change with age. Moreover, in higher amounts, Mn may be toxic, mainly to the brain. Here, we provide an overview of Mn occurrence in food, addressing its bioaccessibility and discussing the dietary standard and recommended intake of Mn consumption. In addition, we review some mechanisms underlying Mn-induced neurotoxicity.

Manganese Neurotoxicity as a Complication of Chronic Total Parenteral Nutrition

Manganese accumulation in the central nervous system creates clinical symptoms of cognitive dysfunction, behavioral changes, and movement disorders resembling Parkinson's disease. Radiographic features of this rare clinical entity include symmetric T1 hyperintensities in the bilateral globus pallidi, with corresponding hypointensities on T2-weighted images. Total parenteral nutrition (TPN) is an increasingly used potentially lifesaving therapy for patients who cannot tolerate enteral nutrition. However, when used over a period of several weeks to months, its associated risks and complications carry significant morbidity and mortality. One of the more rare complications of TPN use is manganese toxicity. We provided care for a 38-year-old female on chronic TPN who presented to the hospital with Parkinsonian features, confusion, falls, and lethargy. MRI brain showed T1 hyperintensities in the bilateral globus pallidi, which were attributed to manganese toxicity from chronic TPN use. Supporting evidence for this rare entity included decreased signal intensity in the bilateral globus pallidi on T2-weighted images and T1 hyperintensities in the substantia nigra. With antifungal treatment and permanent cessation of TPN, her mentation and neurological symptoms began to improve within a week. Repeat MRI brain performed one month after discontinuation of TPN revealed improvement of the T1 hyperintensities in the bilateral globus pallidi. Our objective in presenting this case is to highlight manganese neurotoxicity as a rare complication of TPN in a patient without known hepatic dysfunction and to emphasize the importance of routinely monitoring patients for the possible adverse effects of chronic TPN. Our case is among the handful of published cases in which a patient without known liver dysfunction, which is the primary organ responsible for manganese elimination from the body, developed manganese neurotoxicity.

A Mnemonic for Pharmacists to Ensure Optimal Monitoring and Safety of Total Parenteral Nutrition: I AM FULL

Objective: To present a guideline-derived mnemonic that provides a systematic monitoring process to increase pharmacists’ confidence in total parenteral nutrition (TPN) monitoring and improve safety and efficacy of TPN use. Data Sources: The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines were reviewed. Additional resources included a literature search of PubMed (1980 to May 2016) using the search terms: total parenteral nutrition, mnemonic, indications, allergy, macronutrients, micronutrients, fluid, comorbidities, labs, peripheral line, and central line. Articles (English-language only) were evaluated for content, and additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language observational studies, review articles, meta-analyses, guidelines, and randomized trials assessing monitoring parameters of TPN were evaluated. Data Synthesis: The ASPEN guidelines were referenced to develop key components of the mnemonic. Review articles, observational trials, meta-analyses, and randomized trials were reviewed in cases where guidelines did not adequately address these components. Conclusions: A guideline-derived mnemonic was developed to systematically and safely manage TPN therapy. The mnemonic combines 7 essential components of TPN use and monitoring: Indications, Allergies, Macro/Micro nutrients, Fluid, Underlying comorbidities, Labs, and Line type.

"Manganese-induced neurotoxicity: a review of its behavioral consequences and neuroprotective strategies"

Manganese (Mn) is an essential heavy metal. However, Mn’s nutritional aspects are paralleled by its role as a neurotoxicant upon excessive exposure. In this review, we covered recent advances in identifying mechanisms of Mn uptake and its molecular actions in the brain as well as promising neuroprotective strategies. The authors focused on reporting findings regarding Mn transport mechanisms, Mn effects on cholinergic system, behavioral alterations induced by Mn exposure and studies of neuroprotective strategies against Mn intoxication. We report that exposure to Mn may arise from environmental sources, occupational settings, food, total parenteral nutrition (TPN), methcathinone drug abuse or even genetic factors, such as mutation in the transporter SLC30A10. Accumulation of Mn occurs mainly in the basal ganglia and leads to a syndrome called manganism, whose symptoms of cognitive dysfunction and motor impairment resemble Parkinson’s disease (PD). Various neurotransmitter systems may be impaired due to Mn, especially dopaminergic, but also cholinergic and GABAergic. Several proteins have been identified to transport Mn, including divalent metal tranporter-1 (DMT-1), SLC30A10, transferrin and ferroportin and allow its accumulation in the central nervous system. Parallel to identification of Mn neurotoxic properties, neuroprotective strategies have been reported, and these include endogenous antioxidants (for instance, vitamin E), plant extracts (complex mixtures containing polyphenols and non-characterized components), iron chelating agents, precursors of glutathione (GSH), and synthetic compounds that can experimentally afford protection against Mn-induced neurotoxicity.

Gender and anthropometrics of patients undergoing cisplatin-containing chemotherapy as determinants of acute emesis over repeat courses

Objective. To characterize the anthropometric and pharmacotherapeutic variables related to acute emesis over repeat courses of cisplatin-containing regimens (≥50 mg/m survival analysis.2) by means of survival analysis.

Methods. A prospective, cross-sectional non-controlled study was started to analyse acute vomiting in patients treated in a general hospital. The patients received an intravenous combination of drugs based on metoclopramide (two 3 mg/kg doses), diphenhydramine (20 mg) and dexamethasone (20 mg) as first choice antiemetic treatment. An intravenous regimen based on ondansetron (8 mg) and dexamethasone (20 mg) was given as an alternative regimen. Therapeutic failure was defined as the recording of one or more vomiting episodes on a self-evaluation sheet. Other variables included were chemotherapeutic regimen, antiemetic regimen, gender, age, weight and height. The statistical analysis was developed using the Cox proportional hazards model.

Results. Eighty-eight patients were finally included in the study, 16 women (18%) and 72 men (82%). The metoclopramide-based regimen was administered to 74 patients (84%) and the ondansetron-based regimen to 14 patients (15%). The univariate analysis showed that any variable included in the study was significant. The multivariate survival analysis retained three variables: height (hazard ratio 1.22), gender (hazard ratio 2.12) and weight (hazard ratio 1.44) of the patients. It is hypothesized that gender and anthropometrics of patients could represent differences in pharmacokinetic and/or pharmacodynamic behaviour of cisplatin and/or antiemetics. The potential role of these parameters in these drugs is discussed.

Conclusions. Emesis over repeat courses in cisplatin-containing regimens seems a function of the gender and anthropometrics of patients, irrespective of the antiemetic regimen and the emetogenicity of the cytostatics. Dosing individualization of cisplatin and/or antiemetics based on pharmacokinetic and/or pharmacodynamic parameters can be a valid tool to increase the effectiveness and safety of these drugs.

Parenteral trace element provision: recent clinical research and practical conclusions

The aim of this systematic review (PubMed, www.ncbi.nlm.nih.gov/pubmed and Cochrane, www.cochrane.org; last entry 31 December 2014) was to present data from recent clinical studies investigating parenteral trace element provision in adult patients and to draw conclusions for clinical practice. Important physiological functions in human metabolism are known for nine trace elements: selenium, zinc, copper, manganese, chromium, iron, molybdenum, iodine and fluoride. Lack of, or an insufficient supply of, these trace elements in nutrition therapy over a prolonged period is associated with trace element deprivation, which may lead to a deterioration of existing clinical symptoms and/or the development of characteristic malnutrition syndromes. Therefore, all parenteral nutrition prescriptions should include a daily dose of trace elements. To avoid trace element deprivation or imbalances, physiological doses are recommended.

Manganese Is Essential for Neuronal Health

The understanding of manganese (Mn) biology, in particular its cellular regulation and role in neurological disease, is an area of expanding interest. Mn is an essential micronutrient that is required for the activity of a diverse set of enzymatic proteins (e.g., arginase and glutamine synthase). Although necessary for life, Mn is toxic in excess. Thus, maintaining appropriate levels of intracellular Mn is critical. Unlike other essential metals, cell-level homeostatic mechanisms of Mn have not been identified. In this review, we discuss common forms of Mn exposure, absorption, and transport via regulated uptake/exchange at the gut and blood-brain barrier and via biliary excretion. We present the current understanding of cellular uptake and efflux as well as subcellular storage and transport of Mn. In addition, we highlight the Mn-dependent and Mn-responsive pathways implicated in the growing evidence of its role in Parkinson's disease and Huntington's disease. We conclude with suggestions for future focuses of Mn health-related research.

Significance and Usefulness of Biomarkers of Exposure to Manganese

Manganese (Mn) accomplishes functions essential to maintaining human health, but at the same time this trace element can be toxic at low levels of exposure and accurate estimation of internal exposure is needed. A biomarker of exposure to Mn is meaningful only if there is sufficient knowledge of the toxicokinetics determining its presence in a biological medium (e.g. whole blood, plasma, urine, hair, nail). Moreover, biological monitoring of exposure to Mn is useful only when the biomarker is sufficiently specific and sensitive to distinguish exposed from non-exposed subjects, when it is dose-related to the external exposure (current, recent, or time-integrated), and when it displays reasonable dose–effect/response relationships with the occurrence of adverse effects on the central nervous system, the critical target for Mn exposure. Human investigations in which biomarkers of Mn exposure meet all these criteria are hard to locate. Overall, the available studies report poor or no associations on an individual basis between external (Mn in air or drinking water) and internal (Mn in blood, urine, hair, or nail) Mn exposure indices. This may be to some extent explained by features inherent of the Mn metabolism (homeostatic control), the Mn biomarker's half-life with respect to the exposure window, and the variable nature of external exposure scenarios. Studies particularly dealing with Mn inhalation exposure, different or poorly described methodological approaches, or air sampling strategies may render direct comparison and interpretation of results a tedious task. Nevertheless, several studies report significant dose–effect associations between biomarkers of Mn exposure and subclinical deficits of psychomotor or neuropsychological test performances. Because directly associated with the site of toxic action and providing the magnetic resonance imaging is done no later than three months after Mn exposure ceased, the Mn T1 relaxation time is potentially the better biomarker of Mn exposure in a clinical context (e.g. after long-term parenteral nutrition, chronic liver failure, methcathinone drug abuse). Magnetic resonance imaging is, however, unpractical as a tool for biological monitoring of exposure to Mn in the occupational setting (inhalation) and in the general population (air, drinking water). In conclusion, it would be inappropriate to recommend, on the basis of the currently available evidence, a reliable well-validated biomarker of exposure to Mn, or to establish a health-based threshold value for subclinical neurotoxic effects.

Role of transcription factor yin yang 1 in manganese-induced reduction of astrocytic glutamate transporters: Putative mechanism for manganese-induced neurotoxicity

Astrocytes are the most abundant non-neuronal glial cells in the brain. Once relegated to a mere supportive role for neurons, contemporary dogmas ascribe multiple active roles for these cells in central nervous system (CNS) function, including maintenance of optimal glutamate levels in synapses. Regulation of glutamate levels in the synaptic cleft is crucial for preventing excitotoxic neuronal injury. Glutamate levels are regulated predominantly by two astrocytic glutamate transporters, glutamate transporter 1 (GLT-1) and glutamate aspartate transporter (GLAST). Indeed, the dysregulation of these transporters has been linked to several neurodegenerative diseases such as amyotrophic lateral sclerosis (ALS), Alzheimer's disease (AD) and Parkinson's disease (PD), as well as manganism, which is caused by overexposure to the trace metal, manganese (Mn). Although Mn is an essential trace element, its excessive accumulation in the brain as a result of chronic occupational or environmental exposures induces a neurological disorder referred to as manganism, which shares common pathological features with Parkinsonism. Mn decreases the expression and function of both GLAST and GLT-1. Astrocytes are commonly targeted by Mn, and thus reduction in astrocytic glutamate transporter function represents a critical mechanism of Mn-induced neurotoxicity. In this review, we will discuss the role of astrocytic glutamate transporters in neurodegenerative diseases and Mn-induced neurotoxicity.

Pallidal index as biomarker of manganese brain accumulation and associated with manganese levels in blood: a meta-analysis

OBJECTIVE

The current study was designed to evaluate the sensitivity, feasibility, and effectiveness of the pallidal index (PI) serving as a biomarker of brain manganese (Mn) accumulation, which would be used as an early diagnosis criteria for Mn neurotoxicity.

METHODS

The weighted mean difference (WMD) of the PI between control and Mn-exposed groups was estimated by using a random-effects or fixed-effects meta-analysis with 95% confidence interval (CI) performed by STATA software version 12.1. Moreover, the R package "metacor" was used to estimate correlation coefficients between PI and blood Mn (MnB).

RESULTS

A total of eight studies with 281 occupationally Mn-exposed workers met the inclusion criteria. Results were pooled and performed with the Meta-analysis. Our data indicated that the PI of the exposed group was significantly higher than that of the control (WMD: 7.76; 95% CI: 4.86, 10.65; I2 = 85.7%, p<0.0001). A random effects model was used to perform meta-analysis. These findings were remarkably robust in the sensitivity analysis, and publication bias was shown in the included studies. Seven out of the eight studies reported the Pearson correlation (r) values. Significantly positive correlation between PI and MnB was observed (r = 0.42; 95% CI, 0.31, 0.52).

CONCLUSIONS

PI can be considered as a sensitive, feasible, effective and semi-quantitative index in evaluating brain Mn accumulation. MnB can also augment the evaluation of brain Mn accumulation levels in the near future. However, the results should be interpreted with caution.

Environmental pathways and human exposure to manganese in southern Brazil

The study of environmental pathways and human exposure to Manganese (Mn) in Southern Brazil was performed using two steps. The first step consisted of taking water samples from the surface of the Pardinho River. The average results from this technique showed a significant increase of pollutants, including increased levels of Mn, above the environmentally acceptable standard recommended by the Brazilian National Environment Council. Additionally, 64 soil samples were taken from areas with and without agricultural activity. Many results were above the mean crust and did not indicate significant differences of Mn levels between the sampled areas. For the second step, 12 families were selected and assessed for exposure to Mn in a region with high levels of Mn in the soil. Most of the analyzed foods contained amounts of Mn above the reference values, indicating that food can be an important source of exposure. The Mn content from the hair of most subjects studied was also high compared to reference values from non-exposed populations. Although the contamination appeared to come from a natural origin, the results found in the present study showed that the Mn levels present in the Pardinho River Basin are a relevant public health issue.

Manganese in human parenteral nutrition: considerations for toxicity and biomonitoring

The iatrogenic risks associated with excessive Mn administration in parenteral nutrition (PN) patients are well documented. Hypermanganesemia and neurotoxicity are associated with the duration of Mn supplementation, Mn dosage, as well as pathological conditions, such as anemia or cholestasis. Recent PN guidelines recommend the biomonitoring of patients if they receive Mn in their PN longer than 30 days. The data in the literature are conflicting about the method for assessing Mn stores in humans as a definitive biomarker of Mn exposure or induced-neurotoxicity has yet to be identified. The biomonitoring of Mn relies on the analysis of whole blood Mn (WB Mn) levels, which are highly variable among human population and are not strictly correlated with Mn-induced neurotoxicity. Alterations in dopaminergic (DAergic) and catecholaminergic metabolism have been studied as predictive biomarkers of Mn-induced neurotoxicity. Given these limitations, this review addresses various approaches for biomonitoring Mn exposure and neurotoxic risk.

Evaluation of neurobehavioral and neuroinflammatory end-points in the post-exposure period in rats sub-acutely exposed to manganese

Manganese (Mn) can cause manganism, a neurological disorder similar to Parkinson' Disease (PD). The neurobehavioral and neuroinflammatory end-points in the Mn post exposure period have not been studied yet. Rats were injected on alternate days with 8 doses of MnCl2 (25mg/kg) or saline, then euthanized 1, 10, 30 or 70 days following the last dose. Whole-blood (WB) (p<0.05), urine (p<0.05) and brain cortical (p<0.0001) Mn levels were significantly increased 24h after the last dose. Decreases in the rats' ambulation were noted 1, 10 and 30 days after the last Mn dose (p<0.001; p<0.05; p<0.001, respectively) and also in the rearing activity at the four time-points (p<0.05). Cortical glial fibrillary acid protein immunoreactivity (GFAP-ir) was significantly increased at 1, 10, 30 (p<0.0001) and 70 (p<0.001) days after the last Mn dose, as well as tumor necrosis α (TNF-α) levels (p<0.05) but just on day 1. Taken together, the results show that, during the 70-day clearance phase of Mn, the recovery is not immediate as behavioral alterations and neuroinflammation persist long after Mn is cleared from the cortical brain compartment.

High blood manganese in iron-deficient children in Karachi

Objective

Dietary Fe deficiency has a high incidence in Pakistani children and may be associated with increased gastrointestinal absorption of trace metals such as Mn. Therefore, children residing in heavily polluted cities like Karachi may be prone to Mn toxicity. The present study investigated blood Mn concentrations in Karachi children of different Fe statuses.

Design

A prospective observational study was conducted where children were classified into different categories of Fe status – normal Fe, borderline Fe deficiency, Fe deficiency and Fe-deficiency anaemia – using WHO criteria supported by measurements of soluble transferrin receptors. Blood Mn was determined for children in each category using graphite atomic absorption spectroscopy.

Setting

Three hospital outpatient departments in Karachi, Pakistan.

Subjects

A total of 269 children (156 males, 113 females) aged 6–60 months from low-income families of Karachi.

Results

Blood Mn concentrations were significantly higher in children with Fe-deficiency anaemia and Fe deficiency compared with those of normal Fe status (both P < 0·01). Blood concentrations of soluble transferrin receptors were higher in children with Fe-deficiency anaemia compared with those of borderline or normal Fe status (both P < 0·05).

Conclusions

These findings report for the first time high blood Mn concentrations in Fe-deficient children of this age group. There is therefore an urgent need to identify and remove environmental exposure to Mn in combination with health strategies aimed at eradicating childhood Fe deficiency.

Manganese and the brain

Manganese (Mn) is an essential trace metal that is pivotal for normal cell function and metabolism. Its homeostasis is tightly regulated; however, the mechanisms of Mn homeostasis are poorly characterized. While a number of proteins such as the divalent metal transporter 1, the transferrin/transferrin receptor complex, the ZIP family metal transporters ZIP-8 and ZIP-14, the secretory pathway calcium ATPases SPCA1 and SPCA2, ATP13A2, and ferroportin have been suggested to play a role in Mn transport, the degree that each of them contributes to Mn homeostasis has still to be determined. The recent discovery of SLC30A10 as a crucial Mn transporter in humans has shed further light on our understanding of Mn transport across the cell. Although essential, Mn is toxic at high concentrations. Mn neurotoxicity has been attributed to impaired dopaminergic (DAergic), glutamatergic and GABAergic transmission, mitochondrial dysfunction, oxidative stress, and neuroinflammation. As a result of preferential accumulation of Mn in the DAergic cells of the basal ganglia, particularly the globus pallidus, Mn toxicity causes extrapyramidal motor dysfunction. Firstly described as "manganism" in miners during the nineteenth century, this movement disorder resembles Parkinson's disease characterized by hypokinesia and postural instability. To date, a variety of acquired causes of brain Mn accumulation can be distinguished from an autosomal recessively inherited disorder of Mn metabolism caused by mutations in the SLC30A10 gene. Both, acquired and inherited hypermanganesemia, lead to Mn deposition in the basal ganglia associated with pathognomonic magnetic resonance imaging appearances of hyperintense basal ganglia on T1-weighted images. Current treatment strategies for Mn toxicity combine chelation therapy to reduce the body Mn load and iron (Fe) supplementation to reduce Mn binding to proteins that interact with both Mn and Fe. This chapter summarizes our current understanding of Mn homeostasis and the mechanisms of Mn toxicity and highlights the clinical disorders associated with Mn neurotoxicity.

Long-term survival, nutritional autonomy, and quality of life after intestinal and multivisceral transplantation

OBJECTIVE

To assess long-term survival, graft function, and health-related quality of life (QOL) after visceral transplantation.

BACKGROUND

Despite continual improvement in early survival, the long-term therapeutic efficacy of visceral transplantation has yet to be defined.

METHODS

A prospective cross-sectional study was performed on 227 visceral allograft recipients who survived beyond the 5-year milestone. Clinical data were used to assess outcome including graft function and long-term survival predictors. The socioeconomic milestones and QOL measures were assessed by clinical evaluation, professional consultation, and validated QOL inventory.

RESULTS

Of 376 recipients, 227 survived beyond 5 years, with conditional survival of 75% at 10 years and 61% at 15 years. With a mean follow-up of 10 ± 4 years, 177 (92 adults, 85 children) are alive, with 118 (67%) recipients 18 years or older. Nonfunctional social support and noninclusion of the liver in the visceral allograft are the most significant survival risk factors. Nutritional autonomy was achievable in 160 (90%) survivors, with current serum albumin level of 3.7 ± 0.5 gm/dL and body mass index of 25 ± 6 kg/m(2). Despite coexistence or development of neuropsychiatric disorders, most survivors were reintegrated to society with self-sustained socioeconomic status. In parallel, most of the psychological, emotional, and social QOL measures significantly (P < 0.05) improved after transplantation. Current morbidities with potential impact on global health included dysmotility (59%), hypertension (37%), osteoporosis (22%), and diabetes (11%), with significantly (P < 0.05) higher incidence among adult recipients.

CONCLUSIONS

With new tactics to further improve long-term survival including social support measures, visceral transplantation has achieved excellent nutritional autonomy and good QOL.

Levels of arsenic, cadmium, lead, manganese and zinc in biological samples of paralysed steel mill workers with related to controls

The determination of essential trace and toxic elements in the biological samples of human beings is an important clinical screening procedure. This study aimed to assess the possible effects of environmental exposure on paralysed male workers (n = 75) belonging to the production and quality control departments of a steel mill. In this investigation, the concentrations of arsenic, cadmium, lead, manganese and zinc were determined in biological samples (blood, urine and scalp hair samples) of exposed paralysis and non-paralysed steel mill workers. For comparative purposes, unexposed healthy subjects of same age group were selected as referents. The elements in the biological samples were measured by atomic absorption spectrophotometry prior to microwave-assisted acid digestion. The validity of the methodology was checked by the biological certified reference materials. The results indicate that the level understudy elements in all three biological samples were significantly higher in paralysed workers of both groups (quality control and production) as compared to referents (p < 0.01). The possible connection of these elements with the aetiology of disease is discussed. The results also show the need for immediate improvements of workplace ventilation and industrial hygiene practices.

Manganese encephalopathy: an under-recognized condition in the intensive care unit

BACKGROUND

Manganese encephalopathy is a potential complication of parenteral nutrition. Lack of early recognition leads to unnecessary testing and to continued exposure to manganese.

METHODS

Case report and review of the literature.

RESULTS

We describe the clinical and imaging findings of a patient with manganese encephalopathy in whom the diagnosis was delayed due to lack of recognition of the characteristic imaging findings.

CONCLUSION

Manganese encephalopathy has protean clinical and imaging findings that can easily be overlooked.

Elevated manganese and cognitive performance in school-aged children and their mothers

BACKGROUND

Growing evidence suggests that excess manganese (Mn) in children is associated with neurobehavioral impairments. In Brazil, elevated hair Mn concentrations were reported in children living near a ferro-manganese alloy plant.

OBJECTIVES

We investigated these children's and caregivers' cognitive function in relation to bioindicators of Mn exposure.

METHODS

In this cross-sectional study, the WISC-III was administered to 83 children aged between 6 and 12 years; the Raven Progressive Matrix was administered to the primary caregivers (94% mothers), who likewise responded to a questionnaire on socio demographics and birth history. Mn in hair (MnH) and blood (MnB) and blood lead (PbB) were measured by graphite furnace atomic absorption spectrometry (GFAAS).

RESULTS

Children's mean MnB and MnH were 8.2 μg/L (2.7-23.4) and 5.83 μg/g (0.1-86.68), respectively. Mean maternal MnH was 3.50 μg/g (0.10-77.45) and correlated to children's MnH (rho=0.294, p=0.010). Children's MnH was negatively related to Full-Scale Intelligence Quotient (IQ) and Verbal IQ; β coefficients for MnH were -5.78 (95% CI -10.71 to -0.21) and -6.72 (-11.81 to -0.63), adjusted for maternal education and nutritional status. Maternal MnH was negatively associated with performance on the Raven's (β=-2.69, 95% CI -5.43 to 0.05), adjusted for education years, family income and age.

CONCLUSIONS

These findings confirm that high MnH in children is associated with poorer cognitive performance, especially in the verbal domain. Primary caregiver's IQ is likewise associated to Mn exposure, suggesting that, in this situation, children's cognition may be affected directly and indirectly by Mn exposure.

Multi-dose-route, multi-species pharmacokinetic models for manganese and their use in risk assessment

Manganese (Mn) is an essential element that may be toxic in conditions of overexposure. Nearly 10 years ago, some of the authors of this article published a proposed methodology to perform a tissue-dose-based risk assessment and a detailed list of data needs necessary to perform the assessment. Since that time, a substantial body of Mn pharmacokinetic (PK) data has been generated in rats and nonhuman primates, allowing for the construction of physiologically based pharmacokinetic (PBPK) models for Mn. This study reviews the development of the Mn PBPK models, reassesses the previously identified data needs, and details potential uses of these models in risk assessment of Mn. Based upon numerous animal experiments, pharmacokinetic (PK) models have effectively simulated tissue kinetics of Mn from both inhaled and oral Mn intake. PK models achieve this by incorporating homeostatic control processes, saturable tissue binding capacities, and preferential fluxes in various tissue regions. While minor data gaps still exist, the models captured the main dose-dependent characteristics of Mn disposition in rodents and monkeys and provide a structure to parameterize an equivalent PK description in humans. These models are organized to contribute to a tissue-dose based risk assessment of Mn that simultaneously considers ingestion and inhalation kinetics of Mn along with homeostatic control of Mn.

Manganese neurotoxicity: lessons learned from longitudinal studies in nonhuman primates

BACKGROUND

Exposure to excess levels of the essential trace element manganese produces cognitive, psychiatric, and motor abnormalities. The understanding of Mn neurotoxicology is heavily governed by pathologic and neurochemical observations derived from rodent studies that often employ acute Mn exposures. The comparatively sparse studies incorporating in vivo neuroimaging in nonhuman primates provide invaluable insights on the effects of Mn on brain chemistry.

OBJECTIVES

The purpose of this review is to discuss important aspects of Mn neurotoxicology and to synthesize recent findings from one of the largest cohorts of nonhuman primates used to study the neurologic effects of chronic Mn exposure.

DISCUSSION

We reviewed our recent in vivo and ex vivo studies that have significantly advanced the understanding of Mn-induced neurotoxicity. In those studies, we administered weekly doses of 3.3-5.0 (n=4), 5.0-6.7 (n=5), or 8.3-10.0 mg Mn/kg (n=3) for 7-59 weeks to cynomolgus macaque monkeys. Animals expressed subtle deficits in cognition and motor function and decreases in the N-acetylaspartate-to-creatine ratio in the parietal cortex measured by magnetic resonance spectroscopy reflective of neuronal dysfunction. Impaired striatal dopamine release measured by positron emission tomography was observed in the absence of changes in markers of dopamine neuron degeneration. Neuropathology indicated decreased glutamine synthetase expression in the globus pallidus with otherwise normal markers of glutamatergic and GABAergic neurotransmission. Increased amyloid beta (A4) precursor-like protein 1 gene expression with multiple markers of neurodegeneration and glial cell activation was observed in the frontal cortex.

CONCLUSIONS

These findings provide new information on mechanisms by which Mn affects behavior, neurotransmitter function, and neuropathology in nonhuman primates.

Is manganese an essential supplement for parenteral nutrition?

PURPOSE OF REVIEW

To summarize the role of the essential trace element, manganese, its potential toxicity, monitoring methods and dosage recommendations for nutrition support.

RECENT FINDINGS

Parenteral nutrition usually contains manganese as part of a fixed concentration multiple trace element supplement. Recent literature identifies potential problems in this approach and reports toxic symptoms resulting from hypermanganesaemia in paediatric and long-term home patients. Elimination by the hepatobiliary system is frequently impaired, and parenteral administration bypasses the regulatory mechanisms of homeostasis. Together with occasional oral intake and product contamination, this can lead to brain accumulation and neurotoxicity, with individual responses to supplementation difficult to predict. Regular monitoring is recommended, but plasma and serum analyses are poor indicators of body stores. Whole blood concentrations are more accurate and correlate with signal intensity of MRI. We have identified a need for individual trace element additives to be more widely available and for multitrace element products to be reformulated. There is now a persuasive argument for not routinely adding manganese to parenteral nutrition admixtures.

SUMMARY

High intravenous doses of manganese can lead to neurotoxicity. Current dosage guidelines and trace element formulations need revision. Frequent monitoring to identify tissue accumulation is recommended for paediatric and long-term home parenteral nutrition patients.

Blood manganese concentrations and intrauterine growth restriction

To assess the relationship between blood concentrations of manganese (Mn) and intrauterine growth restriction (IUGR), Mn levels in the umbilical cord blood (UCB) and the mother whole blood (MWB) samples were measured in apparently healthy mothers and their newborns. Measurement was conducted by an inductively coupled plasma mass spectrometry. Manganese concentrations in MWB were significantly lower (p<0.01) in IUGR cases than in appropriate for gestational age (AGA) cases (mean+/-S.D.; 16.7+/-4.8 and 19.1+/-5.9 microg/l, respectively). Conversely, UCB concentrations of Mn were significantly higher (p<0.05) in IUGR newborns than AGA newborns (44.7+/-19.1 and 38.2+/-13.1 microg/l, respectively). Logistic regression analysis demonstrated significant relationships of the mother whole blood and the umbilical cord blood concentrations of Mn in IUGR cases (OR=0.868, 1.044, respectively). The study suggests that manganese concentrations in MWB and UCB might induce different effects on birth weight in healthy mothers. Because intrauterine growth restriction is a multi-factorial problem, further epidemiological and clinical studies on larger numbers of subjects are needed to confirm the findings in the present study.

Assessment of dietary intake and trace element status in patients with ileal pouch-anal anastomosis

PURPOSE

Panproctocolectomy and ileal pouch-anal anastomosis is the operation of choice for patients with ulcerative colitis and familial polyposis. The long-term nutritional consequences after pouch surgery are unknown. We have assessed the nutritional status of the essential trace elements-zinc, copper, manganese, and selenium-in patients several years (median, 10 (range, 2-15) years) after surgery.

METHODS

Fifty-five patients with uncomplicated ileal pouch-anal anastomosis and 46 healthy control subjects were studied. A dietary assessment of trace element intake was undertaken by using a semiquantitative food frequency questionnaire. The patients' trace elements status for zinc, copper, manganese, and selenium was assessed by measuring their concentrations in blood.

RESULTS

The dietary intake of individual trace elements was similar in both groups (all P values > 0.4). There was no significant difference in the concentrations of plasma copper, zinc, and selenium between patients and healthy control subjects (all P values > 0.07). The concentration of whole blood manganese was significantly higher (P = 0.004) in patients (median, 178.5 nmol/l; range, 59-478 nmol/l) compared with healthy control subjects (median, 140 nmol/l; range, 53-267 nmol/l). Four (7 percent) patients had manganese concentrations more than three standard deviations of the mean of control group (>255 nmol/l).

CONCLUSIONS

This study shows that patients who have had uncomplicated pouch surgery have a normal dietary intake of trace elements and do not develop deficiencies in copper, zinc, manganese, and selenium. However, these patients may be at increased risk of manganese toxicity.

Manganese: recent advances in understanding its transport and neurotoxicity

The present review is based on presentations from the meeting of the Society of Toxicology in San Diego, CA (March 2006). It addresses recent developments in the understanding of the transport of manganese (Mn) into the central nervous system (CNS), as well as brain imaging and neurocognitive studies in non-human primates aimed at improving our understanding of the mechanisms of Mn neurotoxicity. Finally, we discuss potential therapeutic modalities for treating Mn intoxication in humans.

Complications of parenteral nutrition

Parenteral nutrition plays a vital role for patients with intestinal failure and those who are unable to maintain oral or enteral nutrition alone. Parenteral nutrition has been shown to improve clinical outcome in patients with malnutrition and intestinal tract dysfunction. The use of parenteral nutrition is not without risk of serious complications. Parenteral nutrition complications can be divided into mechanical related to vascular access, septic, and metabolic. This article provides a review on the short- and long-term complications of parenteral nutrition and their management.

Brain magnetic resonance imaging and manganese concentrations in red blood cells of smelting workers: search for biomarkers of manganese exposure

The MRI technique has been used in diagnosis of manganism in humans and non-human primates. This cross-sectional study was designed to explore whether the pallidal signal intensity in T1-weighted MRI correlated with Mn levels in the blood compartment among Mn-exposed workers and to understand to what extent the MRI signal could reflect Mn exposure. A group of 18 randomly selected male Mn-exposed workers of which 13 were smelting workers with high exposure (mean of airborne Mn in work place: 1.26 mg/m3; range: 0.31-2.93 mg/m3), and 5 power distribution control workers with low exposure (0.66 mg/m3 and 0.23-0.77 mg/m3) from a ferroalloy factory, and another group of 9 male subjects as controls from a non-smelting factory who were office or cafeteria workers (0.01 mg/m3 and 0-0.03 mg/m3) were recruited for neurological tests, MRI examination, and analysis of Mn in whole blood (MnB), plasma (MnP) or red blood cells (MnRBC). No clinical symptoms and signs of manganism were observed among these workers. MRI data showed average increases of 7.4% (p<0.05) and 16.1% (p<0.01) in pallidal index (PI) among low- and high-exposed workers, respectively, as compared to controls. Fourteen out of 18 Mn-exposed workers (78%) had intensified PI values, while this proportion was even higher (85%) among the high Mn-exposed workers. Among exposed workers, the PI values were significantly associated with MnRBC (r=0.55, p=0.02). Our data suggest that the workers exposed to airborne Mn, but without clinical symptoms, display an exposure-related, intensified MRI signal. The MRI, as well as MnRBC, may be useful in early diagnosis of Mn exposure.

Synthesis, characterization, and structures of Mn(DMHP)3 x 12H2O and Mn(DMHP)2Cl x 0.5H2O

This report describes the synthesis, characterization, and X-ray crystal structures of two Mn(III) complexes, Mn(DMHP)3 x 12H2O and Mn(DMHP)2Cl x 0.5H2O (DMHP = 1,2-dimethyl-3-hydroxy-4-pyridinone). Mn(DMHP)2Cl was prepared from the reaction of Mn(II) chloride with 2 equiv of DMHP under reflux in the presence of triethylamine. Mn(DMHP)3 was obtained by reacting Mn(II) acetate with 3 equiv of DMHP in the presence of sodium acetate. Mn(DMHP)3 could also be prepared by reacting Mn(OAc)3 x 2H2O with 3 equiv of DMHP in the presence of triethylamine. Both Mn(III) complexes have been characterized by elemental analysis, infrared spectroscopy, electronic paramagnetic resonance, electrospray ionization spectroscopy, electrochemical method, and X-ray crystallography. The X-ray crystal structure of Mn(DMHP)2Cl x 0.5H2O revealed a rare example of five-coordinated Mn(III) complexes with two bidentate ligands and a square pyramidal coordination geometry. Surprisingly, the average Mn-O (hydroxy) bond distance in Mn(DMHP)2Cl x 0.5H2O is approximately 0.025 A longer than that of the average Mn-O (carbonyl) bond, suggesting an extensive delocalization of electrons in the two pyridinone rings. The structure of Mn(DMHP)3 x 12H2O, a rare example of six-coordinate high-spin Mn(III) complexes without Jahn-Teller distortion, is isostructural to M(DMHP)3 x 12H2O (M = Al, Ga, Fe, and In). The electrochemical data for Mn(DMHP)3 suggests that the Mn(III) oxidation state is highly stabilized by three DMHP ligands. DMHP has the potential as a chelator for the removal of excess intracellular Mn and the treatment of chronic Mn toxicity.

The role of metals in neurodegenerative processes: aluminum, manganese, and zinc

Until the last decade, little attention was given by the neuroscience community to the neurometabolism of metals. However, the neurobiology of heavy metals is now receiving growing interest, since it has been linked to major neurodegenerative diseases. In the present review some metals that could possibly be involved in neurodegeneration are discussed. Two of them, manganese and zinc, are essential metals while aluminum is non-essential. Aluminum has long been known as a neurotoxic agent. It is an etiopathogenic factor in diseases related to long-term dialysis treatment, and it has been controversially invoked as an aggravating factor or cofactor in Alzheimer's disease as well as in other neurodegenerative diseases. Manganese exposure can play an important role in causing Parkinsonian disturbances, possibly enhancing physiological aging of the brain in conjunction with genetic predisposition. An increased environmental burden of manganese may have deleterious effects on more sensitive subgroups of the population, with sub-threshold neurodegeneration in the basal ganglia, generating a pre-Parkinsonian condition. In the case of zinc, there has as yet been no evidence that it is involved in the etiology of neurodegenerative diseases in humans. Zinc is redox-inactive and, as a result of efficient homeostatic control, does not accumulate in excess. However, adverse symptoms in humans are observed on inhalation of zinc fumes, or accidental ingestion of unusually large amounts of zinc. Also, high concentrations of zinc have been found to kill bacteria, viruses, and cultured cells. Some of the possible mechanisms for cell death are reviewed.

Orofacial dyskinesias in a patient with primary biliary cirrhosis: a clinicopathological case report and review

We describe the pathological and clinical aspects, including video and radiological magnetic resonance imaging, of a case of chronic acquired hepatocerebral degeneration with orofacial dyskinesias in relation to a primary biliary cirrhosis. We provide a review of the literature on this subject.

Determination of trace elements (Cu, Zn, Mn, Pb) and magnesium by atomical absorption in patients receiving total parenteral nutrition

OBJECTIVE

We measured the serum levels of four trace elements (Cu, Zn, Mn, Pb) and Mg in surgical patients receiving total parenteral nutrition (TPN). The clinical implications and the results are discussed.

METHODS

Two groups of patients were studied: the first group (n = 40) was our study group and the second (n = 40) was the control group. Four measurements of each trace element (TE) in blood serum were carried out: one before initiating TPN, one 24 h after, one 3 d later, and the last one immediately after discontinuing TPN. Each measurement was repeated twice. The Perkin-Elmer atomic absorption spectrophotometer (model 2380) with furnace graphite HGA-300 was used to measure the TE levels and an acetylene flame was used to measure the Mg levels.

RESULTS

Levels of all the TEs, except Pb, were lower before the administration of TPN compared with the control group (P < 0.05). The levels of TEs during and immediately after TPN were generally lower in comparison with the initial measurement before the administration of TPN.

CONCLUSION

The results of this study suggest that it may be necessary to 1) add Cu, Zn, Mn, and Mg to the parenteral nutritional solution and 2) follow the fluctuations in serum levels during the administration of TPN.

Evaluation of indexes of in vivo manganese status and the optimal intravenous dose for adult patients undergoing home parenteral nutrition

BACKGROUND

There are no accurate indexes for determining the status of manganese in humans, and there is no clear recommended daily dose of this essential trace element to be administered in total parenteral nutrition solutions.

OBJECTIVE

The objectives were to evaluate accurate indexes of manganese status and elucidate the optimal manganese dose to be administered to adult patients undergoing home parenteral nutrition.

DESIGN

Patients were administered total parenteral nutrition solutions providing 0, 1, 2, or 20 micromol Mn/d according to an on-off design, after which manganese concentrations in whole blood and plasma were determined. Magnetic resonance imaging (MRI) was performed to determine the intensity on T(1)-weighted images (MRI intensity) and T(1) values in the globus pallidus. Hematologic and biochemistry tests were also performed.

RESULTS

High degrees of correlation were found between whole-blood manganese concentrations and both MRI intensity (r = 0.7728) and T(1) values (r = -0.7519) in the globus pallidus. A strong negative correlation was found between MRI intensity and T(1) values (r = -0.8407). The dose of 1 micromol Mn/d caused no change in MRI intensity or T(1) values, and the whole-blood manganese concentration remained within the normal range in all patients.

CONCLUSIONS

Whole-blood manganese concentrations and MRI intensity and T(1) values in the globus pallidus are useful indexes of the status of manganese in humans. The optimal dose of manganese may be 1 micromol/d for adult patients undergoing home parenteral nutrition.

On-off study of manganese administration to adult patients undergoing home parenteral nutrition: new indices of in vivo manganese level

BACKGROUND

Recently, there have been reports that magnetic resonance imaging (MRI) reveals high-intensity T1-weighted images (HI) in the basal ganglia (especially in the globus pallidus) of patients receiving total parenteral nutrition (TPN). This finding is presumably due to excess administration of manganese. We investigated the reversibility and reproducibility of these changes by means of an on-off manganese administration study. We also investigated the temporal relationships between the intensity of T1-weighted images (MRI intensity) and the whole-blood and plasma manganese concentrations to evaluate the potential for the MRI intensity to serve as an index of the in vivo manganese level.

METHODS

Eleven adult patients undergoing home parenteral nutrition received TPN solutions containing manganese (0 or 20 micromol/d) according to an on-off design. The whole-blood and plasma manganese concentrations were determined at the same time the brain MRI was performed.

RESULTS

Both the whole-blood manganese concentration and the MRI intensity in the globus pallidus changed in response to the administration and withdrawal of manganese. It took at least 5 months for HI to disappear when manganese was withdrawn, and this change was reversible and reproducible. The whole-blood manganese concentration showed strong correlations with both the MRI intensity and the T1 value (r = 0.7693, -0.7011). The MRI intensity and the T1 value showed a strong correlation (r = -0.9051).

CONCLUSIONS

The whole-blood manganese concentration, the MRI intensity in the globus pallidus and the T1 value, an objective index of the MRI intensity, may be useful indices of the manganese level in the body.

Manganese intoxication during intermittent parenteral nutrition: report of two cases

BACKGROUND AND METHODS

The administration of trace elements is thought to be needed in patients receiving long-term parenteral nutrition. Recently, manganese intoxication or deposition was documented in such patients. We report two cases of manganese intoxication during intermittent parenteral nutrition including manganese. Manganese had been administered for 4 years at a frequency of one or two times per week in one case and for 5 years at a frequency of one or two times per month in the other case. Both cases showed mild symptoms with headache and dizziness. One case had mild hepatic dysfunction and the other did not. The whole-blood manganese level increased in one case, but not in the other case. T1-weighted magnetic resonance images revealed symmetrical high-intensity areas in basal ganglia and thalamus in both cases. After the administration of manganese was stopped, these symptoms all disappeared and the magnetic resonance images abnormalities gradually improved in both patients. Mild long-term manganese intoxication is thus considered to occur regardless of the frequency of using a manganese supplement.

CONCLUSIONS

Patients should be carefully monitored when receiving long-term parenteral nutrition including manganese, even when the manganese dose is small and the frequency of receiving a manganese supplement is low.

Factors associated to hypermanganesemia in patients receiving home parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) patients often present hypermanganesamia.

AIM

To examine which factors may be associated to hypermanganesemia in HPN patients.

METHODS

Plasma manganese (Mn), liver function tests, C-reactive protein concentrations, erythrocyte sedimentation rate (ESR), tumor necrosis factor-alpha (TNF- alpha), interleukin-6, soluble receptors of interleukin-2, and blood neopterin concentrations were determined in 21 HPN patients and 10 healthy controls. Brain magnetic resonance imaging (MRI) and careful neurologic clinical examination were performed in 11 patients.

RESULTS

Mn concentration was higher in HPN patients than controls (1.96+/-1.1 vs 0.81+/- 0.4 microg/L;P<0.001) and positively correlated to the amount of parenteral nutrition (PN) supply, transaminases and alkaline phosphatase (r=0.53, P<0.0001) concentrations, as well as to ESR (r=0.61, P<0.0001), TNF- alpha and blood neopterin. The amount of calories provided by PN was positively correlated to inflammatory markers and liver parameters. All patients investigated by MRI showed hyperintense basal ganglia on T1-weighted images suggesting brain Mn deposition. Only one had slight clinical extrapyramidal symptoms.

CONCLUSION

In HPN patients, sustained inflammation may facilitate hypermanganesemia through 1. cholestatic liver disease and thereby decreased Mn biliary excretion, 2. high nutritional requirements (responsible for increased Mn supply), and/or 3. modified Mn metabolism or body distribution. Neurologic complications appeared marginal whereas Mn brain deposition seems frequent.

Brain manganese deposition and blood levels in patients undergoing home parenteral nutrition

BACKGROUND

Extrapyramidal syndrome and alterations in brain magnetic resonance images are described in patients undergoing long-term home parenteral nutrition (HPN) and in cholestatic patients. These abnormalities have been correlated to basal ganglia manganese (Mn) accumulation.

METHODS

A longitudinal 1-year study was conducted on 15 patients undergoing HPN (median duration, 3.8 years; range, 1.7-10; median Mn parenteral supplementation, 0.1 mg/d). Whole-blood, plasma, intra-erythrocytes, and urinary Mn concentrations were measured and brain magnetic resonance was performed at the beginning (time 0) and after 1 year of Mn intravenous supplementation withdrawal (time 1). No patients showed psychosis, extrapyramidal syndrome, or cholestasis.

RESULTS

At time zero, 10 of 15 patients (67%) showed paramagnetic accumulation on cerebral magnetic resonance images; at time 1 there was a reduction of cerebral Mn accumulation. In all patients, blood-Mn levels were significantly reduced after 1 year of Mn intravenous supplementation withdrawal.

CONCLUSIONS

Patients receiving long-term HPN showed an elevated incidence of alterations in brain magnetic resonance images with a median Mn intravenous supplementation of 0.1 mg/d. Mn supplementation withdrawal significantly decreased metal levels in blood and brain storage. We noticed that the intra-erythrocyte Mn level was a good index of Mn status.

Hypermanganesemia in patients receiving total parenteral nutrition

BACKGROUND

Manganese is one of the trace elements that is routinely administered to total parenteral nutrition (TPN) patients. The recommended daily IV dosage ranges from 100 to 800 MICROg. We have used 500 microg daily. Recent reports have suggested neurologic symptoms seen in some patients receiving home parenteral nutrition (HPN) may be due to hypermanganesemia. Therefore, HPN patients and some short-term inpatients receiving TPN were studied to ascertain the relationship between dose and blood levels.

METHODS

Red blood cell manganese levels were obtained by atomic absorptiometry.

RESULTS

The levels in 36 hospitalized, short-term patients obtained within 48 hours of initiating TPN were all normal. The 30 patients receiving TPN from 3 to 30 days had levels that ranged from 4.8 to 28 microg/L (normal, 11 to 23 microg/L). Two patients had abnormal levels, at days 14 and 18. Fifteen of the 21 patients receiving inpatient TPN or HPN for 36 to 5075 days had elevated Mn levels. Only one patient with hypermanganesemia, an inpatient, had abnormal biochemical liver tests (bilirubin and alkaline phosphatase). One of the patients with a high level had some vestibular symptoms attributed to aminoglycoside use and had increased signal density in the globus pallidus on T1-weighted images on magnetic resonance imaging (MRI). A second patient with Mn levels twice normal had no neurologic symptoms, but had similar MRI findings. A third had some basal ganglia symptoms, confirmed by a neurologic evaluation, seizures, and very high Mn levels. The MRI showed no signal enhancement, but motion artifacts limited the study technically.

CONCLUSIONS

Hypermanganesemia is seen in HPN patients receiving 500 microg manganese daily and may have resulted in some neurologic damage in three patients. Hypermanganesemia is sometimes seen after a short course of TPN in inpatients, as early as 14 days. Patients should be monitored for hypermanganesemia if they receive Mn in their TPN for >30 days. A 500 microg/d dose of Mn is probably excessive, and 100 microg/d should probably never be exceeded. Mn should be eliminated from the solution if the Mn level is elevated and should not be readministered unless the level returns to normal or subnormal. Mn should not be supplemented if the patient has liver disease with an elevated bilirubin.