Neurological and Neuroimaging Signs of Reversible Parkinsonism Associated with Manganese Exposure
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[Downloaded free from http://www.neurologyindia.com on Thursday, March 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Editorial Neurological and neuroimaging signs of reversible Parkinsonism associated with manganese exposure Basant K. Puri Department of Imaging, Hammersmith Hospital, London, UK Address for correspondence: Prof. Basant K. Puri, Department of Imaging, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK. E-mail: [email protected] Received : 03-02-2014 Review completed : 03-02-2014 Accepted : 03-02-2014 In this month’s issue of Neurology India, Han The heavy metal manganese (atomic number 25, relative et al. present an unusual case entitled ‘Reversal atomic mass 54.938) lies in group 7 of the periodic table of pallidal magnetic resonance imaging (MRI) T1 and has a natural abundance in the earth’s crust that, hyperintensity in a welder presenting as reversible among the heavy metals, is second only to that of iron, parkinsonism’.[1] Parkinsonism is a syndrome of multiple with which it is roughly similar in terms of many of its different etiologies and among the toxic causes of physical and chemical properties (although manganese is parkinsonism are alcohol (ethanol) withdrawal, methanol, harder and more brittle but less refractory).[5] It has one of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyrodine, inhalant the highest industrial uses of all metals, being important in abuse, metals (including manganese, iron and copper), the production of steel and batteries, in water purifi cation, cyanide poisoning, agricultural chemicals (including the manufacture of bactericidal and fungicide compounds rotenone, paraquat, maneb and atrazine), isoquinoline and as part of a knockout compound for petrol.[3] In derivatives, 6-hydroxydopamine, cycad seeds commonly used welding methods, such as fl ux-cored (which are associated with the amyotrophic lateral arc welding and shielded manual metal arc welding, sclerosis-parkinsonism dementia complex of Guam), manganese may be present in the fl ux material and in annonacin and carbon monoxide poisoning.[2,3] In the case the metal electrodes used.[6] Thus, as in the accompanying reported in this month’s issue, the cause of parkinsonism case report, those who perform routine welding jobs was manganese intoxication as a result of working as a may be exposed to manganese-containing fumes, for welder. The association of parkinsonism with manganese example as mixed oxidation state oxides formed in the exposure, sometimes referred to as manganism, was high temperature oxidizing environment in which this noted in a paper published as early as 1837 by Couper procedure takes place.[5,6] in pyrolusite ore grinding workers.[4] Racette et al. carried out a case-control study in which Access this article online they compared the clinical features of parkinsonism in 15 career welders with two control groups of Quick Response Code: Website: www.neurologyindia.com idiopathic Parkinson’s disease, one of which was ascertained sequentially to compare the frequency of PMID: *** clinical features and the second age- and sex-matched to compare the frequency of motor fluctuations.[7] DOI: Parkinsonism in welders was distinguished clinically 10.4103/0028-3886.128210 from idiopathic Parkinson’s disease only by an earlier Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1 1 [Downloaded free from http://www.neurologyindia.com on Thursday, March 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Puri: Reversible parkinsonism age of onset (mean 46 years compared with 63 years in A key fi nding in the case report in this month’s issue the sequentially ascertained controls), with no signifi cant of Neurology India is that the manganism was found differences being found in respect of frequency of tremor, to be reversible, with respect to both neurological signs bradykinesia, rigidity, asymmetric onset, postural and neuroimaging fi ndings.[1] I strongly recommend the instability, family history, clinical depression, dementia, reader to compare the before and after structural MRI drug-induced psychosis, response to levodopa, motor fi gures provided in that report. This reversibility holds fluctuations or dyskinesias; furthermore, 6-[18F] out some hope for potential treatment of manganism. fl uorodopa positron emission tomography was carried Finally, this case emphasizes the important point made out in two of the welders and showed fi ndings typical by Professor David Moore that, ‘although Parkinson’s of idiopathic Parkinson’s disease.[7] disease is the most common cause of parkinsonism, it must always be kept in mind that this is but one of In the United States, the San Francisco/Oakland Bay many possible causes and the physician must dutifully Bridge was damaged by the 1989 earthquake and consider the other causes before deciding that a patient reconstruction of a vulnerable part of the bridge began with parkinsonism has Parkinson’s disease’.[2] to be carried out in 2003; this afforded Bowler et al. the opportunity to study the relationship between fume References exposure in confi ned space welding and neurological and neuropsychological sequelae.[8] The researchers 1. Han SH, Ahn SW, Youn YC, Shin HW. Reversal of pallidal MRI T1 reported that ‘[In] 43 eligible welders, 11 cases of hyperintensity in a welder presenting as reversible parkinsonism. Neurol India 2014;62:118-9. manganism were identified presenting with the 2. Moore DP, Puri BK. Textbook of Clinical Neuropsychiatry and following symptoms: Sleep disturbance, mood changes, Behavioral Neuroscience. 3rd ed. London: Hodder Arnold; 2012. bradykinesia, headaches, sexual dysfunction, olfaction 3. Lev N, Melamed E, Offen D. Toxic causes of parkinsonism. Handb Clin loss, muscular rigidity, tremors, hallucinations, slurred Neurol 2007;84:385-98. 4. Couper J. On the effects of black oxide of manganese when inhaled into speech, postural instability, monotonous voice and facial the lungs. Br Ann Med Pharmacol 1837;41-2. masking. Significant associations between outcome 5. Cotton FA. Advanced Inorganic Chemistry. 6th ed., Vol. xv. New York: variables and cumulative exposure index (CEI) or Wiley; 1999. p. 1355. blood Mn (MnB) were obtained with CEI for variables 6. Dale Marcy A, Drake PL. Development of a field method for measuring manganese in welding fume. J Environ Monit 2007;9:1199-204. implicating attention and concentration, working and 7. Racette BA, McGee-Minnich L, Moerlein SM, Mink JW, Videen TO, immediate memory, cognitive fl exibility and verbal Perlmutter JS. Welding-related parkinsonism: Clinical features, learning; and with MnB for executive function, cognitive treatment, and pathophysiology. Neurology 2001;56:8-13. fl exibility, visuo-spatial construction ability and visual 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 contrast sensitivity. This study strongly suggests that and neuropsychological case series. Neurotoxicology 2007;28:298-311. neuropsychological features contribute in a dose-effect related way to the portrait of manganism usually How to cite this article: Puri BK. Neurological and neuroimaging characterized by tremor, loss in balance, diminished signs of reversible Parkinsonism associated with manganese cognitive performance and signs and symptoms of exposure. Neurol India 2014;62:1-2. parkinsonism’.[8] Source of Support: Nil, Confl ict of Interest: None declared. 2 Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1 Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use..