Parkinsonism due to Manganism in a Welder

Abstract

A 33-year-old right-handed male presented complaining of a 2-year history of progressive cognitive slowing, rigidity, tremors, slowing of movements, and gait instability leading to falls. On examination, he had a Mini-Mental Status Examination (MMSE) score of 29, slowed saccadic eye pursuit, hypomimia, cogwheel rigidity, a 3- to 4-Hz tremor, and a "cock-walk" gait. His symptoms and signs were similar to idiopathic Parkinson's disease; however, he was young, inattention and forgetfulness occurred early in the course of the disorder, levodopa was unhelpful, and his gait was atypical. His work up for secondary causes of parkinsonism was negative, except for increased signal intensity on T1-weighted magnetic resonance image (MRI) in the bilateral basal ganglia. Typical etiologies for that finding were ruled-out, which led to further inquiries into the patient's lifestyle. He was a welder, and discussion with his employer revealed that he used a steel-manganese alloy, he often worked in a confined ship's hold, and he did not use a respiratory mask. Because manganese toxicity can produce increased T1-weighted signal intensities in the basal ganglia, the authors tested his serum and urine manganese, and both were elevated. This patient emphasizes the importance of a careful occupational history in persons presenting with atypical manifestations of a neurodegenerative disorder. It also lends support to the hypothesis that welding can produce enough exposure to manganese to produce neurologic impairment.

Neurologic manifestations in welders with pallidal MRI T1 hyperintensity

“…Whereas the syndrome of predominant parkinsonism has been reported, 7,8,10,11,[20][21][22][23][24][25] the second syndrome of cognitive dysfunction and multifocal myoclonus has not been previously described; however, myoclonus has been documented in a single case report, 13 and cognitive impairment is commonly reported. 7,8,10,11,14,20 Myoclonus is uncommon and unlikely to be coincidental; it was confirmed electrophysiologically. A vestibular-auditory syndrome has not been previously emphasized as a syndrome of manganese toxicity; however, two of our patients had prominent vestibular-auditory complaints, and a third patient had less prominent symptoms.…”

“…The tremor in these cases was predominantly postural and kinetic, rather than a prominent rest tremor, as described in other series. 8,14 Second, the response to carbidopa/ levodopa was minimal, 36 or partial at best, unlike PD. Finally, the pallidal MRI hyperintensity is not seen in PD.…”

“…5,12 A biologic marker of manganese accumulation within the CNS is bilaterally increased T1 MRI signal within the basal ganglia, especially the globus pallidus, but also the striatum. 1,[13][14][15][16][17][18] Although T1 signal changes in these nuclei may be seen in several other conditions (e.g., nonketotic hyperglycemic episodes, hypoxia, neurofibromatosis, and other paramagnetic ions), it is an uncommon pattern. When the T1 hyperintensity is confined to the lentiform nuclei, and in the appropriate clinical setting, it has relative specificity for brain manganese.…”

Immunotoxicology of arc welding fume: Worker and experimental animal studies

“…Mn intoxication following chronic human exposure in other occupational settings, such as mining, smelting, ferroalloy, and dry battery industries, has been documented to cause a Parkinson's disease-like syndrome called 'manganism' (Roels et al, 1992;Baldwin, 1997, Lucchini et al, 1999). Neurobehavioral changes have been reported in exposed welders (Bowler et al, 2007a, b;Ellingsen et al, 2008), and case reports show Mn accumulates in dopaminergic brain regions of welders exposed to high concentrations of welding fume (Sadek et al, 2003;Josephs et al, 2005). In addition, some studies describe a potential link between welding and Parkinsonism, and suggest the possibility of an early-onset Parkinsonism among welders (Racette et al, 2001(Racette et al, , 2005, whereas other studies do not (Goldman et al, 2005;Stampfer, 2009;Tanner et al, 2009).…”

Searching for a relationship between manganese and welding and Parkinson’s disease

“…102 While his parkinsonism was attributed to welding, despite unilateral involvement, presence of rest tremor, lack of gait difficulty, and modest improvement with levodopa, reduced fluorodopa uptake on PET in the left putamen, contralateral to his symptoms, was much more consistent with the diagnosis of PD rather than manganese-induced parkinsonism. 102 The only case report suggesting a possible link between welding and manganese and parkinsonism is that by Sadek et al, 103 in which a young welder presented with a 2-year history of cognitive difficulties, tremor, and propulsive gait with tendency to walk on toes. Although the dosage was not stated, there was apparently no response to levodopa.…”