Ver el código de «Manganese toxicity»

==Background==
*An essential element in the diet
**Used in various enzymatic processes
**Mn<sup>2+</sup> can take the place of Mg<sup>2+</sup>, Ca<sup>2+</sup>, and Fe<sup>2+</sup> in various proteins and enzymes, and has been seen to replace Fe<sup>2+</sup> in Hgb
**Low enteral absorption
**Cleared by the liver and excreted in the bile
*Typical routes of exposure
**Inhalation of dusts/fumes
***Seen in industrial areas as manganese is used to make steel
**Parenteral nutrition (TPN)
**IV Methcathinone
*Readily crosses the blood brain barrier and can be seen concentrated in the basal ganglia, particularly the globus pallidus 

==Clinical Features==
*Toxicity typically presents as cognitive issues
*Neuropsychiatric
**Acute
***“Manganese madness”
***Visual [[hallucinations]]
***Behavioral changes
***[[Anxiety]]
***Impotence
**Late manifestations
***[[Tremor]]
***[[dysarthria|Impaired speech]]
***Loss of facial expressions
***[[ataxia|Gait disturbances]]
***Low volume speech
***Can mimic [[Parkinson’s disease]]
*Pulmonary
**Acute / [[Metal fume fever]]
***[[Fever]]
***[[Nausea]]
***[[Headache]]
***[[Myalgia]]
***[[Arthralgia]]
**Chronic
***Persistent dry [[cough]]
***[[Bronchitis]]
***Chemical [[pneumonitis]]
*GI
**Anorexia
*Musculoskeletal
**[[Arthralgia]]
**Muscle rigidity
*Constitutional
**[[Lethargy]]
**[[Weakness|Asthenia]]

==Differential Diagnosis==
{{Heavy metals list}}

==Evaluation==
*Lab
**Whole blood 4-15 μg/L (73-273 nmol/L)
**Serum 0.9-2.9 μg/L (16-52 nmol/L)
**Urine (24h)  <10 μg/L (182 nmol/L)
**No definite toxic level
**Elevated levels are typically seen in acute toxicity, as manganese is quickly cleared from the blood
*[[brain MRI|MRI]]
**Will show abnormal T1- weighted signal hyperintensity in the basal ganglia, particularly in the globus pallidus, with normal T2-weighted images

==Management==
*Supportive care
*Remove source of exposure
*Chelation therapy with CaNa<sub>2</sub>[[EDTA]] or DTPA
**Can improve urinary excretion of manganese without affecting the neurologic manifestations

==Disposition==
*Will depend on severity, most cases are likely seen in patients receiving TPN, and will likely need changes to their TPN orders and a consultation from nutrition
*Consult Toxicology or [[poison control]]

==References==
<references/>
Soghoian, S. Manganese. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1294-1298

[[Category:Toxicology]]