Disclosures: Varun Y. Goswami, MD: Nothing to disclose

Case Description: A 72-year-old female presented with 6-month history of progressively worsening generalized weakness, ataxia, and gait instability. Brain magnetic resonance imaging (MRI) found increased T2 signal abnormality in bilateral anterior lentiform nuclei. These were new findings compared to MRI 6 months prior, when symptoms first began.

Setting: Inpatient Rehabilitation Facility.

Patient: A 72-year-old female with worsening ataxia.

Assessment/Results: Based on clinical symptoms and radiographic findings, differential diagnosis included paraneoplastic syndrome, infection, or toxic/metabolic etiology. Workup was significant for serum manganese at two times the upper limit of normal. Given the elevated levels of serum manganese, the toxicology service was consulted, who determined that chelation treatment was not warranted due to the chronicity of symptoms. Upon admission to rehabilitation, patient underwent a trial of levodopa, in an effort to try to improve her mobility. Levodopa was discontinued on day three due to lack of improvement in motor function and a noted worsening in patient’s mentation and emotional lability. Patient completed three weeks of inpatient rehabilitation with focus on strengthening, endurance, transfers, and mobility. Patient made minimal improvement in her functional independence.

Discussion: The symptoms of manganese toxicity generally appear slowly over a period of months to years. In the most severe cases, manganese toxicity can result in a permanent neurological disorder with symptoms similar to those of Parkinson’s disease, including tremors, bradykinesia, and spasms.

Conclusion: It was determined that patient’s worsening neurological deficits were attributed to manganese toxicity. The etiology and origin of the toxicity could not be determined during this hospitalization, and unfortunately, patient did not show any significant improvement in balance, coordination, and mobility with intensive inpatient rehabilitation. Furthermore, she was determined to be a poor candidate for chelation treatment, as there was concern that treatment may lead to further mobilization of manganese from saturated tissue into the patient’s blood stream.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-rare-case-of-manganese-toxicity-of-unknown-etiology-a-case-report/