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Case Reports
. 2024 Dec 6;16(12):e75198.
doi: 10.7759/cureus.75198. eCollection 2024 Dec.

Chronic Manganese Neuro-Toxicity in a Patient With Cirrhosis and the Role of Iron-Deficiency Anaemia

Jamal Jamal  1 , Muhammad Hashmat  2 , Hasan Al Alwan  2 , Eleanor Harvey  3 , Mansoor Zafar  1 , Panagiotis Stamoulos  4 , Gayatri Chakrabarty  5
Affiliations
Case Reports

Chronic Manganese Neuro-Toxicity in a Patient With Cirrhosis and the Role of Iron-Deficiency Anaemia

Jamal Jamal et al. Cureus. .

Abstract

Patients with chronic liver disease (CLD) are prone to complications associated with impaired liver functioning. This coupled with iron-deficiency anaemia (IDA) can predispose them to multiple comorbidities. We present an interesting case of a 69-year-old woman with a background history of liver cirrhosis due to metabolic dysfunction-associated steatotic liver disease (MASLD) with frequent travels to Bangladesh, a southeast Asian country known for having high levels of manganese (Mn) in water for domestic use. She presented with progressively worsening cognition and extrapyramidal symptoms. She underwent routine blood tests including for liver functions followed by a non-contrast computed tomogram (CT) of the head that did not suggest a possible cause. However, magnetic resonance imaging (MRI) of the brain showed hyperintensities bilaterally in the globus pallidus, subthalamic nucleus, red nucleus, and substantia nigra and raised the possibility of Mn toxicity. This was confirmed with repeated raised blood levels of Mn. The query was raised for acute toxicity to Mn, followed by consideration of CLD history associated with reduced elimination of Mn. This was complicated further by her history of IDA. Her case was discussed in a multi-disciplinary setting with specialities including radiology, gastroenterology, neurology, psychiatry, hepatology, and elderly medicine. Following this, a decision was made for the best supportive management of the patient. This case highlights the importance of MRI in the detection of a rare case of Mn toxicity, in a predisposed individual contributing to cognitive decline with extrapyramidal symptoms.

Keywords: atypical parkinsonism; cirrhosis; manganese neurotoxicity; metabolic dysfunction-associated steatotic liver disease (masld); non-alcoholic fatty liver disease (nafld).

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Conflict of interest statement

Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Axial computed tomogram (CT) head demonstrating a subtle old infarct in the left caudate nucleus (white arrow) and generalised brain involution signifying brain atrophy (red arrows).
Figure 2
Figure 2. Axial T1-weighted magnetic resonance imaging (MRI) head demonstrating T1 hyperintensity in the globi pallidi (white arrows) in A and the red nucleus (red arrow) and subthalamic nucleus (white arrow) in B, characteristic of manganese (Mn) brain accumulation.
Figure 3
Figure 3. Dopamine activator transport (DAT) brain scan demonstrating normal symmetrical uptake of the tracer throughout the striata
See this image and copyright information in PMC

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