Manganese and acute paranoid psychosis: a case report

J Med Case Reports. 2011; 5: 146.
Published online 2011 April 12. doi:  10.1186/1752-1947-5-146
PMCID: PMC3090741

1Vincent van Gogh Institute for Psychiatry, Centre of Excellence for Neuropsychiatry, Venray, The Netherlands
2Erasmus University Medical Centre, Department of Psychiatry, Rotterdam, The Netherlands
3Radboud University Nijmegen, Donders Centre for Cognition, Nijmegen, The Netherlands
4Radboud University Nijmegen, Behavioural Science Institute, Nijmegen, The Netherlands
5Vincent van Gogh Institute for Psychiatry, Outpatient Department Deurne, Venray, The Netherlands
Corresponding author.
Willem M Verhoeven: wverhoeven@vvgi.nl
; Jos I Egger: j.egger@psych.ru.nl
; Harold J Kuijpers: hkuijpers@vvgil.nl
Received September 30, 2010; Accepted April 12, 2011.
Copyright©2011 Verhoeven et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction

Manganese regulates many enzymes and is essential for normal development and body function. Chronic manganese intoxication has an insidious and progressive course and usually starts with complaints of headache, fatigue, sleep disturbances, irritability and emotional instability. Later, several organ systems may be affected and, due to neurotoxicity, an atypical parkinsonian syndrome may emerge. With regard to neuropsychiatry, an array of symptoms may develop up to 30 years after intoxication, of which gait and speech abnormalities, cognitive and motor slowing, mood changes and hallucinations are the most common. Psychotic phenomena are rarely reported.

Case presentation

We describe the case of a 49-year-old Caucasian man working as a welder who was referred to our facility for evaluation of acute paranoid psychotic behavior. Our patient’s medical history made no mention of any somatic complaints or psychiatric symptoms, and he had been involved in a professional career as a metalworker. On magnetic resonance imaging scanning of his brain, a bilateral hyperdensity of the globus pallidus, suggestive for manganese intoxication, was found. His manganese serum level was 52 to 97 nmol/L (range: 7 to 20 nmol/L). A diagnosis of organic psychotic disorder due to manganese overexposure was made. His psychotic symptoms disappeared within two weeks of treatment with low-dose risperidone. At three months later, serum manganese was decreased to slightly elevated levels and the magnetic resonance imaging T1 signal intensity was reduced. No signs of Parkinsonism were found and a definite diagnosis of manganese-induced apathy syndrome was made.

Conclusion

Although neuropsychiatric and neurological symptoms caused by (chronic) manganese exposure have been reported frequently in the past, in the present day the disorder is rarely diagnosed. In this report we stress that manganese intoxication can still occur, in our case in a confined-space welder, and may present clinically with a paranoid psychotic state that necessitates a rapid diagnostic procedure in order to avoid the permanent structural brain damage that may occur with chronic exposure.

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