Massive intravenous manganese overdose due to compounding error: minimal role for hemodialysis

Abstract

Context: Manganese-associated parkinsonism is well described in occupational settings, in chronic methcathinone users, and in patients receiving long-term total parenteral nutrition. We present a unique case of acute intravenous manganese poisoning with a systematic evaluation of hemodialysis efficacy.

Case details: A 52-year-old woman was inadvertently administered a single intravenous dose of 800 mg compounded manganese chloride at an outpatient chelation center. In an attempt to minimize central nervous system (CNS) manganese deposition, she underwent urgent hemodialysis followed by five days of therapy with calcium disodium EDTA (1 g/m² over eight hours daily). Her initial whole blood manganese concentration, obtained six hours after exposure and prior to treatment, was 120 mcg/L (2.19 micromol/L); normal <5 mcg/L (< 0.09 micromol/L). Following the first four-hour hemodialysis session her blood manganese concentration decreased to 20 mcg/L (0.36 micromol/L). Despite the fall in her blood manganese concentration, analysis of dialysate revealed a total elimination of only 604 mcg (11 micromol) manganese (∼1.4% of manganese burden). Although she remained asymptomatic, an MRI on hospital day two revealed T1 hyperintensities within the bilateral globus pallidi, consistent with manganese exposure.

Discussion: Manganese poisoning is associated with irreversible neurologic toxicity. Hemodialysis did not appear to significantly enhance elimination in this case of acute intravenous manganese toxicity, beyond supportive care and calcium disodium EDTA chelation.

Keywords:

• Adverse drug event
• compounding
• hemodialysis
• manganese
• parkinsonism

Disclosure statement

SWS receives salary support for work unrelated to the current study from US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response (ASPR), award number HITEP 150030-01-00 to the NYU School of Medicine and from the Fridolin Charitable Trust to the Ronald O. Perelman Department of Emergency Medicine Safety Program; he is the recipient of an intramural departmental scholarly innovation grant for work unrelated to the current study. Other authors report no declarations of interest.