Case report: a metabolic disorder presenting as pediatric manganism

Exome Sequence Analysis to Characterize Undiagnosed Family Segregating Motor Impairment and Dystonia

Background: Hypermanganesemia with dystonia 1 (HMNDYT1) is a rare genetic disorder characterized by elevated blood manganese levels. This condition is associated with polycythemia, motor neurodegeneration with extrapyramidal features, and hepatic dysfunction, which can progress to cirrhosis in some patients. Materials and Methods: In this study, a consanguineous Saudi family with two affected individuals exhibiting symptoms of severe motor impairment, spastic paraparesis, postural instability, and dystonia was studied. Clinical and radiographic evaluations were conducted on the affected individuals. Whole exome sequencing (WES) was performed to diagnose the disease and to determine the causative variant underlying the phenotype. Moreover, Sanger sequencing was used for validation and segregation analysis of the identified variant. Bioinformatics tools were utilized to predict the pathogenicity of candidate variants based on ACMG criteria. Results: Exome sequencing detected a recurrent homozygous missense variant (c.266T>C; p.L89P) in exon 1 of the SLC30A10 gene. Sanger sequencing was employed to validate the segregation of the discovered variant in all available family members. Bioinformatics tools predicted that the variant is potentially pathogenic. Moreover, conservation analysis showed that the variant is highly conserved in vertebrates. Conclusions: This study shows that exome sequencing is instrumental in diagnosing undiagnosed neurodevelopmental disorders. Moreover, this study expands the mutation spectrum of SLC30A10 in distinct populations.

Magnetic Resonance Imaging and Manganism: A Narrative Review and Laboratory Recommendations

In recent years, a series of articles has been published concerning magnetic resonance imaging (MRI) studies in a group of patients exposed to manganism, specifically factory workers, welders, and individuals with liver diseases, as well as those abusing home-produced ephedrone. Some potential symptoms of manganese toxicity include motor disturbances, neurocognitive problems, sleep disorders, and psychosocial changes. Despite various publications on MRI research in individuals with an elevated risk of manganism, there is a noticeable absence of a comprehensive review in this field. The detection of the accumulation of manganese in the brain through MRI can confirm the diagnosis and guide appropriate treatment. Due to the high cost of determining manganese ion levels in biological material, an additional aim of the manuscript was to identify simple medical laboratory parameters that, when performed concurrently with MRI, could assist in the diagnosis of manganism. Among these types of parameters are the levels of bilirubin, magnesium, liver enzymes, creatinine, hemoglobin, and hematocrit.

Geogenic manganese and iron in groundwater of Southeast Asia and Bangladesh - Machine learning spatial prediction modeling and comparison with arsenic

Naturally occurring, geogenic manganese (Mn) and iron (Fe) are frequently found dissolved in groundwater at concentrations that make the water difficult to use (deposits, unpleasant taste) or, in the case of Mn, a potential health hazard. Over 6000 groundwater measurements of Mn and Fe in Southeast Asia and Bangladesh were assembled and statistically examined with other physicochemical parameters. The machine learning methods random forest and generalized boosted regression modeling were used with spatially continuous environmental parameters (climate, geology, soil, topography) to model and map the probability of groundwater Mn > 400 μg/L and Fe > 0.3 mg/L for Southeast Asia and Bangladesh. The modeling indicated that drier climatic conditions are associated with a tendency of elevated Mn concentrations, whereas high Fe concentrations tend to be found in a more humid climate with elevated levels of soil organic carbon. The spatial distribution of Mn > 400 μg/L and Fe > 0.3 mg/L was compared and contrasted with that of the critical geogenic contaminant arsenic (As), confirming that high Fe concentrations are often associated with high As concentrations, whereas areas of high concentrations of Mn and As are frequently found adjacent to each other. The probability maps draw attention to areas prone to elevated concentrations of geogenic Mn and Fe in groundwater and can help direct efforts to mitigate their negative effects. The greatest Mn hazard is found in densely populated northwest Bangladesh and the Mekong, Red and Ma River Deltas of Cambodia and Vietnam. Widespread elevated Fe concentrations and their associated negative effects on water infrastructure pose challenges to water supply. The Mn and Fe prediction maps demonstrate the value of machine learning for the geospatial prediction modeling and mapping of groundwater contaminants as well as the potential for further constituents to be targeted by this novel approach.

Elevated Whole Blood Manganese is Associated with Impaired Cognition in Older Adults, NHANES 2013 - 2014 cycle

Manganese (Mn) is found in many commonly consumed foods and therefore its deficiency is rare. However, excessive exposure to Mn from contaminated drinking water as well as occupational exposure can result in toxic accumulation in the brain, which has been associated with impaired neurological function. The objective of this study was to examine the NHANES 2013 - 2014 cycle focusing on the relationship between whole blood Mn concentrations and cognitive tests including working memory, word recall and sustained attention in elderly adults (aged 60 years and older). The different cognitive function test scores were used in principal component analysis to develop a composite score. The relationship between blood Mn concentration and cognitive function (principal component score and Digit Symbol Substitution Test (DSST)) were investigated using regression analysis. Median (95% CI) concentrations of blood Mn, serum copper, and serum iron were 8.76 (8.5, 9.1) µg/L, 114.9µg/dL (110.3, 118.1), and 80 (78, 83) µg/dL, respectively. We found that among individuals in the highest quartile of blood Mn concentration (>11.18µg/L), there was an inverse association between blood Mn and cognitive function as assessed using DSST (β (95% CI) = -0.76 (-1.19- -0.33); p=0.003), while the inverse relationship with the composite score trended towards significance (β (95% CI) = -0.04 (-0.08- 0.00); p=0.053). These findings suggest that having elevated blood Mn may be associated with cognitive decline in aging and warrants further studies on how the different sources of Mn may contribute to this outcome.

Manganese in potable water of nine districts, Bangladesh: human health risk

Safe drinking water is directly linked to good human health. An excessive amount of manganese (Mn) in drinking water supplies causes people show symptoms of neurotoxicity. In this study, the level of Mn in potable water sourced from tube wells located in 9 (nine) districts of Bangladesh was monitored. In total, 170 (one hundred and seventy) water samples were collected and Mn was quantified by atomic absorption spectroscopy (AAS). The levels of Mn found in the tube well water samples of Sirajganj, Meherpur, Chuadanga, Jhenaidah, Magura, Faridpur, Jashore, Satkhira, and Khulna were 0.37-1.86, 0.10-4.11, 0.30-0.76, 0.26-0.94, 0.01-0.18, 0.21-1.78, 0.08-1.23, 0.05-0.27, and 0.01-2.11 mg/L, respectively. Results revealed that Mn level was beyond the highest contaminated levels of 0.1 mg/L and 0.4 mg/L, which are recommended by Bangladesh Drinking Standard (BDS) and World Health Organization (WHO), respectively. The maximum Mn contaminated level reached up to 4.11 mg/L (mean, 0.53 mg/L). The Mn level in tube well water exceeded 51.1% and 75.9% set by the recommended value of WHO and BDS, respectively. Furthermore, the calculated hazard quotient (HQ) value for Mn was observed to be greater than unity, indicating both children and adults risked potential non-carcinogenic health issues. The water supply authorities should take steps to provide Mn-free drinking water for communities.

Behavioral and neurochemical studies of inherited manganese-induced dystonia-parkinsonism in Slc39a14-knockout mice

Inherited autosomal recessive mutations of the manganese (Mn) transporter gene SLC39A14 in humans, results in elevated blood and brain Mn concentrations and childhood-onset dystonia-parkinsonism. The pathophysiology of this disease is unknown, but the nigrostriatal dopaminergic system of the basal ganglia has been implicated. Here, we describe pathophysiological studies in Slc39a14-knockout (KO) mice as a preclinical model of dystonia-parkinsonism in SLC39A14 mutation carriers. Blood and brain metal concentrations in Slc39a14-KO mice exhibited a pattern similar to the human disease with highly elevated Mn concentrations. We observed an early-onset backward-walking behavior at postnatal day (PN) 21 which was also noted in PN60 Slc39a14-KO mice as well as dystonia-like movements. Locomotor activity and motor coordination were also impaired in Slc39a14-KO relative to wildtype (WT) mice. From a neurochemical perspective, striatal dopamine (DA) and metabolite concentrations and their ratio in Slc39a14-KO mice did not differ from WT. Striatal tyrosine hydroxylase (TH) immunohistochemistry did not change in Slc39a14-KO mice relative to WT. Unbiased stereological cell quantification of TH-positive and Nissl-stained estimated neuron number, neuron density, and soma volume in the substantia nigra pars compacta (SNc) was the same in Slc39a14-KO mice as in WT. However, we measured a marked inhibition (85-90%) of potassium-stimulated DA release in the striatum of Slc39a14-KO mice relative to WT. Our findings indicate that the dystonia-parkinsonism observed in this genetic animal model of the human disease is associated with a dysfunctional but structurally intact nigrostriatal dopaminergic system. The presynaptic deficit in DA release is unlikely to explain the totality of the behavioral phenotype and points to the involvement of other neuronal systems and brain regions in the pathophysiology of the disease.

GWAS of serum ALT and AST reveals an association of SLC30A10 Thr95Ile with hypermanganesemia symptoms

Understanding mechanisms of hepatocellular damage may lead to new treatments for liver disease, and genome-wide association studies (GWAS) of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) serum activities have proven useful for investigating liver biology. Here we report 100 loci associating with both enzymes, using GWAS across 411,048 subjects in the UK Biobank. The rare missense variant SLC30A10 Thr95Ile (rs188273166) associates with the largest elevation of both enzymes, and this association replicates in the DiscovEHR study. SLC30A10 excretes manganese from the liver to the bile duct, and rare homozygous loss of function causes the syndrome hypermanganesemia with dystonia-1 (HMNDYT1) which involves cirrhosis. Consistent with hematological symptoms of hypermanganesemia, SLC30A10 Thr95Ile carriers have increased hematocrit and risk of iron deficiency anemia. Carriers also have increased risk of extrahepatic bile duct cancer. These results suggest that genetic variation in SLC30A10 adversely affects more individuals than patients with diagnosed HMNDYT1.

Hypermanganesemia Induced Chorea and Cognitive Decline in a Tea Seller

Background

Manganese associated neurotoxicity and neurodegeneration is quite rare yet established neurological disorder. This neurotoxic element has predilection for depositing in basal ganglia structures, manifesting mainly as parkinsonian and dystonic movement disorders with behavioral abnormalities.

Case report

We report a 40-year-old man who presented with a subacute onset bilateral, asymmetric hyperkinetic movement disorder (predominantly left sided chorea) with multi-domain cognitive impairment, dysarthria, and generalized rigidity. Clinical history and examination yielded multiple differential diagnoses including deposition and metabolic disorders, autoimmune and paraneoplastic encephalitis involving basal ganglia, and neurodegenerative disorders with chorea and cognitive impairment. However, magnetic resonance imaging was suggestive of paramagnetic substance deposition, which came out to be manganese after laboratory investigations. History, clinical examinations, and investigation results pointed towards a diagnosis of acquired hypermanganesemia due to over-ingestion of manganese containing substance (i.e., black tea). He was treated symptomatically and with chelation therapy (calcium disodium edetate). At the sixth month of follow-up, complete resolution of chorea, dysarthria and partial amelioration of rigidity were observed. His cognitive decline and behavioral abnormalities improved.

Discussion

This is probably the first reported case of acquired hypermanganesemia that presented as a combination of asymmetric chorea and cognitive dysfunction with atypical imaging characteristics. The clinical picture mimicked that of Huntington's disease. We highlight the potential deleterious effects of an apparently "benign" non-alcoholic beverage (i.e., black tea) on cerebral metabolism.

Manganese exposure induces permeability in renal glomerular endothelial cells via the Smad2/3-Snail-VE-cadherin axis

Manganese (Mn) is an essential micronutrient. However, it is well established that Mn overexposure causes nervous system diseases. In contrast, there are few reports on the effects of Mn exposure on glomerular endothelium. In the present study, the potential effects of Mn exposure on glomerular endothelium were evaluated. Sprague Dawley rats were used as a model of Mn overexposure by intraperitoneal injection of MnCl₂·H₂O at 25 mg/kg body weight. Mn exposure decreased expression of vascular endothelial-cadherin, a key component of adherens junctions, and increased exudate from glomeruli in Sprague Dawley rats. Human renal glomerular endothelial cells were cultured with different concentration of Mn. Exposure to 0.2 mM Mn increased permeability of human renal glomerular endothelial cell monolayers and decreased vascular endothelial-cadherin expression without inducing cytotoxicity. In addition, Mn exposure increased phosphorylation of mothers against decapentaplegic homolog 2/3 and upregulated expression of zinc finger protein SNAI1, a negative transcriptional regulator of vascular endothelial-cadherin. Our data suggest Mn exposure may contribute to development of glomerular diseases by inducing permeability of glomerular endothelium.

Dietary Manganese Exposure in the Adult Population in Germany-What Does it Mean in Relation to Health Risks?

Manganese is both an essential nutrient and a potential neurotoxicant. Therefore, the question arises whether the dietary manganese intake in the German population is on the low or high side. Results from a pilot total diet study in Germany presented here reveal that the average dietary manganese intake in the general population in Germany aged 14-80 years is about 2.8 mg day^-1 for a person of 70 kg body weight. This exposure level is within the intake range of 2-5 mg per person and day as recommended by the societies for nutrition in Germany, Austria, and Switzerland. No information on the dietary exposure of children in Germany can be provided so far. Although reliable information on health effects related to oral manganese exposure is limited, there is no indication from the literature that these dietary intake levels are associated with adverse health effects either by manganese deficiency or excess. However, there is limited evidence that manganese taken up as a highly bioavailable bolus, for example, uptake via drinking water or food supplements, could pose a potential risk to human health-particularly in certain subpopulations-when certain intake amounts, which are currently not well defined, are exceeded.

Changes in water manganese levels and longitudinal assessment of intellectual function in children exposed through drinking water

BACKGROUND

Manganese is commonly found in water but potential neurotoxic effects from exposure through drinking water are poorly understood. We previously reported a cross-sectional study showing that drinking water Mn concentration was associated with lower IQ in children aged 6 to 13 years.

OBJECTIVE

For this follow-up study, we aimed to re-assess the relation between exposure to Mn from drinking water and IQ at adolescence. In addition, we aimed to examine whether changes in drinking water Mn concentration was associated with changes in IQ scores.

METHODS

From the 380 children enrolled in the baseline study, 287 participated to this follow-up study conducted in average 4.4 years after. Mn concentration was measured in home tap water and children's hair. The relationships between these Mn exposure indicators and IQ scores (Weschsler Abbreviated Scale of Intelligence) at follow-up were assessed with linear regression analysis, adjusting for potential confounders. Intra-individual differences in IQ scores between the two examinations were compared for children whose Mn concentration in water remained stable between examinations, increased or decreased.

RESULTS

The mean age at follow-up was 13.7 years (range, 10.5 to 18.0 years). Geometric mean of Mn concentration in water at follow-up was 14.5μg/L. Higher Mn concentration in water measured at follow-up was associated with lower Performance IQ in girls (β for a 10-fold increase=-2.8, 95% confidence intervals [CI] -4.8 to -0.8) and higher Performance IQ in boys (β=3.9, 95% CI 1.4 to 6.4). IQ scores were not significantly associated with Mn concentration in hair, although similar trends as for concentration in water were observed. For children whose Mn concentration in water increased between baseline and follow-up, Performance IQ scores decreased significantly (intra-individual difference, -2.4 points).

CONCLUSION

Higher levels of Mn in drinking water were associated with lower Performance IQ in girls, whereas the opposite was observed in boys. These findings suggest long-term exposure to Mn through drinking water is associated differently with cognition in boys and girls.

Human health risk assessment of lead, manganese and copper from scrapped car paint dust from automobile workshops in Nigeria

The economic downturn in Nigeria and Structural Adjustment Programme led to the flooding of Nigerian market with imported used automobiles. Most of these vehicles needed refurbishing and reworking. The present study is a human health risk assessment of metal exposure resulting from reworking of imported used vehicles in Nigeria. Scrap paint dusts from 56 Japanese made cars were collected from 8 different mechanic villages (workshops A-H] in Southeastern Nigeria. Scrap paints were homogenized, mixed, divided into fine particles and digested by standard method. The filtrates were assayed of lead, manganese and copper with atomic absorption spectrophotometry (AAS). Workshop B has the highest concentration of Pb (4.26 ± 0.93). Manganese in workshops A and F were (3.31 ± 0.85) and (3.04 ± 0.47) respectively and were higher than the levels from workshops C, B, D, G and H. Copper in workshop D (7.11 ± 0.21) was significantly greater than the other workshops. The highest hazard quotient (HQ) through ingestion, inhalation and dermal exposures in adults were 9.44E-05 (workshop B), 4.20E-01 (workshop B) and 1.08E-05 (workshop D) respectively. The highest values for HQ through ingestion, inhalation and dermal in children were 8.82E-04, 7.61E-01 and 2.86E-05 all in workshop B respectively. For children, the highest carcinogenic risk levels were 7.05E-08, 6.09E-05 and 2.29E-10 for ingestion, inhalation and dermal exposures respectively. In adults, the carcinogenic risk levels were 7.55E-09, 3.39E-05 and 8.67E-10 for ingestion, inhalation and dermal exposures respectively. Chronic exposure to scrap car paint dusts may be of significant public health importance in Nigeria as this may add to the body burden of some heavy metals.

Manganese concentrations in drinking water from villages near banana plantations with aerial mancozeb spraying in Costa Rica: Results from the Infants' Environmental Health Study (ISA)

Elevated manganese (Mn) in drinking water has been reported worldwide. While, naturally occurring Mn in groundwater is generally the major source, anthropogenic contamination by Mn-containing fungicides such as mancozeb may also occur. The main objective of this study was to examine factors associated with Mn and ethylenethiourea (ETU), a degradation product of mancozeb, in drinking water samples from villages situated near banana plantations with aerial spraying of mancozeb. Drinking water samples (n = 126) were obtained from 124 homes of women participating in the Infants' Environmental Health Study (ISA, for its acronym in Spanish), living nearby large-scale banana plantations. Concentrations of Mn, iron (Fe), arsenic (As), lead (Pb), cadmium (Cd) and ethylenethiourea (ETU), a degradation product of mancozeb, were measured in water samples. Only six percent of samples had detectable ETU concentrations (limit of detection (LOD) = 0.15 μg/L), whereas 94% of the samples had detectable Mn (LOD = 0.05 μg/L). Mn concentrations were higher than 100 and 500 μg/L in 22% and 7% of the samples, respectively. Mn was highest in samples from private and banana farm wells. Distance from a banana plantation was inversely associated with Mn concentrations, with a 61.5% decrease (95% CI: -97.0, -26.0) in Mn concentrations for each km increase in distance. Mn concentrations in water transported with trucks from one village to another were almost 1000 times higher than Mn in water obtained from taps in houses supplied by the same well but not transported, indicating environmental Mn contamination. Elevated Mn in drinking water may be partly explained by aerial spraying of mancozeb; however, naturally occurring Mn in groundwater, and intensive agriculture may also contribute. Drinking water risk assessment for mancozeb should consider Mn as a health hazard. The findings of this study evidence the need for health-based World Health Organization (WHO) guidelines on Mn in drinking water.

Manganese-Induced Parkinsonism Is Not Idiopathic Parkinson's Disease: Environmental and Genetic Evidence

Movement abnormalities caused by chronic manganese (Mn) intoxication clinically resemble but are not identical to those in idiopathic Parkinson's disease. In fact, the most successful parkinsonian drug treatment, the dopamine precursor levodopa, is ineffective in alleviating Mn-induced motor symptoms, implying that parkinsonism in Mn-exposed individuals may not be linked to midbrain dopaminergic neuron cell loss. Over the last decade, supporting evidence from human and nonhuman primates has emerged that Mn-induced parkinsonism partially results from damage to basal ganglia nuclei of the striatal "direct pathway" (ie, the caudate/putamen, internal globus pallidus, and substantia nigra pars reticulata) and a marked inhibition of striatal dopamine release in the absence of nigrostriatal dopamine terminal degeneration. Recent neuroimaging studies have revealed similar findings in a particular group of young drug users intravenously injecting the Mn-containing psychostimulant ephedron and in individuals with inherited mutations of the Mn transporter gene SLC30A10. This review will provide a detailed discussion about the aforementioned studies, followed by a comparison with their rodent analogs and idiopathic parkinsonism. Together, these findings in combination with a limited knowledge about the underlying neuropathology of Mn-induced parkinsonism strongly support the need for a more complete understanding of the neurotoxic effects of Mn on basal ganglia function to uncover the appropriate cellular and molecular therapeutic targets for this disorder.

Urgent need to reevaluate the latest World Health Organization guidelines for toxic inorganic substances in drinking water

The World Health Organization (WHO) has established guidelines for drinking-water quality that cover biological and chemical hazards from both natural and anthropogenic sources. In the most recent edition of Guidelines for Drinking-water Quality (2011), the WHO withdrew, suspended, did not establish, or raised guidelines for the inorganic toxic substances manganese, molybdenum, nitrite, aluminum, boron, nickel, uranium, mercury, and selenium. In this paper, we review these changes to the WHO drinking-water guidelines, examining in detail the material presented in the WHO background documents for each of these toxic substances. In some cases, these WHO background documents use literature reviews that do not take into account scientific research published within the last 10 or more years. In addition, there are instances in which standard WHO practices for deriving guidelines are not used; for example, rounding and other mathematical errors are made. According to published meeting reports from the WHO Chemical Aspects Working Group, the WHO has a timetable for revising some of its guidelines for drinking-water quality, but for many of these toxic substances the planned changes are minimal or will be delayed for as long as 5 years. Given the limited nature of the planned WHO revisions to the inorganic toxic substances and the extended timetable for these revisions, we suggest that governments, researchers, and other stakeholders might establish independent recommendations for inorganic toxic substances and possibly other chemicals to proactively protect public health, or at the very least, revert to previous editions of the Guidelines for Drinking-water Quality, which were more protective of public health.

Iron deficiency increases blood concentrations of neurotoxic metals in children

Iron deficiency affects approximately one-third of the world's population, occurring most frequently in children aged 6 months to 3 years. Mechanisms of iron absorption are similar to those of other divalent metals, particularly manganese, lead, and cadmium, and a diet deficient in iron can lead to excess absorption of manganese, lead, and cadmium. Iron deficiency may lead to cognitive impairments resulting from the deficiency itself or from increased metal concentrations caused by the deficiency. Iron deficiency combined with increased manganese or lead concentrations may further affect neurodevelopment. We recently showed that blood manganese and lead concentrations are elevated among iron-deficient infants. Increased blood manganese and lead levels are likely associated with prolonged breast-feeding, which is also a risk factor for iron deficiency. Thus, babies who are breast-fed for prolonged periods should be given plain, iron-fortified cereals or other good sources of dietary iron.

Blood manganese concentration is elevated in infants with iron deficiency

The present study was done to determine whether blood Mn concentration is elevated in iron-deficient infants. Thirty-one infants with iron deficiency and thirty-six control subjects (6-24 months of age) were tested for blood Mn concentration, complete blood counts, serum ferritin, and serum iron/transferring iron-binding capacity (Fe/TIBC). All the 31 iron-deficient infants were treated with iron supplement; however, 19 of them underwent blood Mn checkup again in compliance with follow-up schedule when their ferritin levels returned to the normal range. Iron therapies were done for 1-6 months (mean, 2.8; standard deviation, 1.6) using ferric hydroxide-polymaltose complex (6 mg/kg Fe(3+) daily). Infants with iron deficiency had a higher mean blood Mn concentration than controls (2.550 vs. 1.499 μg/dL, respectively). After iron therapy, the blood Mn levels of iron-deficient infants significantly decreased compared to their pre-therapy levels (2.045 vs. 2.971 μg/dL, respectively), and their hemoglobin and ferritin levels significantly increased. After adjustment for covariates (e.g., age and breast-feeding), multiple linear regression models showed that increased blood Mn levels were significantly associated with low serum ferritin and hemoglobin levels, whereas with Fe/TIBC there was only a tendency. Our results indicate that iron deficiency increases blood Mn levels in infants, presumably by increasing Mn absorption.

Emergency Do Not Consume/Do Not Use concentrations for potassium permanganate in drinking water

Over the past decade, regulatory authorities and water purveyors have become increasingly concerned with accidental or intentional adulteration of municipal drinking water. Emergency response guidelines, such as the ‘Do Not Consume’ or use concentration limits derived herein, can be used to notify the public in such cases. Potassium permanganate (KMnO4) is used to control iron concentrations and to reduce the levels of nuisance materials that affect odor or taste of finished drinking water. Manganese (Mn) is recognized an essential nutrient, permanganate (MnO4−) and manganous (Mn+2) ions are caustic, and the acute toxicity of KMnO4 is defined by its oxidant/irritant properties and by the toxicity of Mn. Ingestion of small amounts (4–20 mg/kg) of aqueous KMnO4 solutions that are above 200 mg/L causes gastrointestinal distress, while bolus ingestion has caused respiratory arrest following coagulative necrosis and hemorrhage in the esophagus, stomach, or liver. Dilute KMnO4 solutions (1–100 mg/L) are used as a topical antiseptics and astringents, but >1:5000 (200 mg/L) dilutions can irritate or discolor sensitive mucous membranes and direct skin or ocular contact with concentrated KMnO4 can perforate tissues. Based on clinical experience with 200 mg/L KMnO4, a Do Not Consume concentration of 7 mg/L KMnO4 (equivalent to 2 mg Mn/L) is recommended. Recognizing limited empirical data from which to calculate an ocular reference value, a skin contact ‘Do Not Use’ concentration of 30 mg Mn/L is recommended based on the skin irritation in some patients after a 10-min contact with 100 mg KMnO4/L.

World Health Organization discontinues its drinking-water guideline for manganese

BACKGROUND

The World Health Organization (WHO) released the fourth edition of Guidelines for Drinking-Water Quality in July 2011. In this edition, the 400-µg/L drinking-water guideline for manganese (Mn) was discontinued with the assertion that because "this health-based value is well above concentrations of manganese normally found in drinking water, it is not considered necessary to derive a formal guideline value."

OBJECTIVE

In this commentary, we review the WHO guideline for Mn in drinking water--from its introduction in 1958 through its discontinuation in 2011.

METHODS

For the primary references, we used the WHO publications that documented the Mn guidelines. We used peer-reviewed journal articles, government reports, published conference proceedings, and theses to identify countries with drinking water or potential drinking-water supplies exceeding 400 µg/L Mn and peer-reviewed journal articles to summarize the health effects of Mn.

DISCUSSION

Drinking water or potential drinking-water supplies with Mn concentrations > 400 µg/L are found in a substantial number of countries worldwide. The drinking water of many tens of millions of people has Mn concentrations > 400 µg/L. Recent research on the health effects of Mn suggests that the earlier WHO guideline of 400 µg/L may have been too high to adequately protect public health.

CONCLUSIONS

The toxic effects and geographic distribution of Mn in drinking-water supplies justify a reevaluation by the WHO of its decision to discontinue its drinking-water guideline for Mn.

Syndrome of hepatic cirrhosis, dystonia, polycythemia, and hypermanganesemia caused by mutations in SLC30A10, a manganese transporter in man

Environmental manganese (Mn) toxicity causes an extrapyramidal, parkinsonian-type movement disorder with characteristic magnetic resonance images of Mn accumulation in the basal ganglia. We have recently reported a suspected autosomal recessively inherited syndrome of hepatic cirrhosis, dystonia, polycythemia, and hypermanganesemia in cases without environmental Mn exposure. Whole-genome mapping of two consanguineous families identified SLC30A10 as the affected gene in this inherited type of hypermanganesemia. This gene was subsequently sequenced in eight families, and homozygous sequence changes were identified in all affected individuals. The function of the wild-type protein and the effect of sequence changes were studied in the manganese-sensitive yeast strain Δpmr1. Expressing human wild-type SLC30A10 in the Δpmr1 yeast strain rescued growth in high Mn conditions, confirming its role in Mn transport. The presence of missense (c.266T>C [p.Leu89Pro]) and nonsense (c.585del [p.Thr196Profs(∗)17]) mutations in SLC30A10 failed to restore Mn resistance. Previously, SLC30A10 had been presumed to be a zinc transporter. However, this work has confirmed that SLC30A10 functions as a Mn transporter in humans that, when defective, causes Mn accumulation in liver and brain. This is an important step toward understanding Mn transport and its role in neurodegenerative processes.

Exposure to multiple metals from groundwater-a global crisis: geology, climate change, health effects, testing, and mitigation

This paper presents an overview of the global extent of naturally occurring toxic metals in groundwater. Adverse health effects attributed to the toxic metals most commonly found in groundwater are reviewed, as well as chemical, biochemical, and physiological interactions between these metals. Synergistic and antagonistic effects that have been reported between the toxic metals found in groundwater and the dietary trace elements are highlighted, and common behavioural, cultural, and dietary practices that are likely to significantly modify health risks due to use of metal-contaminated groundwater are reviewed. Methods for analytical testing of samples containing multiple metals are discussed, with special attention to analytical interferences between metals and reagents. An overview is presented of approaches to providing safe water when groundwater contains multiple metallic toxins.

Manganese toxicity in a child with iron deficiency and polycythemia

A previously healthy 5-year-old girl presented with pica, emotional lability, and marked gait abnormalities. She had concurrent severe iron deficiency and polycythemia. Her magnetic resonance imaging (MRI) scan showed increased signal in the basal ganglia on T1-weighted images consistent with manganese neurotoxicity. Manganism was subsequently confirmed as her blood manganese levels were extremely elevated. Chelation therapy resulted in improvement in her mobility but she continues to have significant gait impairment. An epidemiological investigation identified well water as the potential source of manganese exposure for our patient, but to date, we have been unable to identify the nature of her neurotoxic susceptibility.

Intellectual impairment in school-age children exposed to manganese from drinking water

BACKGROUND

Manganese is an essential nutrient, but in excess it can be a potent neurotoxicant. Despite the common occurrence of manganese in groundwater, the risks associated with this source of exposure are largely unknown.

OBJECTIVES

Our first aim was to assess the relations between exposure to manganese from drinking water and children's intelligence quotient (IQ). Second, we examined the relations between manganese exposures from water consumption and from the diet with children's hair manganese concentration.

METHODS

This cross-sectional study included 362 children 6-13 years of age living in communities supplied by groundwater. Manganese concentration was measured in home tap water (MnW) and children's hair (MnH). We estimated manganese intake from water ingestion and the diet using a food frequency questionnaire and assessed IQ with the Wechsler Abbreviated Scale of Intelligence.

RESULTS

The median MnW in children's home tap water was 34 µg/L (range, 1-2,700 µg/L). MnH increased with manganese intake from water consumption, but not with dietary manganese intake. Higher MnW and MnH were significantly associated with lower IQ scores. A 10-fold increase in MnW was associated with a decrease of 2.4 IQ points (95% confidence interval: -3.9 to -0.9; p < 0.01), adjusting for maternal intelligence, family income, and other potential confounders. There was a 6.2-point difference in IQ between children in the lowest and highest MnW quintiles. MnW was more strongly associated with Performance IQ than Verbal IQ.

CONCLUSIONS

The findings of this cross-sectional study suggest that exposure to manganese at levels common in groundwater is associated with intellectual impairment in children.

Intellectual impairment in school-age children exposed to manganese from drinking water

BACKGROUND

Manganese is an essential nutrient, but in excess it can be a potent neurotoxicant. Despite the common occurrence of manganese in groundwater, the risks associated with this source of exposure are largely unknown.

OBJECTIVES

Our first aim was to assess the relations between exposure to manganese from drinking water and children's intelligence quotient (IQ). Second, we examined the relations between manganese exposures from water consumption and from the diet with children's hair manganese concentration.

METHODS

This cross-sectional study included 362 children 6-13 years of age living in communities supplied by groundwater. Manganese concentration was measured in home tap water (MnW) and children's hair (MnH). We estimated manganese intake from water ingestion and the diet using a food frequency questionnaire and assessed IQ with the Wechsler Abbreviated Scale of Intelligence.

RESULTS

The median MnW in children's home tap water was 34 µg/L (range, 1-2,700 µg/L). MnH increased with manganese intake from water consumption, but not with dietary manganese intake. Higher MnW and MnH were significantly associated with lower IQ scores. A 10-fold increase in MnW was associated with a decrease of 2.4 IQ points (95% confidence interval: -3.9 to -0.9; p < 0.01), adjusting for maternal intelligence, family income, and other potential confounders. There was a 6.2-point difference in IQ between children in the lowest and highest MnW quintiles. MnW was more strongly associated with Performance IQ than Verbal IQ.

CONCLUSIONS

The findings of this cross-sectional study suggest that exposure to manganese at levels common in groundwater is associated with intellectual impairment in children.

Incorporating genetics and genomics in risk assessment for inhaled manganese: from data to policy

Manganese is an essential nutrient, and a healthy human with good liver and kidney function can easily excrete excess dietary manganese. Inhaled manganese is a greater concern, because it bypasses the body's normal homeostatic mechanisms and can accumulate in the brain. Prolonged exposure to high manganese concentrations (>1mg/m(3)) in air leads to a Parkinsonian syndrome known as "manganism." Of greatest concern are recent studies which indicate that neurological and neurobehavioral deficits can occur when workers are exposed to much lower levels (<0.2mg/m(3)) of inhaled manganese in welding fumes. Consequently, researchers at NIOSH are conducting a risk assessment for inhaled manganese. Novel components of this risk assessment include an attempt to quantify the range of inter-individual differences using data generated by the Human Genome Project and experimental work to identify genetically based biomarkers of exposure, disease and susceptibility. The difficulties involved in moving from epidemiological and in vivo data to health-based quantitative risk assessment and ultimately enforceable government standards are discussed.

Maternal and early life exposure to manganese in rural Bangladesh

Manganese exposure and biomarker concentrations during early pregnancy and lactation were investigated in 408 women living in an area with elevated concentrations of both arsenic and manganese in drinking water derived from wells. About 40% of the water samples had manganese concentrations above the World Health Organization's guideline value and showed a strong inverse correlation with arsenic concentrations. Water manganese was found to correlate to urine concentrations, but not to blood or breast milk concentrations. No correlations were found among manganese concentrations in urine, blood, or breast milk. Compared to other populations, manganese concentrations in both urine and blood, but not breast milk, were elevated in the Bangladeshi women and more similar to those of occupationally exposed groups. The lack of associations with water manganese is likely due to variable exposure via water and food, and differences in bioavailability, as well as a complex and/or strict regulation of intestinal manganese absorption, in turn being influenced by nutritional as well as physiological and genetic factors. The results indicate that elevated maternal manganese exposure does not necessarily lead to exposure of breast-fed infants, stressing the importance of breast feeding in high manganese areas. However, the implications of fetal exposurefrom elevated maternal exposure need further investigation.