title: Massive intravenous manganese overdose due to compounding error: minimal role for hemodialysis.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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/m(2) 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , NYU School of Medicine , New York , NY , USA ;|b New York City Poison Control Center , New York , NY , USA ;
authors.forename: Elizabeth Quaal
authors.initials: EQ
authors.lastname: Hines
authors.affiliation: c Division of Nephrology, Department of Medicine , NYU School of Medicine , New York , NY , USA ;
authors.forename: Irfana
authors.initials: I
authors.lastname: Soomro
authors.affiliation: a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , NYU School of Medicine , New York , NY , USA ;|b New York City Poison Control Center , New York , NY , USA ;|d College of Pharmacy and Health Sciences, St. John's University , Jamaica , NY , USA.
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Howland
authors.affiliation: a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , NYU School of Medicine , New York , NY , USA ;|b New York City Poison Control Center , New York , NY , USA ;
authors.forename: Robert S
authors.initials: RS
authors.lastname: Hoffman
authors.affiliation: a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , NYU School of Medicine , New York , NY , USA ;|b New York City Poison Control Center , New York , NY , USA ;
authors.forename: Silas W
authors.initials: SW
authors.lastname: Smith
mesh_terms: D061605:Administration, Intravenous; D002614:Chelating Agents / Q000627:therapeutic use; D004305:Dose-Response Relationship, Drug; D062787:Drug Overdose / Q000097:blood / Q000628:therapy*; D004492:Edetic Acid / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008345:Manganese / Q000008:administration & dosage* / Q000097:blood*; D020149:Manganese Poisoning / Q000097:blood / Q000628:therapy*; D008875:Middle Aged; D020258:Neurotoxicity Syndromes / Q000209:etiology / Q000628:therapy; D006435:Renal Dialysis
chemical_list: D002614:Chelating Agents; D008345:Manganese; D004492:Edetic Acid
keywords: Adverse drug event; compounding; hemodialysis; manganese; parkinsonism