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Manganese pneumonitis — Clinical Guidelines

Overview

Manganese pneumonitis is a respiratory condition resulting from inhalation of high levels of manganese, often seen in occupational settings or due to accidental exposure, leading to pulmonary toxicity and potential systemic effects. 1 2 3

Diagnosis

Clinical Presentation: Symptoms may include respiratory distress, cough, and systemic manifestations like lethargy and abdominal pain in severe cases. 2

Exposure History: Key to identifying occupational or accidental exposure to manganese fumes or dust. 5

Laboratory Tests: Elevated urinary manganese levels can indicate exposure; levels >400 nmol/L may signal risk. 4

Imaging: Increased signal intensities on T1-weighted MRI, particularly in the globus pallidus, can reflect manganese accumulation, though not specific to pneumonitis alone. 3

Biomarkers: Blood manganese concentration and pallidal index may correlate with exposure levels. 3

Management

Supportive Care: Intensive care management including intubation, ventilation, and hemofiltration for severe cases. 2

Chelation Therapy: Use of EDTA for treating manganese intoxication, especially in acute poisoning scenarios. 2

Monitoring: Regular assessment of respiratory function and neurological status, especially in chronic exposure cases. 5

Avoidance: Removal from the source of manganese exposure is crucial. 3

Special Populations

Occupational Exposure: Welders and workers exposed to manganese dust or fumes are at higher risk; monitoring and protective measures are essential. 3

No Specific Guidance: Limited data on pregnancy, pediatrics, or elderly populations; general principles of avoidance and supportive care apply. 4 5

Key Recommendations

Identify and Remove Exposure: Promptly identify and eliminate sources of manganese exposure to prevent progression of pneumonitis. (Evidence: Expert opinion) 5

Utilize Chelation Therapy: In cases of acute manganese intoxication, initiate EDTA chelation therapy to reduce manganese levels. (Evidence: Weak) 2

Monitor Biomarkers and Imaging: Regularly monitor urinary manganese levels and consider MRI for signs of manganese accumulation, especially in exposed populations. (Evidence: Moderate) 3 4

References

1 Friedman A, Boselli E, Ogneva-Himmelberger Y, Heiger-Bernays W, Brochu P, Burgess M et al.. Manganese in residential drinking water from a community-initiated case study in Massachusetts. Journal of exposure science & environmental epidemiology 2024. link 2 Sánchez B, Casalots-Casado J, Quintana S, Arroyo A, Martín-Fumadó C, Galtés I. Fatal manganese intoxication due to an error in the elaboration of Epsom salts for a liver cleansing diet. Forensic science international 2012. link 3 Kim Y. High signal intensities on T1-weighted MRI as a biomarker of exposure to manganese. Industrial health 2004. link 4 Pantůcek MB. The determination of manganese in urine. Czechoslovak medicine 1982. link 5 Palladini G, Margotta V, Carolei A, Hernandez MC. Dopamine agonist performance in Planaria after manganese treatment. Experientia 1980. link 6 Hine CH, Pasi A. Manganese intoxication. The Western journal of medicine 1975. link

Manganese pneumonitis