What is the recommended treatment for manganese deficiency causing coordination and movement symptoms?

Treatment for Manganese Deficiency Causing Coordination and Movement Symptoms

For patients with manganese deficiency manifesting as coordination and movement symptoms, oral supplementation of 2-3 mg of manganese per day is recommended as the primary treatment, with careful monitoring to avoid toxicity.

Diagnosis Confirmation

Before initiating treatment, confirm manganese deficiency through:

• Whole blood or RBC manganese measurements 1
• Assessment for clinical symptoms: ataxia, loss of coordination, and movement disorders 1
• Brain MRI to rule out manganese toxicity (which can present with similar symptoms) 1

Treatment Algorithm

First-line Treatment:

• Oral supplementation: 2-3 mg manganese per day 1
  • Available in foods such as whole grains, nuts, legumes, leafy vegetables
  • Supplement forms available if dietary intake insufficient

Special Populations:

• Adults requiring parenteral nutrition:

  • Provide 1 mmol (55 μg) manganese per day 1
  • Maximum of 50 μg/day for routine supplementation 1

• Pediatric patients requiring parenteral nutrition:

  • No more than 1.0 mg/kg/day (maximum 50 μg/day) 1

Monitoring:

• Regular blood manganese measurements (not more frequent than 40-day intervals due to biological half-life) 1
• Regular neurological examinations to assess improvement in coordination and movement symptoms 1
• Monitor for signs of toxicity (see below)

Important Considerations

Differential Diagnosis

Manganese-related movement disorders can be caused by either:

• Deficiency: Rare but documented to cause ataxia and impaired coordination 1
• Toxicity: More common, causing Parkinson-like symptoms, loss of coordination, and movement disorders 1

Risk Factors for Toxicity

• Long-term parenteral nutrition (>30 days) 1
• Liver dysfunction or cholestasis 1
• Iron deficiency (increases manganese absorption) 1, 2
• Polycythemia 2

Warning Signs of Toxicity

• Headache, asthenia, irritability, fatigue
• Progressive movement disorders resembling Parkinson's disease
• MRI showing high signal intensity in globus pallidus 1, 3
• Whole blood manganese >2× upper limit of normal 1

Management of Toxicity

If toxicity develops:

1. Immediately discontinue manganese supplementation 1
2. Consider chelation therapy (EDTA or para-aminosalicylic acid) 1
3. Correct any concurrent iron deficiency 1, 2
4. Monitor with serial MRI and blood manganese levels 3

Special Considerations

• Manganese deficiency is exceptionally rare in humans compared to toxicity 1
• Even low doses of parenteral manganese (110 μg/day) can lead to elevated blood levels 1
• Patients with genetic disorders of manganese transport (SLC30A10 mutations) may present with early-onset movement disorders 4
• Patients with hereditary hemorrhagic telangiectasia may be at risk for manganese-induced parkinsonism 5