Chronic Manganese Neuro-Toxicity in a Patient With Cirrhosis and the Role of Iron-Deficiency Anaemia

Patients with chronic liver disease (CLD) are prone to complications associated with impaired liver functioning. This coupled with iron-deficiency anaemia (IDA) can predispose them to multiple comorbidities. We present an interesting case of a 69-year-old woman with a background history of liver cirrhosis due to metabolic dysfunction-associated steatotic liver disease (MASLD) with frequent travels to Bangladesh, a southeast Asian country known for having high levels of manganese (Mn) in water for domestic use. She presented with progressively worsening cognition and extrapyramidal symptoms. She underwent routine blood tests including for liver functions followed by a non-contrast computed tomogram (CT) of the head that did not suggest a possible cause. However, magnetic resonance imaging (MRI) of the brain showed hyperintensities bilaterally in the globus pallidus, subthalamic nucleus, red nucleus, and substantia nigra and raised the possibility of Mn toxicity. This was confirmed with repeated raised blood levels of Mn. The query was raised for acute toxicity to Mn, followed by consideration of CLD history associated with reduced elimination of Mn. This was complicated further by her history of IDA. Her case was discussed in a multi-disciplinary setting with specialities including radiology, gastroenterology, neurology, psychiatry, hepatology, and elderly medicine. Following this, a decision was made for the best supportive management of the patient. This case highlights the importance of MRI in the detection of a rare case of Mn toxicity, in a predisposed individual contributing to cognitive decline with extrapyramidal symptoms.