Manganese toxicity in critical care: Case report, literature review and recommendations for practice.

We present the case of a 62-year-old man on the intensive care unit with pancreatitis. Since early in his admission, and for the remainder of his prolonged stay in intensive care, he has received parenteral nutrition for intestinal failure. The whole blood manganese concentration was significantly increased after 2½ months of parenteral nutrition (PN). Three months into his stay, he developed a resting tremor and extra-pyramidal dyskinesia. In the absence of other neurological symptoms, and with no history of essential tremor, Parkinsonism or cerebral signs, hypermanganesaemia was presumed to be the cause. We review manganese metabolism and toxicity in patients who are fed with parenteral nutrition and review the current recommendations and guidelines.