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Abstract Details

Manganese Neurotoxicity in the Setting of Alcoholic Cirrhosis
Movement Disorders
P10 - Poster Session 10 (11:45 AM-12:45 PM)
A 53-year- old male with history of alcoholic cirrhosis and PAF was brought to the emergency room due to aggressive behavior. Patient has a 30+ year history of alcohol use and consumes 7-12 drinks per day, including day of admission. Patient was alert and oriented to self and situation, on exam a fine tremor was noted in his upper extremities. Per report, the fine action tremor was present since his 30s and previously improved with alcohol use. His blood alcohol was 166 and UDS was positive for cannabinoids. He was started on a Librium taper. Due to melena, the patient underwent an EGD which revealed esophageal varices. His home metoprolol succinate was switched to carvedilol. At this point, his tremor worsened; therefore, he was transitioned to propranolol with no benefit. Exam was notable for confabulations, nystagmus most prominent on lateral gaze, myoclonic jerks,  high frequency tremor with mild amplitude was present in all extremities, and a rest tremor affecting the right arm. His reflexes were 3+ aside from LLE which was 4+ with 3-4 beats of clonus. He had significant ataxia on FTN and HTS and asterixis of his hands and feet. His gait was wide based, with mild shuffling and reduced arm swing. He reported difficulty with ambulating as he felt as his legs were shaking when he stood. MRI brain revealed mild volume loss and symmetrical abnormal t1 signal in the basal ganglia suggesting hepatocellular dysfunction. A heavy metal screen was negative. Manganese resulted elevated at 20.6 (ref 4.2-16.5), being the likely etiology of his presentation  secondary to decreased clearance in cirrhosis. With maintaining sobriety and treatment of his cirrhosis, his mentation, asterixis, ataxia and tremor improved. 
It is important to consider manganese neurotoxicity with presentation ranging from neuropsychiatric conditions to Parkinsonism. 
Anooshah Ata, MD (USF)
Dr. Ata has nothing to disclose.
Theresa A. Zesiewicz, MD (University of South Florida) Dr. Zesiewicz has received personal compensation for serving as an employee of Medscape. Dr. Zesiewicz has received intellectual property interests from a discovery or technology relating to health care.