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WELDING, MANGANESE AND PARKINSONISM
For Forensic Toxicology, Forensic Medicine, Toxicology and Internal Medicine Experts
By Nachman Brautbar, M.D.
- Welding, Manganese
- Manganese and Neurological Diseases, Parkinsonism
- Neuropathology and Pathophysiology of Manganese Toxicity
- Idiopathic vs. Manganese, Parkinsonism?
- Levels of Exposure to Manganese
- State of the Art
- Establishing Causation
In Forensic Toxicology:
Welding is a common industrial process - so common that up to 2% of the working population in industrialized countries has been engaged in some sort of welding.
Although the types of welding are many, it has been estimated that shielded metal arc welding (SMAW), gas metal arc welding (GMAW) on mild steel, stainless steel
and aluminum are performed by 70% of welders. Arc welding causes emission of manganese.
Manganese (Mn) is an element that is an essential nutrient, but that can be toxic at high exposures. Mn is ubiquitous in the ambient environment, being present
in the soil, water, air, and food. The main source of Mn intake for most individuals is food.
Caution: (INDUSTRY'S OFFICIAL KNOWLEDGE)
Welding may produce fumes and gases hazardous to health.
Avoid breathing these fumes and gases. Use adequate ventilation. See ANSI Z49.1-1967, Safety in Welding and Cutting, published by American Welding Society.
The type of welding identified in all companies was electric arc welding and 90% was MIG on mild steel. A total of 42 welders were monitored for personal
exposure to welding fumes. Nearly 60% were overexposed to manganese and 19% were overexposed to iron. Two welders from two different companies had
the two highest manganese exposures. Both had worked in isolated welding stations.
Facts for the Forensic Toxicologist, Forensic Medicine, Toxicology and Occupational Physician:
Manganese, which enters the body primarily via inhalation, can damage the nervous system and respiratory tract, as well as have other adverse effect.
Occupational exposures occur mainly in mining, alloy production, processing, ferro-manganese operations, welding and work with agrochemicals. Among the
neurologic effects is an irreversible Parkinsonian-like syndrome (Degenerative neurologic disease). A wide spectrum of neuropsychiatric illnesses
have been described with manganese toxicity.
Manganese and Parkinssonism
Manganese can cause an irreversible Parkinsonian-like syndrome, characterized by fixed gaze, bradykinesia, postural difficulties, rigidity,
tremor, dystonia, and decreased mental status. This neurologic condition, first described in two manganese ore-crushing mill workers by Couper
in 1837 has been referred to as manganism.
Neuropathology and Pathophysiology of Manganese Nervous System Damage
Manganese deposits in the brain have been described within the basal ganglia of the brain,the cortex and the medulla.
Manganese can reduce dopamine in the caudate nucleus, norepinephrine in the hypothalamus, and neuromelanin in the substantia nigra. It appears that
manganese may increase dopamine oxidation with associated free radical formation.
Imaging Studies
Some preliminary magnetic resonance imaging studies have shown that manganese accumulates in the globus pallidus. Manganese causes neuronal loss and
gliosis in the striatum, subthalamic nucleus, and pallidum, but little change in the substantia nigra.
Positron emission tomography (PET) scans of two welders showed abnormalities typical of idiopathic Parkinson's disease. The authors concluded
that parkinsonism in welders cannot be distinguished from idiopathic Parkinson's disease, except by early age of onset. (Discussion of their
findings can be found in an accompanying editorial and subsequent letters to the editor).
1. Illustrative of Some Case Reports and Case Studies of Manganese Exposure and Neurologic Disorders
The Racette Study
Racette et al (2001) performed a case control study of 15 career welders and two groups of control subjects with idiopathic Parkinson's disease.
They found that the welders developed parkinsonism at a younger age (on average, 46 years) than sequentially ascertained controls (63 years; p<0.0001).
They found no difference between groups in the following parameters: tremor, bradykinesia, rigidity, asymmetric onset, postural instability, dementia drug
induced psychosis, motor fluctuations and dyskinesias. Since manganese toxicity can cause a wide spectrum of neurological diseases, there is no scientific
"check box" list to determine that the Parkinsonian like syndrome in front of the treating and evaluating expert is "idiopathic." Causation analysis is
based on differential diagnosis, history, review of records, environmental data and Material Safety Data Sheets (MSDS). See the paper on causation.
Levels of Exposure To Manganese and Neurological Damage
Sinczuk-Walczak et al (2001) assessed the effects of manganese on the nervous systems of 62 welders and 13 battery production workers. Increased emotional
irritability, memory impairment, concentration difficulties, sleepiness and limb paresthesias were found in the manganese-exposed workers. The authors concluded
that manganese exposure up to 2.67 mg/m3; geometric mean, 0/15 mg/m3 (arithmetic mean, 0.4 mg/m3; geometric mean 0.15 mg/m3 ) induces subclinical nervous
system effects.
Exposure Limits
- OSHA GENERAL INDUSTRY PEL: 5 mg/m3 Ceiling
- OSHA CONSTRUCTION INDUSTRY PEL: 5 mg/m3 TWA
- ACGIH TLV: 02 mg/m3 TWA Elemental and inorganic compounds
- NIOSH REL: 1 mg/m3 TWA; 3 mg/m3 STEL
State of the Art
State of the art knowledge that manganese from welding was hazardous and associated with Parkinson's.
In 1932, a German study was published that associated the exposure to manganese laden welding fumes to the onset of manganism.
The author found that electric arc welding was a health risk to the welder because of the manganese in the fumes.
Symtoms and Response To Treatment
- The Racette paper demonstrates that clinically idiopathic Parkinson's cannot be distinguished from manganese induced Parkinson's.
- Imaging studies of the brain are not conclusive
Most Rescent Niosh Study
The Racette paper demonstrates that clinically idiopathic Parkinson's cannot be distinguished from manganese induced Parkinson's.
Imaging studies of the brain are not conclusive.
Data That The Experts in Forensic Toxicology, Forensic Medicine, Toxicology and Internal Medicine Should Know
Materials Needed for Causation
- Material Safety Data Sheets
- Modeling range of level of exposure
- Rule out other causes, pesticides, carbon monoxide, certain medications
- Temporal relationship between exposure and development of symptoms
- Scientific papers connecting manganese in welding and neurologic damage (animals, humans)
- Team: MD Toxicologist, industrial hygienist, neurologist, neuroradiologist
[Updated Manuscript in preparation]
References
From Racette, B.A. et al, Weldikng-related parkinsonism, Clinical features, treatment and pathophysiology,
Neurology, 56; p. 8-13; January, 2001
-
Wallace ME, Fischbach T, Kovein RJ. Occupational Safety
and Health Administration. In-depth survey report. Control
technology assessment for the Welding Operations Boilermaker's
Apprenticeship Training School, Kansas City,
KS. June 27, 1997. No. ECTB 214-13a.
-
Hemminki K, Peto J, Stern RM. Summary report: international
conference on health hazards and biological effects of
welding fumes and gases. In: Stern RM, Berlin A, Fletcher
AC, Jarvisalo J, eds. Health hazards and biologic effects of
welding fumes and gases. Amsterdam, the Netherlands: Excerpta
Medica, 1986:1-5.
-
National Institute of Occupational Safety and Health. Criteria
for a recommended standard: occupational exposure to welding,
brazing, and thermal cutting. Cincinnati, OH: US Department
of Health and Human Services, Public Health Service,
Centers for Disease Control, National Institute for Occupational
Safety and Health, 1988. Division of Health and Human
Services (NIOSH) Publication No. 88-110.
-
American Welding Society Safety and Health Committee. Effects
of welding on health VIII. Miami, FL: American Welding Society,
Safety and Health Committee, 1993. ISBN: 0-87171-437-X.
-
Papp JL. Metal fume fever. Postgrad Med 1963;43:160-163.
-
Herbert A, Sterling G, Abraham J, Corrin B. Desquamative
interstitial pneumonia in an aluminum welder. Hum Pathol
1982;13:694-699.
-
Herbert A, Sterling G, Abraham J, Corrin B. Desquamative
interstitial pneumonia in an aluminum welder. Hum Pathol
1982;13:694-699.
-
Meyer EC, Kratzinger SF, Miller WH. Pulmonary fibrosis in
an arc welder. Arch Environ Health 1967;15:462-469.
-
Sjogren B, Gustavsson A, Hedstrom L. Mortality in two cohorts
of welders exposed to high-and low-levels of hexavalent
chromium. Scand J Work Environ Health 1987;13:247-251.
-
Becker N, Claude J, Frentzel-Beyme R. Cancer risk of arc
welders exposed to fumes containing chromium and nickel.
Scand J Work Environ Health 1985;11:75-82.
-
Olsen J Sabroe S, Lajer M. Welding and cancer of the larynx: a
case-control study. Eur J Cancer Clin Oncol 1984;20:639-643.
-
Sykowski P. Dendritic type of keratitis caused by a welding
arc. Am J Ophthalmol 1951;34:99-100.
-
Palmer WG. Effects of welding on health IV. Miami, FL:
American Welding Society, 1983:37.
-
Johnson JS, Kilburn KH. Cadmium induced metal fume fever;
results of inhalation challenge Am J Ind Med 1983;4:533-540.
-
National Institute of Occupational Safety and Health Bulletin.
Preventing lead poisoning in construction workers.
NIOSH alert: April 1992. Division of Health and Human Services
(NIOSH) Publication No. 91-116a.
-
Nelson K, Golnick J, Korn T, Angle C. Manganese encephalopathy:
utility of early magnetic resonance imaging. Br J Ind
Med 1993;50:510-513.
-
Tanaka S, Lieben J. Manganese poisoning and exposure in
Pennsylvania. Arch Environ Health 1969;19:674-684.
-
Feldman RG. Manganese as possible ecoetiologic factor in
Parkinson's disease. Ann NY Acad Sci 1992;648:266-267.
-
Kim Y, Kim HW, Ito K, et al. Idiopathic parkinsonism with
superimposed manganese exposure: utility of positron emission
tomography. Neurotoxicology 1999;20:249-252.
-
Sjogren B, Anders I, Frech W, et al. Effects on the nervous
system among welders exposed to aluminum and manganese.
Occup Environ Med 1996;53:32-40.
-
Chandra SV, Shukla GS, Srivastava RS, Singh H, Gupta VP.
An exploratory study of manganese exposure to welders. Clin
Toxicol 1981;18:407-416.
-
Fahn S, Elton RL, Members of the UPDRS Development Committee.
Unified Parkinson's disease rating scale. In: Fahn S,
Marsden CD, Goldstein M, Calne DB, eds. Recent developments
in Parkinson's disease. New York, NY: Macmillan,
1987:153-163.
-
American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 4th ed. (DSM-IV). Washington,
DC: American Psychiatric Association 1994;143-147.
-
Racette BA, Rundle M, Parsian A, Perlmutter JS. Evaluation
of a screening questionnaire for genetic studies of Parkinson's
disease. Am J Med Genet 1999;88:539-543.
-
Spinks TJ, Jones T, Bailey DL, et al. Physical performance of
a positron tomograph for brain imaging with retractable
septa. Phys Med Biol 1992;37:1637-1655.
-
Fox PT, Perlmutter JS, Raichle ME. A stereotactic method of
anatomical localization for positron emission tomography.
J Comput Assist Tomogr 1985;9:l4l-l53.
-
Moerlein SM, Verrant JA, Bellamy JA, Perlmutter JS, Welch
M.J. Optimized clinical production of the PET tracer 6-[F-
18]fluorodopa. Int Pharm Abst 1999;36:2269. Abstract.
-
Woods RP, Cherry SR, Mazziotta JC. Rapid automated algorithm
for aligning and reslicing PET images. J Comput Assist
Tomogr 1992;16:620-633.
-
Andersson JLR. How to obtain high-accuracy image registration:
application to movement correction of dynamic positron
emission tomography data. Eur J Nucl Med 1998;25:575-586.
-
Patlak CS, Blasberg RG, Fenstermacher JD. Graphical evaluation
of blood-to-brain transfer constants from multiple-time
uptake data. J Cereb Blood Flow Metab 1983;3:1-7.
-
Logan J, Wolf AP, Shiue C-Y, Fowler JS. Kinetic modeling of
receptor-ligand binding applied to positron emission tomographic
studies with neuroleptic tracers. J Neurochem 1987;
48:73-83.
-
Parkinson Study Group. DATATOP: a multicenter controlled
trial in early Parkinson's disease. Arch Neurol 1989;46:1052-
1060.
-
Sjogren B, Gustavsson P, Hogstedt C. Neuropsychiatric symptoms
among welders exposed to neurotoxic metals. Br J Ind
Med 1990;47:704-707.
-
Lucking CB, Durr A, Bonifati V, et al. Association between
early-onset Parkinson's disease and mutations in the Parkin
gene. N Engl J Med 2000;342:1560-1567.
-
Rodier J. Manganese poisoning in Moroccan miners. Br J Ind
Med 1955;12:21-35.
-
Cook DG, Fahn S, Brait KA. Chronic manganese intoxication.
Arch Neurol 1974;30:59-64.
-
Whitlock CM, Amuso SJ, Bittenbender JB. Chronic neurological
disease in two manganese steel workers. Am Ind Hyg
Assoc J 1966;454-459.
-
Wang JD, Huang CC, Hwang YH, Chiang JR, Lin JM, Chen
JS. Manganese induced parkinsonism: an outbreak due to an
unrepaired ventilation control system in a ferromanganese
smelter. Br J Ind Med 1989;46:856-859.
-
Calne DB, Chu NS, Huang CC, Lu CS, Olanow W. Manganism
and idiopathic Parkinsonism: similarities and differences.
Neurology 1994;44:1583-1586.
-
Huang CC, Lu CS, Chu NS, et al. Progression after chronic
manganese exposure. Neurology 1993;43:1479-1483.
-
Lu CS, Chin-Chang H, Chu NS, Calne DB. Levodopa failure
in chronic manganism. Neurology 1994;44:1600-1602.
-
Mena I, Court J, Fuenzalida S, Papavasiliou PS, Cotzias
GC. Modification of chronic manganese poisoning: treatment
with L-dopa or 5-OH tryptophane. N Engl J Med
1970;282:5-10.
-
Tanner CM, Ottman R, Goldman SM, et al. Parkinson disease
in twins: an etiologic study. JAMA 1999;281:341-346.
-
Brooks DJ, Ibanez V, Sawle GV, et al. Differing patterns of
striatal 18F-dopa uptake in Parkinson's disease, multiple system
atrophy, and progressive supranuclear palsy. Ann Neurol
1990;28:547-555.
-
Wolters EC, Huang CC, Clark C, et al. Positron emission
tomography in manganese intoxication. Ann Neurol 1989;26:
647-651.
-
Eriksson H, Tedroff J, Thuomas KA, et al. Manganese induced
brain lesions in Macaca fascicularis as revealed by
positron emission tomography and magnetic resonance imaging.
Arch Toxicol 1992;66:403-407.
-
Mena I, Court J, Fuenzalida S, Papavasilou PS, Cotzias GC.
Chronic manganese poisoning: clinical picture and manganese
turnover. Neurology 1967;17:128-136.
-
Shinotoh H, Snow BJ, Hewitt KA, et al. MRI and PET studies
of manganese-intoxicated monkeys. Neurology 1995;45:1199-
1204.
-
Mirowitz SA, Westrich TJ, Hirgsch JD. Hyperintense basal
ganglia on T1-weighted MR images in patients receiving parenteral
nutrition. Radiology 1991;181:117-120.
Dr. Brautbar is a board-certified internist and nephrologist. If you would like to schedule an appointment with Dr. Brautbar, or if you are interested in retaining Dr. Brautbar for forensic and expert witness testimony services, please submit the Contact Form.
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