Young-onset Parkinsonism needs to be evaluated for all secondary causes especially treatable conditions.  Manganese-induced Parkinsonism is an uncommon cause and herewith report a case series of four patients. 

Manganese is an essential trace element. Excess accumulation of manganese in the brain results in a neurological syndrome with movement, psychiatric and cognitive abnormalities. Chronic manganese intoxication was first described by Couper in 1837, has been recognized as a preventable cause of secondary parkinsonism.

We evaluated four patients in the age group of 20-35 years presented with features of Parkinsonsim., All the subjects had routine blood investigations, ophthalmological examination, MRI brain and blood manganese levels. All four patients have worked in a Ferro-manganese alloy company in local area.

Three patients presented with speech disturbances, gait abnormality, rigidity, handwriting problems, and one of these also had pathological laughter. One patient had only speech problem without any other Parkinson features. All four patients’ blood investigations are within normal limits; their MRI brain has shown bilateral T1 hyper intensities in basal ganglia. Ophthalmological examination was normal without K-F ring. Their blood manganese levels were elevated in three patients, and one patient with upper limit of normal level. All the patients are taken up for EDTA chelation therapy and are on follow up. 

This case series suggests that occupational history should be thoroughly enquired especially in secondary parkinsonism cases. We should not leave the young onset parkinsonism cases without evaluating for all causes and considering them as genetic parkinsonism.