C H A P T E R
45
Manganese
ROBERTO G. LUCCHINI, MICHAEL ASCHNER, YANGHO KIM, AND MARKO ŠARIĆ
ABSTRACT
Manganese (Mn) is an essential element for
humans, animals, and plants. In humans and ani-
mals the systemic Mn status is regulated by homeo-
static mechanisms. The natural presence of Mn and
its compounds in the environment is being progres-
sively overridden by anthropogenic enrichment.
The main sources of Mn exposure are occupational,
including mining, iron/steel making, ferro/silico-
Mn alloy and dry alkaline battery production, and
welding. Environmental Mn exposure is lower and is
usually related to industrial emissions, the use of Mn
compounds in agriculture and as fuel additives, and
a high Mn content in drinking water. A high content
of Mn in milk formula, in total parenteral nutrition
solution, and in drugs of abuse, as well as iron defi-
ciency, can also increase the Mn body burden. Besides
through increased absorption, systemic Mn overload
can derive from impaired biliary excretion due to
hepatic insufficiency. The main toxic effects of Mn
are on the central nervous system, including impair-
ment of motor and cognitive function. Manganism is
a neurological disorder that may occur in response
to high inhalation exposures in occupational settings
and which is characterized by mood changes and
an extrapyramidal syndrome resembling Parkinson
disease. Prolonged exposure to lower Mn doses can
lead to an increased frequency of the signs of par-
kinsonism. Effects on the respiratory, reproductive,
cardiovascular, hematological, endocrine, and immu-
nological systems are also discussed in this chapter,
including genotoxicity and carcinogenicity.
Handbook on the Toxicology of Metals 4E
http://dx.doi.org/10.1016/B978-0-444-59453-2.00045-7
1 INTRODUCTION
As the fifth most abundant metal, manganese (Mn)
is ubiquitous in the environment, comprising 0.1% of
the Earth’s crust; soil levels are progressively increas-
ing from anthropogenic sources. Mn is found in soil,
air, deposited dust, water, and food. Its concentration
in food varies markedly, but on the whole food is the
major source of Mn intake for humans.
Mn absorption by inhalation, ingestion, and via the
olfactory tract, and its distribution in the body, metab-
olism, and excretion are described based on findings
from animal and human studies. The absorption of
ingested Mn is regulated by homeostatic mechanisms
and is predominantly achieved by regulation of its
excretion. Absorbed Mn is rapidly eliminated from
the blood and first becomes concentrated in the liver,
where it conjugates with the bile and is excreted into
the intestine and feces. Urinary excretion is only about
0.01% per day of the body burden. The biological half-
life in humans is 2-5 weeks, depending on body stores.
Mn crosses the blood-brain barrier and accumulates in
the brain, where the half-life is much longer than in
blood.
Mn is an essential element for humans, animals,
and plants. Although the daily Mn intake for many
people is likely to be below the estimated safe and
adequate levels, large-scale deficiency has not been
reported. Long-term exposure to increased concentra-
tions of Mn, associated primarily with inhalation in
occupational settings, may result in neurological, neu-
robehavioral, and mood effects. Research studies sug-
gest a direct link between chronic Mn exposures and
975 Copyright © 2015 Elsevier B.V. All rights reserved.
976 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
parkinsonian-like disturbances. Mn-induced extrapy-
ramidal damage seems to occur postsynaptically to the
nigrostriatal system, predominantly in the globus pal-
lidus and the striatum, as well as in other brain areas
such as the cortex. The principal mechanism of Mn
neurotoxicity has yet to be clarified. Mn may poten-
tiate the auto-oxidation or turnover of various intra-
cellular catecholamines, such as dopamine, leading to
increased production of free radicals, reactive oxygen
species (ROS), and other cytotoxic metabolites. It may
disturb also γ-aminobutyric acid (GABA) regulation, as
well as glutamatergic neurotransmission. It also seems
to impair cellular antioxidant defense mechanisms.
Lungs are the second major target organ affected by
the exposure to Mn. Inhalation exposure to high concen-
trations of Mn dioxide (or tetroxide) can cause chemi-
cal pneumonitis, an inflammatory response. Moreover,
an increased incidence of acute respiratory diseases—
bronchitis and pneumonia—has also been reported
at low exposure levels, suggesting that inhaled Mn in
an insoluble form can impair resistance to respiratory
infections. This assumption has been supported by
experimental and epidemiological studies. The influ-
ence of Mn exposure has also been reported on the
reproductive, cardiovascular, hematological, endocrine,
and immunological systems. Although Mn can cause
mutations, it is not deemed to be a carcinogenic metal.
Mn can be measured in various biological media.
Common biomarkers of exposure are blood and urine
Mn. On a group basis, average levels of Mn in blood
appear to be related to Mn body burden; in contrast,
Mn in urine is less useful than blood-Mn (B-Mn) as an
exposure biomarker at the group level, because of the
high degree of variability and relatively short biologi-
cal half-life (< 30 h). Thus, Mn in urine may to some
extent reflect very recent exposure. On an individual
basis, blood and urine levels of Mn are not reliable
predictors of exposure to Mn. No significant correla-
tion has been found between fecal excretion of Mn
and exposure to the metal. Data on hair measurement
in environmentally exposed children show a relation
with the exposure over the previous months, and new
biomarkers like Mn in nails, saliva, or deciduous teeth,
or the Mn:Fe ratio in plasma or erythrocytes are being
assessed and deserve further validation.
The appearance of pallidal high signal intensities on
T1-weighted magnetic resonance imaging (MRI) may
reflect a target organ dose of occupational Mn expo-
sure. In addition; Mn has a longer half-life in the brain
than in blood. Thus, pallidal signal intensity is likely
to better reflect the cumulative dose compared to the
B-Mn level.
A number of documents on Mn are available by
international agencies regarding toxicity (WHO, 1986,
2004a; EPA, 2012a; ATSDR, 2012), drinking water
guidelines (WHO, 2011; EPA, 2012b), and air quality
(WHO, 2000; EPA, 2010; Health Canada, 2010). Sev-
eral reviews have also been published (Bowman et al.,
2011; Rivera-Mancía et al., 2011; Zheng et al., 2011;
Guilarte, 2010; Lucchini et al., 2009; Yokel, 2009; Roth,
2009; Aschner et al., 2009).
2  PHYSICAL AND CHEMICAL PROPERTIES
Manganese: atomic weight 54.94; atomic number
25; density 7.21-7.44 g/m3, depending on the allotropic
form; melting point 1245°C; boiling point 2097°C;
whitish-gray metal, harder than iron, very brittle. It
is a transitional element that belongs to group VIIB
in the periodic table of the elements and it occurs in
eight oxidation states, of which 0, II, IV, and VII are
the most frequent, and valences I, III, V, and VI are
rare. The only Mn cations are Mn2+ and Mn3+, which
possess strong paramagnetic moments because of sev-
eral uncoupled electrons. Divalent Mn(II), present in
salts such as Mn chloride (MnCl2) or sulfate (MnSO4),
is the most stable valence; Mn dioxide (MnO2) is the
most important Mn compound of the tetravalent state
(IV), and potassium permanganate (KMnO4) of the
(VII) valence state. Most Mn salts are readily soluble in
water, with only the phosphate and the carbonate hav-
ing lower solubilities. Mn oxides are poorly soluble in
water. Mn forms various organometallic compounds
among which methylcyclopentadienyl Mn tricarbonyl
(MMT) is of major practical interest. Mn and its com-
pounds can exist as solids in the soil and as solutes or
small particles in water. Mn can also be present in fine
and ultrafine dust particles in the air. Conversion fac-
tors: 1 μg Mn = 18.2 nmol Mn; 1 μg Mn/L ÷ 18.2 = 1 nmol
Mn/L; 1  μg Mn/g creatinine = 2.06 nmol Mn/mmol
creatinine. The Chemical Abstracts Service (CAS) Nos
are: manganese 7439-96-5; Mn dioxide (Mn2O) 1313-
13-9; Mn oxide (Mn3O4) 1317-35-7; Mn chloride 7773-
01-5; Mn(II) sulfate 7785-87-7; Mn sulfate monohydrate
10034-96-5; potassium permanganate 7722-64-7; MMT
12108-13-3.
3  METHODS AND PROBLEMS OF
ANALYSIS
Classical methods of analysis have been the peri-
odate method for Mn in air, and the permanganate
method for Mn in water. However, these methods are
not satisfactory for biological samples. Ideally, analysis
is now performed using inductively coupled plasma
atomic emission spectroscopy (ICP-AES). It is also
 45 Manganese
possible to use flame atomic absorption spectroscopy
(AAS). In this method, a solution containing Mn is
aspirated into a flame, and the concentration of Mn is
determined from the light absorption at λ = 279.5 nm.
AAS has a lower sensitivity than ICP-AES and has gen-
erally been replaced by ICP-AES because of the greater
suitability of ICP-AES for multielement analysis. High
resolution ICP-coupled mass spectrometry (ICP-MS)
has a greater sensitivity than ICP-AES. Progress in
ICP-MS instrumentation was achieved by the intro-
duction of the collision cell interface to dissociate the
many disturbing argon-based molecular ions, thermal-
ize the ions, and neutralize the disturbing argon ions
of plasma gas (Ar+). Application of the collision cell in
ICP-MS results in higher ion transmission, improved
sensitivity, and more precise isotope ratio measure-
ments compared to quadrupole ICP-MS without the
collision cell (Becker and Dietze, 2000).
Neutron activation analysis is also an effective way
to determine Mn concentrations in different samples
(Pejovic-Milic et al., 2009). This technique uses no
reagents and a minimum of sample handling; thus,
potential contamination with exogenous sources of Mn
can be avoided. It can be used for both environmental
and biological samples. Other methods include spectro-
photometry, MS, and X-ray fluorescence. Mn levels are
nearly always reported as total Mn because none of the
methods listed can distinguish between the different oxi-
dation states of Mn or between different Mn compounds.
A simple determination of total Mn by atomic
absorption or gas chromatography followed by flame-
ionization detection can be used to quantify MMT
concentrations in gasoline. By detecting the metal-
lic portion of the compound, the detected MMT is
reported as Mn. Walton et al. (1991) described high
performance liquid chromatography coupled to laser-
excited atomic fluorescence spectrometry as a method
for detecting various species of MMT.
As for other trace metal determinations, the analysis
of Mn in environmental media and in biological mate-
rial where Mn is present should be performed with a
high standard of cleanliness to prevent external con-
tamination. Analysis of Mn in blood may be influenced
by the anticoagulant used. A high concentration of Mn
can be present in heparin.
Mn in air exists as particulate matter (PM); therefore,
sampling is achieved by drawing air through a filter in
order to collect the suspended particles. A variety of
filter types (e.g. glass fibers and cellulose acetate) and
sampling devices (low volume, high volume, personal,
and dichotomous) are available, depending on the par-
ticle sizes of concern and the concentration range of
interest. Material on the filter may be analyzed directly
by X-ray fluorescence (Borgese et al., 2012), or the filter
977
may be digested in nitric acid prior to analysis. Sensi-
tivity is dependent on the volume of air drawn through
the filter prior to analysis, and typical detection limits
are 1-2 μg/m3.
Standardization of the sampling criteria used for
measurement of airborne dust concentrations in the
workplace has led to the development of particle size-
selective sampling criteria for the inhalable PM (IPM),
thoracic PM (TPM), and respirable PM (RPM) fractions
(CEN, 1993; ACGIH, 1999). Samplers are available for
collecting the inhalable fraction, for example the Insti-
tute of Medicine (IOM) inhalable sampler (Mark and
Vincent, 1986). The Millipore 37-mm closed-face filter
cassette (CFFC) sampler is still in use for the collection
of “total dust”; however, it does not comply with size-
selective sampling criteria. Correction factors for IOM
and CFFC samples are generally between 1.0 and 2.5
(Tatum et al., 2001).
Water may be analyzed directly. If the concentra-
tion of Mn is low, a concentration step (evaporation),
extraction, and binding to a resin may be used. Detec-
tion limits range from 0.005 to 50 μg/L. In all cases, acid
is added to the sample to prevent the precipitation of
Mn. In a study performed by Beklemishev et al. (1997),
a very low detection limit of 0.005 μg/L was obtained
for measuring Mn in tap and river water. Their ana-
lytic method relied on an indicator reaction catalyzed
by Mn(II), which consists of the oxidation of 3,3′,5,5′-
tetramethylbenzidine by potassium periodate (KIO4)
carried out on a paper-based sorbent surface.
Determination of Mn levels in soils, sludge, or other
wastes requires an acid extraction/digestion step prior
to analysis. Treatment will usually involve heating in
nitric acid, oxidation with hydrogen peroxide, and filtra-
tion and/or centrifugation to remove insoluble matter.
4  OCCURRENCE, PRODUCTION AND USES
4.1  Occurrence and Production
Mn is widely distributed in the Earth’s crust, com-
prising about 0.1% of the total; it is the twelfth most
abundant element and the fifth most abundant metal
(ATSDR, 2012). Mn does not occur naturally in its
native state as a base metal, but it is found in over 100
minerals. Oxides, carbonates, and silicates are most
important among Mn-containing minerals. The most
common Mn mineral is pyrolusite (Mn dioxide), con-
taining 60-63% Mn. Rhodocrosite (Mn carbonate) and
rhodonate (Mn silicate) are also common. Mn occurs in
nodules on the bottom of the ocean, in most iron ores,
and over a wide range of concentrations as a natural
trace element in crude oil.
978 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
Most Mn is mined in open-pit or shallow under-
ground mines. More than 80% of the high-grade Mn
ore (> 35% Mn) is mined in South Africa, and also in
Australia, Brazil, Gabon, India, and more recently
China and the former Commonwealth of Independent
States (CIS). According to the International Manga-
nese Institute (IMnI, 2012), the world production of all
grades of Mn ore (wet) decreased by 22% in 2009, to 36
million metric tons (mt), which corresponds to 11 mil-
lion mt in Mn units (content), a year-on-year decline
of 23%. In 2012, the global production of Mn ore (wet)
rose to 53 million mt, representing 16 million mt of Mn
units. China was the largest producer of Mn units (2.7
million mt), followed by South Africa (1.9 million mt),
Australia (1.8 million mt), Brazil (1 million mt), Gabon
(956,000 mt), India (845,000  mt), and Kazakhstan
(377,000 mt). Reserves of high-grade ore are about 500-
600 × 106 tons, and those of low-grade ore are estimated
at several billion tons (Gerber et al., 2002).
4.2 Uses
Manganese is mainly used in metallurgical pro-
cesses. About 90% of the global Mn production is used
in steel manufacture as a deoxidizing and desulfur-
izing additive, and as an alloy constituent. Most Mn
ore is smelted in electric furnaces to produce the ferro/
silico-Mn (Fe/Si-Mn) alloy widely used in the produc-
tion of steel. The production of 97-98% pure Mn metal
is achieved by aluminum reduction of low-iron-content
Mn ore. Manganese with < 0.1% metallic impurities can
be produced electrolytically from a Mn sulfate solution
(HSDB, 2012). The total worldwide production of Mn
alloys dropped to 11.7 million mt in 2009, down 18%
from the previous year, but increased to 17.5 million mt
by 2012. China continued to be the world’s largest Mn
alloy-producing country, having produced nearly 6.6
million mt. It accounted for almost 57% of the global
output. The global economic recession caused a major
drop in the demand for steel by 2009, which led to a
decline in alloy production (IMnI, 2012); however,
3 years later, global steel production increased by 24%.
Metallic Mn in the form of Fe/Si-Mn is principally
used in steel production to improve hardness, stiff-
ness, and strength. It is used in carbon steel, stainless
steel, high-temperature steel, and tool steel, as well as in
cast iron and superalloys (HSDB, 2012). Manganese is
a minor but indispensable component of welding con-
sumables. Most consumables contain less than 6% Mn.
The forms in which it is used include Fe-Mn, Si-Mn, and
Mn carbonate. Mn compounds are produced either Mn
from ores or Mn metal. Mn compounds have a variety
of uses. Manganese dioxide is commonly used in the
manufacture of dry-cell batteries, matches, fireworks,
porcelain and glass-bonding materials, and amethyst
glass, and as the starting material for production of other
Mn compounds. Manganese sulfate is used primarily as
a fertilizer and a livestock supplement where soils are
deficient in Mn, and in some glazes, varnishes, ceram-
ics, and fungicides. Potassium permanganate, due to its
strong oxidizing capacity, is used as a disinfectant, as an
antialgal agent, for metal cleaning, tanning, and bleach-
ing, and as a preservative for fresh flowers and fruits,
and as well as in water and waste-treatment plants for
water purification purposes (HSDB, 2012). Other uses
of Mn compounds are in textile bleaching, for linseed oil
driers, in dyeing, in leather, tanning, and as an oxidizing
agent for the electrode coating of welding rods.
Methcathinone (ephedrone), the oxidation prod-
uct of ephedrine or pseudoephedrine, is a psycho-
stimulant that has become a substantial drug of abuse
(Kelly, 2011). Potassium permanganate can be used as
the oxidation agent, and Mn can therefore directly be
absorbed by drug users as an impurity in ephedrone.
Maneb and mancozeb are Mn-based fungicides.
Maneb is a manganous ethylene bis(dithiocarbamate)
sulfate or chloride, while mancozeb is a polymeric
mixture of a zinc salt and maneb, containing 20% Mn
and 2.5% zinc (HSDB, 2012). Among the organic Mn
compounds, MMT was developed in the 1950s as a
fuel additive to increase the octane level of gasoline
and thus improve the antiknock properties of the fuel.
It was introduced in Canada in 1976 and its use has
increased so substantially that it completely replaced
tetraethyllead in gasoline in that country in 1990
(Zayed et al., 1999). In 1977, MMT was banned by the
U.S. Environmental Protection Agency (EPA, 1978) as
an additive in unleaded gasoline. In 1995, the ban was
lifted and a court decision ordered the EPA to again
register the product for use as a fuel additive (EPA,
1995), although testing for health effects continues.
The Afton (former Ethyl) Corporation, the manufac-
turer of MMT, has been marketing its product to U.S.
refineries since late 1995 (Davis, 1999). Nevertheless,
MMT is currently used only sparsely in the developed
world. The major refiners in Canada have voluntarily
stopped using MMT, owing to concern for the impact
of MMT on advanced vehicles, and as a result as much
as 95% of Canadian gasoline is now MMT free (Inside
Fuels, 2004). MMT is not currently allowed in reformu-
lated gasoline, a gasoline blended with oxygenates to
reduce toxic pollutants primarily from older vehicles
(which is required in the USA in cities with the worst
smog pollution) and is not used by the major oil com-
panies in the United States. In Europe, MMT is used
in Greece (Geivanidis et al., 2003), in a couple of the
Eastern countries, and perhaps by one small refiner
in Belgium (Blumberg and Walsh, 2004). Through
 45 Manganese
Directive 2009/30/EC of the European Parliament and
of the Council of 23 April 2009, EU Fuel Quality legis-
lation set a limit of 6 mg Mn/L in gasoline on 28 April,
2012, falling to 2 mg/L as from 1 January, 2014. China
is following the same requirements as Europe (Michael
Walsh, personal communication).
Another organic Mn compound, mangafodipir
[Mn(II) dipyridoxyl diphosphate (MnDPDP)], is clas-
sified as a drug or therapeutic agent and used as both
a liver- and pancreas-specific contrast agent for MRI.
It improves lesion detection of these organs in MRI by
selectively enhancing the normal parenchyma, but not
the lesions, so that the contrast between tumorous and
normal tissues is increased (Wang et al., 1997).
5  LEVELS AND FATE IN THE
ENVIRONMENT AND EXPOSURE
Mn is ubiquitous in the environment. It occurs in
airborne and deposited particles, water, soil, plants,
and food.
5.1  General Environment
5.1.1  Ambient Air
Airborne Mn exists as a component of PM. A pop-
ulation-based study of personal exposure was carried
out in Riverside, California: participants were all non-
smokers above 10 years of age, and personal exposure
was assessed for Mn in the PM with a mean diameter
of 10 μm (PM10) size fraction only (Clayton et al., 1993).
Daytime exposures (median 49 ng/m3) were greater
than nighttime exposures (median 20 ng/m3). The larg-
est population-based study of personal exposure to
airborne Mn was conducted in Toronto in 1995, dur-
ing the widespread use of the MMT gasoline additive
in Canada (Pellizzari et al., 1999). The mean personal
PM2.5 Mn exposure was 9 ng/m3, with a 90th percentile
of 14 ng/m3. Median, mean, and 90th percentile of the
personal PM10 Mn exposure were 15, 36, and 55 ng/m3
respectively. PM2.5 Mn made up a greater proportion of
PM10 Mn in indoor environments than in outdoor ones.
Another population-based study was conducted in 1996
in Indianapolis, Indiana, a city without MMT use or
major Mn-emitting industries at the time (Pellizzari et al.,
2001). Median, mean, and 90th percentiles of the per-
sonal PM2.5 Mn exposure amounted to 3, 3, and 5 ng/m3
respectively. Mn enrichment of personal samples (i.e.
mass of Mn per mass of PM) was higher in Toronto com-
pared to the U.S. locations (Health Canada, 2010).
Above average exposures to Mn are likely to
occur in or near factories, or at hazardous waste sites
that release significant amounts of Mn dust into the
979
atmosphere, usually measured as total suspended par-
ticulate Mn (TSP air-Mn). In areas with major foundry
facilities, annual averages of air-Mn may amount to
200-300 μg/m3 and Mn absorption from inhalation
may rise to 4-6 μg/day. In areas associated with ferroal-
loy industries, it may be as high as 500 μg/m3 (intake
10 μg/day, with the 24-h peak exceeding 200 μg/day)
(WHO, 1981). Additional releases of Mn to the environ-
ment occur from natural sources (e.g. volcanos) and
from processes such as the combustion of cement.
In recent years, much lower airborne Mn levels
have been reported for communities in the vicinity
of active industrial facilities. In eight Mexican com-
munities living at various distances from Mn-mining
operations, PM10 air-Mn levels averaged 420 ng/m3
(Rodriguez-Agudelo et al., 2006). In the surroundings
of a Brazilian ferro-Mn alloy factory, the PM2.5 air-Mn
levels averaged 150 ng/m3 (Menezes-Filho et al., 2011).
Within the framework of an epidemiological study in
Marietta, Ohio, the EPA used its AERMOD dispersion
model to estimate outdoor TSP air-Mn concentrations
for individual study subjects; the mean estimated
long-term air-Mn exposure level was 180 ng/m3 (range
40-960 ng/m3) (Kim et al., 2011a; Bowler et al., 2012).
Personal air sampling data were collected from 38
children residing at a time-weighted distance (TWD)
between 4.7 and 28.5 km from the active ferroalloy
plan in Marietta (Haynes et al., 2012). Mn concentra-
tion in PM2.5 personal air samples ranged from 1.5
to 54.5 ng/m3 [geometric mean (GM), 8.1]. TWD was
a significant predictor of natural log personal air-Mn
concentration (lnMn) with an associated decrease of
0.075 lnMn for each km TWD (p< 0.05, 95% CI −0.13
to −0.01). Personal PM10 air samples were recently col-
lected on 311 adolescents residing within 3 km from
previously active ferroalloy plants in Valcamonica,
Italy (Lucchini et al., 2012). Mean (49.5 ng/m3), median
(31.4 ng/m3), and range (1.24-517 ng/m3) levels were
significantly higher compared to a reference nonindus-
trial area (27.4, 24.7, and 5.3-85.9 ng/m3, respectively).
Compared to personal air sampling, data from
large-scale ambient monitoring programs allows the
spatial and temporal variability in air-Mn levels to be
considered in both urban and rural settings. Annual
averages of Mn in urban areas without significant Mn
pollution are in the range of 0.01-0.07 μg/m3 (WHO,
2000). Based on measurements obtained in 102 U.S. cit-
ies, the estimated background concentration is 40 ng/
m3 (EPA, 2003; WHO, 2004a). Data compiled for 2006
under the EPA Urban Air Toxics Monitoring Program,
showed ambient air levels of Mn at 20 urban locations
across the United States. PM10 air-Mn was detected in
415 samples of urban air at levels ranging from 0.24
to 89.10 ng/m3 (EPA, 2007); the arithmetic mean, GM,
980 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
and median concentrations were 10.13, 6.68, and
6.29 ng/m3, respectively. TSP air-Mn levels ranged
from 0.85 to 614 ng/m3 in 114 air samples at the same
20 urban locations; the arithmetic mean, GM, and
median concentrations of Mn in TSP were 47.89, 22.39,
and 23.98 ng/m3 respectively.
Manganese can also be released into the air by
combustion of gasoline that contains MMT as an anti-
knock additive. It has been estimated that if MMT
were used in all gasoline, urban air-Mn levels would
be increased by about 50 ng/m3 (Cooper, 1984). The
EPA (1994) estimated that a substantial number of
people could be exposed to airborne Mn particulate
levels above 100 ng/m3 if 100% of gasoline contained
MMT. In Canada, where MMT in gasoline was already
widely in use, the estimated 10% per year increase in
Mn emission rates had been reported (Loranger and
Zayed, 1997; Zayed et al., 1999). Manganese can react
with sulfur dioxide and nitrogen oxide, but the occur-
rence of such reactions in the atmosphere has not been
demonstrated. MMT is rapidly photolyzed by sun-
light in the atmosphere (half-time of less than 2 min)
(Garrison et al., 1995).
5.1.2 Water
Manganese may be released into water by discharge
from industrial facilities or as leachate from landfills
and soil. Concentrations of Mn in surface water are
usually reported as dissolved Mn. Some Mn com-
pounds are readily soluble, so significant exposure can
also occur by the ingestion of contaminated drinking
water. However, Mn in surface water may oxidize or
adsorb to sediment particles and settle to the bottom.
Manganese in soil can migrate as PM in air, as men-
tioned before, but also in water, whereas soluble com-
pounds may dissolve in water and leach from the soil.
The extent of leaching is mainly determined by the
characteristics of the soil and is highly variable. The
transport and partitioning of Mn in water is controlled
by the solubility of the specific chemical form present,
which in turn is determined by pH, oxidation-reduc-
tion potential, and the characteristics of the available
anions. The metal may exist in water in any of four
oxidation states (II, IV, VI, VII). Manganese in water
may be significantly bioconcentrated at lower trophic
levels. A bioconcentration factor relates living organ-
isms to the concentration of the chemical in the water
in which they live. In order to protect consumers from
the risk of Mn bioconcentration in marine mollusks,
the EPA has set a criterion for Mn at 0.1 mg/L for
marine waters (EPA, 1993). Manganese in water may
undergo oxidation at high pH, and it is also subject
to microbial activity (Johnston and Kipphut, 1988).
The rate of MMT degradation in natural aquifer and
sediment systems is very slow under anaerobic condi-
tions. Calculated half-lives range from approximately
0.2 to 1.5 years at 25°C (Garrison et al., 1995). However,
MMT photolyzes rapidly in purified, distilled water
exposed to sunlight (calculated half-life of 0.93 min).
In a survey of U.S. river waters (1974-1981), values
ranging from < 11 μg/L to > 51 μg/L were reported,
with a median concentration of 24 μg/L for dissolved
Mn (Smith et al., 1987). The average manganese con-
centration in drinking water ranged from 4 to 32 μg/L
(NAS, 1980; WHO, 1981). The EPA (2003) reported
median Mn concentrations in groundwater at 5 μg/L,
with the 99th percentile at 2900 μg/L. In urban areas,
the median groundwater Mn concentration was found
to be 150 μg/L, with the 99th percentile at 5600 μg/L.
In public water systems supplied by groundwa-
ter, approximately 3% of the 982 sampled sources
exceeded the U.S. health reference level of 300 μg/L
(EPA, 2003). According to the Geological Survey of
Sweden (SGU, unpublished data), Mn concentrations
in Swedish groundwater used for drinking water are
on average 150 ± 510 μg/L (median 60  μg/L), with
maximum values as high as 30,000 μg/L. Around 20%
of the 12,000 sampled wells had Mn concentrations
exceeding the Swedish recommended guideline value
of 300 μg/L (Ljung and Vahter, 2007). High levels have
been reported in Bangladesh, where the average Mn
concentration in the wells was 800 μg/L, ranging from
4 to 4000 μg/L (Wasserman et al., 2006).
5.1.3 Soil
As a component of Earth’s crust, Mn occurs natu-
rally in virtually all soils. Mn enrichment in soil is
gradually increasing worldwide due to industrial
emissions (Herndon et al., 2011).
The average natural (background) levels of Mn in
soils range from around 40 to 900 mg/kg, with an esti-
mated mean background concentration of 330 mg/kg
(Cooper, 1984). Surface soil Mn was measured within
3 km of previously active ferroalloy plants in Valcamon-
ica, Italy (Lucchini et al., 2012). Average levels (mean
958 mg/kg, median 897, range 465-1729) were signifi-
cantly higher compared to a reference nonindustrial
area (mean 427 mg/kg, median 409, range 160-734).
Significantly higher levels of Mn were also measured
in lettuce grown from domestic gardens of the affected
area compared to the reference area (median 53.6 vs.
30.2 mg/kg) (Ferri et al., 2012).
Accumulation of Mn in soil usually occurs in the
subsoil and not in the soil surface: 60-70% of Mn is
found in the sand fraction of the soil (WHO, 1981).
Soil Mn concentrations arising from the use of MMT
 45 Manganese
in unleaded gasoline are apparently connected to Mn
oxides from Mn-containing motor vehicle exhaust
(Lytle et al., 1995). As they correlate with distance from
the roadway, it can be concluded that the environmen-
tal fate of Mn from vehicle MMT sources is associated
with increased total Mn in soil (Normandin et al.,
1999). The oxidation state of Mn in soils and sediments
may be altered by microbial activity (Ferri et al., 2012)
5.2 Food
Manganese is a natural component of most foods.
Its concentration in foodstuffs varies markedly but,
on the whole, food constitutes the major source of Mn
intake for humans.
The highest Mn concentrations are found in wheat
and rice. Polished rice and wheat flour contain less Mn
because most of it is in the bran. High concentrations
(up to 50 mg/kg) are found in nuts, tea, legumes, pine-
apples, and whole grains; lower levels (up to 5 mg/kg)
are found in milk products, meat, fish, and eggs
(Pennington et al., 1986; Davis, J.M., et al., 1992).
In connection with the levels of Mn in different
foodstuffs, it is interesting to quote a study on Mn
bioaccumulation by plants. Lytle et al. (1994) reported
increased concentrations of Mn in the seeds and stems
of oats grown in the organic and sandy soils at the sta-
tion with the highest traffic density. In a study by Nor-
mandin et al. (1999), Mn was measured in the plants
(flower, stem, leaves, and root). The authors tried to
evaluate the potential of dandelion (Taraxacum offici-
nale) as a bioindicator of Mn arising from the use of
MMT in gasoline. Mn concentrations of the different
parts of the plant did not correlate with the distance
from the roadways. In a Canadian study (Méranger
and Smith, 1972), it was estimated that 54% of the
total Mn intake comes from cereals. The second larg-
est source was potatoes, with 14%, whereas meat, fish,
and poultry provided only 2%. However, there is a dif-
ference in Mn concentrations for the same items in dif-
ferent countries and areas. In the USA and Germany,
the average oral intake by adults has been estimated
to range from 2.1 to 4.1 mg/day (Schelenz, 1977). In
333 Korean subjects aged 19-87 years, 4.2 ± 2.3mg were
reported (Bu and Choi, 2012). With a parallel collec-
tion of identical food aliquots (duplicate meal method)
and chemical analysis, the average intake amounted
to 2.88 mg/day (standard deviation 0.64) (Nkwenkeu
et al., 2002).
Variations in Mn intake can to a large extent be
explained by differences in nutritional habits. In
populations with cereals and rice as the main food
sources, intake will be higher compared to areas
where meat and dairy products make up a larger part
981
of the diet. Manganese intake can be higher in popu-
lations with high tea consumption. A cup of tea may
contain 0.4-1.3 mg Mn (ATSDR, 2012).
Considering all of the available data, it can be esti-
mated that daily intake of Mn from food ranges from
2.0 to 8.8 mg (WHO, 1981). Although gastrointestinal
(GI) absorption of Mn is low (3-5%), oral exposure is
the primary source for absorption of Mn in the general
population. Adequate and safe intake of Mn for adults
is considered to be 2-5 mg/day (NAS, 1980). According
to some data from the USA, it is possible that a signifi-
cant proportion of Americans, especially females, are
not consuming sufficient Mn (NAS, 1980; Pennington
et al., 1986; Davis and Greger, 1992). However, infants
can ingest more than the estimated safe and adequate
dose of 0.3-1.0 mg/day for their age group (Penning-
ton et al., 1986) because of relatively high Mn levels in
prepared infant foods and formulas (Lönnerdal, 1997).
The U.S. Food and Nutrition Board of the IOM has set
adequate intake levels for Mn for both genders at dif-
ferent life stages (FNB/IOM, 2001)
5.3  Work Environment
In the workplace, exposure to Mn occurs by inhala-
tion of airborne fumes and particles. This is a concern
mainly in the mining, Fe/Si-Mn, iron and steel, dry-cell
battery, and welding industries (WHO, 1986). The aver-
age concentration of Mn in total dust was 0.210 mg/m3
in a study of South African mineworkers (Myers et al.,
2003a). In a study on miners in the Middle East, aver-
age concentrations were between 62 and 114 mg/m3 of
Mn in total dust, due to less effective control measures
(Boojar and Goodarzi, 2002). For the ferroalloy indus-
try, the average inhalable Mn exposure measured in
Norway using IOM personal samplers for the inhal-
able fraction was 254 mg/m3, whereas the respirable
fraction averaged 0.028 mg/m3 (Ellingsen et al., 2003a).
This study provided highly detailed exposure infor-
mation on inhalable Mn exposures, based on a total of
153 side-by-side measurements. Information concern-
ing composition was grouped into four species, with
most of the Mn in the oxidation states 0 and 2+.
Average exposure levels measured as Mn in total
dust with the traditional CFFC samplers ranged from
0.005 to 1.49 mg/m3 (GM 0.054) among Italian ferroal-
loy workers (Lucchini et al., 1999). Among welders,
Mn concentrations can vary from 0.1 mg/m3 (Kucera
et al., 2001) to 1.5 mg/m3 (Lu et al., 2005) and 4 mg/m3
(Korczynski, 2000), with peak exposure levels more
frequently reached in confined spaces in the shipbuild-
ing industry. The GM concentrations of Mn and iron
among welders were 97 μg/m3 (range 3-4620, n = 188)
and 894 μg/m3 (range 106-20,300; n = 188), respectively
982 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
(Ellingsen et al., 2006). No substantial difference was
observed in the air-Mn concentrations when welding
mild steel compared to welding stainless steel. Personal
sampling of welding fumes was recently carried out
in 241 German welders during a working shift. Respi-
rable Mn was measured, with a median of 62 μg/m3
(interquartile range 8.4-320  μg/m3); inhalable Mn
amounted to similar concentrations (median 73 μg/m3;
interquartile range 10-340 μg/m3) (Pesch et al., 2012).
These data show that Mn particulate mainly occurs
in the respirable fraction for welding fumes. Man-
ganese exposure among welders is often in excess of
the American Conference of Governmental Industrial
Hygienists’ (ACGIH, 1995) threshold limit value (TLV)
of 0.2 mg Mn/m3 for the inhalable fraction (Flynn and
Susi, 2010). Considering the neurotoxic effects of Mn on
“CNS (i.e. central nervous system) function (neurobe-
havioral and neuropsychological changes),” in 2013
the ACGIH adopted a lower TLV of 20 μg/m3 for the
respirable fraction (ACGIH, 2013). Based on findings
in epidemiological studies and a recent meta-analysis
(Meyer-Baron et al., 2009) showing a reduced perfor-
mance of Mn-exposed workers, predominantly in tests
associated with motor functions, the German MAK
commission has recommended 200 μg/m3 for inhalable
Mn and 20 μg/m3 for respirable Mn as MAK values.
The EU Scientific Committee on Occupational Expo-
sure Limits (SCOEL) recommends a 8-h time-weighted
average (TWA) of 200 μg/m3 for the inhalable fraction
and 50 μg/m3 for the respirable fraction (SCOEL, 2011).
Assuming a TWA level of 1 mg/m3, which is the
National Institute for Occupational Safety and Health
(NIOSH, 2005) recommended exposure limit, the maxi-
mum Mn inhalation exposure would be 10 mg Mn/day
(assuming inhalation of 10 m3 air during an 8-h work-
day). The study by Roels et al. (1992) in alkaline battery
workers reported a 5% probability of increased hand
tremor for a time-integrated air-Mn exposure thresh-
old of 3.575 mg Mn/m3 × year (total dust) and 0.730 mg
Mn/m3 × year (respirable dust), and suggested an 8-h
TWA of 0.089 mg/m3 for total dust and 0.018 mg
Mn/m3 for respirable dust as a protective level to
prevent the onset of early psychomotor effects. The
lowest observable adverse effect level (LOAEL)
for total dust derived by Lucchini et al. (1999) was
0.10 mg Mn/m3 based on neurobehavioral changes.
Mergler et al. (1994) calculated a LOAEL of 0.035 mg/m3
for the respirable fraction, based on early signs of
neurotoxicity in workers of a Fe/Si-Mn alloy plant.
As far as occupational exposure to Mn from the com-
bustion of MMT is concerned, in a study performed
by Sierra et al. (1995) in Montreal, Canada, it was
shown that less than 10% of the Mn exposure of
garage mechanics was due to MMT.
6 TOXICOKINETICS
6.1 Absorption
6.1.1 Inhalation
There are no quantitative animal data on absorption
rates for inhaled Mn. As Mn dioxide and other inhaled
Mn compounds are practically insoluble in water, only
Mn in particles small enough to reach the alveolar lining
can be absorbed into the blood (WHO, 1981). However,
particles that are deposited in the upper airways may
be moved by mucociliary transport to the throat, where
they are swallowed and enter the stomach; thus, Mn
in particulate becomes available for GI absorption (see
Section 6.1.2). This process has been found to account
for clearance of a significant fraction of Mn-containing
particles initially deposited in the lung (Drown et al.,
1986; Newland et al., 1987). In a study performed by
Tjälve et al. (1996), the uptake of Mn into brain regions
of weanling male Sprague-Dawley rats following intra-
nasal administration of 4 μg/kg 54Mn was investigated.
Whole-body autoradiography of the rats at different
time points revealed that the olfactory bulb contained
the vast majority of measured Mn at 1, 3, and 7 days
postdosing (90%, 69%, and 47%, respectively), with val-
ues decreasing to a low of 16% at 12 weeks. Significant
uptake of Mn by other brain regions was not observed
until the third day, when the basal forebrain, cerebral
cortex, hypothalamus, and striatum contained 21%, 2%,
3%, and 1% of the measured label, respectively. Maxi-
mum uptake of the label by these regions was observed
at 7 days postdosing, with the percentage of the label
in the basal forebrain reaching 28%, and with the other
parts containing amounts slightly more than double
their 3-day values. The liver and kidneys each contained
approximately 1% of the measured Mn at 1, 3, and 7
days, with values decreasing consistently to 12 weeks.
Roels et al. (1997) measured B-Mn levels in
3-month-old rats following endotracheal adminis-
tration of 1.22 mg Mn/kg as either MnCl2 or MnO2.
B-Mn following MnCl2 (a water-soluble compound)
administration reached a maximum 30 min postdos-
ing, whereas with MnO2 (insoluble compound) , the
maximal B-Mn level was reached with a much slower
rate 168 h postdosing. The authors also studied the
distribution of Mn in blood, liver, and brain regions
(cortex, cerebellum, striatum) following endotracheal
administration of these Mn compounds (once a week,
4 weeks). Compared to control rats, this subchronic
study of pulmonary Mn exposure showed a signifi-
cant increase in B-Mn, no increase in hepatic Mn, and
significantly increased Mn deposition in the differ-
ent brain regions, with a selective increase of striatal
Mn concentration (205%) for the more bioavailable
 45 Manganese
MnCl2. Other studies in rats indicated that absorption
via the olfactory mucosa is a potential contributor to
brain Mn deposition. Since such a route would bypass
liver uptake and biliary excretion of Mn, its transport
by the olfactory nerve directly to the brain may have
toxicological importance (Fechter, 1999). The trans-
port of Mn across the olfactory pathway is further
demonstrated for ultrafine particles and may result in
the accumulation of Mn and inflammatory changes at
the olfactory bulb to a greater extent than in the lung
(Elder et al., 2006).
The primary combustion products of MMT are Mn
phosphate, Mn sulfate, and a Mn phosphate/sulfate
mixture. Salehi et al. (2003) carried out a study on 129
6-week-old male Sprague-Dawley rats divided in four
groups—one as control and three groups exposed to a
Mn phosphate/sulfate mixture in inhalation chambers
for a period of 13 weeks (5 days a week, 6 h a day). Expo-
sure concentrations were 3000, 300, and 30 μg Mn/m3. At
the end of the exposure period, locomotor activity and
resting time tests were conducted for 36 h using a com-
puterized autotrack system. Rats were then euthanized
by exsanguinations and Mn concentrations in different
tissues, blood, and brain were determined by neutron
activation analysis. Increased Mn concentrations were
found in the blood, kidney, lung, testes, and all brain sec-
tions in the highest exposure group. Manganese in the
lung and the olfactory bulb was dose dependent. Rats
exposed to 300 and 3000 μg Mn/m3 exhibited significant
body-weight loss in comparison with the control group.
6.1.2 Ingestion
The amount of Mn absorbed across the GI tract in
animals and humans depends mainly of the amount
ingested and the iron status. In the absence of iron defi-
ciency, GI absorption in humans averages about 3-5%
(Davidsson et al., 1988, 1989).
In animal studies it was shown that Mn is absorbed
equally well throughout the length of the small intes-
tine (Thomson et al., 1971). On the other hand, Miller
et al. (1972) found in calves that the upper sections of
the small intestine absorb far more 54Mn than the lower
section. It seems that there is not a marked difference
between the retention of Mn ingested via food or water
(Davidsson et al., 1988, 1989), but the absorption rate
depends on the water solubility of the Mn compounds
(Johnson et al., 1991; EPA, 1995).
Studies of oral absorption of Mn in animals have
yielded results that are generally similar to those in
humans. In pigs, which have GI tracts similar to those
of humans, Mn uptake was measured using orally
administered labeled Mn. The results showed a mean
absorption rate of 5% 1-6 h postdosing, 7% 6-12 h post-
dosing, and 3.8% 12-24 h postdosing (Finley et al., 1997).
983
The uptake of Mn is decreased by preexposure to high
dietary levels of Mn (Davis, C.D., et al., 1992).
Studies performed in suckling rat pups (Lönnerdal,
1987, 1997) demonstrated different absorption rates of
Mn for different milks and formulas. Infants fed cow
milk formula may retain five times more Mn, and
infants fed soy formula may retain 25 times more Mn
than breast-fed infants.
Iron deficiency increases the GI uptake of Mn (Kim
and Lee, 2011). As dietary iron (Fe) intake appears to
be one of the key determinants of GI absorption of
Mn, their interdependence has been extensively inves-
tigated. The interdependence of iron and Mn may be
due to the fact that iron and Mn are absorbed by the
same transport system [natural resistance-associated
macrophage protein 2/divalent metal transporter 1
(DMT-1)] in the gut (Rehnberg et al., 1982). Both Mn2+
and Fe2+ are bound by serotransferrin (Tf) and com-
pete for binding to this protein in the body. Therefore,
diets that are low in iron allow Tf to bind more Mn2+.
Interaction between iron and Mn occurs only between
nonheme iron and Mn (Davis, C.D., et al., 1992).
Manganese interactions with other elements (Cd,
Ni, In, Rh, and Se) at the level of GI absorption were
also observed (Jacobs et al., 1978). High dietary intakes
of phosphorus (Wedekind et al., 1991) can decrease Mn
uptake in chicks. More recent data also confirm that
the absorption of Mn is inversely related to the level of
calcium in the diet (Lutz et al., 1993).
Manganese absorption is age-dependent. Dorner
et al. (1989) have shown that infants, especially pre-
mature infants, retain a higher proportion of Mn than
adults. Animal studies support these findings (Rehn-
berg et al., 1980, 1982, 1985). Such age-dependent dif-
ferences in the retention of Mn could also be due to
differences in excretory ability (Miller et al., 1975), or
to age-related changes in the dietary intake levels of
iron and Mn (Ballatori et al., 1987). Animal studies
show that absorption and/or retention of Mn is higher
in neonates, but returns to the level of older animals
at approximately postgestational day 17-18 (Rehnberg
et al., 1982; Lönnerdal, 1987). Dorner et al. (1989) do
not provide adequate data to determine when this
transition takes place in human infants. In a more
recent study by Kostial et al. (2005) on the regulation of
Mn in perinatally exposed rat pups, it was shown that
the concentration of Mn in these pups (whose mothers
were orally exposed to Mn in drinking water—as Mn
chloride at a dose of 2000 mg Mn/L throughout preg-
nancy and 11 days of lactation) was six to eight times
higher than in controls, irrespective of the period and
duration of exposure. After cessation of exposure, the
Mn concentration decreased almost to control levels.
These results indicate the highly efficient regulation of
984 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
Mn accumulation in pups exposed to Mn during the
perinatal period. There are no studies on the absorp-
tion of Mn following oral exposure to MMT in either
humans or animals.
6.1.3  Dermal Exposure
Although many forms of manganese are water sol-
uble, there is little evidence that dermal contact with
manganese results in significant absorption through
the skin. Occupational exposure to MMT may be sig-
nificant via dermal absorption for gasoline attendants
or mechanics (ATSDR, 2012).
6.2 Distribution
Manganese is a normal component of human and
animal tissues and fluids, with the highest levels in
the liver, pancreas, and kidney and the lowest levels in
bone and fat. Most tissue concentrations range between
0.1 and 1 μg Mn/g wet weight (Sumino et al., 1975).
Absorbed Mn is rapidly eliminated from the blood
and first concentrates in the liver. Excess metal may
be distributed to other tissues. Manganese is distrib-
uted throughout the body at relatively constant con-
centrations that are characteristic of the individual
tissues and almost independent of the species. Gen-
erally, organs and tissues do not accumulate large
concentrations of Mn. Minor amounts go to the brain
and bone, as shown in experiments on mice and
monkeys (Dastur et al., 1971). The brain has a small
amount of Mn, but its retention time is rather long.
In monkeys, it was shown that elimination from the
cerebrum was very slow. While the half-time in the
whole body was estimated to be 95 days for the slow
component, it was not possible to obtain an estimate
for the cerebrum even after 278 days, indicating
an extremely long biological half-time in this tissue
(Dastur et al., 1971). In 1999, Aschner wrote a review
on Mn homeostasis in the CNS, focusing on the mech-
anisms of transport across the blood-brain barrier,
and particularly on transport mechanisms associated
with the regulation of Mn uptake and release by astro-
cytes and its requirement for glutamine synthetase
function and regulation (Aschner, 1999). Transport
across the blood-brain barrier was recently attributed
to an active carrier-mediated mechanism for influx
into the brain and to a passive diffusive mechanism
for efflux from the brain (Yokel and Crossgrove, 2004;
Crossgrove and Yokel, 2005). This would be an impor-
tant mechanism to explain the occurrence of a brain
overload after excessive absorption of Mn, but also
after prolonged exposure to low doses. In a review
on the transport of Mn across the blood-brain barrier,
putative carriers for Mn into and out of the brain were
examined, providing an alternative explanation for
the efflux of Mn from the brain (Aschner, 2006a,b).
Vitarella et al. (2000) exposed adult rats to airborne
doses of particulate Mn, as Mn phosphate, at 0, 0.03,
0.3, 3 mg/Mn/m3. The particles had a mean diam-
eter of 1.5 μm. Exposure lasted for 6 h/day for either 5
days/week (10 exposures) or 7 days/week (14 expo-
sures). Plasma, erythrocytes, olfactory bulb, striatum,
cerebellum, lung, liver, femur, and skeletal muscle
were analyzed for Mn content using neutron activation
analysis following exposure to 3 mg/m3 (after either
dosing regimen). A lower dose of 0.3 mg/m3 resulted in
increased Mn concentrations in the olfactory bulb and
lung (14-dose regimen only). Striatal Mn levels were
increased at the two highest doses only after 14 days of
exposure. Concentrations in the cerebellum were simi-
larly elevated, which was interpreted by the authors to
indicate that accumulation of Mn was not selective for
the striatum. Red blood cell and plasma Mn levels were
increased only in rats exposed to the highest dose for
the 10-day exposure period. These data indicate that
Mn can accumulate in the olfactory bulb even at lower
doses. However, it must be noted that tissues were col-
lected and analyzed directly after cessation of exposure.
It is not clear whether the distribution of Mn would be
similar if tissues had been analyzed at a later time.
Studies on humans suffering from chronic liver dis-
ease or some other liver dysfunction (e.g. cirrhosis, por-
tacaval shunt) following oral exposure, presumably via
the diet, with impaired Mn excretion showed that Mn
preferentially accumulates in the basal ganglia, espe-
cially the globus pallidus and the substantia nigra. Tl-
weighted MRI or neutron activation analysis were used
to determine the accumulation of Mn (Devenyi et al.,
1994; Hauser et al., 1996; Fell et al., 1996; Pomier-Layr-
argues et al., 1998; Rose et al., 1999; Lucchini et al., 2000).
The distribution of Mn in the brain was investigated
using capuchin (Newland et al., 1989; Newland and
Weiss, 1992) and macaque (Newland et al., 1989) mon-
keys given intravenous injections of MnCl2 that reached
a cumulative dose of 10-40 mg Mn/kg. MRI indicated
a symmetric hyperintensity in the globus pallidus and
substantia nigra consistent with accumulation of Mn in
these areas. A substantial accumulation of Mn was also
noted in the pituitary at low cumulative doses.
Some experimental animal studies showed that
large increases in tissue levels of Mn compared to the
controls occurred in rats over the first 24 days of expo-
sure to 214 mg Mn/kg body weight/day (as Mn3O4)
for up to 224 days. However, levels tended to decrease
toward the control levels as exposure was continued
(Rehnberg et al., 1980; Kristensson et al., 1986). This pat-
tern is thought to be due to a homeostatic mechanism
that leads to decreased absorption and/or increased
 45 Manganese
excretion of Mn when Mn intake levels are high (Bal-
latori et al., 1987). Davis, C.D., et al. (1992) and Malecki
et al. (1996) demonstrated that rats fed elevated lev-
els of Mn for several weeks had increased tissue Mn
concentrations, despite increased endogenous losses of
Mn from the gut as biliary Mn.
Manganese penetrates the placental barrier in all
species. Children are exposed in utero because Mn in
maternal blood crosses the placenta to satisfy the fetal
need for Mn. Manganese has been measured in cord
blood plasma of premature and full-term infants and
their mothers (Wilson et al., 1991). In a human study on
Mn levels during pregnancy and at birth performed in
a Southwest Quebec population (Takser et al., 2004), it
was shown that maternal B-Mn levels increased signif-
icantly during pregnancy and cord B-Mn levels were
significantly higher than those of maternal blood. This
study also indicated that lifestyle (mother’s smoking
habit) and environmental factors might interfere with
the balance and homeostatic mechanisms required to
maintain Mn at optimal levels for the physiological
changes that occur during pregnancy. In a previous
study, levels of Mn in the umbilical cord and in mater-
nal blood were compared between 160 mother-neonate
pairs in Montreal and 206 pairs in Paris. The prevalence
of high Mn levels in umbilical cord blood was found to
be significantly higher in Montreal, where MMT was
in use in gasoline in 1977 (Smargiassi et al., 2002).
Manganese is secreted into milk. Its concentration
in breast milk varies between 3.4 and 10 μg/L (Collipp
et al., 1983; Arnaud and Favier, 1995).
Manganese is more uniformly distributed in fetal
than in adult tissues. A study on age-related reten-
tion and distribution of ingested Mn3O4 in rats (Cahill
et al., 1980) demonstrated that 24 h after ingestion
infant rats retained up to 20 times more Mn compared
to adolescent or adult rats. The retention of Mn was
also a function of age at exposure in infancy. The liver
was the principal site of deposition at all ages. Brain
concentrations of Mn from a single dose were easily
detectable in infants but not in adults. A study measur-
ing the retention of a single oral dose of radiolabeled
Mn in adult and neonatal rats indicated that retention
of the label 6 days after exposure was much greater
in pups. The addition of Mn to the animals’ drinking
water decreased retention of the radiolabel in pups
and adults (Kostial, 1989). A high rate of Mn absorp-
tion and distribution in selected tissues, especially the
cerebrum, hypothalamus, and pituitary, was found in
preweanling rats dosed daily with particulate Mn3O4
for 12 or 27 days postpartum (Rehnberg et al., 1982).
After GI or pulmonary absorption, Mn is transported
in the blood bound to proteins and low molecular weight
organic compounds. In the trivalent state it can be bound
985
to Tf and in the bivalent state to an α-macroglobulin
(Gibbons et al., 1976). The plasma content of Mn is much
lower than the Mn content of red blood cells (1:5 ratio)
(Weissman, 1981). In healthy control adults on a normal
diet, about 66% of Mn in the blood is found in red blood
cells, 30% in white blood cells and platelets, and only 4%
in the plasma (Milne et al., 1990).
The organic Mn compound MMT is rapidly metabo-
lized in rats. After oral exposure and injection, the liver,
kidneys, and lungs contained the highest concentra-
tions. The distribution in general was similar to that seen
after exposure to inorganic Mn. Gianutsos et al. (1985)
administered 0, 11, or 22 mg Mn/kg as MMT (dissolved
in propylene glycol) to male adult mice via subcutane-
ous (s.c.) injection. The experiment was divided into an
acute study (one dose) and a “chronic” study (10 doses),
and accumulation of Mn in the brain was followed. The
brain Mn level 24 h after the single dose of MMT was
significantly higher than control values: after 10 doses of
11 mg/kg or 22 mg/kg, the brain Mn levels were signifi-
cantly higher than the control values, and significantly
different than the levels reported after acute exposure.
Manganese levels in the brains of mice given a single
dose of MMT at 22 mg Mn/kg were also compared with
those following injection of the same Mn dose as MnCl2.
The Mn level in brain after MnCl2 exposure followed
the same increasing trend over 24-h analysis as seen fol-
lowing the MMT application, but was somewhat higher
at each time point, with a maximum value of > 2.0 μg/g
wet weight (compared with ∼1.4 μg/g wet weight
following MMT exposure).
Another study included young adult rats admin-
istered with MMT dissolved in propylene glycol via
s.c. injection at a dose of 1 mg Mn/kg (McGinley et al.,
1987). The rats were sacrificed 1.5, 3, 6, 12, 24, 48, or 96 h
postinjection. The maximum accumulation of MMT-
derived Mn measured 3 h after dosing was found pri-
marily in the lungs (∼9 mg/kg), kidneys (3.9 mg/kg),
liver (2.75  mg/kg), and blood (∼0.75 mg/kg). The
concentrations of Mn in these four tissues were still
elevated (∼1 mg/kg) at 96 h postdosing. Brain Mn con-
centrations were not significantly elevated over con-
trol levels in MMT-treated animals.
In connection with the clinical use of mangafodipir
as a contrast agent, several qualitative studies have
shown the presence of Mn in the liver due to increased
Tl-weighted MRI signal in that organ following man-
gafodipir administration at 0.17-0.83  mg Mn/kg
(Bernardino et al., 1992; Lim et al., 1991; Padovani et al.,
1996; Wang et al., 1997). Several studies (Gallez et al.,
1997; Hustvedt et al., 1997; Grant et al., 1997) have
determined the distribution of Mn in tissues of ani-
mals following the intravenous (i.v.) administration of
mangafodipir. The results of these studies indicate that
986 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
single, clinical doses of mangafodipir are not likely to
cause persistent Mn accumulation in the brain.
6.2.1 Transport
Manganese homeostasis is vital for the optimal
function of any organism, given the delicate relation-
ship between its essentiality and toxicity. Manga-
nese (Mn2+) enters the portal circulation and binds to
plasma α2-macroglobulin or albumin, its major carriers
in blood. A small fraction of Mn in the 3+ oxidation
state is bound to Tf. In the form of Mn3+, Mn is able to
cross membranes via Tf receptor (TfR)-mediated endo-
cytosis (Aschner and Gannon, 1994). More than 99% of
Mn is in the 2+ oxidation state. DMT-1, a nonspecific
metal transporter, is the major transporter of Mn in this
oxidation state (Fitsanakis et al., 2007).
DMT-1 was previously referred to as NRAMP2 or
the divalent cation transporter (DCT1) because of its
ability to transport cations, such as zinc (Zn2+), Mn2+,
cobalt (Co2+), cadmium (Cd2+), copper (Cu2+), nickel
(Ni2+), lead (Pb2+), and Fe2+ (Forbes and Gros, 2003;
Gunshin et al., 1997; Knopfel et al., 2005). The DMT-1
transporter family is highly conserved. DMT-1 ortho-
logs are hydrophobic integral membrane proteins con-
taining 11-12 transmembrane domains and they share
a conserved “consensus transport sequence,” which is
involved in divalent metal ion translocation, including
that of Mn2+. The human gene spans an excess of 36 kb
and consists of 17 exons, encoding two proteins of 561
and 570 amino acids. The two alternatively spliced
mRNAs differ by a specific sequence that contains
or lacks an iron regulatory element (+IRE and −IRE,
respectively). The genes encode two transporters with
distinct C-termini (Fleming et al., 1998; Lee et al., 1998).
In addition to DMT-1, the choline transporter (Lock-
man et al., 2001), voltage-gated and store-operated cal-
cium channels (Lucaciu et al., 1997; Riccio et al., 2002),
ionotropic glutamate receptor Ca2+ channels (Kannur-
patti et al., 2000), and the citrate transporter (Cross-
grove et al., 2003) have also been implicated in Mn2+
transport. Additional evidence points to Mn trans-
port through the zinc transporters, ZIP8 and ZIP14
(Fujishiro et al., 2011; He et al., 2006), and ATP13A2,
a P-type transmembrane ATPase protein (Gitler et al.,
2009). Ferroportin-1 (Fpn) [also referred to as iron-reg-
ulated transporter 1 (IREG1) or metal tolerance protein
1 (MTP1)] is the only transporter identified to date to
outwardly transport Mn (Yin et al., 2010).
6.3 Metabolism
Manganese is capable of existing in a number
of oxidation states, and limited data suggest that it
may undergo changes in oxidation state in the body.
The oxidation state of the Mn ion in several enzymes
appears to be Mn(III), while most Mn taken in from
the environment is either Mn(II) or Mn(IV). Gibbons
et al. (1976) suggested that oxidation of Mn occurs in
the body. It was observed that human ceruloplasmin
caused the oxidation of Mn(II) to Mn(III) in vitro and,
although the process has not been studied in vivo, it
is a likely mechanism for Mn oxidation in the blood.
The same authors also noted that Mn oxidation led to
a shift in Mn binding in vitro from α2-macroglobulin
to Tf, and that in vivo clearance of Mn(II)-α2-
macroglobulin from cows was much more rapid than
the clearance of Mn(III)-Tf. Another line of evidence
that Mn may undergo changes in oxidation state in
the body is based on measurements of Mn in tissues
and fluids using electron spin resonance (ESR), which
detects the unpaired electrons in Mn(II), Mn(III), and
Mn(IV). When animals were injected with MnCl2, lev-
els of Mn increased in the bile and tissues, but only
a small portion was in a form that gave an ESR sig-
nal (Sakurai et al., 1985). This suggests that Mn(II) is
converted to another oxidation state, probably Mn(III),
although it is also possible that the formation of com-
plexes between Mn(II) and biological molecules (e.g.
bile salts, proteins, nucleotides) results in loss of the
ESR signal without formal oxidation of the Mn ion.
The extent of Mn redox reactions may be an impor-
tant determinant of Mn retention and toxicity in the
body. In a study by Komura and Sakamoto (1991), it
was shown that the form in which Mn was adminis-
tered in the diet affected tissue levels of Mn in rats. In
animals fed Mn acetate or MnCO3, levels of Mn were
significantly higher than in animals fed MnCl2 or
MnO2. Differences in Mn concentrations in the blood
and brain regions depending on the oxidation state of
Mn were also noted in another study (Roels et al., 1997).
The MMT metabolites, hydroxymethylcyclopenta-
dienyl Mn tricarbonyl (CMT-CH2OH) and carboxycy-
clopentadienyl Mn tricarbonyl (CMT-COOH), appear
in urine following i.v. administration of MMT in male
rats, as shown in a study by Hanzlik et al. (1980). These
metabolites are also present in the bile, as indicated by
the fecal recovery of 3H from the ring structure in MMT
following i.v. or intraperitoneal (i.p.) administration of
radiolabelled compounds to rats (Hanzlik et al., 1980).
Maneb and mancozeb are metabolized to several
compounds, including ethylenethiourea (ETU), ethyl-
eneurea, and ethylenediamine, in plants and animals.
ETU has been identified in the urine of occupation-
ally exposed sprayers of these fungicides (Kurttio and
Savolainen, 1990;, Kurttio et al., 1990).
Mangafodipir, after infusion of the clinical dose of
5 μmol/kg (or 0.25 mg/kg), is rapidly dephosphorylated
 45 Manganese
to Mn dipyridoxyl monophosphate. The monophos-
phate then is fully dephosphorylated to Mn dipyridoxyl
ethylenediamine. This compound has been isolated in
blood from 18 min after the start of an infusion of man-
gafodipir until 40 min after the start (Toft et al., 1997).
6.4 Excretion
Manganese homeostasis is primarily achieved by
excretion. Absorbed Mn is almost totally excreted via
the intestinal wall by several routes, and the main
excretion route is via the bile. Manganese is removed
from the blood by the liver, where it conjugates with
bile and is excreted into the intestine. After reaching
the intestine, most of the element is excreted in the
feces (Davis et al., 1993; Malecki et al., 1996). Liver
lysosomes play an important role in intrahepatic
movement and affect the biliary excretion of absorbed
Mn (Suzuki and Wada, 1981). Some of the Mn in the
intestine is reabsorbed through enterohepatic circula-
tion. Small amounts of Mn can also be found in urine,
sweat, and milk. In humans, the urinary excretion of
Mn is less than 1 μg/L. Since the body burden of an
adult is about 10 mg Mn, only about 0.01% of the body
burden is excreted daily via this route.
Rats exposed to either MnCl2 or Mn3O4 by endo-
tracheal instillation excreted about 50% of the dose in
the feces within 3-7 days (Drown et al., 1986). Mon-
keys exposed to an aerosol of 54MnCl2 excreted most
of the Mn with a half-time of 0.2-0.36 days (Newland
et al., 1987). However, a portion of the compound was
retained in the lungs and brain. Clearance of this label
was slower, occurring with half-times of 12-250 days.
Occupationally exposed male workers were
reported to have urine Mn levels significantly higher
than those of unexposed persons (Roels et al., 1987b;
Alessio et al., 1989; Lucchini et al., 1995). Mergler et al.
(1994) did not report a significant difference in urinary
Mn levels between exposed and control workers. The
differences in urinary excretion may be due to differ-
ences in the duration and extent of exposure.
Humans who ingested tracer levels of radioac-
tive Mn, usually as MnCl2, excreted Mn with whole-
body retention half-times of 13-37 days (Sandstrom
et al., 1986; Davidsson et al., 1989). In a study by
Davis and Greger (1992), urinary excretion of Mn by
men was 7.0 μmole/g creatinine and by women was
9.3 μmole/day. Urinary excretion was not responsive
to oral intake of Mn.
After exposure to the organic compound MMT, Mn
excretion takes place to a large extent via urine and is
of the same magnitude as GI excretion. Manganese
originating from clinical application of mangafodipir
is primarily excreted in the feces via the bile and is
987
incompletely cleared from the body 24 h after admin-
istration, with roughly 7-8% of the dose still being
retained in the body after 1 week (Hustvedt et al., 1997).
6.5  Physiologically Based Pharmacokinetic
Model
A qualitative physiologically based pharmacoki-
netic model for Mn toxicity in humans and animals
was developed some years ago by Andersen et al.
(1999). As several data gaps still exist concerning Mn
pharmacokinetics, this model has been updated over
time, and it now includes models for adult, pregnant,
lactating, and neonatal rats, nonhuman primates, and
adult, pregnant, lactating, and neonatal humans. These
models predict manganese tissue concentrations in
fetal, neonatal, pregnant, or aged individuals, as well
as in individuals with liver disease or chronic man-
ganese inhalation (Taylor et al., 2012; Dorman et al.,
2012). When applied to monkeys, this analysis shows
that the dose-response relationship for the neurotoxic
effects of Mn is independent of exposure route, and
indicates the use of target tissue Mn concentration or
cumulative target tissue Mn as the appropriate dose
metric for these comparisons (Schroeter et al., 2012).
7  HEALTH EFFECTS
7.1  Manganese Deficiency
Manganese, like zinc and copper, is essential for nor-
mal prenatal and neonatal development. It is essential
for humans and animals and plays a role in bone min-
eralization, protein and energy metabolism, metabolic
regulation, cellular protection from damaging free radi-
cal species, and the formation of glycosaminoglycans
(Welder, 1994). Mitochondrial superoxide dismutase
(SOD), pyruvate carboxylase, and liver arginase are
known Mn metalloenzymes (NAS/NRC, 1989; Welder,
1994). Several enzyme systems: transferases, decarbox-
ylases, hydrolases, dehydrogenases, synthetases, and
lyases, have been reported to interact with or depend
on Mn for their catalytic or regulatory function (Welder,
1994). Manganese has been shown to stimulate the syn-
thesis of chondroitin sulfate, an important constituent of
the cartilage and connective tissue. There is limited evi-
dence that some disorders or diseases in humans such
as amyotrophic lateral sclerosis, acromegaly, catabolic
disease, and epilepsy may be associated with an imbal-
ance in tissue levels of Mn (Carl et al., 1993). However,
no large-scale deficiency has been reported, although
Mn intakes of many people are believed to be less than
the estimated safe and adequate daily dietary intake
(ESADDI). This may reflect, in part, the lack of adequate
988 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
methods to monitor nutritional status in regard to Mn.
In a study by Friedman et al. (1987), five out of seven
men fed a Mn-deficient diet for 39 days exhibited der-
matitis (miliaria cristallina). The dermatitis cleared rap-
idly when Mn was returned to the diet. Considering
the fact (supported by studies in humans) that Mn is an
essential element, the U.S. Food and Nutrition Board of
the National Research Council established the ESADDI
levels as follows: 0.3-0.6 mg/day for infants from birth
to 6 months; 0.6-1.0 mg/day for infants from 6 months
to 1 year; 1.0-1.5 mg/day for children from 1 to 3 years;
1.0-2.0 mg/day for children from 4 to 6 years, and from
7 to 10 years; and 2.0-5.0 mg/day for adolescents (> 11
years) and adults (NRC, 1989). However, the Food and
Nutrition Board has cautioned that upper levels of these
provisional dietary intakes of ESADDIs should not be
exceeded on a routine basis because toxic levels may
be only a few times the usual intake levels (NRC, 1989).
7.2  Acute Effects
Manganese is less toxic than most metals. The
average median lethal dose ranges from 400 to
830 mg/Mn/kg (guinea pig, mouse, and rat) for oral
administration of soluble Mn compounds and from
38 to 64 mg Mn/kg (rat, mouse) for parenteral injec-
tions (Holbrook et al., 1975). Mn is regarded to be a
metal with relatively low toxicity; acute poisoning by
Mn in humans is very rare. Hobbesland et al. (1997)
reported a significantly increased incidence in sudden
death mortality for workers in Fe/Si-Mn plants during
their employment period [standardized mortality ratio
(SMR) 2.47]. However, these authors caution that the
association between increased death rate and Mn expo-
sure is speculative, and that the incidence in sudden
death could also be caused by common furnace work
conditions (e.g. heat, stress, noise, carbon monoxide).
There is only one study (Kawamura, 1941) in which
death in humans may have been associated with inges-
tion of Mn. In this report, death from “emaciation”
occurred in two adults who ingested drinking water con-
taminated with high levels of Mn (14 mg/L). Although
many of the symptoms in the group of six Japanese fam-
ilies (about 25 persons) could be connected with expo-
sure to Mn, there is considerable doubt that all of the
features of this outbreak (particularly the deaths) were
due to Mn alone (ATSDR, 2012). Namely, symptoms
appeared to have developed very quickly: the course
of the disease was very rapid, in one case progressing
from initial symptoms to death in 3 days; and all survi-
vors recovered from the symptoms even before the Mn
content of the well had decreased significantly after the
removal of batteries (from which Mn had leached to the
drinking water) buried near the well.
7.3  Neurotoxic Effect
CNS is the primary target of Mn toxicity. Although
Mn is known to be a cellular toxicant that can impair
transport systems, enzyme activities, and receptor
functions, the principal manner in which Mn neuro-
toxicity occurs has not been yet clearly established
(Aschner and Aschner, 1991).
7.3.1  Mode of Action
Insight into which brain areas preferentially accu-
mulate Mn were obtained from autopsy samples from
individuals working in heavily contaminated environ-
ments (Yamada et al., 1986). These and other studies
have shown that the corpus striatum and the extrapy-
ramidal motor system are targeted by excessive expo-
sure to Mn (Archibald and Tyree, 1987; Eriksson et al.,
1992b). Manganese concentrations vary across various
brain regions, attaining the highest level in the globus
pallidus (Prohaska, 1987), and concentrating predomi-
nantly within the mitochondria of the basal ganglia
(Morello et al., 2008; Liccione and Maines, 1988). Studies
in nonhuman primates have shown by means of MRI
the presence of Mn in the striatum, pituitary, and globus
pallidus, with preferential accumulation in the globus
pallidus, substantia nigra pars reticularis, and striatum
(Newland et al., 1989). The specific area of injury par-
allels the preferential accumulation of Mn within the
globus pallidus. Significant neuropathological changes
such as cell loss and gliosis have been reported not only
in the globus pallidus but also in the caudate, putamen,
and subthalamic nucleus (Yamada et al., 1986).
The substantia nigra may be affected by Mn, but
generally to a lesser extent than the globus pallidus
(Katsuragi et al., 1996; Newland et al., 1989; Yamada
et al., 1986). Positron emission tomography (PET)
studies have shown that Mn does not alter the integ-
rity of nigrostriatal dopaminergic neurons (Shinotoh
et al., 1995). In general, it appears that the substantia
nigra pars compacta (SNpc), the primary area affected
in Parkinson disease (PD), is largely intact after Mn
exposure (Yamada et al., 1986). However, insult to
the globus pallidus by Mn may affect SNpc through
downstream pathways, consistent with the occurrence
of parkinsonian symptoms (Verity, 1999).
There is limited evidence that dopamine levels in
the caudate nucleus and the putamen are decreased in
affected patients. Dopamine is one of the most com-
mon catecholamines and it functions to control loco-
motion, emotions, and neuroendocrine secretion. To
date, most emphasis on the neurotoxic effects of Mn
has been directed at its ability to alter the dopamine
transporter (DAT) or dopamine receptor (DAR). Sev-
eral studies have shown that postnatal exposure to Mn
 45 Manganese
causes a decrease in presynaptic dopaminergic function
through reducing expression of the DAT protein and
uptake of dopamine in the striatum, as well as decreas-
ing long-term dopamine efflux (Huang et al., 2003;
McDougall et al., 2008). Additional evidence suggests
that dopaminergic neurotransmission is attenuated by
Mn, concomitant with depletion of striatal dopamine
(Calne et al., 1994; Pal et al., 1999; Reichel et al., 2006;
Chen et al., 2008). It has also been shown that Mn can
affect the dopamine D1 receptors in the striatum of
monkeys (Eriksson et al., 1992a), as well as the density
of D2 receptors in developing rats (Seth and Chandra,
1984). The valence of Mn may influence its toxicity as
to dopamine. In vitro, Mn3+ appears more toxic than
Mn2+, possibly due to higher oxidative reactivity and a
closer radius resemblance to iron. In biological media,
Mn in the 3+ oxidation state reacts with dopamine
more potently than it does in the 2+ state, catalyzing
its auto-oxidation to reactive quinones that generate
ROS, resulting in oxidative stress, lipid peroxidation,
and cellular damage (Lloyd, 1995; Shen and Dryhurst,
1998; Ahmadi et al., 2008; Stokes et al., 1999). The auto-
oxidation of dopamine may lead to the formation of
highly reactive semiquinone and aminochrome inter-
mediates (Baranyi et al., 2006; Shen and Dryhurst, 1998;
Lloyd, 1995; Graumann et al., 2002; Florence and Stau-
ber, 1989; Oikawa et al., 2006). The loss of dopamine
in the brain and the concomitant neuronal cell dam-
age might be reflected as an increase in motor activity
(Bonilla, 1984; Nachtman et al., 1986). Calabresi et al.
(2001) also reported that Mn-treated rats exhibited a
complex behavior syndrome, with increased activity
in the absence of significant striatal neuronal loss and
gliosis. Studies in Mn-exposed nonhuman primates
have demonstrated a lack of nigrostriatal dopaminer-
gic degeneration in the striatum; however, these ani-
mals do express dopamine neuron dysfunction: there
is marked inhibition of in vivo dopamine release in the
striatum as measured by PET (Guilarte et al., 2008), a
finding that has been confirmed in rodent models of
Mn exposure (Peneder et al., 2011).
In addition to the dopaminergic system, other neu-
rotransmitter systems have been implicated in the
neurotoxicity of Mn. Glutamate uptake by astrocytes is
significantly reduced by Mn, thus increasing the extra-
cellular concentration of glutamate and its excitotoxic-
ity. This effect is probably mediated by the propensity
of Mn to decrease the expression of genes encoding the
astrocytic glutamate transporters, such as excitatory
amino acid transporters 1 and 2 (SLC1A3/GLAST
and SLC1A2/GLT1) (Erikson and Aschner, 2002, 2003;
Erikson et al., 2002b). Manganese may also increase
the sensitivity of postsynaptic receptors to glutamate,
thus activating Mn-affected pallidal neurons (Spadoni
989
et al., 2000). Furthermore, given the important role of
glutamate in mediating neurotransmission, this amino
acid is highly sensitive to changes in energy supply
(see below). Overactivation of ionotropic glutamate
receptors (GluRs) by Mn leads to increased energy
consumption, which may lead to accelerated depletion
of ATP levels and a generalized failure in maintaining
optimal cellular energy stores.
Several studies also point to an effect of Mn on
γ-aminobutyric acid (GABA). GABA content (Bonilla,
1978; Fitsanakis et al., 2006; Gwiazda et al., 2007) and its
release have been shown to increase in response to Mn
(Prestifilippo et al., 2008). It has also been demonstrated
that striatal GABA-containing neurons show height-
ened sensitivity to Mn compared to mesencephalic
dopaminergic neurons (Defazio et al., 1996). Other stud-
ies showed inhibition of GABA uptake in response to
Mn treatment (Anderson et al., 2007), with diminished
pallidal GABA concentration (Struve et al., 2007), while
no changes in GABA levels were reported by Garcia
and colleagues (2007). These discrepancies may reflect
a temporal factor that contributes to these effects. They
may also reflect differences in treatment regime (con-
centration and time of dose) as well as species varia-
tions; however, in general they are consistent with the
vulnerability of GABA-containing regions to Mn.
While the cholinergic system does not appear to
be a primary target of Mn toxicity, it may affect pre-
synaptic choline uptake (Lockman et al., 2001; Eriks-
son et al., 1984; Lai et al., 1984), acetylcholine (ACh)
transferase activity (Lai et al., 1984), the release of
ACh (Kita et al., 1981), postsynaptic ACh binding to
receptors, and ACh clearance by acetylcholinesterase
(Lai et al., 1992). Moreover, Mn influences ACh bind-
ing and transport proteins in astrocytes (Finkelstein
et al., 2007). Changes in the levels of this neurotrans-
mitter are consistent with the early psychotic phase
of manganism, referred to as “Mn madness” as well
as cognitive deficits in memory and intellectual decay
(Feldman and Ratner, 1999; Iregren, 1999; Tanner, 1992;
Wennberg et al., 1991), and deficits in audioverbal
short-term memory and hand-eye coordination (Roels
et al., 1987b; Mergler et al., 1994).
It is also thought that ACh activity may impact
the dopaminergic system (Eells and Brown, 2009).
Increased ACh levels in the cortex, striatum, and hippo-
campus have been reported (Fosbraey et al., 1990). Since
these areas also contain dopaminergic neurons prone to
degenerate upon Mn exposure, and since dopamine is
known to affect ACh release by the septohippocampal
and striatal cholinergic neurons (Nilsson et al., 1992;
Robertson et al., 1992; Sato et al., 1994), this relationship
between dopamine and ACh may explain the symptom-
atology and clinical picture inherent in Mn exposure.
990 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
Mitochondria are the target organelles of Mn. Man-
ganese has a greater affinity than Ca2+ for the calcium
uniporter, thus favoring its influx. Furthermore, once
within mitochondria, Ca2+ has greater affinity for the
efflux transport. Therefore, Mn is essentially trapped
within the mitochondria, readily affecting its function
(Gavin et al., 1992). Manganese triggers mitochondrial
dysfunction through several mechanisms, predomi-
nantly via oxidative stress. Mn can impair mitochon-
drial function by inhibition of mitochondrial electron
transfer chain, affecting the activity of respiratory
chain enzymes, inhibiting complexes I-IV, and inter-
fering with oxidative phosphorylation (Zhang et al.,
2004). In addition, Mn can bind to a specific magne-
sium (Mg2+)-binding site on the F1-ATPase, thereby
slowing its activity (Smith et al., 1985) and effectively
reducing ATP production. This leads to increased leak-
age of electrons and increased superoxide (O2•−) pro-
duction, with eventual collapse of cellular function,
which may be followed by cell death (Scholte, 1988).
In addition, Mn can alter calcium homeostasis in
mitochondria by inhibiting its efflux and increasing
its levels in the organelle (Gavin et al., 1990; Spadoni
et al., 2000). Elevated calcium levels per se may trigger
excessive ROS production with subsequent opening of
the mitochondrial permeability transition pore (MTP),
thereby increasing the permeability to protons, ions,
and solutes (Zoratti and Szabo, 1995). These effects
culminate in the loss of the inner membrane potential
(Δψm), mitochondrial swelling, and finally impaired
oxidative phosphorylation and ATP synthesis (Gunter
and Pfeiffer, 1990).
Manganese has also been shown to trigger apop-
tosis. Manganese-induced MTP opening leads to the
activation of Bcl-2 family proteins, especially Bax/Bak,
culminating in the release of cytochrome c and activa-
tion via the extracellular signal-regulated kinase (ERK)
pathway of the cysteine protease caspase-3, the apop-
totic executioner protein. It has been shown that Mn
is a potent inducer of ERK and caspase-3 activation
(Malecki, 2001), consistent with observations of DNA
strand breakage [Malecki, 2001].
7.3.2  Health Impairment
As early as 1837, John Couper reported five cases of
“manganism” among men employed in grinding Mn
dioxide in the manufacture of chlorine for bleaching
powder (Couper, 1837). The clinical picture was similar
to paralysis agitans and was published only 20 years
after Sir James Parkinson’s description of the “shaking
palsy.” According to the EPA (1993), 7550 cases of man-
ganism had been recorded since the first report in 1837.
Exposure to Mn in mines or in ore processing plants
and in ferroalloy industry was the most common cause
of Mn clinical intoxication from Chile, Cuba, Germany,
India, Mexico, Morocco, Romania, Sinai, Spain, and
the former U.S.S.R. (WHO, 1981).
The clinical features of classic manganism include
psychiatric and neurological manifestations related
to the extrapyramidal system. The disease typically
begins with feeling of weakness and lethargy. As the
disease progresses, a number of other neurological
signs become manifest. Although not all individuals
develop identical signs, the most common are a slow
and clumsy gait, speech disturbances, a mask-like
face, and tremors. The speech disorder may progress
to muteness. Patients develop a fixed facial expres-
sion. Increasing clumsiness and an inability to make
certain movements have also been observed. In the
third stage, the disease is fully developed. Difficulties
in walking caused by muscular hypertonia, muscle
rigidity, and tremor in the upper limbs, as well as diffi-
culties in writing, are among the symptoms and signs.
In addition, a syndrome of psychological and psychic
disturbances (aggressiveness, hallucination, psychosis)
frequently emerges. Although neurological symptoms
may improve in some cases (Ky et al., 1992), clinical
progression is irreversible, persisting after exposure
ceases (Huang et al., 1998). Individual susceptibility is
thought to play a role in the development of mangan-
ism, as it occurs after only a few months of exposure,
whereas in many workers with more than 20 years of
exposure, no adverse neurological effects have been
observed (WHO, 1981).
Differences between the classical features of man-
ganism and PD have been described. Barbeau (1984)
reported that dystonia, hypokinesia, and intentional
tremor presented in patients suffering from mangan-
ism more frequently than in parkinsonian patients.
Psychiatric disturbances early in the disease (although
not always), a cock-walk, a propensity to fall backward
when displaced, less frequent resting tremor, more fre-
quent dystonia, and failure to respond to dopamino-
mimetics, are other characteristics that distinguished
manganism from PD (Calne et al., 1994). In PD patients,
pathological lesions are found in the substantia nigra
and other pigmented areas of the brain (Barbeau, 1984).
Parkinsonism is due to the selective loss of subcortical
neurons, whose cell bodies lie in the substantia nigra
and whose axons terminate in the basal ganglia, which
includes the caudate nucleus, the putamen, the globus
pallidus, and other structures. These nigral neurons
use dopamine as their neurotransmitter. Manganese
appears to affect pathways that are postsynaptic to the
nigrostriatal system, mostly the globus pallidus (Chu
et al., 1995). MRI of the brain reveals the accumulation
of Mn in cases of manganism, but few or no changes
 45 Manganese
in subjects with PD. 18Fluorodopa (F-dopa) PET scans
were generally normal in cases of manganism but
abnormal in subjects with PD (Calne et al., 1994).
However, this paradigmatic description of differ-
ences and similarities has evolved until now there is
a less clear distinction made between the two clinical
manifestations. Preventive measures have virtually
eliminated the possibility of uncontrolled occupational
exposure to high levels of Mn. Therefore, outbreaks of
classical manganism are no longer reported. Prolonged
and lifetime exposures to lower levels have become
the more common situation (Lucchini and Zimmer-
man, 2009), related to a parallel increase of Mn levels
in the environment (Herndon et al., 2011). In this con-
text, damage induced by Mn can also extend into the
dopaminergic pathways that are typically damaged in
PD (Baek et al., 2004; Kim et al., 2002; Lucchini et al.,
2009). Typical signs of Mn deposition at MRI scan, with
elevated B-Mn and abnormal F-dopa PET scan, have
been shown in welders (Kim et al., 1999a). A patient
with parkinsonism associated with elevated serum
Mn from hepatic dysfunction demonstrated relatively
symmetrically and severely reduced F-dopa levels in
the posterior putamen. MRI revealed selective abnor-
mality within the internal segment of the pallidum
(Racette et al., 2005a). Reduced uptake of F-dopa is
also shown in end-stage liver disease (Criswell et al.,
2011) and in welders (Criswell et al., 2012a) in rela-
tion to Mn exposure. Elevated T1-weighted intensity
indices and increased apparent diffusion coefficients at
MRI are shown throughout the basal ganglia in weld-
ers (Criswell et al., 2012b).
Manganese can be considered an environmen-
tal trigger of PD or parkinsonian disorders that can
accelerate the onset of neurodegenerative damage
(Martin, 2006) by interacting with genetic factors (Le
Couteur et al., 2002; Zatta et al., 2003). The relationship
between these two manifestations has triggered fur-
ther research, also in view of the close interconnection
between the target area of Mn toxicity (represented by
the globus pallidus) and the substantia nigra, where
the degeneration of dopaminergic neurons takes place
(Weiss, 2006).
Elevated environmental Mn exposure may affect
nonoccupational populations living in the vicini-
ties of elevated Mn emissions. Studies have shown
an increased risk of PD or parkinsonian disturbances
in older adults living in areas with elevated envi-
ronmental Mn (Lucchini et al., 2007; Finkelstein and
Jerrett, 2007). The frequency of parkinsonian distur-
bances in the surroundings of ferroalloy plants in an
Italian prealps valley (crude prevalence 358/100,000
population; standardized for age and sex 438) was sig-
nificantly higher [SMR 1.58; 95% confidence interval
991
(CI) 1.41-1.76] compared to the other counties in the
same province (crude prevalence 246/100.000). This
observation may indicate the interaction of prolonged
environmental exposure to Mn with genetic factors,
potentially relevant in this mountain population (Luc-
chini et al., 2007). A study by Finkelstein and Jerrett
(2007) of the relationship between PD and markers
of traffic-derived and environmental Mn air pollu-
tion in two Canadian cities has shown no association
in Toronto (only traffic-associated air-Mn), whereas
in Hamilton (both traffic and industry-associated air-
Mn) the odds for a physician’s diagnosis of PD was
1.034 (95%CI 1.00-1.07) per 10 ng/m3 increase of Mn in
TSP. The prevalence curves suggested that exposure to
ambient Mn advances the age of PD diagnosis, which
is consistent with the theory that exposure to Mn adds
to the natural loss of neurons attributable to the aging
process.
An increased frequency of parkinsonian distur-
bances has also been shown in case-control studies on
large groups of welders (Racette et al., 2005b). The esti-
mated prevalence of parkinsonism among active male
welders aged 40-69 years was 977-1336 cases/100,000
population, and was significantly higher compared to
age-standardized data for the general population (prev-
alence ratio 10.19; 95% CI 4.43-23.43). The parkinsonian
features in welders seem not to be different from those
of PD, except for a younger age of onset (Racette et al.,
2001). Studies in Korea (Park et al., 2006) and Sweden
(Fored et al., 2006) did not observe an increased preva-
lence of disturbances in welder cohorts. An increased
risk of parkinsonism has been further confirmed in a
large cohort of 811 shipyard and fabrication welders
and associated with weighted welding exposure-years
(Racette et al., 2012). Parkinsonism (rigidity, bradyki-
nesia, rest tremor, and postural instability) is present
in 15% of Mn-exposed workers in welding indus-
tries; these parkinsonian signs also overlap consider-
ably with the clinical findings seen in early stages of
PD, although molecular imaging suggests that Mn-
exposed workers have dopaminergic dysfunction in a
pattern that differs from PD (Racette et al., 2013).
Studies to estimate the impact of occupational expo-
sure to Mn on neurological health have employed
sensitive tests designed to detect early signs of neuro-
psychological and neuromotor deficit (Iregren, 1999).
Dose-response relationships were shown when expo-
sure was expressed with cumulative exposure indices
(Roels et al., 1987a, 1992; Lucchini et al., 1995, 1999).
Average Mn levels in the air reported to lead to early
signs of nervous system toxicity after inhalation expo-
sure range from 0.027 to 1 mg Mn/m3 (Chia et al., 1993,
1995; Iregren, 1990; Mergler et al., 1994; Lucchini et al.,
1995, 1997, 1999; Roels et al., 1987a, 1992; Wennberg
992 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
et al., 1991). Overt manganism was observed at expo-
sure levels ranging from 2 to 22 mg Mn/m3 (Šarić
et al., 1977). According to World Health Organization
(WHO, 1981), clinical manifestation of Mn intoxication
can occur at 1 mg/m3 in susceptible individuals.
Roels et al. (1987b) detected early preclinical neuro-
logical effects in > 25% of a group of workers exposed
to 0.97 mg Mn/m3 (median concentration in total dust)
for 7.1 years on average. Similarly, Iregren (1990) used
neurobehavioral tests (simple reaction time, digit span,
finger tapping, verbal ability, hand dexterity, and finger
dexterity tests from Swedish performance evaluation
system) to study adverse effects in 30 male workers
from two different Mn foundries exposed to an esti-
mated median concentration of 0.14 mg Mn (in total
dust)/m3 as MnO2 for 1-35 years. The exposed workers
had below average scores on a number of the tests, such
as reaction time and finger tapping, when compared
to matched controls. Dose-dependent (cumulative Mn
exposure) worsening of eye-hand coordination, hand
steadiness, and visual reaction time were reported in
dry battery workers exposed on average to about 1 mg
Mn/m3 in total dust for about 5 years (Roels et al.,
1992). In the subsequent 8-year follow-up study by
Roels et al. (1999), only the low-exposure group showed
normalization of performance in the eye-hand coordi-
nation test following a decrease in the average annual
Mn level in total dust from 0.471 to 0.158  mg/m3.
The medium- and high-exposure groups showed a
persistent performance deficit after this period, during
which the average annual air-Mn levels dropped from
0.818 to 0.241 mg/m3 and from 2.941 to 0.744 mg/m3,
respectively (Roels et al., 1999, 2012). None of the
exposure groups showed a significant improvement in
hand stability and simple visual reaction time. In the
study by Mergler et al. (1994), the Mn-exposed work-
ers had similar deficits and also differed significantly
from the controls in cognitive flexibility and emo-
tional state. They also exhibited significantly greater
levels of tension, fatigue, and confusion, as well as a
significantly lower olfactory threshold than controls.
Workplace levels of Mn in this study were measured
at 0.014-11.48 mg/m3, while Mn levels in the respirable
fraction were 0.001-1.273 mg/m3, and mean duration
of exposure was 16.7 years. Epidemiological studies
by Lucchini et al. (1995, 1997, 1999) using neuropsy-
chological tests have shown similar findings on neu-
robehavioral and motor function. These studies have
also shown dose-effect relationships with cumulative
exposure indices. Mergler and Baldwin (1997) pointed
out that although outcomes from individual studies
using neurophysiologic and neurobehavioral tests in
the absence of clinical manifestation can vary, they col-
lectively show a pattern of slowing motor functions,
increased tremor, reduced response speed, enhanced
olfactory sense, possible memory and intellectual
deficit, and mood changes. Several studies suggest the
existence of dose-effect relationships, such as between
Mn exposure (cumulative air-Mn exposure index or
B-Mn) and neuromotor or neuropsychological (cog-
nitive) test results, for example in 43 confined space
welders exposed to Mn welding fume for 1.5 years
on average (Bowler et al., 2007). The mean TWA of
air-Mn ranged from 0.11-0.46 mg/m3 (overall mean
0.21 mg/m3; 55% of the personal air samples >0.20 mg/
m3). A follow-up study in this welder cohort (n = 26)
after 3.5 years of reduced or cessation of Mn exposure,
revealed that only cognitive function improved sig-
nificantly, while olfactory, extrapyramidal, and mood
disturbances remained the same or were exacerbated.
This suggests differential intrinsic vulnerabilities of
brain loci involved in Mn exposure (Bowler et al., 2011).
A meta-analysis of performance effects resulting
from occupational exposure to Mn has been conducted
on 13 epidemiological studies published between 1987
and 2008 (Meyer-Baron et al., 2009). Mean concentra-
tions of inhalable Mn ranged from 0.05 to 1.59 mg/m3,
and mean concentrations of Mn in whole blood ranged
from 8.1 to 48.4 μg/L. Nineteen neuropsychological
performance variables were analyzed and, apart from
two outcomes, the overall effects displayed a negative
impact of Mn on performance. Significant overall defi-
cits were obtained for six test variables; their effect size
ranged from d = −0.23 to −0.36. Four of the variables
measured motor speed and two of them speed of infor-
mation processing. The analysis of exposure-effect
relationships showed that larger effect sizes were more
consistently associated with higher concentrations of
inhalable Mn than with Mn in blood. Confounding
from individual-level and study-level covariates was
shown by analyses of variance, but could be reduced
by linear regressions and z-normalization using data
from the respective control groups (Meyer-Baron et al.,
2011). Results from the meta-analysis prompted a
pool analysis of data from eight studies. Four cogni-
tive and motor performance variables each indicated
significantly lower performances of exposed individu-
als when confounding was considered; slowed motor
performances and deficits in attention and short-term
memory were found (Meyer-Baron et al., 2013).
There is evidence to suggest that Mn neurotoxicity
can result also from prolonged exposure to much lower
Mn exposure levels, such as those occurring in the gen-
eral population. This has been studied in residents liv-
ing in the proximity of industries emitting Mn into the
environment. In 1999, there was a dose-effect associa-
tion between Mn in blood and several neurobehavioral
tests examining motor and cognitive functions and
 45 Manganese
mood in residents in the vicinity of a former ferro-Mn
alloy plant in South Quebec. These effects were more
pronounced in individuals over 50-year old and in men
(Mergler et al., 1999). Santos-Burgoa et al. (2001) pub-
lished a cross-sectional study into the health effects of
Mn in a group of adult subjects from a mining district
in Central Mexico with different levels of airborne Mn.
Using a multivariate logistic regression analysis, the
authors identified a significant relationship between
deficient cognitive performance (Mini-Mental score of
less than 17) and Mn blood levels. The same group has
confirmed that impaired motor functions in residents
in the vicinity of Mn mines is associated with the air-
borne concentration of Mn, which had an average GM
of 0.13 μg/m3 as (Rodriguez-Agudelo et al., 2006). Sub-
clinical findings on motor functions, measured using
the Unified Parkinson’s Disease Rating Scale and
postural sway, were observed among a group of 100
residents from Marietta (Ohio, USA) living an aver-
age of about 7 km from a ferro-Mn alloy smelter (Kim
et al., 2011b). The modeled residential air-Mn estimate
ranged from 0.04 to 0.96 μg/m3 (average 0.18 μg/m3).
Although no substantial differences in neuropsycho-
logical test scores were found compared to a group of
matched residents of an Ohio control town, the results
suggest the existence of some association of anxiety
states and neuropsychological function with environ-
mental air-Mn exposure at the Marietta site. It remains
an open question whether these associations are due
to direct neurotoxic effects of air-Mn or to the Marietta
residents’ concern about the potential health effects
of air pollution (Bowler et al., 2012; Roels et al., 2012).
Impairment of motor coordination and odor identifica-
tion were observed among elderly residing in the vicin-
ity of historical ferro-Mn plant sites in Valcamonica,
Italy (Zoni et al., 2012). Polymorphisms rs4920608 and
rs2871776 of the PD-related gene ATP13A2/PARK9
(encoding probable cation-transporting ATPase 13A2)
significantly modified the effects of Mn exposure
on impaired motor coordination in these subjects
(Rentschler et al., 2012).
Manganese can also cause neurotoxic effects in
young children, who may represent a more sensitive
subgroup of the general population because they show
increased absorption of Mn compared to adults (Dorner
et al., 1989). Except for recent reports of impaired motor
skills and odor identification (Lucchini et al., 2012;
Zoni et al., 2012), health effects associated with ele-
vated Mn exposure in children are impaired cognitive
function, with decrements in memory, verbal learn-
ing, and intelligence (Wasserman et al., 2006; Wright
et al., 2006; Bouchard et al., 2011; Riojas-Rodriguez
et al., 2010; Menezes-Filho et al., 2011, 2013; Khan et al.,
2012). Some of these studies reported neurotoxicity in
993
children whose drinking water contained high concen-
trations of Mn. A study of the association between Mn
exposure through drinking water and infant mortality
(Hafeman et al., 2007) showed that infants exposed to
water Mn concentrations greater than or equal to the
WHO (2004b) standard of 0.4 mg Mn/L had an ele-
vated mortality risk during the first year of life com-
pared with unexposed infants.
A study conducted in Bangladesh showed that Mn
may affect intellectual function, resulting in lower
intelligence quotient (IQ) (Wasserman et al., 2006).
This study examined a cross-section of 142 10-year old
children whose well water supply was contaminated
with a mean concentration of 793 μg Mn/L. The data
indicated that Mn exposure was significantly associ-
ated with reduced full-scale, performance, and verbal
raw scores on the Wechsler Intelligence Scale for Chil-
dren in a dose-response fashion. The same population
also showed an association between an impairment of
children’s mathematical academic achievement and
Mn in drinking water (Khan et al., 2012).
A study conducted to explore the potential associa-
tions between hair metal levels and the neuropsycho-
logical function and behavior of school-aged children,
showed that children’s general intelligence scores,
particularly verbal IQ scores, were inversely related
to Mn and arsenic levels in hair. Significant interaction
between these two metals was observed. The mean hair
metal levels were 471.5 parts per billion (ppb or μg/kg)
for Mn and 17.8 ppb for arsenic (Wright et al., 2006).
Additionally, a study conducted in Quebec, Canada,
examined the relationship between chronic exposure to
levels of water Mn and hyperactive behavior in children
(Bouchard et al., 2007). The same group observed intel-
lectual impairment (i.e. lowered IQ score) in 362 chil-
dren exposed to a median Mn concentration in home
tap water of 34 μg Mn/L (range 1-2700 μg Mn/L). Man-
ganese in water was correlated with Mn in hair and both
were negatively associated with the IQ score (Bouchard
et al., 2011). The hair Mn concentration correlated with
hyperactive and oppositional behaviors, with the high-
exposure group having significantly greater levels of
Mn in hair and a stronger association with hyperactive
behaviors. Likewise, inhaled Mn was negatively associ-
ated with intellectual function in school-aged children
living near a Mn mining and processing facility (Riojas-
Rodriguez et al., 2010). Recent findings show that mice
exposed to Mn during juvenile development experi-
enced greater neuroinflammatory injury and behav-
ioral dysfunction upon exposure to Mn later in adult
life than mice without juvenile Mn exposure (Moreno
et al., 2009). Hence, a background of Mn exposure, par-
ticularly during critical developmental years, could ren-
der individuals more susceptible to neurotoxic insults
994 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
later in life that predispose to neurological disease. The
literature on pediatric exposure indicates that cognitive
functions also form an important target of Mn toxicity
(Zoni et al., 2007; Roels et al., 2012). The cerebral cortex
is probably a critical target area, in addition to the basal
ganglia. Working memory seems to be affected by Mn
toxicity in the caudate nucleus in the striatum, frontal
cortex, and parietal cortex, as shown in nonhuman
­primates (Guilarte, 2013).
Children who suffer from cholestatic liver disease
or who are under total parenteral nutrition for GI dis-
orders are at risk of Mn overload (Devenyi et al., 1994;
Fell et al., 1996; Ono et al., 1995). Impaired biliary
excretion entailed signs of manganism (Fell et al., 1996;
Kafritsa et al., 1998; Ono et al., 1995; Nagatomo et al.,
1999). High levels of brain Mn have been shown in
patients with liver dysfunction, referred to as hepatic
encephalopathy (Butterworth et al., 1995; Butterworth,
2000, 2010; Zerón et al., 2011).
Mutations in the SLC30A10 gene (encoding a man-
ganese transporter) were discovered to cause a syn-
drome of hepatic cirrhosis, early onset generalized
dystonia, polycythemia, and hypermanganesemia
(Stamelou et al., 2012). This rare disorder, together
with Wilson disease, is the only potentially treatable
inherited metal storage disease to date, and it can be
fatal as a result of complications of cirrhosis.
Manganese poisoning may also occur upon abuse
of illicit drug such as methcathinone (or ephedrine).
Methcathinone is a homemade drug derived from the
oxidation of pseudoephedrine with potassium per-
manganate (Sikk et al., 2011). The source of the high
level of Mn in these preparations is residual potas-
sium permanganate, which is used in the synthesis
of these drugs (Sikk et al., 2011). Critically premature
neonates are commonly fed total parenteral nutrition
supplemented with variable amounts of Mn. Hepatic
dysfunction and cholestasis are known risk factors of
increased brain Mn accumulation (Butterworth, 2010;
Butterworth, et al., 1995).
7.3.3  Treatment of Manganism
The similarity of manganism to PD prompted Mena
et al. (1970) to administer the amino acids l-3,4-dihy-
droxyphenylamine (levodopa, l-dopa) and 5-hydroxy-
tryptophan—precursors of dopamine and serotonin,
respectively—for the treatment of chronic Mn poison-
ing. Barbeau (1984) also reported that oral l-dopa can
temporarily improve the symptoms of Mn-induced
neurotoxicity. In an experimental study on rats, Shukla
and Chandra (1981) found that l-dopa treatment mark-
edly increases striatal dopamine level. Therefore, they
advised that l-dopa therapy should not be used in
early Mn intoxication because it may aggravate manic
symptoms due to the increase in brain dopamine.
Patients affected by classic manganism typically do
not respond to l-dopa treatment (Huang et al., 1989;
Calne et al., 1994; Chu et al., 1995; Koller et al., 2004),
indicating that they likely suffer degeneration of the
receptors and neurons that normally respond to this
neurochemical (Chu et al., 1995). New data show, con-
versely, that l-dopa treatment reverses Mn-induced
motor alterations in mice after inhalation of 0.04 M
Mn chloride and Mn acetate for 1 h twice a week for 5
months (Ordoñez-Librado et al., 2010).
Chelating agent therapy has also been tried, but
mainly without success. Nevertheless, recent reports
indicate that chelation treatment may improve the
clinical features in overexposed welders, when
administered in the early phases of the clinical onset
(Discalzi et al., 2000). In a follow-up of seven patients
affected by Mn-induced parkinsonism after treatment
with CaNa2 ethylenediaminetetraacetic acid (CaNa2
EDTA; edetate disodium calcium), good clinical, bio-
logical, and neurological results were obtained by a
combination of timely removal from exposure and
chelating therapy (Herrero Hernandez et al., 2006).
Sodium p-aminosalicylic acid has been observed to be
also effective in treating Mn-induced clinical manifes-
tations in severe cases (Jiang et al., 2006). Chelation
therapy with edetate disodium calcium combined
with iron supplementation is the treatment of choice
to lower B-Mn and improve clinical symptoms asso-
ciated with the newly recognized metabolic disorder
characterized by hypermanganesemia, liver cirrhosis,
extrapyramidal motor manifestations, and polycythe-
mia (Tuschl et al., 2012).
7.4  Effect on the Lungs
7.4.1  Mode of Action
Acute or intermediate exposure to excess Mn affects
the respiratory system. Inhalation exposure to high
concentrations of Mn dusts (Mn dioxide and Mn tetrox-
ide) can cause an inflammatory response in the lung
(chemical pneumonitis). However, exposure to Mn in
an insoluble form, such as MnO2, may also be harmful
for lung also at low exposure levels. As quoted in the
WHO Regional Office for Europe document (2000), an
increase in pneumonia incidence has been registered
in rats exposed to 43-139 μg Mn/m3 as MnO2 (mean
mass median aerodynamic diameter 0.76 μg; mean
standard geometric deviation 2.28) for 2 weeks (Shio-
tsuka, 1984), and pulmonary emphysema in monkeys
exposed to 0.7-3.0 mg Mn/m3 as MnO2 (80% < 1 μm)
for 10 months (Suzuki et al., 1978).
 45 Manganese
In order to obtain information on the histological
characterization of pulmonary responses induced by
Mn, Dorman et al. (2005) performed an experimental
study on rhesus monkeys exposed by inhalation to Mn
sulfate at 0.06, 0.3, or 1.5 mg Mn for 65 exposure days.
Animals exposed to Mn sulfate at ≥ 0.3 mg Mn/m3 had
increased lung Mn concentration. Exposure to Mn sul-
fate at 1.5 mg Mn/m3 for ≥ 15 exposure days resulted in
increased lung Mn concentration, mild subacute bron-
chiolitis, alveolar duct inflammation, and proliferation
of bronchus-associated lymphoid tissue. Bronchiolitis
and alveolar duct inflammatory changes were absent
45 days postexposure, suggesting that these lesions
are reversible upon cessation of subchronic high-dose
Mn exposure. Subchronic exposure at concentration
≤ 0.3 mg Mn/m3, close to the current 8-h occupational
TLVs established for inhaled Mn, was not associated
with pulmonary pathology.
A toxicologic in vitro study (Jang, 2009) on prosta-
glandin G/H synthase 2/cyclooxygenase-2 (COX-2),
which is involved in the biosynthesis of inflammatory
prostaglandins, investigated the effect of Mn chloride
on COX-2 expression in A549 human lung epithe-
lial cells. The data obtained showed that Mn induces
COX-2 expression by transcriptional upregulation in
A549 cells and that the induction is mediated through
multiple cellular events. The findings may provide a
molecular basis for Mn-associated airway inflamma-
tion via COX-2 upregulation.
Laboratory animal studies have also shown that
inhaled Mn may increase susceptibility to infec-
tious agents such as Streptococcus pyogenes in mice
(Adkins et al., 1980), Enterobacter cloacae in guinea pigs
(Bergström, 1977), and Klebsiella pneumoniae in mice
(Maigetter et al., 1976). There is sufficient evidence
that exposure to Mn has cytotoxic effects, including a
depressive effect on the number and phagocytic capac-
ity of alveolar macrophages (Škreb et al., 1980; Fisher
and Škreb, 1980). Thus, toxicological findings in exper-
imental animals and in vitro studies have supported
human studies and corroborated the hypothesis about
the mechanism of Mn action on the lungs. However, it
has to be taken into consideration that an inflamma-
tory response is not unique to Mn-containing particles
but is characteristic of nearly all inhalable PM.
7.4.2  Human Studies of Lung Impairment
An increased morbidity and mortality rate from
pneumonia had been found among workers exposed
to Mn dusts (Wassermann and Mihail, 1961). Clinically,
Mn pneumonia has been characterized as an acute
alveolar inflammation with marked dyspnea. A typical
finding was that antibiotics were often without effect.
995
An increased incidence of pneumonia, as well as bron-
chitis, was found in workers exposed to Mn concentra-
tions of 0.39-16.35 mg/m3 in a factory producing Mn
alloys (Šarić et al., 1977). In this study, smoking hab-
its were taken into account. Roels et al. (1987b) found
in workers of a Mn oxide and salt production plant a
slight but significant decrease in spirometric values
[forced vital capacity, forced expiratory volume in 1
second (FEV1)], whereas at a similar average air-Mn
level of about 1 mg/m3 no spirometric changes were
found in workers of a dry alkaline battery exposed
only to MnO2 (Roels et al., 1992). In both studies, smok-
ing habits were accounted for and no interaction was
found between smoking and Mn exposure regarding
the spirometric test outcome. Based on the spirometric
performance of the control groups in both studies, it is
likely that the workers from the dry battery plant had
intrinsically a much better respiratory function than
those of the Mn oxide and salt production plant.
Studies on populations living in the vicinity of Mn-
emitting plants indicated that Mn exposure might affect
the respiratory system. Effects at lower levels of air-
borne Mn have been claimed (Šarić et al., 1978) to occur
in a population living near a ferro-Mn plant (Šibenik,
Croatia). Over a period of 4 years, acute bronchitis
and peribronchitis were consistently more common
among people living near the plant. A less consistent
pattern could be seen for pneumonia. Average annual
Mn concentrations in two zones of the town area
near the plant were 0.236-0.39 and 0.164-0.243 μg/m3,
whereas in a third zone at a distance of 4-5 km from
the plant the annual means for 4 years varied from
0.042 to 0.099 μg/m3. The highest weekly means for the
zones were 1.24, 1.08, and 0.27 μg/m3, respectively. In
addition, in a study carried out in school children in
the same area and repeated 1 year later, it was shown
that during the study period of 6 months the recorded
incidence of acute respiratory diseases, as well as the
values of FEVs, correlated in both studies with the lev-
els of air-Mn measured at the locations of the schools
attended by the studied children (two schools were
in zones with higher air-Mn levels, and one in a zone
with levels of air-Mn about 10 times lower). Acute
bronchitis was significantly more frequent and FEVs
were lower in children from the schools with higher
air-Mn levels (Hrustić and Šarić 1980).
Bergström (1977) summarized data from epidemio-
logical and experimental studies concerning the effect
of Mn on the lung. He supported the concept that a pri-
mary inflammatory reaction can occur in the lung after
exposure to MnO2 without the presence of pathogenic
bacteria. Such a reaction pattern also explains the inef-
fectiveness of the antibiotics commonly used for the
treatment of pneumonia caused by Mn. On the other
996 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
hand, experimental studies suggest that exposure to
MnO2 causes a decrease in resistance toward respira-
tory infections. Consequently, some of the observed
cases of Mn-induced pneumonia might have had a
bacterial genesis (Šarić and Piasek, 2000).
It has been suggested (Šarić and Lučić-Palaić, 1977)
that long-term exposure to Mn combined with a smok-
ing habit may contribute to the development of chronic
nonspecific lung disease.
In a longitudinal follow-up study on pulmonary
function and respiratory symptoms in 145 miners
exposed to Mn and 65 matched controls (Mashhadi
Abar Boojar and Goodarzi, 2002), the results indicated
a synergistic effect of Mn and smoking on the devel-
opment of chronic respiratory impairment. Pulmonary
function was also impaired among welders exposed to
manganese (Bowler et al., 2007). In a study by Halatek
et al. (2005) on neurological and respiratory symptoms
in shipyard welders exposed to Mn, it was pointed
out that inhibition of Clara cell protein secretion in
younger welders, i.e. not adapted to the Mn environ-
ment, suppressed the anti-inflammatory effect in the
respiratory tract and probably enhanced Mn absorp-
tion and thus the incidence of subclinical neurotoxic
symptoms related to airborne and B-Mn levels.
7.5  Effects on Other Organs and Systems
7.5.1  Reproductive Effects
Impotence and loss of libido are common com-
plaints in workers occupationally exposed to Mn who
have been afflicted with the clinical signs of mangan-
ism (Emara et al., 1971). Impaired fertility (measured
as a decrease in the number of children per married
couple) has been observed in male workers exposed
for 1-19 years at air-Mn levels that did not produce
frank signs of manganism (Lauwerys et al., 1985). On
the other hand, in a study performed by Jiang (1996a),
on 314 men in a Mn plant exposed for up to 35 years to
Mn to levels of 0.145 mg/m3 as MnO2 (GM) no signifi-
cant differences were found in reproductive outcomes
between exposed and control workers. However,
impotence and lack of sexual desire were higher in Mn-
exposed workers. In contrast, a study into the reproduc-
tive effects in 70 male workers of a dry alkaline battery
plant exposed to Mn dioxide at a median concentration
of 0.71 mg/m3 in total dust for an average of 6.2 years
did not register any difference compared with controls
(Gennart et al., 1992). Moreover, MnO2-exposed work-
ers in this plant did not show changes in the activity of
the hypothalamo-pituitary-testicular axis compared to
controls, as revealed by the measurement of the serum
concentrations of follicle-stimulating hormone (FSH),
luteinizing hormone (LH), and prolactin (PRL) (Roels
et al., 1992). In a study carried out in three groups of
workers occupationally exposed to Mn (63 miners or
ore processing workers, 38 electric welders in mechani-
cal fields, and 110 electric welders in shipbuilding), Wu
et al. (1996) found increased semen liquefaction time
and decreased sperm count and viability. Although
this study indicates that Mn exposure can cause sperm
toxicity, the presence of other metals in the welders
(i.e. copper, nickel, chromium, and iron), which were
also elevated in semen, also had to be taken in con-
sideration. In animal experiments on rats and rabbits
(Chandra et al., 1973), it was shown that excessive Mn
exposure might produce marked degenerative changes
in the seminiferous tubules. This effect did not occur
immediately but developed slowly over the course of
4-8 months following exposure. Direct damage to the
testes has not been reported in humans occupation-
ally exposed for longer periods. Large amounts of Mn
affect fertility in mammals and are toxic to the embryo
and fetus (Colomina et al., 1996).
Reported data reveal conflicting evidence for
whether occupational exposure to Mn causes adverse
reproductive effects. Noted effects may occur as a sec-
ondary result of neurotoxicity to Mn (ATSDR, 2012). In
a study on ambient Mn exposure and sperm mobility
performed in 200 clients of an infertility clinic, Wirth
et al. (2007) showed that a high Mn level was associ-
ated with an increased risk of low sperm mobility and
low sperm concentration. There was a U-shaped dose-
response pattern between quartiles of Mn exposure
and all three sperm parameters. In a cross-sectional
study, Ellingsen et al. (2007) compared the serum con-
centrations of inhibin B and PRL in 96 male current
welders and 23 patients who were all former weld-
ers diagnosed as having welding-related manganism,
with 96 age-matched referents. The current welders’
GM airborne exposure to Mn was 121 μg/m3 (range
7-2320). PRL level adjusted for age and smoking habits
(GM 193 mIU/L vs. 166 mIU/L; P = 0.047) and inhibin
B adjusted for alcohol consumption (arithmetic mean
151 ng/L vs. 123 ng/L; P = 0.001) were higher in the
welders than in referents. The whole-blood Mn con-
centration was associated with the serum PRL concen-
tration. Tobacco smoking resulted in lower serum PRL
concentrations. The GM of serum PRL concentrations
of the patients did not significantly differ from that of
referents, but the arithmetic mean of serum inhibin B
concentrations was significantly lower. These results
suggest an effect of Mn on the pituitary that is revers-
ible upon cessation of exposure. Lower inhibin B con-
centrations in the patients could point to a functional
impairment of the testicular Sertoli cells, which may be
caused by a welding fume component.
 45 Manganese
Since 2000, there have been several studies deal-
ing with Mn exposure in pregnancy, the fetus, and the
newborn. The study of Dorman et al. (2005) deals with
the maternal-fetus distribution of Mn in rats following
inhalation exposure to Mn sulfate. The results of this
study showed that the placenta partially sequesters
inhaled Mn, thereby limiting exposure to the fetus. In a
study on B-Mn concentrations and intrauterine growth
(Vigeh et al., 2008), Mn levels in umbilical cord blood
and maternal whole blood were measured in appar-
ently healthy mothers and their newborns. The study
suggested that Mn in maternal and umbilical cord
blood might induce different effects on birth weight.
Another study on maternal B-Mn levels and infant
birth weight (Zota et al., 2009) showed that maternal
B-Mn levels during pregnancy are associated in a non-
linear pattern with birth weight in full-term infants.
Claus Henn et al. (2010) observed an inverted U-shaped
association between 12-month blood manganese and
concurrent mental development scores. These results
suggest that an inverted U-shape association between
B-Mn at 12 months of age and concurrent Mental
Development Index Score (MDIS), suggesting that both
low and high B-Mn levels may have adverse effects on
mental development (highest MDIS at a B-Mn level of
around 25 μg/L, which is a rather high value). The data
are consistent with manganese being both an essential
nutrient and a toxicant. Because there is no association
with B-Mn at 24 months of age, it is possible that 12
months is a sensitive time point for Mn effects on cogni-
tion. The same group observed evidence of synergism
between lead and manganese on neurodevelopmental
testing in 455 children tested every 6 months between
12 and 36 months of age, whereby lead toxicity was
increased among children with high manganese coex-
posure (Claus Henn et al., 2012).
7.5.2  Cardiovascular Effects
In an epidemiological study performed in ferroal-
loy workers, a decrease in systolic blood pressure was
found (Šarić and Hrustić 1975). Arterial blood pressure
was measured and compared in three groups of male
workers aged 20-59 years at different levels of expo-
sure to airborne Mn. The lowest mean values of systolic
blood pressure were found in workers with the highest
occupational exposure (0.39-20.44 mg/m3), although
this group was comparatively the oldest. The lowest
mean diastolic pressure values were found in control
workers. Confounders such as age, body mass index,
and smoking habits, which might have an impact on
the results obtained, were accounted for. Jiang (1996b)
studied the potential cardiotoxicity of MnO2 exposure
in 656 workers (547 males and 109 females) engaged
997
in Mn milling, smelting, and sintering. The GM of Mn
in air was 0.13 mg/m3. The length of exposure varied
from 0 to 35 years. There was no increase in abnor-
mal electrocardiograms between Mn workers and
their matched controls. Arterial blood pressure values
showed a greater frequency of low diastolic pressure,
but this effect was highest in young workers with the
lowest tenure in the plant. Lee and Kim (2012) recently
showed that B-Mn was associated with an increased
risk of hypertension in data representative of the
Korean adult population. Different results with respect
to the relationship between Mn and blood pressure
may be due to small samples that do not represent a
general population or due to different Mn exposure
status and a lack of control for various confounders
affecting blood pressure. Therefore, prospective stud-
ies are needed to obtain a better understanding of the
role of Mn in hypertension, which may have important
implications for health policy and disease prevention.
Animal studies into the relationship between blood
pressure and Mn also showed contradictory results.
Kimura et al. (1978) reported that a high dietary expo-
sure to Mn (564 mg/kg) in rats produced a significant
increase in serotonin concentrations and a decrease in
blood pressure. The authors attributed the final marked
decrease in blood pressure to the elevated blood sero-
tonin concentrations, most probably released from dif-
ferent tissues.
Following previous studies suggesting that Mn
exposure can be toxic to the heart, Miller et al. (2006)
performed a study on rats. The results showed that
high dietary Mn reduced mitochondrial O2 consump-
tion. However, dietary Mn, even at high concentra-
tions, is unlikely to pose a serious threat to health
when ingested along with adequate dietary Mg.
In an experimental study (Yang et al., 2007), Mn
cytotoxicity was examined in neonatal rat ventricu-
lar myocytes in vitro by 3-(4,5-dimethythiazol-2-yl)-
2,5-diphenyl tetrazolium bromide (commonly known
as MTT) cell proliferation assays: after incubation with
different concentrations of Mn for 24 h, apparent cyto-
toxicity was observed.
7.5.3  Hematological Effects
In subjects chronically exposed to high levels of
Mn in the workplace, no significant hematological
effects have been observed. From studies into chronic
Mn poisoning, it was presumed that large amounts
of Mn caused depression of both erythropoiesis and
granulocyte formation (WHO, 1981). Yiin et al. (1996)
observed increased erythrocyte SOD and plasma malon­
dialdehyde in males who worked in Mn smelters. In
the dry alkaline battery study by Roels et al. (1992),
998 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
erythropoietic parameters (red blood cell counts,
hemoglobin, mean corpuscular volume, and mean cor-
puscular hemoglobin concentration) and serum iron
concentration in Mn-exposed workers showed a con-
sistent and statistically significant trend toward lower
values, although the distributions of the values were
well within the normal ranges.
7.5.4  Endocrine Effects
In a study by Alessio et al. (1989), performed in
foundry workers exposed to Mn levels of 0.04-1.1 mg/m3
(PM) and 0.5-0.9 mg/m3 as fumes for approximately 10
years, elevated PRL and cortisol levels were reported.
No changes in the levels of FSH and LH were noted.
Except for serum PRL, a similar observation was
made by Roels et al. (1992) for serum FSH and LH in
dry alkaline battery workers exposed to MnO2 air-
borne dust. Smargiassi and Mutti (1999) reported also
an increase of serum PRL levels in a group of work-
ers from a ferroalloy plant. Measurements were made
twice in the same workers (in 1992 and 1997). Serum
PRL levels that were significantly elevated in the ear-
lier analysis (i.e. 1992) had increased significantly
during the intervening period in 1997. During the
5-year period between studies, exposure levels were
consistent.
Pine et al. (2005) performed an experimental study
on female rats to determine the effects of Mn exposure
on puberty-related hormones and the onset of female
puberty. MnCl2 administered acutely into the third
ventricle of the brain acted in a dose-dependent man-
ner to stimulate LH release in prepubertal female rats.
These results suggest that Mn may contribute to preco-
cious puberty if an individual is exposed to elevated
levels of Mn at an early stage in their development.
7.5.5  Immunological Effects
In a study performed in male welders exposed to
Mn (0.29-0.64 mg/m3) for an unspecified duration,
suppression of T and B lymphocytes, characterized
by reductions in serum immunoglobulin G and total
E rosette-forming cells were observed (Boshnakova
et al., 1989). However, the welders in this study were
also exposed to other compounds, including cobalt,
carbon dioxide, and nitric acid, as well as to noise and
vibration. In addition, it is not known whether any of
the registered changes are associated with significant
impairment of immunological system function.
Manganese belongs to a group of agents called
transition metals, together with chromium, cobalt,
and nickel, which are known to induce occupational
asthma. The similar chemical structure of Mn may thus
determine its asthmogenic potential. A case report on
occupational asthma due to Mn exposure in a 42-year-
old nonsmoking welder with work-related dyspnea
(Wittczak et al., 2008) is the first well-documented case
of Mn-induced occupational asthma. The argument for
recognizing the condition as occupational asthma was
a positive clinical response to the specific challenge
test, as well as morphological changes found in the
induced sputum.
7.5.6  Genotoxic and Carcinogenic Effects
Relatively high doses of Mn affect DNA replication
and repair in bacteria, and cause mutations in both
microorganism and mammalian cells, although the
Ames test does not appear to be particularly respon-
sive to Mn. In mammalian cells, Mn causes DNA dam-
age and chromosome aberrations (Gerber et al., 2002).
In a more recent study performed by Lima et al. (2008)
with the aim of evaluating the mutagenic potential of
Mn chloride, the comet assay and chromosome aber-
ration analysis were applied to determine the DNA-
damaging and clastogenic effects of MnCl2.4H2O.
Cultured human lymphocytes were treated with
15, 20, and 25 μM Mn chloride. MnCl2.4H2O showed
strong cytotoxicity at all phases of the cell cycle. Both
genotoxicity observed at the G2 phase and the comet
assay may reflect the lack of time for cellular repair
system to act. The absence of chromosome aberrations
at all other phases of the cell cycle suggests that Mn-
mediated damage may be repaired in vitro.
In another study published in the same year (Jiao
et al., 2008), the authors examined single-strand breaks
(SSBs) in mitochondrial DNA (mtDNA) induced by
MnCl2 in vitro and in vivo and discuss the possible
underlying mechanism. In vitro results indicated that
MnCl2 increased the formation of mtDNA SSBs and ROS
in hepatic mitochondria in a dose-dependent manner.
MnCl2 exposure in vivo increased mtDNA SSBs in rat
brain and liver, and decreased the level of glutathione
in rat hepatic mitochondria and brain homogenates in
a dose-dependent manner. The level of malondialde-
hyde and the activities of SOD and glutathione per-
oxidase (GPx) were not significantly changed in both
hepatic mitochondria and brain homogenates in rats.
These results indicate that Mn treatment increases the
amount of mtDNA SSBs in vitro and in vivo, probably
mediated by Mn-induced oxidative stress.
The fungicide maneb and the contrasting agent
MnDPDP can be embryotoxic, but for MnDPDP the
effect only occurs at doses much higher than those
employed clinically (Maci and Arias, 1987).
There is only one human study into the genotoxic
effects of exposure to Mn. In this study, an increased
incidence of chromosomal aberrations was registered
 45 Manganese
in three groups of welders with occupational expo-
sures lasting 10-26 years (Elias et al., 1989). In addition
to Mn exposure (median concentrations of 0.18 mg/m3
for respirable dust and 0.71 mg/m3 for total dust), the
welders were also exposed to nickel and chromium.
Therefore, the observed increase in chromosomal
aberrations could not be attributed to exposure to any
single metal (nickel is known to cause chromosomal
aberrations by the inhalation route).
In a study into the genotoxic effects of occupational
exposure to mancozeb (in 14 women and 30 men, all
of reproductive age), Jablonickà et al. (1989) showed a
significantly increased incidence of chromatid breaks
in exposed women compared to controls, and in the
combined exposed cohort compared to the combined
control group. Isochromatid breaks were significantly
increased in exposed men and in the combined group,
compared to their respective controls. Gaps were
significantly increased in both exposed groups. The
number of sister chromatid exchanges (SCEs) was
not significantly increased in any group. Mancozeb-
exposed smokers had a significantly increased inci-
dence of SCEs compared to exposed nonsmokers.
Information on cancer due to Mn is scanty, but the
available data do not indicate that inorganic Mn is car-
cinogenic. The EPA (1996) has concluded that Mn is not
classifiable as a human carcinogen. The International
Agency for Research on Cancer has not evaluated Mn
(Boffetta, 1993). So far, there is insufficient evidence to
indicate that inorganic Mn exposure produces cancer
in animals or humans.
8  GUIDELINES AND REGULATIONS
The WHO Regional Office for Europe indicated a
guideline value for environmental air-Mn of 0.15 μg/m3
(WHO, 1994). Based on early neurotoxic effects
observed in occupationally exposed workers and
using the benchmark approach, an estimated no
observed adverse effect level [or NOAEL; the lower
95% confidence limit of the benchmark dose lower
limit (BMDL5) for a 5% excess in the background prev-
alence] of 30 μg/m3 was obtained. The guideline value
should be applied as an annual average. The EPA pub-
lished a reference concentration (RfC) of 0.05 μg Mn/
m3 (EPA, 2012a), based on the lowest observed adverse
effect level of 0.15  mg/m3 from the occupational
study by Roels et al. (1992) and conducted a reevalu-
ation that recommended a range of 0.09-0.20 μg Mn/
m3, although the RfC was not formally changed (EPA,
1994). Health Canada (2010) has reviewed the health
effects of manganese and derived a RfC of 0.05 μg/m3
from the occupational study by Lucchini et al. (1999).
999
The RfC is intended to be the air manganese concentra-
tion to which the population can be exposed for a life-
time without appreciable risk of adverse health effects.
The United States Agency for Toxic Substances and
Disease Registry recently published a new “minimal
risk level” for respirable Mn of 0.3 μg/m3 for chronic
exposure inhalation for 365 days (ATSDR, 2012).
For occupational exposure, the ACGIH currently
adopts for inhalable Mn particles a TLV-TWA of 0.2 mg
Mn/m3 (listed as elemental Mn and inorganic com-
pounds, as Mn) and a 0.02 mg Mn/m3 TLV-TWA for
respirable particles with a notation that the TLV is
based on “CNS func” (i.e. neurobehavioral and neuro-
psychological changes) (ACGIH, 2013). The U.S. Occu-
pational Safety and Health Administration (OSHA,
1998) adopted in 1998 0.2 mg/m3 as the permissible
exposure limit (PEL)-TWA for Mn, both elemental and
inorganic compounds. The earlier OSHA PEL value of
5 mg Mn/m3 is still valid as the ceiling value.
The upper range of the ESADDI (i.e. 5 mg/day)
(NAS/NRC, 1989) was indicated as a provisional
guidance value (0.07 mg/kg/day) for oral exposure
to Mn. The EPA has derived a chronic oral reference
dose (RfD) of 0.14 mg/kg/day for Mn. This value cor-
responds to the average daily intake of Mn in the diet
considered to be adequate and safe (10 mg/day). The
RfD was derived assuming an average body weight of
70 kg and was based on a composite of data provided
by the WHO and the NRC. An uncertainty factor was
not employed for the following reasons: the informa-
tion used to determine the RfD was taken from many
large populations; humans exert efficient homeostatic
control over Mn such that body burdens are kept con-
stant with variations in diet; there are not subpopula-
tions that are believed to be more sensitive to Mn at this
level; Mn is an essential element that is required for
normal human growth and the maintenance of health
(ATSDR, 2012). However the EPA has recommended
that a “modifying factor” of three should be applied
when assessing risk from Mn in drinking water or soil
because the study by Kondakis et al. (1989) raises sig-
nificant concerns about possible adverse neurological
effects at doses not far from the range of essentiality
(ATSDR, 2012).
For drinking water, the WHO issued a guideline
of 400 μg/L for Mn in the third edition of “Guidelines
for Drinking-Water Quality” (WHO, 2004a). However,
the 400-μg/L guideline for Mn was discontinued in
the fourth edition because “this health-based value
[400 μg/L] is well above concentrations of Mn nor-
mally found in drinking-water, [so] it is not considered
necessary to derive a formal guideline value” (WHO,
2011). A review of WHO publications, peer-reviewed
journal articles, government reports, and published
1000 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
conference proceedings strongly suggests that Mn
levels > 400 μg/L in drinking water or in potential
drinking-water supplies are found in a substantial
number of countries (Frisbie et al., 2012). In addition,
drinking mineral water regularly can add significantly
to Mn intake (Dieter et al., 1992). Recent research into
the health effects of Mn on children suggests that the
earlier WHO guideline of 400 μg/L was too high to
adequately protect public health.
9  BIOMARKERS OF EXPOSURE AND
EFFECTS
9.1  Mn Concentration in Biological Media
as a Biomarker of Exposure
Being an essential element, Mn is actively controlled
by homeostatic mechanisms regulating its absorption,
distribution, and excretion. These processes also play
an important role in Mn toxicokinetics, in contrast to
many nonessential toxic metals such as mercury and
lead. As a result of this highly efficient control, the
association between external and internal exposure
indicators is weak at the individual level. Several bio-
markers are used and others are being investigated
in an attempt to develop accurate indicators to reflect
the body burden or current exposure. Monitoring con-
centrations in body fluids can identify individuals
with excessive exposure and those at risk of develop-
ing clinical abnormalities (Lucchini and Kim, 2009).
Manganese can be measured with good sensitivity
in biological fluids and tissues, and levels in blood,
urine, feces, and hair have been investigated as pos-
sible biomarkers of exposure. The reported normal
concentrations of Mn in blood, serum, and urine show
a wide range. Data by Buchet et al. (1976), Zielhuis
et al. (1978), Baldwin et al. (1999), and Kim and Lee
(2011) using electrothermal atomic absorption indi-
cate that the average normal level in whole blood is
7-13 μg/L. Approximately 85% of B-Mn is in erythro-
cytes; for serum or plasma, the average Mn concentra-
tions are reported to be 0.6-1.0 μg/L, as determined
by electrothermal atomic absorption (Halls and Fell,
1981). Milne et al. (1990) reported the mean Mn contri-
bution of blood components to whole blood (and per-
centage of total Mn) for healthy adult Americans (24
men, 24 women; 25-49 years of age): for whole blood,
10.9 μg/L (100%); for red blood cells, 7.39 μg/L (65.8%);
for plasma, 0.49 μg/L (4.4%); for white blood cells,
2.60 μg/L (23.2%); and for platelets, 0.74 μg/L (6.6%).
In healthy, unexposed people living in the Lombardy
region in northern Italy, B-Mn was 8.8 ± 0.2 μg/L and
serum Mn was 0.6 ± 0.014 μg/L (Minoia et al., 1990).
A recent study by Kim and Lee (2011) showed that
women had a higher GM of B-Mn concentrations
than men in a representative Korean general adult
population (14.03 μg/L vs. 11.92 μg/L). This difference
is mainly due to differences in iron status between
men and women (Baldwin et al., 1999; Aschner and
Aschner, 2005; Meltzer et al., 2010) because iron defi-
ciency increases B-Mn level and the prevalence of iron
deficiency in women is higher than in men (Davis,
C.D., et al., 1992; Erikson et al., 2002a, Kim and Lee,
2011). However, the study by Kim and Lee (2011) also
showed that women with normal hemoglobin or fer-
ritin levels nevertheless had significantly higher B-Mn
concentrations than men. The difference in B-Mn even
after controlling for iron deficiency status may be due
to gender differences instead of differences in ferritin
level (Kim and Lee, 2011). Norwegian women with
serum ferritin concentrations ≥ 12 μg/L and hemo-
globin ≥ 12.0 g/dL (120g/L) had average B-Mn con-
centrations of 9.7 μg/L (Meltzer et al., 2010), whereas
Norwegian men on average had blood concentrations
of 8.8 μg Mn/L at a normal mean serum ferritin level.
Ellingsen et al. (2003b) observed a lower mean concen-
tration of soluble TfR in Mn-exposed workers than in
controls (2.2 vs. 2.6 mg/L; P < 0.001), and the concen-
tration was negatively associated with current expo-
sure to “soluble” Mn in the inhalable aerosol fraction
and with current smoking habits. They also observed
an association between the concentration of serum-sol-
uble TfR and the concentration of Mn in whole blood
(Pearson’s r = 0.48; P < 0.001) in controls. According to
the authors, these results suggest that Mn-exposed
workers have higher intracellular iron concentration in
erythrocyte precursors compared to controls, resulting
in downregulation of TfRs on the surface of these cells.
A recent study showed that premenopausal women
had on average 1.5 μg/L higher B-Mn concentrations
than did postmenopausal women, mainly due to dif-
ferences in iron status between premenopausal and
postmenopausal women (Lee and Kim, 2012).
Baldwin et al. (1999) also reported that GMs for Mn
levels were higher in women than in men (7.50 μg/L
versus 6.75 μg/L). In addition, for women, Mn blood
levels correlated with serum iron and decreased as age
increased.
Manganese levels in blood increase in pregnant
women, with levels at full term measured to be at least
twice as high as in nonpregnant women, while cord
B-Mn levels were approximately twice as high as mater-
nal levels (Smargiassi et al., 2002; Takser et al., 2004; Zota
et al., 2009). Infants have higher levels of B-Mn compared
to children or adults (Rukgauer et al., 1997; Rice et al.,
2010). The increase in Mn is mainly due to increased
needs for iron in pregnancy, the fetus, and infants.
 45 Manganese
Although urinary excretion of Mn is low (less than
1% of the absorbed dose), measurements of urine con-
centrations have been made. The reported normal con-
centrations of Mn in urine vary to a large extent. Hoet
et al. (2013) recently performed a nationwide survey
to determine (using ICP-MS) the reference urinary Mn
concentration in the general Belgian population (460
men, 514 women; age 18-80 years). The P5-P95 urinary
Mn concentration interval in men and women (n = 974)
combined amounted from < 0.043 to 0.36 μg/L; the
arithmetic mean was < 0.043 μg/L (range < 0.043 to
1.72 μg/L). Earlier data by Buchet et al. (1976), Halls
and Fell (1981), Oberdorster and Cherian (1988), and
Minoia et al. (1990) corroborate the Hoet et al. (2013)
findings in that they indicate that less than 1 μg Mn/L
is normally found in the urine of humans never occu-
pationally exposed to Mn.
On a group basis, workers exposed to a mean con-
centration of 1 mg Mn/m3 had higher levels of Mn in
whole blood and urine compared to unexposed con-
trols (Roels et al., 1987b); the group average levels of
whole B-Mn appear to be related to Mn body burden
and the urine Mn levels to current exposure. However,
the individual measurements of blood or urine Mn do
not correspond to individual external exposure levels
(Roels et al., 1987a,b, 1992; Zheng et al., 2011).
The study by Lucchini et al. (1995) suggests that
blood and urine levels are correlated with exposure
levels on individual basis. In this study, a correlation
was observed between a cumulative exposure index
(CEI) and B-Mn, and both B-Mn and CEI were asso-
ciated with neurobehavioral outcomes. Workers were
tested during a month of being laid off, and all cor-
relations increased proportionally to the period from
the exposure cessation. Mergler and Baldwin (1997)
suggested that in this study the correlation between
CEI and B-Mn was evident because B-Mn levels were
not influenced by current exposure and were there-
fore better related to the Mn levels accumulated in the
body storage deposits. This situation has not yet been
reproduced in the literature. In a follow-up study of
currently exposed workers, Lucchini et al. (1999) did
not observe any correlation between CEI and B-Mn,
although the CEI was still associated with the impair-
ment of neurobehavioral functions.
Other studies on currently exposed workers by Jär-
visalo et al. (1992) and Roels et al. (1987a,b, 1992) indi-
cate that on an individual basis, correlations between
the level of workplace air-Mn exposure and the lev-
els of Mn in blood and urine are not reliable predic-
tors of external Mn exposure. Järvisalo et al. (1992),
as well as Roels et al. (1987a,b, 1992), suggested that
blood and urinary Mn levels may be useful to moni-
tor group exposure. A factor that limits the usefulness
1001
of measuring Mn in blood and urine as a measure of
excess Mn exposure is the relatively rapid rate of Mn
clearance from the blood circulation and the very low
excretion rate in urine. Manganese excreted in urine
represents only a small fraction of eliminated Mn, and
the variability of Mn in urine is high among exposed
and even among control subjects; therefore, Mn in
urine is less useful than Mn in blood as an exposure
biomarker at the group level (Lucchini and Kim, 2009;
Zheng et al., 2011).
In a Canadian study by Baldwin et al. (1999) into the
relationship between levels of Mn in the air and in blood,
significantly higher levels of B-Mn correlated with high
levels of airborne Mn. Data obtained in this study com-
bined with the occupational studies indicate that there
may be a plateau level related to homeostatic control of
Mn on an individual basis. At low levels, B-Mn concen-
trations would be related to food, water, and air levels
of Mn, and large differences in individual blood levels
would be observed. At high exposure levels, such as in
occupational environments, this plateau may be reached
or exceeded. A study by Hoet et al. (2013) in 27 Mn-
exposed welders (air-Mn 1.3 to 729 μg/m3; GM 28 μg/m3)
showed after the first shift of the working week (thus,
after 2 days of nonexposure), values of Mn in plasma
(P-Mn) that correlated well on an individual basis with
air-Mn levels above 10 μg/m3 (n = 20; r = 0.69; P < 0.001).
At the end of the second working day, the slope of the
P-Mn values vs. air-Mn dropped 2.3 times because of the
increased response of the homeostatic system to main-
tain “normal” systemic Mn levels. A P-Mn cutoff value of
2 μg/L can distinguish air-Mn above or below 20 μg/m3
with a sensitivity of 69% and a specificity of 82%.
The use of hair as a possible biomarker of Mn expo-
sure is problematic. In hair, Mn concentrations are
reported to be normally below 4 mg/kg (Oberdorster
and Cherian, 1988). While some studies have found a
correlation between exposure levels and Mn concen-
tration in the hair (Collipp et al., 1983; Huang and Cao,
2003; Lin, 2002; Wang and Wu, 2000), the majority of
studies reported different limits concerning the valid-
ity of scalp hair analysis as a biomarker of exposure
(Lyden et al., 1984; Stauber et al., 1987; Sturaro et al.,
1994). A more rigorous hair cleaning methodology was
developed by Eastman et al. (2013) to establish the
utility of hair as an exposure biomarker for Mn and
other metals (Pb, Cr, Cu), using ICP-MS, scanning elec-
tron microscopy, and laser-ablation ICP-MS to evalu-
ate cleaning efficacy. The cleaning method included
0.5%Triton X-100 sonication plus 1 N nitric acid soni-
cation and was highly effective in removing dust
contamination from hair samples from adolescents.
Manganese hair concentration was ∼4-70-fold lower
than levels reported in other pediatric Mn studies and
1002 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
were significantly higher in the proximity of ferroalloy
emissions.
Given the complex and limited relationship between
exposure and B-Mn levels may depend upon exposure
attributes and the latency of blood sampling relative to
exposure and the scarce utility of plasma and urine as
exposure biomarkers (Smith et al., 2007), other candi-
date biomarkers are being measured in different occu-
pational and environmental settings: tooth enamels
(Ericson et al., 2007), nails (Wongwit et al., 2004; Gil
et al., 2011; Laohaudomchok et al., 2011; Sriram et al.,
2012), and saliva (Gil et al., 2011; Wang et al., 2008).
Particularly relevant is the possibility of measuring
Mn in teeth using laser-ablation ICP-MS. This new
technique allows the determination of pre- and post-
natal exposure, as well as a cumulative early life expo-
sure. Higher Mn levels in prenatal dentin provided
retrospective and time-specific levels of fetal expo-
sure resulting from environmental and occupational
sources in the community of Salinas, California, one of
the areas with the highest use of Mn-containing fungi-
cides (Gunier et al., 2013). Mn dust loading (μg/m2 of
floor area) during pregnancy were associated with the
possibility of determining fetal levels from the mantle
dentine in deciduous teeth (Arora et al., 2012). In many
ways, animal studies have been highly productive for
understanding the mechanism of toxicity and for dif-
ferentiating the impact of different exposure windows
in relation to cumulative lifelong exposure. Prewean-
ing Mn exposure caused hyperactivity, disinhibition,
and spatial learning and memory deficits associated
with altered D1 and D2 DARs and DAT levels (Kern
et al., 2010). The results of different tests for motor
skills were differentially impacted by early life and/or
lifelong exposure through oral administration of Mn
(Beaudin et al., 2013).
9.2  Other Biomarkers
Lymphocyte Mn-dependent SOD activity increases
with increased Mn uptake (Yiin et al., 1996). As sug-
gested by the results of some studies (Davis and Gre-
ger, 1992; Greger, 1999), the analysis of this enzyme,
in conjunction with serum Mn levels, may be used in
assessing low and moderate levels of exposure to Mn.
Ethylene thiourea is readily detected in the urine
of humans (and animals) exposed to maneb and man-
cozeb, but there is no clear relationship between dose
and urinary levels (Kurttio et al., 1990; Kurttio and
Savolainen, 1990).
Clara cell secretory protein CC16 is a potential
biomarker for the pulmonary effects of exposure to
MMT (Halatek et al., 1998). Clara cells are unciliated
cells that occur at the boundary where alveolar ducts
branch from the bronchioles. CC16 damage causes a
significant change in the levels of this protein. The pro-
tein can be quantified in serum and urine. Until now,
the protein has only been studied experimentally fol-
lowing i.p. administration of MMT.
Manganese exposure is known to alter iron (Fe)
homeostasis. Zheng et al. (2011) showed that the
plasma or erythrocyte Mn:Fe ratio reflects not only
steady-state concentrations of Mn or Fe in tested indi-
viduals but also a biological response (i.e. altered Fe
homeostasis) to Mn exposure; the ratio may be a sen-
sitive measure of Mn exposure. However, the cutoff
values for plasma or erythrocyte Mn:Fe ratio among
the general population needs to be further explored,
verified, and established.
Serum PRL has been identified as a possible bio-
marker of Mn effects on dopamine neurotransmis-
sion (Montes et al., 2011; Marreilha Dos Santos et al.,
2011; Aschner, 2006b; Takser et al., 2004); namely, the
tuberoinfundibular dopaminergic system, which
exerts tonic inhibition of PRL secretion, is affected by
Mn action (Smargiassi and Mutti, 1999). Still, it is not
clear whether PRL levels indicate recent or cumulative
exposure. It should also be mentioned that in studies
by Roels et al. (1992) and Myers et al. (2003b) serum
PRL levels were not increased in workers chronically
exposed to airborne Mn.
9.3 Neuroimaging
Tremendous progress has been made in medical
imaging of the human body since the invention of com-
puted tomography (CT) and MRI. Neuroimaging of
patients with metal neurotoxicity can be divided into
two types: morphological neuroimaging (anatomy-
based imaging), including CT and MRI; and functional
neuroimaging (physiology-based imaging), such as
magnetic resonance spectroscopy (MRS), single-pho-
ton emission computed tomography (SPECT), PET,
diffusion tensor imaging (DTI), and functional MRI
(fMRI). Neuroimaging is undergoing a shift from mor-
phological to functional imaging as new technologies
are introduced (Lang, 2000; Walker et al., 2004). MRI,
PET, and SPECT have been used for 10 years or more
to evaluate workers exposed to Mn, and to examine the
neurological consequences of such exposure. Recently,
functional neuroimaging modalities such as fMRI,
MRS, and DTI have also been applied (Kim, 2011).
9.3.1  Pallidal Signal Intensity on T1-Weighted
Magnetic Resonance Imaging
The paramagnetic properties of Mn cause shortening
of the nuclear magnetic resonance proton T1 relaxation
 45 Manganese
times and signal hyperintensity on T1-weighted brain
MRI. A Mn-induced bilateral symmetrical increase
in signal intensities, confined to the globus pallidus
and midbrain, can be observed on T1-weighted MRI,
but with no alteration to the T2-weighted images
(Kim, 2004). However, Mn-induced high signals on
T1-weighted MRI do not correspond to any abnormal
findings on brain CT (Park et al., 2003). The characteris-
tic high signal caused by Mn can be differentiated from
signals that increase in intensity for other reasons. Thus,
high signals from fat, hemoglobin breakdown products,
melanomas, neurofibromatosis, and calcification can be
seen on T1-weighted images. High signals from hemo-
globin breakdown products, melanomas, and neurofi-
bromatosis can be differentiated from Mn-induced high
signals on the basis of signal site and symmetry. Iron
deposits cause a greater shortening of the T2-relaxation
time than the T1-relaxation time, resulting in low signal
intensity upon T2-weighted imaging, which is distinct
from that of an Mn deposit (Kim, 2004). Calcification
can be easily identified by CT (Ahn et al., 2003). Krieger
et al. (1995) coined the term pallidal index (PI) to quan-
tify Mn accumulation in the globus pallidus, defined as
the ratio of the signal intensity in the globus pallidus
to that in the subcortical frontal white matter (WM) in
axial T1-weighted MRI planes, multiplied by 100. An
increase in signal upon T1-weighted imaging has been
shown in experimental Mn intoxication of rats (Gallez
et al., 2001) and nonhuman primates (Erikson et al.,
1992a; Newland et al., 1989; Dorman et al., 2006), and
in persons with occupational Mn intoxication (Nelson
et al., 1993; Kim, 2004: Chang et al., 2009b). A similar
MRI pattern has also been observed in patients receiv-
ing total parenteral nutrition (TPN) by direct intrave-
nous Mn administration (Ejima et al., 1992; Mirowitz
et al., 1991) and in patients with portal systemic shunts
such as occur in individuals with liver cirrhosis, lead-
ing to an inability to clear Mn via biliary excretion (But-
terworth et al., 1995; Butterworth, 2010; Hauser et al.,
1994, 1996; Krieger et al., 1995; Park et al., 2003; Spahr
et al., 1996). Manganese-induced high signals can
occasionally be observed in patients with severe iron-
deficiency anemia (Kim et al., 2005). Kim et al. (1999a)
showed for the first time that the characteristic high T1
signals were also frequently observed in asymptomatic
workers exposed to Mn. The authors found a high prev-
alence (41.6%) of increased MRI signals in Mn-exposed
workers. High MRI signals also have been successfully
used to identify Mn accumulation in children exposed
to excess Mn (Devenyi et al., 1994; Fell et al., 1996; Ono
et al., 1995). The increased signal intensities resolved
significantly approximately 1 year after Mn exposure
ceased (Kim et al., 1999b). The disappearance of high
signal abnormalities on MRI following withdrawal of
1003
the Mn source has been shown after cessation of occu-
pational exposure (Nelson et al., 1993), discontinuation
of TPN (Mirowitz et al., 1991), and liver transplanta-
tion in patients with hepatic failure (Choi et al., 2005;
Pujol et al., 1993). These findings suggest that increased
signal intensities on a T1-weighted image reflect expo-
sure to Mn, but do not necessarily indicate the presence
of manganism. Many reports have shown that B-Mn
is highly correlated with PI in liver cirrhotics (Hauser
et al., 1996; Krieger et al., 1995; Spahr et al., 1996). In
Mn-exposed workers, B-Mn was also found to correlate
with PI (Chang et al., 2009a; Jiang et al., 2007; Kim et al.,
1999a).
A recent study showed that PI was significantly
associated with digit symbol test results, digit span
backward ratings, scores on the Stroop Word and
Stroop Error indices, and grooved pegboard (domi-
nant hand) data (Chang et al., 2009a ). This means that
PI is a good predictor of neurobehavioral performance
in welders without clinical manganism. In particular,
PI was a better predictor than B-Mn levels of neurobe-
havioral performance in such welders (Chang et al.,
2009a).
Taken together, the data suggest that the appear-
ance of PI on MRI may reflect a target organ dose of
occupational Mn exposure (Kim, 2006). In addition,
Mn in the brain has a longer half-life than in the blood
(Lucchini and Kim, 2009). Thus, PI reflects the cumula-
tive dose better than the B-Mn level. However, there
are some limitations. While the PI is a valid measure
for comparing MRI images of subjects within a single
study (using the same scanner, MRI sequence param-
eters, coils, etc.), its numerical value may depend on
the exact imaging parameters, as well as on the com-
parison region of the brain used for the denominator
in the PI (Guilarte et al., 2006). Exact numerical values
of PI may therefore vary between studies (Zheng et al.,
2011). Further, the level of signal intensity indicating
progression to manganism from Mn exposure remains
to be determined.
9.3.2  PET/SPECT Indicate the Integrity of the
Dopaminergic Nigrostriatal Pathway
In nonhuman primates and humans intoxicated
with Mn, 18F-dopa PET scans are normal (Erikson
et al., 1992a; Kim et al., 1998; Shinotoh et al., 1995, 1997;
Wolters et al., 1989), whereas in PD, dopamine uptake
is reduced in the striatum, particularly the posterior
putamen, thus resulting in reduced F-dopa uptake in
PET. This supports the view that in Mn intoxication
the nigrostriatal pathway is relatively well preserved,
which is consistent with many pathological obser-
vations showing that Mn-induced damage occurs
1004 Roberto G. Lucchini, Michael Aschner, Yangho Kim, and Marko Šarić
primarily in pathways postsynaptic to the nigrostria-
tal system (Kim, 2006; Guilarte, 2010). DAT imaging
using (1r)-2b-carboxymethoxy-3b-(4-iodophenyl) tro-
pane (β-CIT), employed as a SPECT ligand, reveals
the DAT density, and therefore explores the integrity
of the nigrostriatal dopaminergic system. In PD, 123I-β-
CIT SPECT reveals that specific striatal β-CIT uptake
is reduced (Seibyl et al., 1995). However, striatal DAT
uptake is nearly normal in patients with Mn-induced
parkinsonism (Huang et al., 2003). Various ligands that
bind to DAT, such as 123I-β-CIT, 123I-fluoropropyl-CIT,
and 99mTc-TRODAT-1, have been used in SPECT stud-
ies (Huang et al., 2003; Kim et al., 2002). DAT SPECT is
more easily accessible and less expensive than F-dopa
PET. Racette et al. (2005a) found relatively symmetri-
cal and severely reduced F-dopa uptake on PET in the
posterior putamen of a patient with manganism sec-
ondary to liver failure, together with T1 hyperintensi-
ties in the basal ganglia on MRI. Criswell et al. (2012a)
also reported a reduced striatal F-dopa uptake on PET
in a patient with manganism secondary to liver failure,
together with T1 hyperintensities in the basal ganglia
on MRI. However, SPECT data from secondary man-
ganism patients (Kim et al., 2010) revealed two differ-
ent patterns of clinical and neuroradiological features.
Four out of five patients showed atypical parkinson-
ism with normal DAT density, which could be clearly
differentiated from PD, whereas one patient showed
l-dopa-responsive parkinsonism with reduced DAT
density (classical PD). Further work with PET scan-
ning is needed to clarify whether Mn damage can also
extend to the nigrostriatal pathway, as suggested by
Racette et al. (2005a).
Some welders showed clinical features and PET/
SPECT findings typical of PD, with concurrent high
pallidal signals and increased B-Mn (Kim et al., 1999b,
2002; Racette et al., 2001). Recently, active, asymptom-
atic welders with Mn exposure demonstrated reduced
caudate F-dopa PET, which appeared to be distinct
from the pattern of dysfunction found in symptomatic
PD (Criswell et al., 2011). Kim et al. (1999b) suggested
that Mn might have been a risk factor for the develop-
ment of PD, although they could not exclude the pos-
sibility that the patient simply suffered from PD, with
coincident exposure to Mn (Kim et al., 2002). Neuro-
imaging modalities such as MRI and PET/SPECT may
therefore be useful for the differential diagnosis of par-
kinsonism (Calne et al., 1994; Kim, 2006).
9.3.3  Functional Neuroimaging
In vivo proton MRS ([1H]-MRS) is an image-guided,
noninvasive method of monitoring neurochemical
metabolites in the brain (Rosen and Lenkinski, 2007).
Using [1H]-MRS, Chang et al. (2009b) showed that the
ratios of N-acetylaspartate (NAA):total creatine (tCr),
Glx including both glutamine and glutamate (Glx):tCr,
and total choline (tCho):tCr in both the anterior cin-
gulate cortex (ACC) and parietal WM did not differ
significantly between welders and controls. However,
myoinositol (mI) levels in the ACC, but not in parietal
WM, were significantly lower in welders compared to
controls. Further, in the frontal brain lobe the mI:tCr
ratio was significantly positively correlated with ver-
bal memory scores and negatively with blood-Mn. The
authors suggested that reduction of the mI:tCr in weld-
ers may reflect a possible glial cell effect rather than
a neuronal effect, and may be associated with long-
term exposure to Mn. These results agree with those
of a previous study by Kim et al. (2007), who found
no significant differences in the levels of brain metabo-
lites (only NAA and Cho were measured) between
welders and controls, although a direct comparison
of mI levels was not possible. However, Guilarte et al.
(2006) reported a reduction in the NAA level in the
parietal cortex and frontal WM in the brains of Mn-
exposed monkeys. Recently, Dydak et al. (2011) used
[1H]-MRS with the MEGA-PRESS (i.e. point-resolved
spectroscopic sequence) to determine GABA levels in
the thalamus of Mn-exposed smelters. They showed a
significant decrease in the NAA:Cr ratio in the frontal
cortex and a significant increase of GABA level in the
thalamus of exposed subjects. Further studies using
MRS are needed to identify brain metabolites in Mn-
exposed workers.
Chang et al. (2010a) performed the first fMRI experi-
ment, using sequential finger tapping, to investigate
the behavioral significance of additionally recruited
brain regions in welders who had experienced chronic
Mn exposure. Their findings suggest that when rela-
tively simple tasks are set, motor fMRI may uncover
evidence of compromised brain function in patients
with subclinical manganism. The finding of excessive
recruitment of the cortical motor network in chroni-
cally Mn-exposed group is in line with the emerging
concept of the use of adaptive neural mechanisms to
compensate for latent dysfunction in the basal ganglia
(Buhmann et al., 2005).
Chang et al. (2010b) also performed the first-ever
fMRI combined with 2-back memory tests to assess the
neural correlates of Mn-induced memory impairment
in response to subclinical dysfunction in the working
memory networks of welders exposed to Mn chroni-
cally. fMRI with a 2-back memory task indicated that
Mn-exposed welders are likely to require more neural
resources in working memory networks to compen-
sate for subtle deficits in working memory and altered
working memory processes.
 45 Manganese
DTI is a unique method used to characterize WM
microintegrity, and relies on the principle that water
diffusion is highly anisotropic in brain WM structures
(Beaulieu, 2002). Direct comparison between 30 welders
and 19 controls using investigator-independent statistical
parametric mapping voxel-wise analysis of DTI metrics
revealed in Mn-exposed welders a reduction in fractional
anisotropy (FA) in the genu, body, and splenium of the
corpus callosum (CC), and in the frontal WM (Kim et al.,
2011b). Further, marked increases in radial diffusivity
(RD), but negligible changes in axial diffusivity, were evi-
dent in the genu, body, and splenium of the CC, and in
the frontal WM. These findings suggest that microstruc-
tural changes such as a reduction of FA with increases in
RD in the CC and frontal WM result from a compromised
radial directionality of fibers in such areas, primarily
caused by demyelination. The correlations between FA in
the frontal WM and the Stroop test scores suggest that
poor performance of executive function is closely associ-
ated with lower FA values in the frontal WM.
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