Case presentation A 43 year old male presented with 6 months history of gradual onset and progressive bradykinesia, tremors of upper limbs and walking difficulty in the form of imbalance and short shuffling gait, slurring of speech with hypophonia. Neurological examination revealed slow broken saccades, rigidity with cogwheeling, bradykinesia and short shuffling, festinant gait. He had action and postural tremors of upper limbs. Pull test was positive. Thus a diagnosis of young onset Parkinsonism was considered. But, occupational history revealed that he worked in blast furnace of a steel and allied factory for past 14 years where manganese ore has been using for the strengthening of the stainless steel. He was evaluated with MRI Brain which showed symmetrical hyperintensities involving basal ganglia and subcortical white matter in T2 weighted images. T1 weighted images showed evidence of basal ganglia hyperintensities probably related to mineral deposition. Renal function, thyroid function tests including anti thyroid antibodies, KF Ring, S. Ceruloplasmin, Liver function tests, CSF, ultrasound abdomen- all were normal. Two consecutive serum manganese level tests in six months interval showed initial rise (two times) with the history of exposure and followed by normal level without the exposure. Patient was started on symptomatic medications like levodopa and trihexiphenidyl but after 8 months of medication (March- October, 2018) he had not showed any significant improvement. The written consent was taken from patient for this study.

Conclusion In view of strong occupational history of manganese exposure, the clinical features and non responsiveness of treatment with levodopa, a possibility of manganese toxicity was strongly considered for this rare case of secondary parkinsonism. Also non adherence with the legal mandate of periodical medical examination of workers exposed to toxic metals with long term consequence is very important factor to be corrected in the developing country like India.