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Ryder H, Mosalski S, Bramah V, Page R, Faux SG, Shiner CT. Multidisciplinary rehabilitation following recreational nitrous oxide (N 2O) misuse: evaluating service provision and rehabilitation outcomes in a cohort with serious disability. Disabil Rehabil 2024:1-10. [PMID: 38950561 DOI: 10.1080/09638288.2024.2365987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 06/05/2024] [Indexed: 07/03/2024]
Abstract
Purpose: Recreational nitrous oxide (N2O) misuse is increasing globally. Chronic misuse can cause neurological impairments that require rehabilitation, though literature characterising rehabilitation is limited. This study aimed to evaluate rehabilitation service provision for impairments resulting from N2O misuse. Methods: A retrospective audit of hospitalised patients referred for rehabilitation for N2O toxicity was conducted between 2015 and 2022 at a single metropolitan hospital. Data were collected via medical record audit and analysed via descriptive and non-parametric statistics. Results: 16 eligible cases were identified, aged 18-43 years (50% female/male), with increasing case frequency. 12 cases received inpatient rehabilitation episodes for multifactorial sensorimotor, cognitive and psychosocial impairments. Cases articulated diverse rehabilitation goals and received intervention from a median of 6 clinical disciplines. All cases required assistance to mobilise or perform self-care activities on admission. Functional Independence Measure (FIM) scores significantly improved with rehabilitation (median FIM 84[75-93] to 117[112-123], p < .001). Despite gains in independence, all cases required referral for ongoing rehabilitation post-discharge. Conclusions: Demand for inpatient rehabilitation for disabling N2O toxicity appears to be increasing. In this series, cases were young, exhibited serious impairments, and had multidisciplinary rehabilitation needs. Inpatient rehabilitation led to significant functional improvements, though ongoing disability was evident post-discharge.
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Affiliation(s)
- Hannah Ryder
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - Simon Mosalski
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
- School of Medicine, Sydney Campus, University of Notre Dame, Australia
| | - Valerie Bramah
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
| | - Robert Page
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
- Alcohol and Drug Service, St Vincent's Hospital Sydney, Australia
| | - Steven G Faux
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
- School of Medicine, Sydney Campus, University of Notre Dame, Australia
| | - Christine T Shiner
- Department of Rehabilitation, St Vincent's Hospital Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
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2
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Pichon M, Majhadi L, Menn AM. Neurological Manifestations Induced by Nitrous Oxide Abuse: A Case Series and Review of Literature. Neurologist 2024; 29:113-119. [PMID: 37839087 DOI: 10.1097/nrl.0000000000000531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Nitrous oxide (NO) abuse is increasing among young people. This can result in severe neurological disorders such as myelopathy and/or peripheral neuropathy. We report the clinical presentations, biological, radiologic and electrophysiological findings of 5 patients hospitalized with neurological symptoms consecutive to NO abuse. In addition, a literature review was conducted to describe the neurological characteristics and to identify factors associated with a poor recovery. CASE REPORT Among the 5 patients included, 2 had a myeloneuropathy, 2 had a sensorimotor neuropathy, and 1 had a normal spinal cord magnetic resonance imaging and electromyography despite neurological manifestations consistent with myeloneuropathy. After vitamin B 12 supplementation, recovery was reported in 4 patients, and 1 was lost to follow-up.From the literature review, 154 patients were included [94 males; median age 22 (19 to 26) y; NO exposure 9 (3 to 18) mo]. A myelopathy was identified in 116 patients (75%) and a peripheral neuropathy was documented in 89 patients (58%). Compared with patients who recovered, those with sequelae were more likely to have a motor deficit at presentation ( P <0.001), to use NO regularly ( P <0.001), to have a lower vitamin B 12 level ( P =0.04), and a higher concentration of homocysteine ( P =0.04). A less extensive myelopathy was more frequently found in the group with favorable outcomes ( P =0.002). CONCLUSION Neurological disorders caused by NO may be challenging with severe clinical patterns. We identified several factors associated with a poor recovery, to make clinicians aware of NO-induced neurotoxicity.
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Affiliation(s)
| | - Loubna Majhadi
- Neurology, Centre Hospitalier Victor Dupouy, Argenteuil, France
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3
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Holroyd KB, Berkowitz AL. Metabolic and Toxic Myelopathies. Continuum (Minneap Minn) 2024; 30:199-223. [PMID: 38330479 DOI: 10.1212/con.0000000000001376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This article reviews the clinical presentation, diagnostic evaluation, and treatment of metabolic and toxic myelopathies resulting from nutritional deficiencies, environmental and dietary toxins, drugs of abuse, systemic medical illnesses, and oncologic treatments. LATEST DEVELOPMENTS Increased use of bariatric surgery for obesity has led to higher incidences of deficiencies in nutrients such as vitamin B12 and copper, which can cause subacute combined degeneration. Myelopathies secondary to dietary toxins including konzo and lathyrism are likely to become more prevalent in the setting of climate change leading to drought and flooding. Although modern advances in radiation therapy techniques have reduced the incidence of radiation myelopathy, patients with cancer are living longer due to improved treatments and may require reirradiation that can increase the risk of this condition. Immune checkpoint inhibitors are increasingly used for the treatment of cancer and are associated with a wide variety of immune-mediated neurologic syndromes including myelitis. ESSENTIAL POINTS Metabolic and toxic causes should be considered in the diagnosis of myelopathy in patients with particular clinical syndromes, risk factors, and neuroimaging findings. Some of these conditions may be reversible if identified and treated early, requiring careful history, examination, and laboratory and radiologic evaluation for prompt diagnosis.
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Riccò M, Ferraro P, Corrado S, Bottazzoli M, Marchesi F. Nitrous Oxide Inhalant Abuse: Preliminary Results from a Cross-Sectional Study on Knowledge, Attitudes, and Practices of Italian Physicians (2023). MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1820. [PMID: 37893538 PMCID: PMC10608448 DOI: 10.3390/medicina59101820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 09/24/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: Nitrous oxide (N2O) has recently emerged as a cheap alternative to other recreational substances. Although legally available, its chronic use is associated with severe neurological and hematological complications due to the irreversible inactivation of vitamin B12. While no reliable data on abuse of N2O in Italy have been provided to date, we assessed the knowledge, attitudes, and practices of Italian medical professionals on the management of N2O abuse cases. Materials and Methods: A cross-sectional study was performed as a web-based survey through a series of Facebook discussion groups (targeted medical professionals: 12,103), and participants were specifically asked about their previous understanding of N2O abuse and whether they had or not any previous experience in this topic. Results: A total 396 medical professionals participated in the survey. Overall, 115 participants had previous knowledge about N2O abuse (29.04%), with higher odds for professionals with a background in emergency medicine (adjusted odds ratio (aOR) 3.075; 95% confidence intervals (95%CI) 1.071 to 8.828) and lower for specialists in psychiatry (aOR 0.328; 95%CI 0.130 to 0.825). Knowledge status on N2O abuse was largely unsatisfying, as knowledge status, reported as a percent value, was estimated to 45.33% ± 24.71. Having previously managed a case of N2O abuse was associated with higher risk perception of the actual severity of this condition (aOR 5.070; 95%CI 1.520 to 16.980). Conclusions: Our study suggests that N2O poisoning cases are occurring in Italian settings but are not reasonably reported to national authorities. As substantial knowledge gaps of Italian medical workforces were identified, we cannot rule out that the actual abuse of N2O in the population may be far larger than currently suspected.
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Affiliation(s)
- Matteo Riccò
- Occupational Health and Safety Service on the Workplace/Servizio di Prevenzione e Sicurezza Ambienti di Lavoro (SPSAL), Department of Public Health, AUSL–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy
| | - Pietro Ferraro
- Occupational Medicine Unit, Direzione Sanità, Italian Railways’ Infrastructure Division, RFI SpA, 00161 Rome, Italy;
| | - Silvia Corrado
- ASST Rhodense, Dipartimento della donna e Area Materno-Infantile, UOC Pediatria, 20024 Garbagnate Milanese, Italy;
| | - Marco Bottazzoli
- Department of Otorhinolaryngology, APSS Trento, 31223 Trento, Italy;
| | - Federico Marchesi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
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5
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Bonev V, Wyatt M, Barton MJ, Leitch MA. Severe length-dependent peripheral polyneuropathy in a patient with subacute combined spinal cord degeneration secondary to recreational nitrous oxide abuse: A case report and literature review. Clin Case Rep 2023; 11:e6881. [PMID: 36794039 PMCID: PMC9923462 DOI: 10.1002/ccr3.6881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/15/2022] [Accepted: 12/27/2022] [Indexed: 02/15/2023] Open
Abstract
Nitrous oxide abuse can have detrimental effects on the central and peripheral nervous systems. This case study report aims to demonstrate a combination of severe generalized sensorimotor polyneuropathy and cervical myelopathy related to vitamin B12 deficiency following nitrous oxide abuse. We present a clinical case study and literature review examining primary research-published between 2012 and 2022-reporting nitrous oxide abuse affecting the spinal cord (myelopathy) and peripheral nerves (polyneuropathy); 35 articles were included in the review with a total of 96 patients, where the mean "patients" age was 23.9 years and were in a 2:1 male/female ratio. Of the 96 cases, within the review, 56% of patients were diagnosed with polyneuropathy, most commonly impacting the nerves of the lower limb (62%), while 70% of patients were diagnosed with myelopathy, most commonly impacting the cervical region (78%) on the spinal cord. In our clinical case study, a 28-year-old male underwent a multitude of diagnostic investigations for bilateral "foot drop" and sense of lower limb stiffness as ongoing complications of a vitamin B12 deficiency secondary to recreational nitrous oxide abuse. Both the literature review and our case report emphasize the dangers of recreational nitrous oxide inhalation, colloquially termed "nanging" and the risks it presents to both the central and peripheral nervous systems, which is erroneously considered by many recreational drug users to be less harmful than other illicit substances.
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Affiliation(s)
- Ventzislav Bonev
- School of MedicineGriffith UniversityGold CoastQueenslandAustralia,Coastal Neurophysiology ServicesGold CoastQueenslandAustralia
| | - Mark Wyatt
- School of MedicineGriffith UniversityGold CoastQueenslandAustralia,Coastal Neurophysiology ServicesGold CoastQueenslandAustralia
| | - Matthew J. Barton
- School of Nursing and MidwiferyGriffith UniversityGold CoastQueenslandAustralia,Menzies Health Institute QueenslandGold CoastQueenslandAustralia
| | - Michael A. Leitch
- School of MedicineGriffith UniversityGold CoastQueenslandAustralia,Neurosciences QueenslandBrisbaneQueenslandAustralia
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6
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Guerlais M, Aquizerate A, Lionnet A, Daveluy A, Duval M, Gérardin M, Istvan M, Laforgue EJ, Victorri-Vigneau C. Nitrous oxide: a unique official French addictovigilance national survey. Front Public Health 2023; 11:1167746. [PMID: 37206871 PMCID: PMC10189051 DOI: 10.3389/fpubh.2023.1167746] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/31/2023] [Indexed: 05/21/2023] Open
Abstract
Introduction Nitrous oxide has become over the last few years a public health problem in many countries. France has a dedicated health monitoring system dedicated to the surveillance of the abuse, dependence and consequences associated with the use of psychoactive substances coordinated by the French National Agency for the Safety of Medicines and Health Products.We present the French national survey of nitrous oxide. Materials and methods We analyzed all the cases with nitrous oxide from 2012 to 2021: number of notifications, characteristics of the subjects and consumption, consequences reported and their evolutions over time. In addition, we have made a special focus on the four main complications reported. Results A total of 525 cases were received with an exponential increase since 2019. We observed changes in the characteristics of the notifications with an increase in the proportion of women [42.7% in 2021 vs. 30.8% in 2020 (p = 0.02)]; an increase in the quantities consumed (use of cylinders); a negative evolution of the contexts of use with a search for self-therapeutic effects and use in violent contexts; an increasing trend of the severity of cases [78.1% in 2021 vs. 70.0% in 2020 (p = 0.07)].The main effects were substance use disorders and/or associated criteria (82.5%), neurological disorders (75.4%), psychiatric symptoms (15.4%) and cardiovascular events (8.6%). In terms of evolution, we observed a significant increase in cases with a use disorder and an increase in neurological complications. Moreover, new serious effects, notably cardiovascular events were reported. Discussion The combination of high availability, varied effects from euphoria to relief of discomfort in a stressful global pandemic context and the development of dependence could explain the rapid growth of consumption and the seriousness of the cases.It must now be taken into account that (i) Substance use disorders are associated with nitrous oxide consumption; (ii) clinicians must consider "nitrous oxide" in young subjects presenting different types of manifestations; and (iii) stopping consumption is imperative and is the first treatment. In this context, an addictological assessment must also be carried out.
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Affiliation(s)
- Marylène Guerlais
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique – Centre d’Evaluation et d’Information sur la Pharmacodépendance-Addictovigilance, Nantes, France
| | - Aurélie Aquizerate
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique – Centre d’Evaluation et d’Information sur la Pharmacodépendance-Addictovigilance, Nantes, France
| | - Arthur Lionnet
- Nantes Université, CHU Nantes, Service de Neurologie, Nantes, France
- Inserm, U1235, Nantes, France
| | - Amélie Daveluy
- Centre d’Addictovigilance, Département de Pharmacologie Médicale, INSERM, BPH, U1219, CHU de Bordeaux, Bordeaux, France
| | - Mélanie Duval
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique – Centre d’Evaluation et d’Information sur la Pharmacodépendance-Addictovigilance, Nantes, France
- Nantes Université, CHU Nantes, INSERM, methodS in Patient-centered outcomes and HEalth ResEarch, Nantes, France
| | - Marie Gérardin
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique – Centre d’Evaluation et d’Information sur la Pharmacodépendance-Addictovigilance, Nantes, France
| | - Marion Istvan
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique – Centre d’Evaluation et d’Information sur la Pharmacodépendance-Addictovigilance, Nantes, France
- Nantes Université, CHU Nantes, INSERM, methodS in Patient-centered outcomes and HEalth ResEarch, Nantes, France
| | - Edouard-Jules Laforgue
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique – Centre d’Evaluation et d’Information sur la Pharmacodépendance-Addictovigilance, Nantes, France
- Nantes Université, CHU Nantes, INSERM, methodS in Patient-centered outcomes and HEalth ResEarch, Nantes, France
| | - Caroline Victorri-Vigneau
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique – Centre d’Evaluation et d’Information sur la Pharmacodépendance-Addictovigilance, Nantes, France
- Nantes Université, CHU Nantes, INSERM, methodS in Patient-centered outcomes and HEalth ResEarch, Nantes, France
- *Correspondence: Caroline Victorri-Vigneau,
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7
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Largeau B, Karam A, Potey C, Caous AS, Tard C, Carton L, Kuchcinski G, Gautier S, Deheul S, Bordet R. Myeloneuropathy induced by recreational nitrous oxide use with variable exposure levels. Eur J Neurol 2022; 29:2173-2180. [PMID: 35460312 DOI: 10.1111/ene.15370] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 04/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although several case series have described nitrous oxide-associated neurological disorders, a comprehensive assessment of exposure characteristics (e.g., time to onset, level of exposure) in substance abusers has not been performed. The aim of this study was to describe the onset patterns of recreational use of nitrous oxide-induced neurological disorders. METHODS All cases of neurological disorders related to nitrous oxide recreational use reported to the Hauts-de-France addictovigilance center between January 2019 and August 2020 were selected. Only cases requiring hospitalization with informative data to perform the nitrous oxide causality assessment were included. RESULTS A total of 20 cases from 5 hospitals were included. The male-to-female ratio was 6:1 and the median age was 19 years (range 16-34). The neurological presentation [myeloneuropathy 64% (7/11), sensorimotor neuropathy 36% (4/11)] included for all patients gait disorders due to proprioceptive ataxia and limb hypoesthesia. The median dose used per occasion was 100 cartridges (range 5-960; n=19). The median time from the start of nitrous oxide use to the onset of neurological symptoms was 6 months (range 0.7-54; n=16). The cumulative dose was significantly higher in patients with damage to all four limbs than in patients with lower limbs symptoms only (p=0.042). CONCLUSIONS A low intermittent exposure may be sufficient to cause neurological damage in some subjects, suggesting that, at the population level, there is no safe exposure to nitrous oxide in recreational settings. The severity of neurological impairment could increase once used at high doses and for prolonged durations of nitrous oxide.
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Affiliation(s)
- Bérenger Largeau
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France
| | - Arnaud Karam
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Centre de Référence des Maladies Neuromusculaires Nord-Est-Ile de France, F-59000, Lille, France
| | - Camille Potey
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. PharmacoVigilance Regional Center (CRPV), F-59000, Lille, France
| | - Anne-Sylvie Caous
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France
| | - Céline Tard
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Centre de Référence des Maladies Neuromusculaires Nord-Est-Ile de France, F-59000, Lille, France
| | - Louise Carton
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France
| | - Grégory Kuchcinski
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Neuroradiology Department, F-59000, Lille, France
| | - Sophie Gautier
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. PharmacoVigilance Regional Center (CRPV), F-59000, Lille, France
| | - Sylvie Deheul
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Poison Control Center, F-59000, Lille, France
| | - Régis Bordet
- Univ. Lille, Inserm, CHU Lille. Lille Neuroscience & Cognition, Degenerative and vascular cognitive disorders, F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. Addictovigilance Center (CEIP Hauts-De-France), F-59000, Lille, France.,Univ. Lille, Inserm, CHU Lille. PharmacoVigilance Regional Center (CRPV), F-59000, Lille, France
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8
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Joncquel Chevalier-Curt M, Grzych G, Tard C, Lannoy J, Deheul S, Hanafi R, Douillard C, Vamecq J. Nitrous oxide abuse in the emergency practice, and Review of toxicity mechanisms and potential markers. Food Chem Toxicol 2022; 162:112894. [PMID: 35219765 DOI: 10.1016/j.fct.2022.112894] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/21/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022]
Abstract
Nitrous oxide (N2O) toxicity is a concern common to several medical fields. Here, retrospective study of four N2O abuses with neurological signs in the emergency practice provides a preliminary basis for a metabolic Discussion/Review. This latter highlights N2O abuse as pathology of DNA/RNA/protein methylations, for instance consistent with impairments of protein arginine methyltransferases involved in myelinogenesis and myelopathy in patients. Basically, pathogenesis starts with oxidation by N2O of coordinated cobalamine cobalt ions at enzyme sites with impairments of vitamin-B12-dependent pathways. Methionine synthase (methylcobalamine) and methymalonyl-CoA mutase (adenosylcobalamine) are inactivated and cofactor-depleted, respectively. The number of impacted pathways (folate cycle, methylation cycle, S-adenosylmethionine-dependent methyltransferases, transulfuration pathway, Krebs cycle fueling by methylmalonyl-CoA, glutathione synthesis) explains the variety of potential research/laboratory markers, and may provide new clues and future angles to explore N2O toxicity. Overall, homocysteine measurements obviously help diagnosis of N2O abuses. Additional markers may include vitamin-B12, methionine, methylmalonate, dimethylglycine, sarcosine, S-adenosylmethionine to S-adenosylhomocysteine ratio, various S-adenosylamino acids, S-adenosylmethionine-dependent cellular methylations, and additional analytes (propionylcarnitine, propionylglycine, cystathionine and derived metabolites, methylated amino acids [eg arginine], betaine).
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Affiliation(s)
| | - Guillaume Grzych
- CHU Lille, Service d'Hormonologie, Métabolisme, Nutrition, Oncologie, F-59000, Lille, France; Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, F-59000, Lille, France.
| | - Céline Tard
- U1172, Centre de référence des maladies neuromusculaires Nord/Est/Ile-de-France, Service de neurologie, CHU de Lille, F-59000 Lille, France.
| | - Julien Lannoy
- CHU Lille, Service de Neurologie, CHU Lille, F-59000 Lille, France.
| | - Sylvie Deheul
- CHU Lille, Centre d'Addictovigilance des Hauts de France, Lille, France.
| | - Riyad Hanafi
- CHU Lille, Neuroradiology, CHU Lille, F-59000 Lille, France.
| | - Claire Douillard
- Endocrinology-Diabetology-Metabolism Department, Huriez Hospital, CHU Lille, F-59000 Lille, France.
| | - Joseph Vamecq
- Inserm, Univ. Lille EA 7364 RADEME, CHU Lille, Centre de Biologie Pathologie Génétique, UF Métabolisme Général et Maladies Rares, F-59000, Lille, France.
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9
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Strauss J, Qadri SF. Myelopathy Secondary to Vitamin B12 Deficiency Induced by Nitrous Oxide Abuse. Cureus 2021; 13:e18644. [PMID: 34786239 PMCID: PMC8580124 DOI: 10.7759/cureus.18644] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2021] [Indexed: 11/30/2022] Open
Abstract
Nitrous oxide (N2O), a colorless gas known to have abuse potential, can induce vitamin B12 deficiency that eventually leads to peripheral neuropathy, central nervous demyelination, and myelopathy. N2O abuse has rarely caused subacute combined degeneration of the spinal cord despite being reported in a few studies. Although numerous published studies have demonstrated the toxic effects of N2O abuse, it is still a controversial topic of debate among neurologists. We outline a case of a patient presenting with acute onset of numbness who was ultimately diagnosed with myelopathy secondary to vitamin B12 deficiency induced by nitrous oxide abuse. This case report emphasizes the early diagnosis and management of vitamin B12 deficiency to prevent the severe complications associated with it.
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Affiliation(s)
- Joshua Strauss
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | - Syed F Qadri
- Psychiatry, Creighton University School of Medicine, Omaha, USA
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10
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Bode SA, Bienfait HP, Adriaansen HJ, van Suijlen JDE. No Laughing Matter: Burning Feet. J Appl Lab Med 2021; 6:1067-1071. [PMID: 33444452 DOI: 10.1093/jalm/jfaa220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/23/2020] [Indexed: 11/12/2022]
Affiliation(s)
- Saskia A Bode
- Department of Clinical Chemistry and Hematology, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Henri P Bienfait
- Department of Neurology, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Henk J Adriaansen
- Department of Clinical Chemistry and Hematology, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Jeroen D E van Suijlen
- Department of Clinical Chemistry and Hematology, Gelre Hospitals, Apeldoorn, the Netherlands
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11
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Problematic Use of Nitrous Oxide by Young Moroccan-Dutch Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115574. [PMID: 34071087 PMCID: PMC8197142 DOI: 10.3390/ijerph18115574] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/14/2021] [Accepted: 05/21/2021] [Indexed: 01/25/2023]
Abstract
The recreational use of nitrous oxide (N2O; laughing gas) has largely expanded in recent years. Although incidental use of nitrous oxide hardly causes any health damage, problematic or heavy use of nitrous oxide can lead to serious adverse effects. Amsterdam care centres noticed that Moroccan–Dutch young adults reported neurological symptoms, including severe paralysis, as a result of problematic nitrous oxide use. In this qualitative exploratory study, thirteen young adult Moroccan–Dutch excessive nitrous oxide users were interviewed. The determinants of problematic nitrous oxide use in this ethnic group are discussed, including their low treatment demand with respect to nitrous oxide abuse related medical–psychological problems. Motives for using nitrous oxide are to relieve boredom, to seek out relaxation with friends and to suppress psychosocial stress and negative thoughts. Other motives are depression, discrimination and conflict with friends or parents. The taboo culture surrounding substance use—mistrust, shame and macho culture—frustrates timely medical/psychological treatment of Moroccan–Dutch problematic nitrous oxide users. It is recommended to use influencers in media campaigns with the aim to decrease the risks of heavy nitrous oxide use and improve treatment access. Outreach youth workers can also play an important role in motivating socially isolated users to seek medical and or psychological help.
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Zhang J, Xie D, Zou Y, Yu X, Ji Y, Wang C, Lv X, Zhou N, Jiang X, Wang K, Tian Y. Key Characteristics of Nitrous Oxide-Induced Neurological Disorders and Differences Between Populations. Front Neurol 2021; 12:627183. [PMID: 33986715 PMCID: PMC8110825 DOI: 10.3389/fneur.2021.627183] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 04/01/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Nitrous oxide (N2O), commonly known as laughing gas, is inhaled recreationally because it produces the feelings of euphoria and freedom from pain. The risk of neurological dysfunction secondary to N2O abuse and its clinical diagnosis are, however, not yet sufficiently recognized, especially in China. Here, we have summarized the key clinical characteristics of N2O-induced neurological disorders. Materials and Methods: We recruited 20 patients with N2O-induced neurological disorders and analyzed their clinical features, laboratory data, magnetic resonance imaging and electromyography. We also carried out a literature review and compared 99 previously reported patients with our case series to confirm our results. Subgroup analysis was performed to explore the difference in demographical and clinical characteristics of N2O abuse between Asian and non-Asian patients. Results: The most common initial symptoms of N2O-induced neurological disorders were weakness and/or paresthesia. Most patients presented with myelopathy and/or peripheral neuropathy. The most commonly involved segment of the spinal cord was the cervical spinal cord, extending over 4–6 vertebral levels, but more than half of the patients with myelopathy had no sensory change at the corresponding spinal level. Homocysteine was found to be the most sensitive and practical indicator for diagnosis. Subgroup analysis showed that the Asian patients (median: 22.0 years old, Q1–Q3:19.0–26.0 years old) with N2O abuse were younger than non-Asian patients [26.0 (22.3–31.0) years old, P = 2.8 × 10−4]. The incidence of myelopathy combined with peripheral neuropathy was significantly higher in Asian patients than in non-Asian patients, who had myelopathy or peripheral neuropathy (P = 2 × 10−5). Conclusions: Key clinical characteristics of N2O abuse are longitudinally extensive cervical myelopathy and peripheral neuropathy. Recognition of these traits in young people in the age group of 20–30 years will provide important guidance for accurate diagnosis of neurological disease associated with N2O abuse. The clinical manifestations differ in Asian patients and non-Asian patients.
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Affiliation(s)
- Juanjuan Zhang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dandan Xie
- Department of Neurology, The Affiliated Anqing Hospital of Anhui Medical University, Anqing, China
| | - Yanfeng Zou
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China
| | - Xuen Yu
- Department of Neurology, The Institute of Neurology of Anhui University of Chinese Medicine, Hefei, China
| | - Yang Ji
- Anhui Medical University, Hefei, China
| | - Chengyou Wang
- Department of Neurology, The Affiliated Tongling Hospital of Anhui Medical University, Tongling, China
| | - Xinyi Lv
- Department of Neurology, The First Affiliated Hospital of the University of Science and Technology of China, Hefei, China
| | - Nong Zhou
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiao Jiang
- The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China
| | - Kai Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China.,The School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Cognition and Neuropsychiatric Disorders, Hefei, China.,Collaborative Innovation Center for Neuropsychiatric Disorders and Mental Health, Hefei, China.,Institute of Artificial Intelligence, Hefei Comprehensive National Science Center, Hefei, China
| | - Yanghua Tian
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Jhunjhnuwala D, Tanglay O, Briggs NE, Yuen MTY, Huynh W. Prognostic indicators of subacute combined degeneration from B12 deficiency: A systematic review. PM R 2021; 14:504-514. [PMID: 33780172 DOI: 10.1002/pmrj.12600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE A systematic review was conducted on published data of subacute combined degeneration (SCD) from B12 deficiency to investigate potential prognostic indicators of final ambulatory function in affected patients. TYPE: Systematic review. LITERATURE SURVEY Records published from 1999 through 2018 were searched on the electronic databases MEDLINE, PUBMED, and SCOPUS. The publication language was restricted to English and French. METHODOLOGY Records that described cases of SCD from B12 deficiency in patients ≥16 years of age at onset were included. From a final total of 66 cases of SCD identified, ambulation scores were assigned based on the clinical descriptions reported. Patient characteristics, clinical manifestations, and ambulatory function were reported descriptively. Subanalyses on potential prognostic indicators were performed. SYNTHESIS Greater ambulatory function at diagnosis was associated with recovery of normal ambulatory function at follow-up (P < .001). Nearly 90% of patients walking unsupported at diagnosis made a complete recovery regardless of etiology. For patients initially walking with support, 22% of cases from impaired B12 digestion/absorption made a complete recovery compared with ≥50% of cases from other etiologies. For patients initially requiring a wheelchair, 33% of cases from impaired digestion/absorption were able to walk with support compared with ≥50% of cases from other etiologies. The total B12 administered over the course of treatment was correlated with improved ambulation (P = .024) for all patients, with a higher B12 replacement regimen associated with better outcomes in patients who were unable to walk unsupported at diagnosis (number needed to treat = 4). CONCLUSIONS Initial ambulatory function may be a useful clinical marker of the severity of spinal cord dysfunction and final functional outcome. Etiological risk factors influenced both clinical manifestations and final walking ability in SCD, suggesting a distinct pathophysiological mechanism among the causes. In addition, a more intensive B12 replacement regimen may improve ultimate ambulatory function in advanced cases of SCD.
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Affiliation(s)
- Dhruv Jhunjhnuwala
- Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Onur Tanglay
- Faculty of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Nancy E Briggs
- Stats Central, Mark Wainwright Analytical Centre, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Margaret T Y Yuen
- Department of Physical Medicine & Rehabilitation, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong
| | - William Huynh
- Prince of Wales Clinical School, University of New South Wales Sydney, Sydney, New South Wales, Australia.,Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
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Xiang Y, Li L, Ma X, Li S, Xue Y, Yan P, Chen M, Wu J. Recreational Nitrous Oxide Abuse: Prevalence, Neurotoxicity, and Treatment. Neurotox Res 2021; 39:975-985. [PMID: 33770366 DOI: 10.1007/s12640-021-00352-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 01/16/2023]
Abstract
Nitrous oxide (N2O), also known as "laughing gas," is a colorless, nonirritating gas. Clinically, it is widely used as an inhaled anesthetic, analgesic, and anxiolytic. In recent years, recreational abuse of N2O has become increasingly common, especially among young adults and adolescents, but many of them lack awareness of the possible side effects associated with this drug. N2O abuse can damage multiple systems, especially the nervous system, but the exact mechanism of N2O toxicity remains controversial. At present, an increasing number of cases of nervous system damage caused by N2O abuse have been reported both at home and abroad. Discontinuation of N2O use and timely supplementation with vitamin B12 are essential for a good prognosis. Long-term abuse without timely treatment will eventually lead to irreversible neurological damage. In this article, we discuss the epidemiology of N2O abuse, neurotoxicity mechanisms, clinical manifestations, relevant auxiliary examinations, treatments, and prognosis to improve social awareness of N2O exposure risk, especially among users and clinicians.
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Affiliation(s)
- Yuanyuan Xiang
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Lei Li
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, People's Republic of China
| | - Xiaotong Ma
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Shan Li
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Yuan Xue
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Peng Yan
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Meijie Chen
- Department of Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China
| | - Junwei Wu
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 JingWu Road, 250021, Jinan, Shandong, People's Republic of China.
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Marillier M, Karila L, Miguet-Alfonsi C. Quand le protoxyde d’azote ne fait plus rire : épidémiologie, aspects analytiques, incidences clinique et médicojudiciaire. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2020. [DOI: 10.1016/j.toxac.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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16
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Marotta DA, Kesserwani H. Nitrous Oxide Induced Posterior Cord Myelopathy: Beware of the Methyl Folate Trap. Cureus 2020; 12:e9319. [PMID: 32850197 PMCID: PMC7444745 DOI: 10.7759/cureus.9319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Posterior cord myelopathy and subacute combined degeneration of the spinal cord are well-known complications of nitrous oxide abuse. Supplementation with vitamin B12 is an effective treatment strategy to correct low serum B12 levels or normal serum levels of dysfunctional vitamin B12 associated with this pathology. In this case, we report a patient with a one-year history of heavy nitrous oxide consumption; anywhere from eight to 30 canisters of 8 grams of nitrous oxide daily. The patient’s symptoms worsened after the institution of megadoses of vitamin B12, despite normal serum folate levels. This can be explained by the phenomenon of the methyl folate trap and warrants prompt supplementation with synthetic folate. We discuss the biochemistry of nitrous oxide toxicity and the underlying mechanisms contributing to the methyl folate trap.
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Affiliation(s)
- Dario A Marotta
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA.,Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, USA
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Zheng R, Wang Q, Li M, Liu F, Zhang Y, Zhao B, Sun Y, Zhang D, Yan C, Zhao Y, Li W. Reversible Neuropsychiatric Disturbances Caused by Nitrous Oxide Toxicity: Clinical, Imaging and Electrophysiological Profiles of 21 Patients with 6-12 Months Follow-up. Neuropsychiatr Dis Treat 2020; 16:2817-2825. [PMID: 33262596 PMCID: PMC7695601 DOI: 10.2147/ndt.s270179] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/18/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Nitrous oxide (N2O) abuse has become an increasingly severe problem in China. The aim of the study was to summarize the features of N2O-induced neurology and enhance the awareness of this disease among physicians. PATIENTS AND METHODS We retrospectively reviewed the clinical, imaging, electrophysiological characteristics and the prognosis of patients with N2O neurotoxicity in our hospital from January 2016 to August 2019. RESULTS Twenty-one patients (average age: 22.6±4.6 years) were collected. Eighty-six percent (18/21) patients presented with acute or subacute neurological disorders as their initial symptoms. The remaining fourteen percent (3/21) had psychiatric symptoms as the earliest symptoms. With progression, movement dysfunction appeared in ninety percent (19/21) of the patients with fifty-three percent (10/19) presented with weakness limited to both lower extremities. Sixty-two percent (13/21) of the patients presented with subjective sensory deficit. Seventy-one percent (15/21) had vibration sense impairment and positive Romberg's sign. Sixty-seven percent of the patients had hyporeflexia or areflexia. Fourteen percent (3/21) showed positive Babinski's sign. Seventy-eight percent (14/18) showed significantly increased homocysteine (HCY) level and only seventeen percent (3/18) showed decreased serum vitamin B12 level. T2 hyperintensity involving the posterior columns and lateral columns with inverted V sign in cervical spinal MRI had been observed in forty-seven percent (8/17) of the patients. Axonal peripheral neuropathy occurred in eighty-five percent (17/20) of the patients. The level of serum vitamin B12 and HCY, as well as imaging findings, were rapidly recovered after supplementation of Vitamin B12. CONCLUSION The N2O-induced neuropsychiatric disturbances mainly occurred in the young groups and should be recognized by clinicians. The prognosis of N2O intoxication is relatively good.
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Affiliation(s)
- Rui Zheng
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China
| | - Qinzhou Wang
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
| | - Mingyuan Li
- EMG-Evoked Potential Room, Binzhou Medical University Hospital, Binzhou City, People's Republic of China
| | - Fuchen Liu
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Yongqing Zhang
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China
| | - Bing Zhao
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China
| | - Yuan Sun
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China
| | - Dong Zhang
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
| | - Chuanzhu Yan
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao City, People's Republic of China.,Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
| | - Yuying Zhao
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
| | - Wei Li
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, People's Republic of China
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