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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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2
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De Halleux C, Juurlink DN. Diagnostic et prise en charge des effets toxiques du protoxyde d’azote utilisé à des fins récréatives. CMAJ 2023; 195:E1449-E1456. [PMID: 37903521 PMCID: PMC10615342 DOI: 10.1503/cmaj.230196-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023] Open
Affiliation(s)
- Cyrille De Halleux
- Département de médecine, de pédiatrie et Institut des politiques, de la gestion et de l'évaluation de la santé (Juurlink), Université de Toronto; Centre antipoison de l'Ontario (De Halleux, Juurlink); Institut de recherche Sunnybrook (Juurlink), Toronto, Ont.; Institut de recherche en services de santé (Juurlink), Toronto, Ont.; Centre antipoison du Québec (De Halleux), Québec, Qc
| | - David N Juurlink
- Département de médecine, de pédiatrie et Institut des politiques, de la gestion et de l'évaluation de la santé (Juurlink), Université de Toronto; Centre antipoison de l'Ontario (De Halleux, Juurlink); Institut de recherche Sunnybrook (Juurlink), Toronto, Ont.; Institut de recherche en services de santé (Juurlink), Toronto, Ont.; Centre antipoison du Québec (De Halleux), Québec, Qc.
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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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De Halleux C, Juurlink DN. Diagnosis and management of toxicity associated with the recreational use of nitrous oxide. CMAJ 2023; 195:E1075-E1081. [PMID: 37604519 PMCID: PMC10442242 DOI: 10.1503/cmaj.230196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Affiliation(s)
- Cyrille De Halleux
- Departments of Medicine, Pediatrics, and Health Policy, Management and Evaluation (Juurlink), University of Toronto; Ontario Poison Centre (De Halleux, Juurlink); Sunnybrook Research Institute (Juurlink), Toronto, Ont.; ICES (Juurlink), Toronto, Ont.; Centre Antipoison du Québec (De Halleux), Québec, Que
| | - David N Juurlink
- Departments of Medicine, Pediatrics, and Health Policy, Management and Evaluation (Juurlink), University of Toronto; Ontario Poison Centre (De Halleux, Juurlink); Sunnybrook Research Institute (Juurlink), Toronto, Ont.; ICES (Juurlink), Toronto, Ont.; Centre Antipoison du Québec (De Halleux), Québec, Que.
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5
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Delijewski M, Bartoń A, Maksym B, Pawlas N. The Link between Iron Turnover and Pharmacotherapy in Transplant Patients. Nutrients 2023; 15:nu15061453. [PMID: 36986181 PMCID: PMC10052361 DOI: 10.3390/nu15061453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Iron is a transition metal that plays a crucial role in several physiological processes. It can also exhibit toxic effects on cells, due to its role in the formation of free radicals. Iron deficiency and anemia, as well as iron overload, are the result of impaired iron metabolism, in which a number of proteins, such as hepcidin, hemojuvelin and transferrin, take part. Iron deficiency is common in individuals with renal and cardiac transplants, while iron overload is more common in patients with hepatic transplantation. The current knowledge about iron metabolism in lung graft recipients and donors is limited. The problem is even more complex when we consider the fact that iron metabolism may be also driven by certain drugs used by graft recipients and donors. In this work, we overview the available literature reports on iron turnover in the human body, with particular emphasis on transplant patients, and we also attempt to assess the drugs’ impact on iron metabolism, which may be useful in perioperative treatment in transplantology.
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Affiliation(s)
- Marcin Delijewski
- Department of Pharmacology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Jordana 38, 41-808 Zabrze, Poland
- Correspondence: ; Tel.: +48-(32)-2722683
| | | | - Beata Maksym
- Department of Pharmacology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Jordana 38, 41-808 Zabrze, Poland
| | - Natalia Pawlas
- Department of Pharmacology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Jordana 38, 41-808 Zabrze, Poland
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Fang X, Yu M, Zheng D, Gao H, Li W, Ma Y. Electrophysiologic Characteristics of Nitrous-Oxide-Associated Peripheral Neuropathy: A Retrospective Study of 76 Patients. J Clin Neurol 2023; 19:44-51. [PMID: 36606645 PMCID: PMC9833873 DOI: 10.3988/jcn.2023.19.1.44] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/31/2022] [Accepted: 05/31/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE The electrophysiologic characteristics of peripheral neuropathy secondary to nitrous oxide (N2O) abuse remain unclear. The paper therefore aimed to summarize the electrophysiologic characteristics of N2O-associated peripheral neuropathy and identify the risk factors of severe nerve injury. METHODS The electrophysiologic results and clinical data of patients with peripheral neuropathy secondary to N2O abuse at our hospital between 2018 and 2020 were analyzed retrospectively, and their electrophysiologic changes were summarized. RESULTS Most patients exhibited decreased sensory and motor nerve conduction velocities (75% and 76%), decreased sensory nerve and compound motor action potentials (57% and 59%), and prolonged distal motor latency (59%), while a response was absent in 36%. These findings indicate that N2O abuse can result in generalized injury to sensory and motor nerves. Electrophysiologic results indicated axonal neuropathy in 37 cases (49%), demyelinating peripheral neuropathy in 4 (5%), and mixed neuropathy in 12 (16%). Peripheral nerve injury was more common in the lower limbs (72%) than in the upper limbs (42%, p<0.0001). The upper and lower limbs were primarily affected by sensory nerve demyelination (35%) and motor axonal injury (67%), respectively. Subgroup analysis indicated that longer N2O exposure and longer disease course were associated with more-severe motor axonal injury in the lower limbs. CONCLUSIONS N2O-associated peripheral neuropathy can lead to sensory and motor nerve injury, with axonal injury being the most common. Injuries were more severe in the lower limbs. Prolonged N2O exposure and disease course increased the severity of motor axonal injury in the lower limbs.
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Affiliation(s)
- Xiuying Fang
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Miao Yu
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Dongming Zheng
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Han Gao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weishuai Li
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ying Ma
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
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Sowers ML, Tang H, Singh VK, Khan A, Mishra A, Restrepo BI, Jagannath C, Zhang K. Multi-OMICs analysis reveals metabolic and epigenetic changes associated with macrophage polarization. J Biol Chem 2022; 298:102418. [PMID: 36030823 PMCID: PMC9525912 DOI: 10.1016/j.jbc.2022.102418] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 12/04/2022] Open
Abstract
Macrophages (MФ) are an essential immune cell for defense and repair that travel to different tissues and adapt based on local stimuli. A critical factor that may govern their polarization is the crosstalk between metabolism and epigenetics. However, simultaneous measurements of metabolites, epigenetics, and proteins (phenotype) have been a major technical challenge. To address this, we have developed a novel triomics approach using mass spectrometry to comprehensively analyze metabolites, proteins, and histone modifications in a single sample. To demonstrate this technique, we investigated the metabolic-epigenetic-phenotype axis following polarization of human blood–derived monocytes into either ‘proinflammatory M1-’ or ‘anti-inflammatory M2-’ MФs. We report here a complex relationship between arginine, tryptophan, glucose, and the citric acid cycle metabolism, protein and histone post-translational modifications, and human macrophage polarization that was previously not described. Surprisingly, M1-MФs had globally reduced histone acetylation levels but high levels of acetylated amino acids. This suggests acetyl-CoA was diverted, in part, toward acetylated amino acids. Consistent with this, stable isotope tracing of glucose revealed reduced usage of acetyl-CoA for histone acetylation in M1-MФs. Furthermore, isotope tracing also revealed MФs uncoupled glycolysis from the tricarboxylic acid cycle, as evidenced by poor isotope enrichment of succinate. M2-MФs had high levels of kynurenine and serotonin, which are reported to have immune-suppressive effects. Kynurenine is upstream of de novo NAD+ metabolism that is a necessary cofactor for Sirtuin-type histone deacetylases. Taken together, we demonstrate a complex interplay between metabolism and epigenetics that may ultimately influence cell phenotype.
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Affiliation(s)
- Mark L Sowers
- Dept. of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX
| | - Hui Tang
- Dept. of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX
| | - Vipul K Singh
- Dept. of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research Houston Methodist Research Institute, Weill-Cornell Medicine, Houston, TX
| | - Arshad Khan
- Dept. of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research Houston Methodist Research Institute, Weill-Cornell Medicine, Houston, TX
| | - Abhishek Mishra
- Dept. of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research Houston Methodist Research Institute, Weill-Cornell Medicine, Houston, TX
| | | | - Chinnaswamy Jagannath
- Dept. of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research Houston Methodist Research Institute, Weill-Cornell Medicine, Houston, TX.
| | - Kangling Zhang
- Dept. of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX.
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8
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Yu M, Qiao Y, Li W, Fang X, Gao H, Zheng D, Ma Y. Analysis of clinical characteristics and prognostic factors in 110 patients with nitrous oxide abuse. Brain Behav 2022; 12:e2533. [PMID: 35307992 PMCID: PMC9015005 DOI: 10.1002/brb3.2533] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/31/2021] [Accepted: 02/06/2022] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To review the clinical symptoms, auxiliary examination findings, and outcomes of patients with nitrous oxide (N2 O) abuse, and analyze the factors that affect outcomes. METHODS Patients with N2 O abuse treated in the Department of Neurology between January 2018 and December 2020 were included. The clinical data of these patients were collected, and follow-up was conducted to determine the outcomes. RESULTS The average age of the 110 patients with N2 O abuse was 21.4 ± 4.2 years (range: 14-33 years). Clinical presentation primarily included neurological symptoms, such as limb numbness and/or weakness (97%), psychiatric symptoms, changes in appetite, and skin hyperpigmentation. Laboratory test results were characterized by vitamin B12 deficiency (60%, 34 out of 57 cases) and high homocysteine level (69%, 31 out of 45 cases). Electromyography indicated mixed axonal and demyelination injury (92%, 80 out of 87 cases). Motor and sensory nerves were simultaneously involved, and injury primarily involved the lower limbs. One hundred and seven (97%) patients were clinically diagnosed with peripheral neuropathy, of whom 26 (24%) exhibited spinal abnormalities on magnetic resonance imaging, supporting a diagnosis of subacute combined degeneration. Treatment included N2 O withdrawal and vitamin B12 supplementation. Reexamination of six patients indicated that treatment was effective. Follow-up was completed for 51 patients. Thirty-four patients (67%) recovered completely, 17 patients (33%) had residual limb numbness, and only one patient experienced relapse. Sex was an independent prognostic factor; the outcomes of female patients were better than that of male patients. CONCLUSION The recreational use of N2 O has largely expanded among youth in recent decades, which has become a growing public health concern in China. It highlights the importance of the recognition of various clinical symptoms, particularly limb numbness and/or weakness related to the cases of N2 O abuse. The therapeutic administration of vitamin B12 supplementation and N2 O withdrawal can make the overall prognosis good, especially for female patients.
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Affiliation(s)
- Miao Yu
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yue Qiao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Weishuai Li
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xiuying Fang
- Department of Neurofunction, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Han Gao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Dongming Zheng
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ying Ma
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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Wong J, Viyasar T, Layton B, Lauder J. The dangers of recreational inhalation of nitrous oxide. Br J Hosp Med (Lond) 2021; 82:1-8. [PMID: 34983231 DOI: 10.12968/hmed.2021.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Nitrous oxide, also known as 'laughing gas', is one of the most widely used recreational drugs among teenagers in the UK. Copious inhalation of nitrous oxide may increase intra-alveolar pressure, resulting in barotrauma secondary to alveolar rupture. Pneumomediastinum and subcutaneous emphysema are common clinical findings in nitrous oxide-associated barotrauma. Prolonged nitrous oxide misuse may inactivate vitamin B12 through the alteration of its metabolism, causing demyelination of the central and peripheral nervous system. A spectrum of neurological manifestations has been reported, including peripheral neuropathy, myelopathy and subacute combined degeneration of the spinal cord. Medical therapies and psychosocial interventions aiming at nitrous oxide cessation are important treatment steps to achieve partial or complete recovery from the adverse effects associated with inhalation of nitrous oxide.
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Affiliation(s)
- Joshua Wong
- School of Medicine, University of Central Lancashire, Preston, UK
| | | | - Benjamin Layton
- Department of Radiology, Royal Blackburn Hospital, Blackburn, UK
| | - Joshua Lauder
- Department of Radiology, Royal Blackburn Hospital, Blackburn, UK
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10
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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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de Valck L, Defelippe VM, Bouwman NAMG. Cerebral venous sinus thrombosis: a complication of nitrous oxide abuse. BMJ Case Rep 2021; 14:e244478. [PMID: 34400432 PMCID: PMC8370558 DOI: 10.1136/bcr-2021-244478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 11/04/2022] Open
Abstract
Nitrous oxide (NO) is an inhalant that has become increasingly popular as a recreational drug. While it is presumed to be harmless, a number of adverse effects of NO have been described. We discuss the case of a 24-year-old man with no medical history, who initially presented to the emergency department with progressive polyneuropathy caused by vitamin B12 deficiency after NO abuse. Two days after being discharged with hydroxocobalamin supplementation, the patient returned with a severe headache, blurry vision and slurred speech. Imaging revealed cerebral venous sinus thrombosis. Hypercoagulability workup showed slightly elevated homocysteine and normalised vitamin B12 after supplementation. Genetic testing showed a heterozygous prothrombin G20210A mutation. He was treated with low-molecular-weight heparin followed by dabigatran. We hypothesise that NO use may increase the risk of developing cerebral venous thrombosis, especially in patients with multiple risk factors and elevated homocysteine levels.
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Affiliation(s)
- Laura de Valck
- Neurology, Zuyderland Medisch Centrum Sittard-Geleen, Sittard-Geleen, The Netherlands
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12
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Paulus MC, Wijnhoven AM, Maessen GC, Blankensteijn SR, van der Heyden MAG. Does vitamin B12 deficiency explain psychiatric symptoms in recreational nitrous oxide users? A narrative review. Clin Toxicol (Phila) 2021; 59:947-955. [PMID: 34348072 DOI: 10.1080/15563650.2021.1938107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background Recreational use of nitrous oxide (N2O) is associated with many side effects, of which neurological complications are most common. Nitrous oxide abuse is also associated with psychiatric symptoms, but these have received less attention so far. Vitamin B12 deficiency may play a role in the development of these psychiatric symptoms.Aims To explore the relationship among the occurrence of recreational nitrous oxide-induced psychiatric symptoms, accompanying neurological symptoms, vitamin B12 status and choice of treatment.Methods A retrospective search for case reports was conducted across multiple databases (Pubmed, Embase, Web of Science, PsycINFO and CINAHL). Keywords included variants of "nitrous oxide", "case report" and "abuse". No restrictions to language or publication date were applied.Results The search retrieved 372 articles. A total of 25 case reports were included, representing 31 patients with psychiatric complications following nitrous oxide abuse. The most often reported symptoms were: hallucinations (n = 16), delusions (n = 11), and paranoia (n = 11). When neurological symptoms were present, patients were treated more frequently with vitamin B12 supplementation.Conclusions This review highlights the need to recognize that psychiatric symptoms may appear in association with nitrous oxide use. Approximately half of the cases that presented with nitrous oxide-induced psychiatric complaints did not show neurological symptoms, and their vitamin B12 concentration was often within the hospital's reference range. Psychiatrists and emergency physicians should be aware of isolated psychiatric symptoms caused by recreational nitrous oxide abuse. We suggest asking all patients with new psychiatric symptoms about nitrous oxide use and protocolizing the management of nitrous oxide-induced psychiatric symptoms.
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Affiliation(s)
- Michelle C Paulus
- CRU + Master, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anjali M Wijnhoven
- CRU + Master, University Medical Center Utrecht, Utrecht, The Netherlands
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13
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Abstract
Objective: In the young generations with nitrous oxide abuse (N2O), featured electrophysiological response of the peripheral neuropathy caused by nitrous oxide remains to be defined.Methods: Patients with nitrous oxide abuse (20 cases), two variants of Guillain-Barré syndrome (GBS), that is, acute inflammatory demyelinating polyradiculoneuropathy (GBS-AIDP, 19 cases) and acute motor axonal neuropathy (GBS-AMAN, 18 cases), as well as diabetic peripheral neuropathy (DPN, 20 cases) were enrolled into this study. Electrophysiological parameters including distal motor latency (DML), motor nerve conduction velocity (MNCV), sensory nerve conduction velocity (SNCV), amplitudes of compound muscle action potential (CMAP), and sensory nerve action potential (SNAP) were measured and analyzed by comparing the parameters between the aforementioned patients groups as well as normal control group (20 subjects).Results: Compared to normal control subjects, patients with nitrous oxide abuse showed prolonged DML, slower MNCV and SNCV in the limbs, lower amplitudes of CMAP in the median, tibial and peroneal nerves, and lower SNAP in median and ulnar nerves. Abnormalities of MNCV and amplitudes of CMAP in the lower limbs were significantly higher than that in the upper limbs . Abnormal electrophysiological features of patients with nitrous oxide abuse were dramatically different from those in GBS-AIDP or DPN patients, but similar to those in GBS-AMAN patients.Conclusions: Nitrous oxide abuse could cause abnormal electrophysiological response in the limbs. Some of the parameters (DML, MNCV, SNCV, CMAP and SNAP) appeared significantly different between the patients with nitrous oxide abuse, GBS with AIDP or AMAN, and DPN patients.Significance: Electrophysiological examination could be considered as an important supporting factor in differential diagnosis for nitrous oxide abuse, GBS with AIDP or AMAN, and DPN.
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Affiliation(s)
- Yan Li
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | - Xiuchun Zhang
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | - Chuansheng Zhao
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
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14
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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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15
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Padayachee Y, Richards C, Morgan O. Inhaled nitrous oxide-induced functional B 12 deficiency. BMJ Case Rep 2021; 14:14/3/e240447. [PMID: 33722915 PMCID: PMC7959227 DOI: 10.1136/bcr-2020-240447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Recreational nitrous oxide (N2O) is commonly used among young people partly due to its low cost and accessibility, and awareness of its potential adverse effects is poor in this group. One such adverse effect is degeneration of the spinal cord due to its disruption of DNA synthesis by inactivating cobalamin (B12).A 19-year-old man presented to the emergency department with a 4-week history of worsening paraesthesia in his fingers and lower limbs, and weakness in the hands and lower limbs for 2 weeks. On examination, he had an ataxic gait, reduced power of grip strength and ankle movements, and impaired sensation in the lower limbs. An MRI brain and spine revealed myelopathy of the cervical and thoracic cord.On further questioning, he reported recreational N2O inhalation. His symptoms improved after stopping this and he was treated with supplementation of B vitamins. Education strategies regarding the risks of N2O misuse are indicated.
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Affiliation(s)
| | - Chris Richards
- Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Owen Morgan
- Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
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16
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Abstract
Nitrous oxide is a commonly abused inhalant by adolescents and young adults. There is limited data describing the adverse effects of nitrous oxide abuse, known colloquially as "whippets". We present a 21-year-old female with no medical history who presented to the emergency department for confusion, hallucinations, weakness, and falls. She was accompanied by her roommates, who endorsed significant nitrous oxide abuse. Imaging revealed a large cerebral sinus venous thrombus with extension into the transverse sinus, sigmoid sinus and internal jugular vein. She had no prior history of venous or arterial thrombosis. Hypercoagulability workup demonstrated an elevated homocysteine level, elevated methylmalonic acid level, and normal cobalamin and folate levels. Additionally, she was found to be 11 weeks pregnant, with no prior spontaneous abortions. Genetic testing was significant for methylenetetrahydrofolate reductase polymorphisms. She was managed with enoxaparin, cobalamin and folate supplementation. Homocysteine and methylmalonic acid levels normalized after cessation of nitrous oxide use, with no recurrence of venous thrombosis. This case represents the first reported patient with a venous thrombus associated with nitrous oxide abuse.
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Affiliation(s)
- David N Pratt
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Kevin Charles Patterson
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kai Quin
- Division of Hospital Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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17
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Vitamin B12 and folic acid alleviate symptoms of nutritional deficiency by antagonizing aryl hydrocarbon receptor. Proc Natl Acad Sci U S A 2020; 117:15837-15845. [PMID: 32571957 DOI: 10.1073/pnas.2006949117] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Despite broad appreciation of their clinical utility, it has been unclear how vitamin B12 and folic acid (FA) function at the molecular level to directly prevent their hallmark symptoms of deficiency like anemia or birth defects. To this point, B12 and FA have largely been studied as cofactors for enzymes in the one-carbon (1C) cycle in facilitating the de novo generation of nucleotides and methylation of DNA and protein. Here, we report that B12 and FA function as natural antagonists of aryl hydrocarbon receptor (AhR). Our studies indicate that B12 and FA bind AhR directly as competitive antagonists, blocking AhR nuclear localization, XRE binding, and target gene induction mediated by AhR agonists like 2,3,7,8-tetrachlorodibenzodioxin (TCDD) and 6-formylindolo[3,2-b]carbazole (FICZ). In mice, TCDD treatment replicated many of the hallmark symptoms of B12/FA deficiency and cotreatment with aryl hydrocarbon portions of B12/FA rescued mice from these toxic effects. Moreover, we found that B12/FA deficiency in mice induces AhR transcriptional activity and accumulation of erythroid progenitors and that it may do so in an AhR-dependent fashion. Consistent with these results, we observed that human cancer samples with deficient B12/FA uptake demonstrated higher transcription of AhR target genes and lower transcription of pathways implicated in birth defects. In contrast, there was no significant difference observed between samples with mutated and intact 1C cycle proteins. Thus, we propose a model in which B12 and FA blunt the effect of natural AhR agonists at baseline to prevent the symptoms that arise with AhR overactivation.
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18
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Kanin M, Nguyen J, Rotblatt M. Say N 2O to Drugs: A Unique Presentation of Symptomatic Vitamin B 12 Deficiency. Am J Med 2020; 133:e145-e146. [PMID: 31585064 DOI: 10.1016/j.amjmed.2019.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 10/25/2022]
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19
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Winstock AR, Ferris JA. Nitrous oxide causes peripheral neuropathy in a dose dependent manner among recreational users. J Psychopharmacol 2020; 34:229-236. [PMID: 31679459 DOI: 10.1177/0269881119882532] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Nitrous oxide (N2O) has been used in clinical and recreational settings for over 150 years. Through inactivation of the Vitamin B12 dependent enzyme, methionine synthase, N2O can lead to the development of peripheral neuropathy. This study sought to determine the relationship between the exposure and risk of neurological symptoms in the largest ever sample of users. DESIGN Data are drawn from the Global Drug Survey (GDS) over three consecutive years (2014-2016). The Global Drug Survey is an online, cross-sectional survey of substance use, translated into multiple languages. PARTICIPANTS Respondents to the Global Drug Survey who provided details on N2O use and the experience of paraesthesia in the previous 12 months. MEASUREMENTS Questions relating to N2O use, peripheral neuropathy, age and gender were explored among last year's users. FINDINGS Of 241,566 respondents, 41,181 (17.0%) indicated that they had ever used nitrous oxide; of these, 42.1% had used in the last 12 months. For the final model, data from 16,124 participants who had used N2O in the last 12 months and had provided responses on age, dose, gender and paraesthesia were used. Of these, the number of respondents reporting persistent numbness/tingling (paraesthesia) in their hands or feet was 537 (3.3%). Although the risk was very low among infrequent users, there was a strong dose-response relationship. For people indicating one or two doses per session, the probability of reporting paraesthesia was approximately 0.018 by comparison; for people indicating 100 doses per session the probability was approximately 0.085. The association, between dose and paraesthesia was influenced by gender and age. CONCLUSION While infrequent, episodic users are not at risk, a minority of heavy users are at dose-dependent risk of developing serious neurological consequences. Better education and raised awareness of early symptoms are required.
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Affiliation(s)
- Adam R Winstock
- Institute of Epidemilogy and Health Care, University College London, London, UK.,Global Drug Survey, London, UK
| | - Jason A Ferris
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, Woolloongabba, QLD, Australia
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20
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The sharp rise of neurological disorders associated with recreational nitrous oxide use in China: a single-center experience and a brief review of Chinese literature. J Neurol 2019; 267:422-429. [PMID: 31655888 DOI: 10.1007/s00415-019-09600-w] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 02/01/2023]
Abstract
INTRODUCTION In recent years, there has been a sharp increase in the number of patients with neurological disorders associated with recreational use of nitrous oxide (N2O) in China. Here, we summarize the clinical characteristics of patients with neurological disorders associated with N2O abuse diagnosed in our Hospital. Further, we conducted a literature search on recent cases reported in mainland China to improve the awareness of the outbreak of neurological disorders associated with N2O abuse. METHODS We retrospectively collected data of patients diagnosed with neurological disorders associated with recreational use of N2O in Shengjing Hospital of China Medical University from January 2018 to June 2019, and performed a literature search using the "nitrous oxide" and "neurological disorder" as keywords in the Chinese literature databases of WANFANG and CNKI and the English literature databases of Pubmed and Web of Science RESULTS: We enrolled 43 patients (average age: 21.9 ± 3.3 years). The main clinical manifestations were weakness and paresthesia in the four extremities and unsteady gait. Further, most patients showed significantly lower levels of serum vitamin B12 (169.4 ± 79.1 pg/mL) and increased homocysteine levels (78.1 ± 32.2 μmol/L). MRI of the spinal cord showed longitudinal high T2 signal lesions in the dorsal spinal cord in some patients. Moreover, electromyography showed sensory and motor nerve axonal damage combined with demyelination, which was relatively more severe in the lower limbs. There was rapid improvement of the symptoms after treatment with intramuscular injections of vitamin B12 and the overall prognosis was good. The literature search indicated that the number of published papers and related patients showed a rapid annual increase since the first Chinese case reported in 2016 CONCLUSION: Recreational use of N2O is an emerging public health problem in China that needs prompt action from the society and government. Early diagnosis and treatment allow a good overall prognosis.
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21
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Fang X, Li W, Gao H, Ma Y, Dong X, Zheng D. Skin hyperpigmentation: a rare presenting symptom of nitrous oxide abuse. Clin Toxicol (Phila) 2019; 58:476-481. [PMID: 31522576 DOI: 10.1080/15563650.2019.1665181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Context: Recreational nitrogen oxide (N2O) abuse can cause nervous system damage. There was a sharp increase in the number of patients with neurological disorders associated with recreational N2O use in China, as recreational N2O use became popular in young people nationwide. Among cases with neurological disorders caused by N2O abuse, a few showed skin hyperpigmentation, which has rarely been reported. We explored the characteristics of hyperpigmentation in N2O abusers to draw the attention of clinicians to this rare cutaneous symptom related to N2O abuse.Methods: We retrospectively collected data of patients with neurological disorders related to recreational N2O abuse in Shengjing Hospital of China Medical University from January 2014 to June 2019. Detailed clinical data were gathered from patients who manifested skin pigmentation, including the history of N2O abuse and characteristics of neurological lesions and skin pigmentation.Results: In total, 66 patients (average age: 22.7 ± 4.5 years, 36 males) with neurological disorders due to N2O abuse were included; four of them (17-23 years old, 1 male) manifested skin hyperpigmentation. The duration of N2O abuse of the four patients ranged from 2 to 24 months, and they all had peripheral neuropathy; the two patients also had subacute combined degeneration of the spinal cord. One patient exhibited significant hyperpigmentation throughout the body (trunk, limbs, and face), with no abnormalities in cortisol and other biochemical tests. One patient presented with punctuate pigmentation throughout the trunk. Two patients presented with finger skin pigmentation, especially in the distal phalanxes. Pigmentation after N2O use remitted slowly with vitamin B12 supplementation.Conclusion: Skin hyperpigmentation is a rare symptom in N2O abusers, which can distribute locally in hands or diffusely throughout the body. Therefore, attention should be paid to a history of N2O abuse and serum vitamin B12 level should be tested.
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Affiliation(s)
- Xiuying Fang
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weishuai Li
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Han Gao
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ying Ma
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaoyu Dong
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Dongming Zheng
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, China
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22
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Fidalgo M, Prud’homme T, Allio A, Bronnec M, Bulteau S, Jolliet P, Victorri-Vigneau C. Nitrous oxide: What do we know about its use disorder potential? Results of the French Monitoring Centre for Addiction network survey and literature review. Subst Abus 2019; 40:33-42. [DOI: 10.1080/08897077.2019.1573210] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Martin Fidalgo
- Department of Pharmacology, Addictovigilance (Monitoring Centre for Addiction), Nantes University Hospital, Nantes, France
| | - Tony Prud’homme
- Department of Pedodonty, Nantes University Hospital, Nantes, France
- INSERM UMR U1246 SPHERE, Institut de Recherche en Santé 2, Nantes, France
| | - Adrien Allio
- Department of Pharmacology, Addictovigilance (Monitoring Centre for Addiction), Nantes University Hospital, Nantes, France
| | - Marie Bronnec
- INSERM UMR U1246 SPHERE, Institut de Recherche en Santé 2, Nantes, France
- Department of Addictology, Nantes University Hospital, Bâtiment Louis Philippe, Hôpital Saint Jacques, Nantes, France
| | - Samuel Bulteau
- INSERM UMR U1246 SPHERE, Institut de Recherche en Santé 2, Nantes, France
- Department of Psychiatry, Nantes University Hospital, Nantes, France
| | - Pascale Jolliet
- Department of Pharmacology, Addictovigilance (Monitoring Centre for Addiction), Nantes University Hospital, Nantes, France
- INSERM UMR U1246 SPHERE, Institut de Recherche en Santé 2, Nantes, France
| | - Caroline Victorri-Vigneau
- Department of Pharmacology, Addictovigilance (Monitoring Centre for Addiction), Nantes University Hospital, Nantes, France
- INSERM UMR U1246 SPHERE, Institut de Recherche en Santé 2, Nantes, France
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23
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Buhre W, Disma N, Hendrickx J, DeHert S, Hollmann MW, Huhn R, Jakobsson J, Nagele P, Peyton P, Vutskits L. European Society of Anaesthesiology Task Force on Nitrous Oxide: a narrative review of its role in clinical practice. Br J Anaesth 2019; 122:587-604. [PMID: 30916011 DOI: 10.1016/j.bja.2019.01.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 12/26/2018] [Accepted: 01/13/2019] [Indexed: 12/12/2022] Open
Abstract
Nitrous oxide (N2O) is one of the oldest drugs still in use in medicine. Despite its superior pharmacokinetic properties, controversy remains over its continued use in clinical practice, reflecting in part significant improvements in the pharmacology of other anaesthetic agents and developing awareness of its shortcomings. This narrative review describes current knowledge regarding the clinical use of N2O based on a systematic and critical analysis of the available scientific literature. The pharmacological properties of N2O are reviewed in detail along with current evidence for the indications and contraindications of this drug in specific settings, both in perioperative care and in procedural sedation. Novel potential applications for N2O for the prevention or treatment of chronic pain and depression are also discussed. In view of the available evidence, we recommend that the supply of N2O in hospitals be maintained while encouraging its economic delivery using modern low flow delivery systems. Future research into its potential novel applications in prevention or treatment of chronic conditions should be pursued to better identify its role place in the developing era of precision medicine.
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Affiliation(s)
- Wolfgang Buhre
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, University of Maastricht, Maastricht, the Netherlands
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Jan Hendrickx
- Department of Anesthesiology, Onze-Lieve-Vrouwziekenhuis Hospital Aalst, Aalst, Belgium
| | - Stefan DeHert
- Department of Anesthesiology and Perioperative Medicine, University Hospital Ghent, Ghent, Belgium
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center (AUMC), AMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ragnar Huhn
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jan Jakobsson
- Department of Anesthesiology and Intensive Care, Institution for Clinical Science, Karolinska Institute, Danderyds University Hospital, Danderyd, Sweden
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, IL, USA
| | - Philip Peyton
- Department of Anaesthesia, Austin Health, and Anaesthesia Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals Geneva, Genève, Switzerland
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24
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Lundin MS, Cherian J, Andrew MN, Tikaria R. One month of nitrous oxide abuse causing acute vitamin B 12 deficiency with severe neuropsychiatric symptoms. BMJ Case Rep 2019; 12:12/2/bcr-2018-228001. [PMID: 30737329 DOI: 10.1136/bcr-2018-228001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 21-year-old university student studying abroad in the USA presented to the emergency department with double vision, lower extremity weakness with difficulty ambulating and other neuropsychiatric symptoms. MRI of the brain and spinal cord were normal. Vitamin B12 was 78 pg/mL (58 pmol/L, reference 211-911 pg/mL). The patient had been using nitrous oxide capsules used for whipped cream recharging, which she obtained from other students, a few times daily for a month for the purpose of anxiety relief. The patient was not a vegan or vegetarian. The patient was treated with intramuscular vitamin B12 repletion with partial resolution of neurologic symptoms and discharged on vitamin B12 supplementation.
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Affiliation(s)
- Michael S Lundin
- Internal Medicine, Michigan State University, East Lansing, Michigan, USA.,Internal Medicine, Sparrow Hospital, Lansing, Michigan, USA
| | - John Cherian
- Internal Medicine, Michigan State University, East Lansing, Michigan, USA.,Internal Medicine, Sparrow Hospital, Lansing, Michigan, USA
| | - Michael Nyika Andrew
- Internal Medicine, Michigan State University, East Lansing, Michigan, USA.,Internal Medicine, Sparrow Hospital, Lansing, Michigan, USA
| | - Richa Tikaria
- Internal Medicine, Michigan State University, East Lansing, Michigan, USA.,Internal Medicine, Sparrow Hospital, Lansing, Michigan, USA
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25
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Dong X, Ba F, Wang R, Zheng D. Imaging appearance of myelopathy secondary to nitrous oxide abuse: a case report and review of the literature. Int J Neurosci 2018; 129:225-229. [PMID: 30234413 DOI: 10.1080/00207454.2018.1526801] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Purpose The abuse of nitrous oxide (N2O) can induce Vitamin B12 deficiency that subsequently leads to central nervous demyelination, myelopathy and peripheral neuropathy. Although myelopathy has been reported in the past, the specific locations and prognosis of the disease are still unclear. MATERIALS AND METHODS We report the case of a 22-year-old male who presented with quadriplegia that began after a 3-month history of inhalation of N2O. We summarized the clinical data of this entity and performed a comprehensive literature review of various presentations and MRI features of myelopathy secondary to N2O abuse. RESULTS In combination with previous reports of 14 cases, we found that the onset of the disease was usually subacute, and the majority of patients (92.85%) were young men. There was no definite relationship between myelopathy and the amount or duration of N2O inhalation. The most common clinical manifestation was sensory ataxia, and the cervical spinal cord was the most frequently impaired area of the whole spinal cord. The spinal cord lesions had a high signal intensity on T2-weighted MRI and usually involved more than three spinal segments and impaired the posterior column more significantly. Most patients recovered well after vitamin B12 supplementation. CONCLUSIONS Myelopathy secondary to N2O abuse is generally seen in young men. The clinical diagnosis mainly depends on a history of N2O inhalation and the characteristic imaging changes in the posterior cervical spinal cord. Early diagnosis and intervention are important for a satisfactory prognosis.
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Affiliation(s)
- Xiaoyu Dong
- a Department of Neurology , Shengjing Hospital of China Medical University , Shenyang , PR China
| | - Fang Ba
- b Department of Rehabilitation , Shengjing Hospital of China Medical University , Shenyang , PR China
| | - Ruihua Wang
- a Department of Neurology , Shengjing Hospital of China Medical University , Shenyang , PR China
| | - Dongming Zheng
- a Department of Neurology , Shengjing Hospital of China Medical University , Shenyang , PR China
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26
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Rzepka Z, Respondek M, Rok J, Beberok A, Ó Proinsias K, Gryko D, Wrześniok D. Vitamin B 12 Deficiency Induces Imbalance in Melanocytes Homeostasis-A Cellular Basis of Hypocobalaminemia Pigmentary Manifestations. Int J Mol Sci 2018; 19:ijms19092845. [PMID: 30235895 PMCID: PMC6163934 DOI: 10.3390/ijms19092845] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 01/12/2023] Open
Abstract
Vitamin B12 deficiency causes significant changes in cellular metabolism leading to various clinical symptoms, such as hematological, psychiatric, and neurological disorders. We hypothesize that skin pigmentation disorders may be a diagnostically important manifestation of vitamin B12 deficiency, however the cellular and molecular mechanisms underlying these effects remain unknown. The aim of this study was to examine the effect of vitamin B12 deficiency on melanocytes homeostasis. Hypocobalaminemia in vitro model was developed by treating epidermal melanocytes with synthesized vitamin B12 antagonist—hydroxycobalamin(c-lactam). The cells were examined using immunoenzymatic, spectrophotometric, and fluorimetric assays as well as image cytometry. Significant melanogenesis stimulation—the increase of relative melanin content and tyrosinase activity up to 131% and 135%, respectively—has been indicated. Cobalamin-deficient cells displayed the elevation (by 120%) in reactive oxygen species level. Moreover, the redox status imbalance was stated. The study provided a scientific evidence for melanocytes homeostasis disturbance under hypocobalaminemia, thus indicating a significant element of the hyperpigmentation mechanism due to vitamin B12 deficiency. Furthermore, the implication between pigmentary and hematological and/or neuropsychiatric symptoms in cobalamin-deficient patients may be an important issue.
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Affiliation(s)
- Zuzanna Rzepka
- Department of Pharmaceutical Chemistry, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Jagiellońska 4, 41-200 Sosnowiec, Poland.
| | - Michalina Respondek
- Department of Pharmaceutical Chemistry, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Jagiellońska 4, 41-200 Sosnowiec, Poland.
| | - Jakub Rok
- Department of Pharmaceutical Chemistry, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Jagiellońska 4, 41-200 Sosnowiec, Poland.
| | - Artur Beberok
- Department of Pharmaceutical Chemistry, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Jagiellońska 4, 41-200 Sosnowiec, Poland.
| | - Keith Ó Proinsias
- Institute of Organic Chemistry, Polish Academy of Science, Kasprzaka 44/52, 01-224 Warsaw, Poland.
| | - Dorota Gryko
- Institute of Organic Chemistry, Polish Academy of Science, Kasprzaka 44/52, 01-224 Warsaw, Poland.
| | - Dorota Wrześniok
- Department of Pharmaceutical Chemistry, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Jagiellońska 4, 41-200 Sosnowiec, Poland.
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27
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Johnson K, Mikhail P, Kim MG, Bosco A, Huynh W. Recreational nitrous oxide-associated neurotoxicity. J Neurol Neurosurg Psychiatry 2018; 89:897-898. [PMID: 29367261 DOI: 10.1136/jnnp-2017-317768] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/04/2018] [Accepted: 01/07/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Kate Johnson
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Philopatir Mikhail
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Myong Gyu Kim
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Annmarie Bosco
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - William Huynh
- Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Brain and Mind Centre, University of Sydney, Camperdown, New South Wales, Australia
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28
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Egan W, Steinberg E, Rose J. Vitamin B 12 deficiency-induced neuropathy secondary to prolonged recreational use of nitrous oxide. Am J Emerg Med 2018; 36:1717.e1-1717.e2. [PMID: 29859645 DOI: 10.1016/j.ajem.2018.05.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/13/2018] [Indexed: 11/15/2022] Open
Abstract
A 24-year-old female, otherwise healthy, presented to the Emergency Department (ED) with difficulty walking and bilateral leg pain. The patient was a recreational nitrous oxide (NO2) user, also known as "whippets" or simply nitrous. Neurologic examination demonstrated an unsteady gait and positive Romberg sign along with normal deep tendon reflexes and normal muscle strength in upper and lower extremities. Laboratory results demonstrated macrocytic erythropoiesis, reduced B12, elevated homocysteine, and elevated methylmalonic acid. Outpatient MRI later demonstrated degeneration of the posterior spinal column. The patient was empirically treated in the ED with intramuscular B12 and admitted to the evaluation unit for pain control and Physical Therapy (PT) evaluation. Emergency Medicine (EM) physicians should be aware of this condition because NO2 is used both recreationally and in medicine. With the popularity of recreational nitrous oxide, many emergency patients have experience with this drug. As in our case report, the toxic effects can be profound and mimic other emergent conditions like stroke. Emergency physicians should have a higher index of suspicion for the toxic effects of this common drug. Elderly, vegetarians and patients with Irritable Bowel Disease are at higher risk and may even experience toxicity from nitrous oxide used therapeutically during routine anesthesia.
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Garakani A, Jaffe RJ, Savla D, Welch AK, Protin CA, Bryson EO, McDowell DM. Neurologic, psychiatric, and other medical manifestations of nitrous oxide abuse: A systematic review of the case literature. Am J Addict 2016; 25:358-69. [PMID: 27037733 DOI: 10.1111/ajad.12372] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/28/2016] [Accepted: 03/11/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/OBJECTIVES Nitrous oxide (N2 O) is known to have abuse potential, although debate regarding the toxic effects of such abuse continues. Our objective was to review the case literature and present the neurologic, psychiatric and medical consequences of N2 O abuse. METHODS A systematic literature review was completed for case reports using keywords "nitrous oxide" with "abuse/abusing" or "misuse/misusing" or "overuse/overusing" or "addiction." Non-English-language cases and cases not involving direct toxic effects of N2 O were excluded as were commentaries or personal essays. Clinical presentation, frequency of N2 O abuse, laboratory studies, imaging, ancillary tests, treatments and outcomes were collected from case reports. RESULTS Our review returned 335 Pubmed, 204 Web of Science, 73 PsycINFO, 6 CINAHL, 55 EMBASE and 0 Grey Literature results, and after exclusion and removal of duplicates, 91 individual cases across 77 publications were included. There were also 11 publications reporting 29 cases of death related to N2 O abuse. The majority of cases (N = 72) reported neurologic sequelae including myeloneuropathy and subacute combined degeneration, commonly (N = 39) with neuroimaging changes. Psychiatric (N = 11) effects included psychosis while other medical effects (N = 8) included pneumomediastinum and frostbite. Across all cases N2 O abuse was correlated with low or low-normal Vitamin B12 (cyanocobalamin) levels (N = 52) and occasionally elevated homocysteine and methylmalonic acid. CONCLUSIONS/SCIENTIFIC SIGNIFICANCE N2 O abuse represents a significant problem because of the difficulty involved with identification and the toxicity related to chronic abuse including possible death. Health professionals should be aware of the toxic effects of N2 O and be able to identify potential N2 O abuse. (Am J Addict 2016;25:358-369).
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Affiliation(s)
- Amir Garakani
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.,Silver Hill Hospital, New Canaan, Connecticut
| | - Robert J Jaffe
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dipal Savla
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alison K Welch
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Caroline A Protin
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Ethan O Bryson
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
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Pugliese RS, Slagle EJ, Oettinger GR, Neuburger KJ, Ambrose TM. Subacute combined degeneration of the spinal cord in a patient abusing nitrous oxide and self-medicating with cyanocobalamin. Am J Health Syst Pharm 2016; 72:952-7. [PMID: 25987690 DOI: 10.2146/ajhp140583] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE A case of subacute combined degeneration (SCD) of the spinal cord manifesting as severe ataxia and urinary retention in a patient with a history of heavy nitrous oxide abuse and self-supplementation with cyanocobalamin is reported. SUMMARY A 27-year-old woman was treated in the emergency department for complaints of abdominal pain and inability to urinate for about 12 hours. The patient also complained of worsening lower-extremity weakness for 10 days and a "pins and needles" sensation in the lower extremities for approximately 1 year. She reported nitrous oxide abuse over 3 years (an average of 100-200 "whippit" cartridges daily on 3 or 4 days per week), as well as long-term self-medication with oral and i.m. cyanocobalamin for the purpose of preventing nitrous oxide-induced neurologic symptoms. Results of magnetic resonance imaging (MRI) were highly suggestive of SCD, which is typically seen in primary vitamin B12 deficiency but has been reported in the context of chronic nitrous oxide exposure. Treatment was initiated with cyanocobalamin 1000 μg i.m. daily, to be continued for 5 days and followed by a four-week regimen of 1000 μg i.m. weekly. The patient was discharged after 3 days, despite continued symptoms, with instructions to obtain ongoing care but was lost to follow-up. CONCLUSION A patient who abused nitrous oxide chronically developed ataxia, paresthesia, and urinary retention while self-medicating with cyanocobalamin. A diagnosis of SCD was supported by MRI findings, symptoms, and the known relationship between nitrous oxide exposure and vitamin B12 deficiency.
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Affiliation(s)
- Robert S Pugliese
- Robert S. Pugliese, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University, Philadelphia, PA. Evan J. Slagle, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, Saint Joseph Medical Center, Reading, PA. Glenn R. Oettinger, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University. Kenneth J. Neuburger, M.D., is Clinical Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Thomas Jefferson University. Timothy M. Ambrose, M.D., is Epilepsy Fellow, Department of Neurology, Thomas Jefferson University Hospital.
| | - Evan J Slagle
- Robert S. Pugliese, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University, Philadelphia, PA. Evan J. Slagle, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, Saint Joseph Medical Center, Reading, PA. Glenn R. Oettinger, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University. Kenneth J. Neuburger, M.D., is Clinical Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Thomas Jefferson University. Timothy M. Ambrose, M.D., is Epilepsy Fellow, Department of Neurology, Thomas Jefferson University Hospital
| | - Glenn R Oettinger
- Robert S. Pugliese, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University, Philadelphia, PA. Evan J. Slagle, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, Saint Joseph Medical Center, Reading, PA. Glenn R. Oettinger, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University. Kenneth J. Neuburger, M.D., is Clinical Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Thomas Jefferson University. Timothy M. Ambrose, M.D., is Epilepsy Fellow, Department of Neurology, Thomas Jefferson University Hospital
| | - Kenneth J Neuburger
- Robert S. Pugliese, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University, Philadelphia, PA. Evan J. Slagle, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, Saint Joseph Medical Center, Reading, PA. Glenn R. Oettinger, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University. Kenneth J. Neuburger, M.D., is Clinical Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Thomas Jefferson University. Timothy M. Ambrose, M.D., is Epilepsy Fellow, Department of Neurology, Thomas Jefferson University Hospital
| | - Timothy M Ambrose
- Robert S. Pugliese, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University, Philadelphia, PA. Evan J. Slagle, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Department of Pharmacy, Saint Joseph Medical Center, Reading, PA. Glenn R. Oettinger, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Emergency Medicine, Thomas Jefferson University Hospital, and Clinical Assistant Professor, School of Pharmacy, Thomas Jefferson University. Kenneth J. Neuburger, M.D., is Clinical Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Thomas Jefferson University. Timothy M. Ambrose, M.D., is Epilepsy Fellow, Department of Neurology, Thomas Jefferson University Hospital
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Randhawa G, Bodenham A. The increasing recreational use of nitrous oxide: history revisited. Br J Anaesth 2015; 116:321-4. [PMID: 26323292 DOI: 10.1093/bja/aev297] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- G Randhawa
- Leeds General Infirmary, Anaesthesia and Critical Care, Great George Street, Leeds LS1 3EX, UK
| | - A Bodenham
- Leeds General Infirmary, Anaesthesia and Critical Care, Great George Street, Leeds LS1 3EX, UK
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Bäckström B, Johansson B, Eriksson A. Death from Nitrous Oxide. J Forensic Sci 2015; 60:1662-5. [PMID: 26258592 DOI: 10.1111/1556-4029.12879] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 09/18/2014] [Accepted: 09/22/2014] [Indexed: 11/30/2022]
Abstract
Nitrous oxide is an inflammable gas that gives no smell or taste. It has a history of abuse as long as its clinical use, and deaths, although rare, have been reported. We describe two cases of accidental deaths related to voluntary inhalation of nitrous oxide, both found dead with a gas mask covering the face. In an attempt to find an explanation to why the victims did not react properly to oncoming hypoxia, we performed experiments where a test person was allowed to breath in a closed system, with or without nitrous oxide added. Vital signs and gas concentrations as well as subjective symptoms were recorded. The experiments indicated that the explanation to the fact that neither of the descendents had reacted to oncoming hypoxia and hypercapnia was due to the inhalation of nitrous oxide. This study raises the question whether nitrous oxide really should be easily, commercially available.
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Affiliation(s)
- Björn Bäckström
- Department of Forensic Medicine, National Board of Forensic Medicine, PO Box 7616, SE-907 12 Umeå, Sweden.,Section of Forensic Medicine, Department of Community Medicine and Rehabilitation, Umeå University, PO Box 7616, SE-907 12 Umeå, Sweden
| | - Bengt Johansson
- Department of Public Health and Clinical Medicine, Norrlands Universitetssjukhus SE-901 87, Umeå, Sweden
| | - Anders Eriksson
- Section of Forensic Medicine, Department of Community Medicine and Rehabilitation, Umeå University, PO Box 7616, SE-907 12 Umeå, Sweden
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Abstract
Vitamin B12, also known as cobalamin, is a water-soluble vitamin that is important in the hematological and nervous systems, and it has a complex relationship with the skin. Altered cobalamin levels can lead to dermatological manifestations, which may indicate a deficiency or excess of this vitamin. The biochemistry and metabolism of cobalamin is complex, and diseases can be associated with alterations of this metabolic pathway. The cutaneous manifestations of cobalamin deficiency include hyperpigmentation (most commonly); hair and nail changes; and oral changes, including glossitis. Additionally, several dermatologic conditions, including vitiligo, aphthous stomatitis, atopic dermatitis, and acne are related to cobalamin excess or deficiency. The cutaneous complications of cobalamin therapy include acne, rosacea, and allergic site reactions, or anaphylaxis with cobalamin injections. As cobalt is a component of cobalamin, patients with cobalt sensitivity have been reported to have cutaneous manifestations when receiving cobalamin replacement therapy.
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