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Soderstrom J, Grigg J, McWilliam O, Fatovich D. Brain and body disconnect: A retrospective case series of subacute combined degeneration of the spinal cord from chronic nitrous oxide use in Perth, Western Australia. Drug Alcohol Rev 2024; 43:1636-1644. [PMID: 38740512 DOI: 10.1111/dar.13858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Chronic nitrous oxide (N2O) use causes inactivation of vitamin B12, resulting in neurological and psychiatric symptoms. This case series presents all N2O-related presentations to the emergency department at Royal Perth Hospital between June 2019 and June 2021, alongside the costs of these admissions. CASE PRESENTATION Twenty-two patients were identified; 68% (n = 15) were male. The median age was 22.4 years (interquartile range [IQR], 20-30). Median daily number of N2O bulbs inhaled was 150 (IQR, 64-300) with a median duration of use of 9 months (IQR, 3-12). Presentations included ataxia, paraesthesia and falls (n = 18), urinary retention (n = 3) and psychotic symptoms (n = 2). Fourteen patients had severe symptoms prompting a magnetic resonance imaging of brain and spine, confirming 12 cases of subacute combined degeneration of the spinal cord. All patients had IMI vitamin B12 therapy, while 14 had oral methionine therapy. The median length of admission was 4 days (IQR 1-23 days). The median cost of admission per day for patients where costs were accessible (n = 7) was $2061 (IQR, $1903-$2860). DISCUSSION AND CONCLUSIONS A case series of symptomatic chronic N2O use with severe neurological sequelae and significant costs associated per admission. Triangulation of emergency department and Ecstasy and Related Drugs Reporting System data helped prompt a swift public health response, including mandatory warning labels, limits to transaction amounts and legislative changes to the Medicines and Poisons Act to make it illegal for sale if there is a suspicion that it will be abused.
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Affiliation(s)
- Jessamine Soderstrom
- Emergency Medicine, Royal Perth Hospital, Perth, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
| | - Jodie Grigg
- National Drug Research Institute and enAble Institute, Curtin University, Perth, Australia
| | - Owen McWilliam
- Emergency Medicine, Royal Perth Hospital, Perth, Australia
| | - Daniel Fatovich
- Emergency Medicine, Royal Perth Hospital, Perth, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia
- Emergency Medicine, University of Western Australia, Perth, Australia
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2
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Motallebi A, Fathi M, Mazhari F, Hoseinzadeh M, Parisay I. Hypnosis and nitrous oxide impact on the school aged patients' anxiety and cooperation candidate for tooth extraction: A randomized clinical trial. Heliyon 2024; 10:e35223. [PMID: 39170235 PMCID: PMC11336481 DOI: 10.1016/j.heliyon.2024.e35223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/15/2024] [Accepted: 07/24/2024] [Indexed: 08/23/2024] Open
Abstract
Background This randomized clinical trial (RCT) investigated whether hypnosis would lead to favorable outcomes in reducing anxiety, enhancing cooperation, and improving physiological responses in school-aged children undergoing tooth extraction compared to nitrous oxide/oxygen (N2O/O2) and conventional behavior guidance (CBG). Methods Sixty-six school-aged children (mean age: 7.87 ± 1.18 years) who needed one posterior primary tooth extraction were included. Children with low-to-moderate anxiety were randomly divided into three groups (n = 22 each): hypnosis, N2O/O2, and CBG. Anxiety levels during and after anesthetic injection and tooth extraction were assessed using the Venham Clinical Anxiety Scale (VCAS) and the Venham Picture Test (VPT). Changes in heart rate (HR) and oxygen saturation (SpO2) were monitored. Children's cooperation levels were measured using the Venham Clinical Cooperation Scale (VCCS). Results The VPT scores were significantly higher in the CBG group than in the N2O/O2 and hypnosis groups (p < 0.001). The VCAS scores in the N2O/O2 group were lower than those in the CBG group (p < 0.05) and were comparable to those in the hypnosis group. The VCCS scores were significantly higher in the CBG group than in the N2O/O2 and hypnosis groups (p < 0.05). HR changes in the N2O/O2 group were significantly lower than in the hypnosis and CBG groups (p < 0.05). No significant difference in pain was observed between the groups the day after the intervention. Conclusion N2O/O2 inhalation and hypnosis are effective in reducing self-reported and observed anxiety and improving cooperation levels in pediatric patients during dental extraction. Moreover, the frequency of reported pain was lower in the hypnosis group compared to the other groups.
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Affiliation(s)
- Afsoon Motallebi
- Department of Pediatric Dentistry, School of Dentistry, North Khorasan University of Medical Sciences, Bojnourd, Iran
| | - Mehdi Fathi
- Department of Anaesthesiology, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Mazhari
- Professor of Pediatric Dentistry Department, Dental Materials Research Center, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Melika Hoseinzadeh
- Dentist, Research Assistant, Dental Research Center, Mashhad Dental School, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Iman Parisay
- Department of Pediatric Dentistry, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
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Tripathi R, Verma D, Tiwary S, Agarwal A. Letter to the editor about psychiatric manifestations in a patient of nitrous oxide abuse. Indian J Psychiatry 2024; 66:761-762. [PMID: 39398518 PMCID: PMC11469558 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_486_24] [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: 05/31/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 10/15/2024] Open
Affiliation(s)
- Richa Tripathi
- Department of Psychiatry, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India E-mail:
| | - Dwarika Verma
- Department of Psychiatry, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India E-mail:
| | - Shubhankar Tiwary
- Department of Psychiatry, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India E-mail:
| | - Astha Agarwal
- Department of Psychiatry, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India E-mail:
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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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5
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Dai Q, Chen S, Zhang X, Fan K, Zhang J, Zheng J. Nitrous oxide abuse in a 21-year-old female: a case report and review of literature. Front Neurol 2024; 15:1416557. [PMID: 38994489 PMCID: PMC11236749 DOI: 10.3389/fneur.2024.1416557] [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: 04/12/2024] [Accepted: 06/17/2024] [Indexed: 07/13/2024] Open
Abstract
The abuse of nitrous oxide (N2O) poses a substantial public health challenge. In many countries, including China, regulations governing the utilization and accessibility to N2O remain ambiguous, particularly within the food industry. Here, we report a case of a 21-year-old female who presented with symptoms of subacute combined degeneration (SCD) of the spinal cord due to N2O abuse. The patient exhibited bilateral lower limb numbness and weakness, low serum vitamin B12 levels with elevated homocysteine levels, and lumbar spine magnetic resonance imaging (MRI) revealed abnormal signals of the spinal cord. Following cessation of N2O and comprehensive therapy including methylcobalamin and nerve growth factor, the symptoms significantly improved. A follow-up examination 3 months later showed good progress in gait stability. At a 5-year follow-up, the patient's previous clinical symptoms had completely disappeared, and her quality of life had returned to normal. This case underscores the urgency of raising awareness and prevention of N2O abuse, emphasizing the importance of timely diagnosis and comprehensive treatment for patient recovery. Clear formulation and enforcement of relevant regulatory measures are equally crucial in reducing instances of abuse.
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Affiliation(s)
- Qi Dai
- Department of Radiology, Ningbo No.2 Hospital, Ningbo, China
| | - Shutong Chen
- School of Medical Imaging, Hangzhou Medical College, Hangzhou, China
| | - Xiaodan Zhang
- Department of Emergency Medicine, The University of Hong Kong, Hong Kong, China
| | - Kuixin Fan
- Department of Emergency Medicine, Ningbo No.2 Hospital, Ningbo, China
| | - Jingfeng Zhang
- Department of Radiology, Ningbo No.2 Hospital, Ningbo, China
| | - Jianjun Zheng
- Department of Radiology, Ningbo No.2 Hospital, Ningbo, China
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Green R. Causes and Risk Factors of Vitamin B12 Deficiency at the Bookends of Life, From Infancy to Old Age. Food Nutr Bull 2024; 45:S5-S9. [PMID: 38987884 DOI: 10.1177/03795721241252503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
The causes and risk factors of vitamin B12 deficiency are many and varied. Importantly, they vary considerably across the lifespan, from infancy to old age. The complexity of the physiology of vitamin B12 bespeaks the myriad of possible causes of deficiency and possible disruptions of its functional integrity. These lead ultimately to the pathobiological effects witnessed in deficiency of this fascinating micronutrient. This brief overview of the multiplicity of mechanisms that can result in vitamin B12 deficiency, and the panoply of its manifestations explores the underlying reasons for the protean presentations of the disease. As the human organism progresses through the chronology and milestones of age, various susceptibility factors arise resulting from the interplay of environmental and genetic factors. Acting independently and in concert, these factors produce the common denominator of vitamin B12 deficiency. However, the rate at which such deficiency develops and the way in which it presents clinically vary widely, subject to such influences as genetic variability, end-organ susceptibility, and concomitant micronutrient status. Some examples of unusual cases of vitamin B12 deficiency are described. Much has been learned about the last of the numbered vitamins in almost a century. Much yet remains to be discovered.
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7
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Pino S, Vega E, Fragoso M, Salazar G. Nitrous Oxide as an Emerging Cause of Subacute Combined Degeneration and Polyneuropathy: A Two-Case Report. Cureus 2024; 16:e63003. [PMID: 38915835 PMCID: PMC11194535 DOI: 10.7759/cureus.63003] [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] [Accepted: 06/23/2024] [Indexed: 06/26/2024] Open
Abstract
Recreational use of nitrous oxide (N2O), commonly known as laughing gas, has increased in the last few years, bringing an increase in the number of reported cases of toxicity due to this gas. Subacute combined degeneration (SCD) of the spinal cord is the most frequently reported neurological disorder due to the use of N2O, as well as polyneuropathy and even psychiatric symptoms. All of these disorders are consequences of a functional deficit of vitamin B12. We are reporting the cases of two patients with a history of N2O abusive use presenting to the emergency department with progressive symptoms of paresthesia, ascending symmetric paraparesis, and gait ataxia, emulating the clinical characteristics of Guillain-Barré Syndrome (GBS). In both cases, magnetic resonance imaging (MRI) showed findings compatible with transverse myelitis of the cervical spinal cord, and electrodiagnosis studies reported the presence of polyneuropathy with a mixed mechanism. All these findings together pointed to the presence of myeloneuropathy due to a vitamin B12 deficit induced by the prolonged use of N2O. Symptoms improved gradually with vitamin B12 supplementation and abstinence from N2O. It is important to acknowledge the clinical characteristics of complications due to neurotoxicity induced by N2O. Such complications are potentially reversible if they are treated appropriately and quickly. Considering the increase in N2O abuse, it should be considered a probable cause when treating patients with myelopathy and/or neuropathy of an unusual etiology.
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Affiliation(s)
- Silvano Pino
- Neurology, Hospital Universitari de Terrassa, Consorci Sanitari de Terrassa, Barcelona, ESP
| | - Edison Vega
- Neurology, Hospital Universitari de Terrassa, Consorci Sanitari de Terrassa, Barcelona, ESP
| | - Marta Fragoso
- Neurology, Hospital Universitari de Terrassa, Consorci Sanitari de Terrassa, Barcelona, ESP
| | - Gabriel Salazar
- Neurology, Hospital Universitari de Terrassa, Consorci Sanitari de Terrassa, Barcelona, ESP
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8
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Wolffenbuttel BHR, McCaddon A, Ahmadi KR, Green R. A Brief Overview of the Diagnosis and Treatment of Cobalamin (B12) Deficiency. Food Nutr Bull 2024; 45:S40-S49. [PMID: 38987879 DOI: 10.1177/03795721241229500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND An increasing number of adult individuals are at risk of vitamin B12 deficiency, either from reduced nutritional intake or impaired gastrointestinal B12 absorption. OBJECTIVE This study aims to review the current best practices for the diagnosis and treatment of individuals with vitamin B12 deficiency. METHODS A narrative literature review of the diagnosis and treatment of vitamin B12 deficiency. RESULTS Prevention and early treatment of B12 deficiency is essential to avoid irreversible neurological consequences. Diagnosis is often difficult due to diverse symptoms, marked differences in diagnostic assays' performance and the unreliability of second-line biomarkers, including holo-transcobalamin, methylmalonic acid and total homocysteine. Reduced dietary intake of B12 requires oral supplementation. In B12 malabsorption, oral supplementation is likely insufficient, and parenteral (i.e. intramuscular) supplementation is preferred. There is no consensus on the optimal long-term management of B12 deficiency with intramuscular therapy. According to the British National Formulary guidelines, many individuals with B12 deficiency due to malabsorption can be managed with 1000 µg intramuscular hydroxocobalamin once every two months after the initial loading. Long-term B12 supplementation is effective and safe, but responses to treatment may vary considerably. Clinical and patient experience strongly suggests that up to 50% of individuals require individualized injection regimens with more frequent administration, ranging from daily or twice weekly to every 2-4 weeks, to remain symptom-free and maintain a normal quality of life. 'Titration' of injection frequency based on measuring biomarkers such as serum B12 or MMA should not be practiced. There is currently no evidence to support that oral/sublingual supplementation can safely and effectively replace injections. CONCLUSIONS This study highlights the interindividual differences in symptomatology and treatment of people with B12 deficiency. Treatment follows an individualized approach, based on the cause of the deficiency, and tailored to help someone to become and remain symptom-free.
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Affiliation(s)
| | - Andrew McCaddon
- Faculty of Social and Life Sciences, Wrexham University, Wrexham, United Kingdom
| | - Kourosh R Ahmadi
- School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Ralph Green
- University of California Davis, Sacramento, CA, USA
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9
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Dawudi Y, Azoyan L, Broucker TDE, Gendre T, Miloudi A, Echaniz-Laguna A, Mazoyer J, Zanin A, Kubis N, Dubessy AL, Gorza L, Ben Nasr H, Caré W, d'Izarny-Gargas T, Formoso A, Vilcu AM, Bonnan M. Marked increase in severe neurological disorders after nitrous oxide abuse: a retrospective study in the Greater Paris area. J Neurol 2024; 271:3340-3346. [PMID: 38478030 PMCID: PMC11136741 DOI: 10.1007/s00415-024-12264-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Recreational nitrous oxide (N2O) use has become more widespread worldwide, leading to an increase in myelopathies and peripheral neuropathies. The aim of this study was to describe clinical and socioeconomical characteristics of severe N2O-induced (NI) neurological disorders (NI-NDs), to determine its incidence in the Greater Paris area and to compare it with that of similar inflammatory neurological disorders. METHODS We performed a retrospective multicentric cohort study of all adult patients with severe NI-NDs in the neurology and general internal medicine departments of the Greater Paris area from 2018 to 2021. The incidence was compared with that of non-NI-myelitis and Guillain-Barré syndrome (GBS) using a sample of 91,000 hospitalized patients sourced from health insurance data. RESULTS Among 181 patients, 25% had myelopathy, 37% had peripheral neuropathy and 38% had mixed disease. Most were aged between 20 and 25 years, lived in socially disadvantaged urban areas, and exhibited high rates of unemployment (37%). The incidence of NI-NDs increased during 2020 and reached a peak mid-2021. The 2021 incidence in 20-25-year-olds was 6.15 [4.72; 8.24] per 100,000 persons for NI-myelopathy and 7.48 [5.59; 9.37] for NI-peripheral neuropathy. This was significantly higher than for non-NI-myelitis (0.35 [0.02; 2.00]) and GBS (2.47 [0.64; 4.30]). The incidence of NI-NDs was two to three times higher in the most socially disadvantaged areas. CONCLUSION The recent increase in recreational N2O use has led to a rise in the incidence of severe NI-NDs, particularly in young adults with low socioeconomic status for whom NI-NDs strongly outweigh similar neurological disorders.
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Affiliation(s)
- Yachar Dawudi
- Neurology Department, Centre Hospitalier de Saint-Denis, 2 Rue du Dr Delafontaine, 93200, Saint-Denis, France.
- Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136, Sorbonne Université INSERM, Paris, France.
| | - Loris Azoyan
- Neurology Department, Centre Hospitalier de Saint-Denis, 2 Rue du Dr Delafontaine, 93200, Saint-Denis, France
- Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136, Sorbonne Université INSERM, Paris, France
| | - Thomas D E Broucker
- Neurology Department, Centre Hospitalier de Saint-Denis, 2 Rue du Dr Delafontaine, 93200, Saint-Denis, France
| | - Thierry Gendre
- Neurology Department, Hôpital Henri-Mondor, 1 Rue Gustave Eiffel, 94000, Créteil, France
| | - Amal Miloudi
- Neurology Department, Centre Hospitalier Intercommunal Robert Ballanger, Bd Robert Ballanger, 93600, Aulnay-Sous-Bois, France
| | - Andoni Echaniz-Laguna
- Neurology Department, Hôpital Bicêtre, 78 Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Julie Mazoyer
- Neurology Department, Hôpital Avicenne, 125 Route de Stalingrad, 93009, Bobigny, France
| | - Adrien Zanin
- Clinical Physiology Department, Hôpital Lariboisière, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Nathalie Kubis
- Clinical Physiology Department, Hôpital Lariboisière, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Anne-Laure Dubessy
- Neurology Department, Hôpital Saint-Antoine, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Lucas Gorza
- Neurology Department, Hôpital Foch, 40 Rue Worth, 92150, Suresnes, France
| | - Haifa Ben Nasr
- Neurology Department, Centre Hospitalier Sud Francilien, 40 Avenue Serge Dassault, 91100, Corbeil-Essonnes, France
| | - Weniko Caré
- Department of Internal Medicine, Bégin Military Teaching Hospital, Saint-Mandé, France
- Paris Poison Control Center, Toxicology Federation (FeTox), Hôpital Fernand Widal, AP-HP, Paris, France
| | | | - Aude Formoso
- Neurology Department, Hôpital de La Pitié Salpêtrière, 47-83 Bd de L'Hôpital, 75013, Paris, France
| | - Ana-Maria Vilcu
- Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136, Sorbonne Université INSERM, Paris, France
| | - Mickael Bonnan
- Neurology Department, Centre Hospitalier de Saint-Denis, 2 Rue du Dr Delafontaine, 93200, Saint-Denis, France
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Rao AK, Syed F, Lee TJ, Umanzor GU, Bodle J. Falling From Laughing: Laughing Gas-Induced Subacute Combined Degeneration From Nitrous Oxide. Cureus 2024; 16:e62138. [PMID: 38993425 PMCID: PMC11238261 DOI: 10.7759/cureus.62138] [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] [Accepted: 06/11/2024] [Indexed: 07/13/2024] Open
Abstract
Laughing gas is becoming increasingly popular as a recreational drug of choice, particularly among young adults. Nitrous oxide, the toxic component of laughing gas, can cause neuronal injury when used in high doses. Through multiple mechanisms, nitrous oxide leads to B12 depletion and subsequent demyelination, particularly in the spinal cord. Here, we present the case of a 27-year-old female who presented with ataxia and was found to have laughing gas-induced subacute combined degeneration from nitrous oxide. After aggressive vitamin B12 repletion and laughing gas cessation for three months, the patient improved.
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Affiliation(s)
- Abhinav K Rao
- Internal Medicine, Trident Medical Center, Charleston, USA
| | - Fahim Syed
- Internal Medicine, Trident Medical Center, Charleston, USA
| | - Thomas J Lee
- Internal Medicine, Rutgers University New Jersey Medical School, Newark, USA
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11
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Zou X, Yi F, Zhou W, Dong Y, Alhaskawi A, Zhou H, Ezzi SHA, Kota VG, Abdulla MHAH, Alenikova O, Abdalbary SA, Lu H, Wang C. Mechanisms and recent advances in the diagnosis and treatment of nitrous oxide-induced peripheral neuropathy: a narrative review. Front Neurol 2024; 15:1381938. [PMID: 38854969 PMCID: PMC11158622 DOI: 10.3389/fneur.2024.1381938] [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: 02/04/2024] [Accepted: 05/06/2024] [Indexed: 06/11/2024] Open
Abstract
Under standard conditions, nitrous oxide (N2O) manifests as a colorless, odorless gas with a mildly sweet taste. The compound finds applications in various fields, including its use as an aerosol propellants, an accelerant in motor racing, and an anesthetic in surgical procedures and dentistry. Unfortunately, the recreational misuse of N2O has become prevalent among young individuals due to its euphoric and hallucinogenic effects. Compounding this issue is the fact that nitrous oxide can be easily obtained from over-the-counter household items, facilitating its non-medical use. The global community has witnessed a surge in the recreational utilization of nitrous oxide gas in recent years. Despite the widespread non-medical abuse of N2O, there remains inadequate understanding of the potential adverse effects resulting from exposure to it. This paper provides an overview of management findings, laboratory and electrodiagnostic characteristics, as well as clinical presentations associated with neurological disorders induced by nitrous oxide usage.
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Affiliation(s)
- Xiaodi Zou
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Fangyu Yi
- The First School of Clinical of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Weijie Zhou
- Department of Orthopedics, No. 903 Hospital of PLA Joint Logistic Support Force, Hangzhou, China
| | - Yanzhao Dong
- Department of Orthopedics, No. 903 Hospital of PLA Joint Logistic Support Force, Hangzhou, China
| | - Ahmad Alhaskawi
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Haiying Zhou
- School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | | | | | | | - Olga Alenikova
- Department of Neurology, Republican Research and Clinical Center of Neurology and Neurosurgery, Minsk, Belarus
| | - Sahar Ahmed Abdalbary
- Department of Orthopedic Physical Therapy, Faculty of Physical Therapy, Nahda University in Beni Suef, Beni Suef, Egypt
| | - Hui Lu
- Department of Orthopedics, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Changxin Wang
- Department of Orthopedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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12
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Ruijter BJ, de Mooij MJ, Bruijnes JE, van Oosterhout WPJ, Kwa VIH. Neurological complications of excessive recreational nitrous oxide use: a case series based on a text mining algorithm. J Neurol 2024; 271:1267-1276. [PMID: 37914912 DOI: 10.1007/s00415-023-12061-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The recreational use of nitrous oxide (N2O) has gained popularity over recent years. We present a case series of excessive N2O users with neurological complications. METHODS In this retrospective three-centre study, we used a text mining algorithm to search for patients who used N2O recreationally and visited a neurologist. RESULTS We identified 251 patients. The median duration of N2O use was 11 months (interquartile range [IQR], 3-24) and the median amount of N2O used per occasion 1.6 kg (IQR 0.5-4.0). Clinically, polyneuropathy (78%), myelopathy (41%), and encephalopathy (14%) were the most common diagnoses. An absolute vitamin B12 deficiency of < 150 pmol/L was found in 40% of cases. In 90%, at least one indicator of functional vitamin B12 status (vitamin B12, homocysteine, or methylmalonic acid) was abnormal. MRI showed signs of myelopathy in 30/55 (55%) of cases. In 28/44 (64%) of those who underwent electromyography, evidence of axonal polyneuropathy was found. Most (83%) patients were treated with vitamin B12 supplementation, and 23% were admitted to the hospital. Only 41% had follow-up for ≥ 30 days, and 79% of those showed partial or complete recovery. CONCLUSIONS In this case series of excessive N2O users, we describe a high prevalence of polyneuropathy, myelopathy, and encephalopathy. Stepwise testing for serum levels of vitamin B12, homocysteine, and methylmalonic acid may support the clinical diagnosis. Due to low sensitivity, MRI of the spinal cord and electromyography have limited value. Effective treatment should incorporate supplementation of vitamin B12 and strategies to prevent relapses in N2O use.
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Affiliation(s)
- B J Ruijter
- Department of Neurology, OLVG, Amsterdam, the Netherlands.
| | - M J de Mooij
- Department of Neurology, OLVG, Amsterdam, the Netherlands
| | - J E Bruijnes
- Department of Neurology, Zuyderland Medical Centre, Heerlen, the Netherlands
- Department of Neurology, Maastricht UMC+, Maastricht, the Netherlands
| | | | - V I H Kwa
- Department of Neurology, OLVG, Amsterdam, the Netherlands
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13
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Leleu D, Denimal D. A case of functional vitamin B12 deficiency after recreational nitrous oxide use. Biochem Med (Zagreb) 2024; 34:010801. [PMID: 38125615 PMCID: PMC10731736 DOI: 10.11613/bm.2024.010801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/22/2023] [Indexed: 12/23/2023] Open
Abstract
The recreational use of nitrous oxide as laughing gas becomes a real public health issue among adolescents and young adults. Chronic use is deleterious and can lead to severe neurological disorders. Nitrous oxide inactivates vitamin B12, and the functional defect of vitamin B12 plays a major role in the pathogenesis of nitrous oxide-related neurological disorders. Here we report the case of a 22-year-old woman who came to the hospital after an unexplained loss of consciousness. She exhibited typical features of vitamin B12 or folate deficiency such as macrocytic anemia and hypersegmented neutrophils. However, serum concentrations of folate and vitamin B12 were normal. In contrast, circulating concentrations of total homocysteine and methylmalonic acid were significantly increased. These results clearly indicated a defect in vitamin B12 functions. The reason for this defect was clarified when she revealed that she had been consuming nitrous oxide recreationally for over a year. The present case points out the challenges in diagnosing vitamin B12 deficiency in the context of nitrous oxide abuse due to normal concentrations of total serum vitamin B12 in a significant proportion of cases. The medical community should be aware of how difficult it can be to interpret B12 status in this specific population.
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Affiliation(s)
- Damien Leleu
- Department of Clinical Biochemistry, Dijon University Hospital, Dijon, France
- National institute for health and medical research, University of Burgundy, Dijon, France
| | - Damien Denimal
- Department of Clinical Biochemistry, Dijon University Hospital, Dijon, France
- National institute for health and medical research, University of Burgundy, Dijon, France
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14
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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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15
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Hassing LT, Jiang FY, Zutt R, Arends S. Nitrous-oxide-induced polyneuropathy and subacute combined degeneration of the spine: clinical and diagnostic characteristics in 70 patients, with focus on electrodiagnostic studies. Eur J Neurol 2024; 31:e16076. [PMID: 37754673 PMCID: PMC11235686 DOI: 10.1111/ene.16076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND AND PURPOSE Nitrous oxide (N2 O) induced neurological symptoms are increasingly encountered. Our aim is to provide clinical and diagnostic characteristics with a focus on electrodiagnostic studies. METHODS Patients with neurological sequelae due to N2 O presenting in our hospital between November 2018 and December 2021 reporting clinical and diagnostic data were retrospectively reviewed. RESULTS Seventy patients (median 22 years) were included. Median N2 O usage was 4 kg/week during 12 months. Patients' history revealed a higher rate of sensory symptoms compared to motor (97% vs. 57%) and 77% walking difficulties. Clinical diagnosis was polyneuropathy (PNP) in 44%, subacute combined degeneration (SCD) of the spine in 19%, both in 37%. Median vitamin B12 level was low (159 pmol/L), normal in 16%. The median methylmalonic acid was increased (2.66 μmol/L). Electrodiagnostic abnormalities were observed in 91%, with 72% fulfilling axonal PNP criteria, 20% showing mild to intermediate slowing. One patient fulfilled demyelinating PNP criteria not related to N2 O abuse (Charcot-Marie-Tooth type 1a). More prominent motor nerve conduction abnormalities were found; lower limbs were more affected. In 64% with normal conduction, myography showed signs of axonal loss. Magnetic resonance imaging showed cervical myelopathy in 58% involving generally five to six segments. CONCLUSIONS Nitrous oxide (N2 O) leads to neurological symptoms by causing PNP and/or SCD primarily involving the legs. Distinguishing PNP and SCD clinically was shown to be insufficient. Electrodiagnostic studies showed axonal PNP. Demyelinating PNP due to N2 O abuse was not present in our cohort. Therefore, further diagnostic work-up is warranted if demyelinating features are present.
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Affiliation(s)
- L. T. Hassing
- HagaZiekenhuis, Department of NeurologyThe HagueThe Netherlands
| | - F. Y. Jiang
- HagaZiekenhuis, Department of RadiologyThe HagueThe Netherlands
| | - R. Zutt
- HagaZiekenhuis, Department of NeurologyThe HagueThe Netherlands
| | - S. Arends
- HagaZiekenhuis, Department of NeurologyThe HagueThe Netherlands
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16
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Crisp RS. Cracking the Whippet: The Inconsistent Treatment of Myeloneuropathy Secondary to Chronic Nitrous Oxide Misuse. Cureus 2024; 16:e52978. [PMID: 38406057 PMCID: PMC10894457 DOI: 10.7759/cureus.52978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/27/2024] Open
Abstract
Background The recreational abuse of nitrous oxide (N2O) is becoming increasingly prevalent within the United Kingdom and across the globe. Chronic abuse can cause nerve and spinal cord damage through the functional inactivation of vitamin B12. We present six cases from a single centre in the United Kingdom between 2016 and 2020 with neurological complications from N2O abuse, ranging from paraesthesia to subacute combined degeneration of the spinal cord. Methodology A retrospective review of all neurology admissions to Queen Elizabeth Hospital Birmingham (QEHB) between 2016 and 2020 was conducted to identify patients admitted with a diagnosis of neurological dysfunction (neuropathy or myelopathy) in association with chronic N2O misuse. The Prescribing Information and Communication System was used to collect data on demographics, reported N2O misuse, presenting symptoms, results of blood tests, nerve conduction studies and treatment regimens. All patients gave verbal consent for inclusion in the case series. Data were anonymised and analysed by the corresponding author. Results All patients were males aged between 22 and 28 years. In all cases, the patients were admitted with the abuse of N2O whippet canisters (ranging from 20 to 500 canisters per session), presenting with a combination of sensory and motor disturbance. Clinical suspicion, in the context of a history of N2O abuse, along with elevated blood concentrations of methylmalonic acid (MMA) and homocysteine, and nerve conduction studies, was the cornerstone of the diagnosis. All patients were treated with parenteral vitamin B12, though individual regimens differed, with no standardisation in the duration or frequency of treatment. All patients received intramuscular (IM) vitamin B12 injections during admission, with one patient receiving oral vitamin B12 before being switched to IM vitamin B12 injections. One patient received additional folic acid as a treatment adjunct. Prescriptions were most varied on discharge with huge discrepancies in duration and frequency of vitamin B12 replacement, ranging from no B12 replacement at all to IM injections once weekly for eight weeks. Conclusions The variability in route, dose and duration of vitamin B12 treatment, along with the variable use of adjunctive therapy reported in the literature, highlights the current lack of consensus in managing N2O neurotoxicity.
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Affiliation(s)
- Rehman S Crisp
- Emergency Department, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
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17
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Shermetaro J, Bridges M, Patel N, Vosko B. Subacute Combined Degeneration of the Spinal Cord Induced by Nitrous Oxide Abuse: A Rare Patient Presentation to a Spine Surgery Clinic: Illustrative Case. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202401000-00002. [PMID: 38231988 DOI: 10.5435/jaaosglobal-d-23-00104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/26/2023] [Indexed: 01/19/2024]
Abstract
Subacute combined degeneration (SCD) of the spinal cord is a disease involving the lateral and posterior columns of the spinal cord that can manifest in patients with vitamin B12 deficiency. Nitrous oxide (N2O)-induced SCD of the spinal cord is a result of N2O interfering with the metabolism of vitamin B12 and results in nervous system demyelination. This is an infrequent complication of N2O anesthesia; however, cases are rising with recreational N2O use. This case report describes a patient with SCD of the spinal cord induced by recreational N2O abuse. The patient presented to a spine surgery clinic with a 3-week history of progressive global weakness and paresthesias. After a detailed history and physical examination, the diagnosis was made and supported by various tests and imaging findings. Despite marked neurologic deficits, the patient's symptoms improved markedly with therapy and vitamin B12 supplementation. Spine surgery clinicians may be confronted with these cases and should be aware of this atypical presentation of SCD. As in our case, patients may present with neurologic deficits of unclear etiology. Neurologic dysfunction may be irreversible; therefore, accurate diagnosis, medical treatment, and complete neurologic evaluation are of the utmost importance to prevent additional progression.
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Affiliation(s)
- Jacob Shermetaro
- From the Department of Orthopedic Surgery, Corewell Health Dearborn Hospital, Dearborn, MI
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18
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Gernez E, Lee GR, Niguet JP, Zerimech F, Bennis A, Grzych G. Nitrous Oxide Abuse: Clinical Outcomes, Pharmacology, Pharmacokinetics, Toxicity and Impact on Metabolism. TOXICS 2023; 11:962. [PMID: 38133363 PMCID: PMC10747624 DOI: 10.3390/toxics11120962] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/22/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
The recreational use of nitrous oxide (N2O), also called laughing gas, has increased significantly in recent years. In 2022, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) recognized it as one of the most prevalent psychoactive substances used in Europe. Chronic nitrous oxide (N2O) exposure can lead to various clinical manifestations. The most frequent symptoms are neurological (sensitive or motor disorders), but there are also other manifestations like psychiatric manifestations or cardiovascular disorders (thrombosis events). N2O also affects various neurotransmitter systems, leading to its anesthetic, analgesic, anxiolytic and antidepressant properties. N2O is very challenging to measure in biological matrices. Thus, in cases of N2O intoxication, indirect biomarkers such as vitamin B12, plasma homocysteine and plasma MMA should be explored for diagnosis and assessment. Others markers, like oxidative stress markers, could be promising but need to be further investigated.
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Affiliation(s)
- Emeline Gernez
- CHU de Lille, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (E.G.); (F.Z.)
| | | | - Jean-Paul Niguet
- Service de Neurologie, Hôpital Saint Vincent de Paul–GHICL, 59000 Lille, France;
| | - Farid Zerimech
- CHU de Lille, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (E.G.); (F.Z.)
| | - Anas Bennis
- Assistance Publique—Hôpitaux de Paris, Service de Neurologie, Groupe Hospitalier Universitaire Paris Sud, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France;
| | - Guillaume Grzych
- CHU de Lille, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (E.G.); (F.Z.)
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19
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Wu H, Xu L, Zheng X, Zhou X, Zhang Y, Sun Y. Neuropsychiatric disorders associated with recreational nitrous oxide use. Clin Toxicol (Phila) 2023; 61:961-967. [PMID: 37999959 DOI: 10.1080/15563650.2023.2279936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Recreational nitrous oxide use has grown in popularity among young people and has become a serious public health problem. Chronic use of nitrous oxide can lead to a functional vitamin B12 deficiency and neuropsychiatric complications. PURPOSE This study aimed to investigate the characteristics of neuropsychiatric complications associated with nitrous oxide use and to enhance clinicians' awareness of this public health problem. METHODS We retrospectively reviewed 16 patients with neuropsychiatric disorders related to nitrous oxide use who were treated in our hospital from June 2021 to October 2022. Their demographics, clinical features, investigations, treatments and outcomes were analyzed. RESULTS There were ten males and six females between the ages of 17 and 25 with a mean age of 20.5 ± 2.6 years. Thirteen patients sought medical help from the neurology clinic. Two patients presented to the psychiatric department and one patient presented to the emergency department with acute cognitive impairment. All 16 patients presented with neurological symptoms, such as paresthesia in four limbs or the lower limbs, unsteady gait and weakness. Twelve patients developed psychiatric symptoms, such as hallucinations, agitation, depression, emotional indifference and personality changes. Twelve patients had vitamin B12 deficiency. All 16 patients had hyperhomocysteinemia. Fourteen patients showed abnormal high signal on T2-weighted imaging and an inverted "V" sign in axial view, mainly involving the cervical cord. Neuropsychiatric symptoms improved with vitamin B12 treatment and cessation of nitrous oxide use in all cases. CONCLUSION Young adults are predominately involved in recreational use of nitrous oxide, which can cause neuropsychiatric complications. The clinical response to vitamin B12 supplementation and cessation of nitrous oxide use is generally good. Clinicians should recognize nitrous oxide use as a public health problem and a cause of a wide range of neuropsychiatric symptoms, particularly in younger patients.
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Affiliation(s)
- Huijuan Wu
- Jinzhou Medical University, Jinzhou, China
| | - Liaoyang Xu
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Xingyongpei Zheng
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Xinyu Zhou
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
- Department of Neurology, The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, China
| | - Yongjin Zhang
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
- Department of Neurology, The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, China
| | - Yong Sun
- Department of Neurosurgery, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
- Department of Neurosurgery, The First Affiliated Hospital of Kangda College of Nanjing Medical University, Lianyungang, China
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20
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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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21
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Fortanier E, Berling E, Zanin A, Guillou AL, Micaleff J, Nicolas G, Lozeron P, Attarian S. How to distinguish Guillain-Barré syndrome from nitrous oxide-induced neuropathy: A 2-year, multicentric, retrospective study. Eur J Neurol 2023; 30:3296-3306. [PMID: 37494104 DOI: 10.1111/ene.15998] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/10/2023] [Accepted: 07/20/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Recreational use of nitrous oxide (N2 O) has dramatically increased in recent years, resulting in numerous cases of acute sensorimotor tetraparesis secondary to nitrous oxide-induced neuropathy (N2 On). Challenging clinical features can mimic Guillain-Barré syndrome (GBS), the main differential diagnosis upon admission. The most sensitive biomarkers for distinguishing between these two conditions remain to be determined. METHODS Fifty-eight N2 On patients from three referral centers were retrospectively included over a 2-year period and compared to GBS patients hospitalized during the same timeframe (47 patients). Collected demographic, clinical, biological, and electrophysiological data were compared between the two groups. RESULTS The typical N2 On clinical pattern included distal sensorimotor deficit in lower limbs with absent reflexes, proprioceptive ataxia, and no cranial involvement (56.7% of our cohort). Misleading GBS-like presentations were found in 14 N2 On patients (24.1%), and 13 patients (22.4%) did not report N2 O use during initial interview. Only half the N2 On patients presented with reduced vitamin B12 serum levels upon admission. A slightly increased cut-off (<200 pmol/L) demonstrated 85.1% sensitivity and 84.5% specificity in distinguishing N2 On from GBS. Only 6.9% of N2 On patients met the criteria for primary demyelination (p < 0.01), with only one presenting conduction blocks. A diagnostic algorithm combining these two biomarkers successfully classified all GBS-like N2 On patients. CONCLUSIONS Vitamin B12 serum level < 200 pmol/L cut-off and conduction blocks in initial electrophysiological study are the two most sensitive biomarkers for rapidly distinguishing N2 On from GBS patients. These two parameters are particularly useful in clinically atypical N2 On with GBS-like presentation.
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Affiliation(s)
- Etienne Fortanier
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Edouard Berling
- APHP, Service de Neurologie, Hôpital Raymond Poincaré, Centre de référence Nord-Est-Ile-de-France, FHU PHENIX, Garches, France
- Université de Versailles Saint-Quentin-en-Yvelines, U 1179 INSERM, Paris-Saclay, France
| | - Adrien Zanin
- Service de Physiologie Clinique-Explorations Fonctionnelles, DMU DREAM, APHP, Hôpital Lariboisière, Paris, France
- Laboratory for Vascular Translational Science, U1148, Université de Paris, INSERM, Paris, France
| | | | - Joelle Micaleff
- Marseille University Hospital, Clinical Pharmacology and Pharmacosurveillance, Regional Addictovigilance Center of Marseille, Marseille, France
- Aix-Marseille University, INSERM UMR 1106, Marseille, France
| | - Guillaume Nicolas
- APHP, Service de Neurologie, Hôpital Raymond Poincaré, Centre de référence Nord-Est-Ile-de-France, FHU PHENIX, Garches, France
- Université de Versailles Saint-Quentin-en-Yvelines, U 1179 INSERM, Paris-Saclay, France
| | - Pierre Lozeron
- Service de Physiologie Clinique-Explorations Fonctionnelles, DMU DREAM, APHP, Hôpital Lariboisière, Paris, France
- Laboratory for Vascular Translational Science, U1148, Université de Paris, INSERM, Paris, France
| | - Shahram Attarian
- Reference Center for Neuromuscular Diseases and ALS, La Timone University Hospital, Aix-Marseille University, Marseille, France
- Aix-Marseille University, INSERM, GMGF, Marseille, France
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22
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Meißner JN, Hill K, Lakghomi A, Nitsch L. [Inhaled nitrous oxide-induced subacute combined degeneration-A differential diagnosis of Guillain-Barré syndrome]. DER NERVENARZT 2023; 94:951-955. [PMID: 36799957 PMCID: PMC10575797 DOI: 10.1007/s00115-023-01443-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/31/2022] [Indexed: 02/18/2023]
Affiliation(s)
- Julius N Meißner
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland.
| | - Katharina Hill
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - Asadeh Lakghomi
- Klinik für Neuroradiologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Louisa Nitsch
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
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23
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Rossor AM, Manji H. Toxic neuropathies. Curr Opin Neurol 2023; 36:402-409. [PMID: 37639472 DOI: 10.1097/wco.0000000000001193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Immunotherapy has had a significant impact on the treatment of an increasing number of cancers as well as in inflammatory, rheumatological and gastroenterological conditions.Recreational nitrous oxide use is now a global epidemic. Linezolid is now recommended for the treatment of drug-resistant tuberculosis (TB); neuropathy is a significant cause of morbidity.Global warming will result in increasing toxin exposure, such as ciguatera, in previously unaffected areas. RECENT FINDINGS With increasing experience, the pathophysiology underlying the neuropathic complications of these drugs has become clear with guidelines now available, for the complications of immune check-point inhibitors and nitrous oxide toxicity. The optimum dose and duration of treatment for resistant TB with regimens, including linezolid, has been ascertained. SUMMARY Although neuropathic complications with immunotherapy are relatively rare, it is essential that they are recognized and treated early. Nitrous oxide toxicity should be in the differential diagnosis for all patients, particularly those of younger age, presenting with a neuropathy or myleo-neuropathy. Ciguatera toxicity is under recognized and its geographical spread will increase due to global warming. Further research is necessary on the mechanisms and treatment of both acute and chronic effects, which at present, are only symptomatic.
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Affiliation(s)
- Alexander M Rossor
- Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology, London, UK
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24
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Mair D, Paris A, Zaloum SA, White LM, Dodd KC, Englezou C, Patel F, Abualnaja S, Lilleker JB, Gosal D, Hayton T, Liang D, Allroggen H, Pucci M, Keddie S, Noyce AJ. Nitrous oxide-induced myeloneuropathy: a case series. J Neurol Neurosurg Psychiatry 2023; 94:681-688. [PMID: 37253616 PMCID: PMC10447413 DOI: 10.1136/jnnp-2023-331131] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/03/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Nitrous oxide (N2O) is the second most common recreational drug used by 16- to 24-year-olds in the UK. Neurological symptoms can occur in some people that use N2O recreationally, but most information comes from small case series. METHODS We describe 119 patients with N2O-myeloneuropathy seen at NHS teaching hospitals in three of the UK's largest cities: London, Birmingham and Manchester. This work summarises the clinical and investigative findings in the largest case series to date. RESULTS Paraesthesia was the presenting complaint in 85% of cases, with the lower limbs more commonly affected than the upper limbs. Gait ataxia was common, and bladder and bowel disturbance were frequent additional symptoms. The mid-cervical region of the spinal cord (C3-C5) was most often affected on MRI T2-weighted imaging. The number of N2O canisters consumed per week correlated with methylmalonic acid levels in the blood as a measure of functional B12 deficiency (rho (ρ)=0.44, p=0.04). CONCLUSIONS Preventable neurological harm from N2O abuse is increasingly seen worldwide. Ease of access to canisters and larger cylinders of N2O has led to an apparent rise in cases of N2O-myeloneuropathy in several areas of the UK. Our results highlight the range of clinical manifestations in a large group of patients to improve awareness of risk, aid early recognition, and promote timely treatment.
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Affiliation(s)
- Devan Mair
- Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
- Barts Health NHS Trust, London, UK
| | - Alvar Paris
- Barts Health NHS Trust, London, UK
- Preventive Neurology Unit, Centre for Prevention, Diagnosis and Detection, Faculty of Medicine and Dentistry, Queen Mary University of London, Wolfson Institute of Population Health, London, UK
| | - Safiya A Zaloum
- Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
- Barts Health NHS Trust, London, UK
| | - Laura M White
- Manchester Centre for Clinical Neuroscience, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Katherine C Dodd
- Manchester Centre for Clinical Neuroscience, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Lydia Becker Institute for Immunology and Inflammation, Division of Immunology, Immunity to Infection and Respiratory Medicine, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - Christina Englezou
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Neurology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Farhin Patel
- Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | - Siraj Abualnaja
- Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | - James B Lilleker
- Manchester Centre for Clinical Neuroscience, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - David Gosal
- Manchester Centre for Clinical Neuroscience, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Tom Hayton
- Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Di Liang
- Department of Neurosciences, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Holger Allroggen
- Department of Neurosciences, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Mark Pucci
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stephen Keddie
- Barts Health NHS Trust, London, UK
- MRC Centre for Neuromuscular Disease and Department of Molecular Neuroscience, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Alastair J Noyce
- Barts Health NHS Trust, London, UK
- Preventive Neurology Unit, Centre for Prevention, Diagnosis and Detection, Faculty of Medicine and Dentistry, Queen Mary University of London, Wolfson Institute of Population Health, London, UK
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25
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Mondesert E, Eiden C, Peyriere H, Formoso A, Corti L, Cristol JP, Badiou S. Functional vitamin B 12 deficiency is a consistent feature in hospital admissions for neurological disorders due to the use of nitrous oxide. Clin Toxicol (Phila) 2023; 61:674-679. [PMID: 37917184 DOI: 10.1080/15563650.2023.2274282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
Introduction: Misuse of inhaled nitrous oxide is a growing concern in France. It is known to alter concentrations of vitamin B12, which is required as a cofactor for methionine synthase and methylmalonyl-CoA mutase activity. Hence, measurement of the concentrations of cobalamin metabolism biomarkers, including vitamin B12, homocysteine, and methylmalonic acid, could assist in the management of patients with a complex clinical presentation or in those who deny the consumption of nitrous oxide.Methods: We retrospectively collected clinical and biological data in patients hospitalized for nitrous oxide use in a university hospital in southern France between January 2020 and October 2022.Results: Thirty-one patients were identified during 34 months; 79% were men with a median age of 23.7 years. Most (97%) presented with peripheral polyneuropathy and/or myelopathy. The median vitamin B12 concentration was 134.6 pmol/L, with 17 of 31 patients having values less than 145 pmol/L (the lower limit of the normal range). The median plasma folate concentration was 20.1 nmol/L, which is within the normal range. The median plasma homocysteine concentration was 87.7 µmol/L (normal range <15 µmol/L), and the median plasma methylmalonic acid concentration was 3.8 µmol/L (normal range <0.5 µmol/L).Conclusion: Nitrous oxide use is an emerging public health problem in France, as shown by the number of patients admitted to our hospital. The presence of a functional vitamin B12 deficiency was a consistent feature that could be helpful in diagnosis in complex cases.
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Affiliation(s)
- Etienne Mondesert
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France
| | - Céline Eiden
- Addictovigilance Center, Department of Pharmacology and Toxicology, University Hospital of Montpellier, Montpellier, France
| | - Hélène Peyriere
- Addictovigilance Center, Department of Pharmacology and Toxicology, University Hospital of Montpellier, Montpellier, France
| | - Aude Formoso
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
| | - Lucas Corti
- Department of Neurology, University Hospital of Montpellier, Montpellier, France
| | - Jean-Paul Cristol
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Stéphanie Badiou
- Department of Biochemistry, University Hospital of Montpellier, Montpellier, France
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
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26
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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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Parein G, Bollens B. Nitrous oxide-induced polyneuropathy, pancytopenia and pulmonary embolism: a case report. J Med Case Rep 2023; 17:350. [PMID: 37587485 PMCID: PMC10433604 DOI: 10.1186/s13256-023-04075-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/12/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Nitrous oxide is a medical and household gas that has seen its use drift to recreational purpose among the young population in recent years. Significant neurological, hematological and psychiatric side effects, generally related to an induced functional vitamin B12 deficiency, have been described separately in the literature. CASE REPORT A 22-year-old woman of North African origin experienced an exceptional combination of polyneuropathy, bilateral pulmonary embolism and severe pancytopenia related to vitamin B12 deficiency and hyperhomocysteinemia induced by recreational nitrous oxide use. After treatment with vitamin B12 supplementation and intensive rehabilitative management, the patient progressively regained the ability to walk and her biological parameters gradually returned to normal. The pathophysiological mechanisms related to a decrease in vitamin B12 activity are the reduction of products needed for synthesis of deoxyribonucleic acid, carbohydrate or fatty acids, and the increase of hyperhomocysteinemia. Other mechanisms involving a direct action of N2O are also suspected. CONCLUSION This case report brings elements to support our knowledge about pathological pathway, recovery and prognosis of recreational N2O abuse complications. The general and medical population should be aware to the serious consequences of this type of consumption.
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Affiliation(s)
- Guillaume Parein
- Physical and Rehabilitation Medicine Department, CHU Ambroise Paré, Mons, Wallonie, Belgium.
| | - Benjamin Bollens
- Physical and Rehabilitation Medicine Department, CHU Ambroise Paré, Mons, Wallonie, Belgium
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28
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H Moussa A, Mohamed W, Zidouh S. From Medical Analgesic to Recreational Use: A Rare Case of Acute Myelitis Caused by Laughing Gas Abuse. Cureus 2023; 15:e41018. [PMID: 37519576 PMCID: PMC10372704 DOI: 10.7759/cureus.41018] [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] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
Nitrous oxide, commonly known as laughing gas, which is originally intended to be used in various industries as well as for legitimate medical purposes, has unfortunately come to be used recreationally. However, it is crucial to recognize that the seemingly innocent recreational use of nitrous oxide can have serious repercussions on one's health. When consumed in excessive quantities and for prolonged periods, this substance can lead to serious adverse effects. In this article, we shed light on the abuse potential of the substance by discussing a distressing case of a young nitrous oxide user who developed severe myelitis.
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Affiliation(s)
- Aicha H Moussa
- Emergency Department, Faculty of Medicine and Pharmacy, Military Hospital Mohamed V, Rabat, MAR
| | - Walid Mohamed
- Emergency Department, Faculty of Medicine and Pharmacy, Military Hospital Mohamed V, Rabat, MAR
| | - Saad Zidouh
- Emergency Department, Faculty of Medicine and Pharmacy, Military Hospital Mohamed V, Rabat, MAR
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29
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Ménétrier T, Denimal D. Vitamin B12 Status in Recreational Users of Nitrous Oxide: A Systematic Review Focusing on the Prevalence of Laboratory Abnormalities. Antioxidants (Basel) 2023; 12:1191. [PMID: 37371921 DOI: 10.3390/antiox12061191] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 05/22/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
The recreational use of nitrous oxide (N2O) as "laughing gas" is a growing problem. The chronic toxicity of N2O is mainly due to its ability to oxidize vitamin B12, making it dysfunctional as a cofactor in metabolic pathways. This mechanism plays a major role in the development of neurological disorders in N2O users. The assessment of vitamin B12 status in N2O users is important but challenging due to the lack of decrease in total vitamin B12 in most cases despite genuine vitamin B12 functional deficiency. Other biomarkers, such as holotranscobalamin (holoTC), homocysteine (tHcy) and methylmalonic acid (MMA), are interesting candidates to properly assess vitamin B12 status. Here, we conducted a systematic review of case series in order to assess the prevalence of abnormal values of total vitamin B12, holoTC, tHcy and MMA in recreational N2O users, which is an important prerequisite for determining the best screening strategy in future guidelines. We included 23 case series (574 N2O users) from the PubMed database. Total circulating vitamin B12 concentration was low in 42.2% (95% confidence interval 37.8-46.6%, n = 486) of N2O users, while 28.6% (7.5-49.6%, n = 21) of N2O users had low circulating concentrations of holoTC. tHcy levels were elevated in 79.7% (75.9-83.5%, n = 429) of N2O users, while 79.6% (71.5-87.7%, n = 98) of N2O users had increased concentrations of MMA. In summary, the increases in tHcy and MMA were the most prevalent abnormalities, and should be measured alone or in combination in symptomatic N2O users rather than total vitamin B12 or holoTC.
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Affiliation(s)
- Tanguy Ménétrier
- Department of Biochemistry, University Hospital of Dijon, F-21079 Dijon, France
| | - Damien Denimal
- Department of Biochemistry, University Hospital of Dijon, F-21079 Dijon, France
- UMR1231 LNC INSERM, University of Burgundy, F-21079 Dijon, France
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30
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Schmitt WP, Rohatgi S, Matiello M. Case 15-2023: A 33-Year-Old Man with Paresthesia of the Arms and Legs. N Engl J Med 2023; 388:1893-1900. [PMID: 37195945 DOI: 10.1056/nejmcpc2300895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- William P Schmitt
- From the Departments of Medicine (W.P.S.), Radiology (S.R.), and Neurology (M.M.), Massachusetts General Hospital, and the Departments of Medicine (W.P.S.), Radiology (S.R.), and Neurology (M.M.), Harvard Medical School - both in Boston
| | - Saurabh Rohatgi
- From the Departments of Medicine (W.P.S.), Radiology (S.R.), and Neurology (M.M.), Massachusetts General Hospital, and the Departments of Medicine (W.P.S.), Radiology (S.R.), and Neurology (M.M.), Harvard Medical School - both in Boston
| | - Marcelo Matiello
- From the Departments of Medicine (W.P.S.), Radiology (S.R.), and Neurology (M.M.), Massachusetts General Hospital, and the Departments of Medicine (W.P.S.), Radiology (S.R.), and Neurology (M.M.), Harvard Medical School - both in Boston
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31
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Grzych G, Deheul S, Gernez E, Davion JB, Dobbelaere D, Carton L, Kim I, Guichard JC, Girot M, Humbert L, Bennis A, Joncquel M, Chieux V, Joly A, Nasserdine P, Trillot N, Douillard C, Pigny P, Tard C. Comparison of biomarker for diagnosis of nitrous oxide abuse: challenge of cobalamin metabolic parameters, a retrospective study. J Neurol 2023; 270:2237-2245. [PMID: 36690804 DOI: 10.1007/s00415-023-11570-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Recreational use of nitrous oxide (N2O) leads to neurological disorders including combined subacute degeneration of spinal cord, psychological disorders, and thrombosis. Serum or urine N2O assays could not be routinely performed. Hence, it is necessary to investigate other biological markers such as metabolic markers. We aimed here to challenge the three main biological markers used for the diagnosis of nitrous oxide abuse as total vitamin B12, homocysteine, and methylmalonic acid. METHODS We retrospectively collected clinical and biological data from 52 patients with known, documented chronic N2O abuse and associated clinical signs (peripheral neuropathy disability score or thrombosis event). Sera and plasma total vitamin B12, methylmalonic acid (MMA), and homocysteine were performed to identify the most specific marker of chronic N2O intoxication and related clinical outcomes. RESULTS Plasma homocysteine was almost consistently increased in case of N2O chronic consumption, whereas MMA increase and total vitamin B12 decrease are not systematically found. Our results showed that none of the markers are correlated with levels of N2O consumptions. However, homocysteine and MMA are correlated with clinical severity, but MMA seems to be a better marker of clinical severity. CONCLUSION There is no specific marker of nitrous oxide abuse according to levels of consumption, total vitamin B12 decrease could not be used either as consumption or as severity marker. However, we showed that homocysteine is consistently increased and could be used as marker of recent N2O consumption. On the other hand, we showed that MMA could be used as a marker of clinical gravity.
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Affiliation(s)
- Guillaume Grzych
- CHU de Lille, Service Hormonologie Métabolisme Nutrition Oncologie, 59000, Lille, France.
- CHU de Lille - Centre de Biologie Pathologie Génétique - Service Hormonologie Métabolisme Nutrition Oncologie, 1 boulevard du professeur Jules Leclercq, 59000, Lille, France.
| | - Sylvie Deheul
- CHU de Lille, Centre d'Addictovigilance des Hauts-de-France, Centre Anti-Poison, Service de Pharmacologie, 59000, Lille, France
| | - Emeline Gernez
- CHU de Lille, Service Hormonologie Métabolisme Nutrition Oncologie, 59000, Lille, France
| | | | - Dries Dobbelaere
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHU Lille, 59000, Lille, France
| | - Louise Carton
- CHU de Lille, Centre d'Addictovigilance des Hauts-de-France, Centre Anti-Poison, Service de Pharmacologie, 59000, Lille, France
- CHU de Lille, Service d'Addictologie, 59000, Lille, France
| | - Isabelle Kim
- CHU de Lille, Service Hormonologie Métabolisme Nutrition Oncologie, 59000, Lille, France
| | | | - Marie Girot
- CHU Lille, Service des Urgences adultes, F-59000, Lille, France
| | - Linda Humbert
- CHU de Lille, Service d'Endocrinologie, Diabétologie et Maladies métaboliques, 59000, Lille, France
| | - Anas Bennis
- CH de Roubaix, Service de Neurologie, 59100, Roubaix, France
| | - Marie Joncquel
- CHU de Lille, Service Hormonologie Métabolisme Nutrition Oncologie, 59000, Lille, France
| | - Vincent Chieux
- CH Saint Philibert, Laboratoire des hôpitaux du GHICL, 59160, Lomme, France
| | - Audrey Joly
- Agence Régionale de Santé Hauts de France, Amiens, France
| | - Phénicia Nasserdine
- CHU de Lille, Service d'Explorations Fonctionnelles Cardiovasculaires, 59000, Lille, France
| | - Nathalie Trillot
- CHU de Lille, Institut Hématologie Transfusion, 59000, Lille, France
| | - Claire Douillard
- Medical Reference Center for Inherited Metabolic Diseases, Jeanne de Flandre University Hospital and RADEME Research Team for Rare Metabolic and Developmental Diseases, EA 7364 CHU Lille, 59000, Lille, France
- CHU de Lille, Service d'Endocrinologie, Diabétologie et Maladies métaboliques, 59000, Lille, France
| | - Pascal Pigny
- CHU de Lille, Service Hormonologie Métabolisme Nutrition Oncologie, 59000, Lille, France
| | - Céline Tard
- U1172, CHU de Lille, Centre de référence des maladies neuromusculaires Nord, Est, Ile-de-France, Service de neurologie, Lille, France
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32
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Paris A, Lake L, Joseph A, Workman A, Walton J, Hayton T, Evangelou N, Lilleker JB, Ayling RM, Nicholl D, Noyce AJ. Nitrous oxide-induced subacute combined degeneration of the cord: diagnosis and treatment. Pract Neurol 2023; 23:222-228. [PMID: 36813556 DOI: 10.1136/pn-2022-003631] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 02/24/2023]
Abstract
Recreational use of nitrous oxide (N2O) has increased rapidly in recent years and is now the second most commonly used recreational drug among young people in the UK. There has been a corresponding rise in cases of nitrous oxide-induced subacute combined degeneration of the cord (N2O-SACD), a pattern of myeloneuropathy usually associated with severe vitamin B12 deficiency. This can cause serious and permanent disability in young people but, if recognised early, may be effectively treated. All neurologists should be aware of N2O-SACD and its treatment; however, there are currently no agreed guidelines. Based on our experience in East London, an area of high N2O use, we provide practical advice on its recognition, investigation and treatment.
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Affiliation(s)
- Alvar Paris
- Preventive Neurology Unit, Centre for Prevention, Diagnosis and Detection, Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK.,Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Luke Lake
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Albert Joseph
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Anna Workman
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Joseph Walton
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Tom Hayton
- Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Birmingham, UK
| | - Nikos Evangelou
- Academic Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - James B Lilleker
- Muscle Diseases Unit, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust, Salford, UK.,Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
| | - Ruth M Ayling
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - David Nicholl
- Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Alastair J Noyce
- Preventive Neurology Unit, Centre for Prevention, Diagnosis and Detection, Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK .,Royal London Hospital, Barts Health NHS Trust, London, UK
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33
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Buttery C, Birns J, Gibson J, Jones GD. Use of the Rehabilitation Treatment Specification System (RTSS) in the management of nitrous oxide (N 2O)-induced spinal cord injury. BMJ Case Rep 2023; 16:16/2/e252529. [PMID: 36750296 PMCID: PMC9906271 DOI: 10.1136/bcr-2022-252529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Nitrous oxide (N2O) is an inhaled anaesthetic gas and a popular intoxicant. Excessive recreational use can cause spinal cord myelopathy. Previous studies have discussed the medical management. However, none have specified the sensorimotor rehabilitation management. This case report documents the investigations, physical rehabilitation and functional outcomes in two cases of N2O-associated myelopathy. Both presented with lower limb strength and sensorimotor integration impairments resulting in ataxic ambulation. Dorsal column signal abnormality was observed on T2-weighted MRI in one case. Myelopathy was diagnosed based on clinical presentation and both were treated with vitamin B12 Rehabilitation was conceived and specified using the Rehabilitation Treatment Specification System (RTSS). Both cases achieved independent indoor gait on hospital discharge, and full function at 9 months in one case. Appropriate and timely medical management and reasoned rehabilitation provided excellent functional outcomes for N2O-related myelopathy. By using the RTSS, reasoned rehabilitation efficacy can be tested in the future.
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Affiliation(s)
- Charlotte Buttery
- Physiotherapy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK,Physiotherapy Department, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - Jonathan Birns
- Department of Ageing & Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jamie Gibson
- Physiotherapy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK,Workforce Transformation, Health Education England (HEE), Leeds, UK
| | - Gareth David Jones
- Physiotherapy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK .,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
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34
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Gao H, Wang R, Zeng Y, Qin L, Cai H, Zhou D, Chen Q. Nitrous oxide-induced neurotoxicity: Clinical characteristics and impacts on overall neurological impairments. Front Neurol 2023; 14:1132542. [PMID: 36908607 PMCID: PMC9995698 DOI: 10.3389/fneur.2023.1132542] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Objective The reports of the recreational use of nitrous oxide (N2O) and its related neuropathy are increasing. However, it is unclear whether specific clinical characteristics are associated with the overall neurological impairments among these individuals. Methods We retrospectively included 20 hospitalized patients with N2O-related neurological complaints between January 2016 and March 2021 at the West China Hospital of Sichuan University. Detailed demographic, clinical features, lab tests, and imaging data were collected. A functional disability rating score (FDRS) was calculated to determine the degree of neurological impairment. The relationships between the aforementioned factors and the FDRS sum score were explored. Results These individuals were aged between 16 and 30 years (mean ± SD: 21.90 ± 4.06). At admission, unsteady gait (95%, nineteen of twenty), weakness (95%, nineteen of twenty), and limb paresthesia (70%, fourteen of twenty) were the most common symptoms; decreased deep tendon reflexes (100%, nineteen of nineteen), reduced muscle strength (95%, nineteen of twenty), and impaired coordination (95%, nineteen of twenty) were frequently found. The FDRS sum scores ranged from 3 to 12. Among all the factors, admission from the emergency room (p = 0.033), decreased hemoglobin (p = 0.004) (without previous VitB12 supplements), decreased red blood cell (RBC) count (p = 0.004) (without previous VitB12 supplements), and increased mean corpuscular volume (p = 0.036) (with previous VitB12 supplements) positively correlated with the FDRS sum score. Conclusion Nitrous oxide (N2O) could lead to severe neurological impairments among users. Abnormal RBC indicators at admission may be associated with a worse clinical presentation and need further attention. Population education about the consequences of N2O consumption and control measures concerning access to N2O should be further emphasized.
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Affiliation(s)
- Hui Gao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruihan Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Zeng
- Neurobiological Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Linyuan Qin
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hanlin Cai
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qin Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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35
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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: 11] [Impact Index Per Article: 11.0] [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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Sharma S, Benatar M, Herskovitz S, Granit V. The Inverse Lhermitte Phenomenon Suggests Nitrous Oxide-Induced Myelopathy: Case Report and Review of the Literature. Case Rep Neurol 2023; 15:81-86. [PMID: 37384038 PMCID: PMC10294243 DOI: 10.1159/000529325] [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: 08/29/2022] [Accepted: 01/16/2023] [Indexed: 06/30/2023] Open
Abstract
Nitrous oxide-induced myelopathy is a relatively well-known clinical entity. Less well-known, however, is the rare inverse Lhermitte phenomenon, where neck flexion elicits an ascending, rather than descending, electric shock-like sensation. This is a characteristic symptom and sign that may occur in nitrous oxide toxicity. In this article, we present the case of a patient who was admitted to our hospital with suspected Guillain-Barré syndrome due to her ascending numbness and unsteady gait. We describe her examination and laboratory features leading to the correct diagnosis, along with a historical review of the various subtypes of the Lhermitte phenomenon and the pathophysiology of nitrous oxide-induced myelopathy.
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Affiliation(s)
- Sonali Sharma
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Michael Benatar
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Steven Herskovitz
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Volkan Granit
- Department of Neurology, University of Miami, Miami, FL, USA
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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: 6] [Impact Index Per Article: 6.0] [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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Chen S, Guo L, Wang Y. Acute pancreatitis after nitrous oxide abuse: A case report. JGH Open 2022; 7:75-77. [PMID: 36660054 PMCID: PMC9840187 DOI: 10.1002/jgh3.12838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/13/2022] [Accepted: 10/22/2022] [Indexed: 12/04/2022]
Abstract
The recreational use of nitrous oxide (N2O) is sharply increasing among young adults. N2O abuse can cause serious complications. However, the association between acute pancreatitis and N2O is rarely reported. Here we report a case of a young and previously healthy female with widespread cutaneous lesions, neurologic symptoms, and abdominal pain. Acute pancreatitis was the patient's primary diagnosis when she was admitted to the gastroenterology unit. We added the diagnosis of N2O intoxication after an additional inquiry into the patient's personal history revealed that she had abused N2O for 1 month. With the application of mecobalamin and other symptomatic treatments, the symptoms and laboratory indexes improved gradually. In this case, we highlight that acute pancreatitis may be a rare complication induced by N2O.
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Affiliation(s)
- Shanshan Chen
- West China School of Medicine, Sichuan UniversityChengduChina
| | - Linjie Guo
- Department of GastroenterologyWest China Hospital of Sichuan UniversityChengduChina
| | - Yufang Wang
- Department of GastroenterologyWest China Hospital of Sichuan UniversityChengduChina
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Mechanisms Involved in the Neurotoxicity and Abuse Liability of Nitrous Oxide: A Narrative Review. Int J Mol Sci 2022; 23:ijms232314747. [PMID: 36499072 PMCID: PMC9738214 DOI: 10.3390/ijms232314747] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
The recreational use of nitrous oxide (N2O) has increased over the years. At the same time, more N2O intoxications are presented to hospitals. The incidental use of N2O is relatively harmless, but heavy, frequent and chronic use comes with considerable health risks. Most importantly, N2O can inactivate the co-factor cobalamin, which, in turn, leads to paresthesia's, partial paralysis and generalized demyelinating polyneuropathy. In some patients, these disorders are irreversible. Several metabolic cascades have been identified by which N2O can cause harmful effects. Because these effects mostly occur after prolonged use, it raises the question of whether N2O has addictive properties, explaining its prolonged and frequent use at high dose. Several lines of evidence for N2O's dependence liability can be found in the literature, but the underlying mechanism of action remains controversial. N2O interacts with the opioid system, but N2O also acts as an N-methyl-D-aspartate (NMDA) receptor antagonist, by which it can cause dopamine disinhibition. In this narrative review, we provide a detailed description of animal and human evidence for N2O-induced abuse/dependence and for N2O-induced neurotoxicity.
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Affiliation(s)
- Harry Sumnall
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
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Chen W, Si Z, Bi Y, Yang B. An unusual case of subacute combined degeneration due to nitrous oxide abuse, which relapsed after bariatric surgery: A case report. Medicine (Baltimore) 2022; 101:e30442. [PMID: 36107547 PMCID: PMC9439783 DOI: 10.1097/md.0000000000030442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Several studies have reported subacute combined degeneration (SCD) induced by nitrous oxide (N2O) abuse. However, few studies have reported that N2O-induced SCD recurred because of sleeve gastrectomy after neurological symptoms improved. PATIENT CONCERNS We report the case of an 18-year-old woman who developed paresthesia, weakness in 4 limbs, and an unstable gait after frequent, excessive N2O inhalation. DIAGNOSIS The patient was diagnosed as having SCD. INTERVENTIONS AND OUTCOMES Nineteen days after intravenous mecobalamin and supplementation with other kinds of vitamin B, her weakness and paresthesia resolved. However, 7 months after discharge, the patient experienced recurrence following sleeve gastrectomy. Blood biochemistry revealed low vitamin B12 levels. After a 22-day treatment, similar to the first hospitalization, her residual numbness and unsteady gait improved. LESSONS This case highlights that patients, especially those at high risk of vitamin B12 deficiency, undergoing sleeve gastrectomy require careful nutritional follow-up and routine monitoring of micronutrients such as vitamin B12 and homocysteine. Continuous vigilance is essential for patients with common and rare neurological complications.
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Affiliation(s)
- Wei Chen
- Department of Gastroenterology, Shuguang Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhihua Si
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
| | - Yanping Bi
- Department of Emergency Medicine, First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, PR China
| | - Bing Yang
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
- Shandong Institute of Neuroimmunology, Jinan, Shandong, China
- Shandong Provincial Key Laboratory of Rheumatic Disease and Translational Medicine, Jinan, Shandong, China
- *Correspondence: Bing Yang, Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, No.16766, Jingshi Road, Jinan, Shandong, 250014, China (e-mail: )
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Sood R, Parent T. Peripheral polyneuropathy and acute psychosis from chronic nitrous oxide poisoning: A case report with literature review. Medicine (Baltimore) 2022; 101:e28611. [PMID: 35945749 PMCID: PMC9351869 DOI: 10.1097/md.0000000000028611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Nitrous oxide (NO) is a commonly used drug in medical practice, restoration, and the automobile industry. Recreational abuse is an emerging public health problem owing to its accessibility and drug properties. PATIENT CONCERNS A 25-year-old male was hospitalized with acute psychosis and lower-extremity sensorimotor proprioceptive ataxia due to nitrous oxide abuse. DIAGNOSIS Laboratory studies confirmed a vitamin B12 deficiency. Magnetic resonance imaging of the spinal cord showed normal findings. Electrophysiological testing confirmed length-dependent sensorimotor polyneuropathy, with a predominant motor component and axonal degeneration. INTERVENTION AND OUTCOMES Abstinence from toxic substances was suggested, and vitamin B12 substitution was introduced. The patient was lost to follow up. LESSONS Nitrous oxide toxicity is multisystemic and is thought to result from vitamin B12 inactivation. Recent case reports postulated direct paranodal lesions resulting from nitrous oxide consumption. Neurological, neuropsychiatric, and hematological toxicities are among those explored in this case report. Correction of the functional vitamin B12 status and nitrous oxide abstinence are essential in the treatment process.
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Affiliation(s)
- Radhika Sood
- Department of Internal Medicine, Hôpitaux Universitaires de Genève, HUG, Geneva, Switzerland
- *Correspondence: Radhika Sood, Department of internal medicine, Hôpitaux universitaires de Genève, HUG, Rue Gabrielle Perret Gentil 4, 1205 Genève, Switzerland (e-mail: )
| | - Thibault Parent
- Department of Internal Medicine, Hôpitaux Universitaires de Genève, HUG, Geneva, Switzerland
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van Amsterdam JG, Nabben T, van den Brink W. Increasing recreational nitrous oxide use: Should we worry? A narrative review. J Psychopharmacol 2022; 36:943-950. [PMID: 35678512 DOI: 10.1177/02698811221082442] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Since 2000, the prevalence of recreational nitrous oxide (N2O) use has increased in the Western world. Although N2O is a relatively safe drug, the overall increase in the use of N2O has concomitantly also initiated a modest but important increase in the number of young excessive users. The recent introduction of large 2 kg N2O tanks, allowing high and prolonged dosing, has facilitated this excessive use. This is of concern, because repeated exposure to high doses of N2O for a prolonged time is known to induce neurological damage, such as (irreversible) neuropathy and paralysis due to N2O-induced vitamin B12 deficiency. The increasing trend of recreational users with N2O-induced neurological damage at emergency departments confirms the urgency of this development. OBJECTIVE/METHODS This narrative review describes recent trends in N2O use and misuse, the adverse health effects associated with excessive use and the risk factors of excessive use. RESULTS Considering the rising trend in N2O use, particularly among young and other vulnerable people, we propose to take legislative action to limit the availability of N2O, and also advocate for better and timely education of non-users, users and medical professionals about the serious side-effects associated with excessive N2O use. CONCLUSION It is concluded that the increase in excessive N2O use is of serious concern.
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Affiliation(s)
- Jan Gc van Amsterdam
- Department of Psychiatry, Academic Medical Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ton Nabben
- Urban Governance and Social Innovation, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Wim van den Brink
- Department of Psychiatry, Academic Medical Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Wu G, Wang S, Wang T, Han J, Yu A, Feng C, Wang Y, Liu S. Neurological and Psychological Characteristics of Young Nitrous Oxide Abusers and Its Underlying Causes During the COVID-19 Lockdown. Front Public Health 2022; 10:854977. [PMID: 35719623 PMCID: PMC9201030 DOI: 10.3389/fpubh.2022.854977] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background The COVID-19 pandemic has a serious impact on the mental health of the public due to its economic and social impact. And psychological effects have led to drug and alcohol abuse. After the city lifted the lockdown, we consecutively encountered several young nitrous oxide abusers admitted to hospital for neurological treatment. Purpose To inform physician decisions and social intervention, this observational study aimed at investigating the neurological and psychological characteristics of nitrous oxide abusers and its underlying causes during the COVID-19 lockdown. Methods The nitrous oxide abusers who sought neurological treatment at our hospital between May 2020 and June 2020 were enrolled. Clinical data including socio-demographic, physical examination, laboratory examination, electromyography and neuroimaging were collected. Their motivations for inhaling nitrous oxide, knowledge about the nitrous oxide abuse and the accompanying of family were investigated face to face. Psychological status was assessed by the Symptom Checklist 90 (SCL-90) psychological evaluation. Results Six nitrous oxide abusers were enrolled and the age was 22 ± 4.3. Clinical presentations included varying degrees of limb numbness and an ataxic gait. Laboratory examination revealed that all the patients did not have pernicious anemia, 4 patients had decreased vitamin B12 while 3 patients exhibited elevated homocysteine levels. MR of the spinal cord revealed that 4 patients had abnormal signals in the cervical spinal cord of high symmetry with splayed or inverted V sign after T2WI. Electromyogram (EMG) test showed 5 patients had peripheral nerve damage. The SCL-90 psychological evaluation results indicated that all patients had severe anxiety, depression and psychosis and they had severer psychological problems than ordinary citizens. Their motives for inhaling nitrous oxide are to relieve boredom, curiosity and buddy pressure. Their family spent <1 day per week to stay with them during city lockdown. Conclusion The enrolled patients caused by abuse of nitrous oxide presented with symptoms of subacute combined with spinal degeneration. They had more serious psychological problems related to the COVID-19 pandemic. These cases make us value the psychological problems of young people under the outbreak and take multi-layered measures from families, schools (companies), hospitals, and governments to address it.
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Affiliation(s)
- Gang Wu
- Department of Pharmacy, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Shanshan Wang
- Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Tingling Wang
- Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Jiali Han
- Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Anna Yu
- Department of Mental Health, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Changqiang Feng
- Department of Pharmacy, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Yajing Wang
- Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Suzhi Liu
- Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
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Denis MA, Pete-Bonneton C, Riche B, Cadot R, Massardier-Pilonchery A, Iwaz J, Charbotel B. Exposure of paediatric healthcare personnel to nitrous oxide in paediatric care units. INDUSTRIAL HEALTH 2022; 60:276-283. [PMID: 34690255 PMCID: PMC9171129 DOI: 10.2486/indhealth.2021-0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/15/2021] [Indexed: 06/13/2023]
Abstract
Nitrous oxide (N2O) was found responsible for genetic and reproductive toxicities, whereas it is widely used in paediatric care units where most healthcare providers are women of childbearing age. This motivated investigating occupational overexposure and overexposure factors in several paediatric hospital units. A cross-sectional study was carried out in seven healthcare units. On each of 34 healthcare providers, air samples were extracted (portable pumps and Tedlar® bags) and N2O quantified (gas chromatography, pulsed discharge ionization detection, and infrared spectrometry). The data allowed calculating mean instantaneous exposures. The mean instantaneous exposure was: i) four times higher in closed vs. open treatment rooms; ii) two times higher in case of use vs. non-use of N2O; iii) significantly higher in junior vs. senior healthcare providers (by 12%); and, iv) higher during presumably short vs. presumably long procedures (by 20%). Overexposures to N2O were mainly seen in the emergency unit and in day hospitals for thoracic/abdominal diseases and nephrology. Overexposures were frequent during short-duration procedures; among 88 N2O measurements, 77 (87.5%) exceeded the 200 ppm threshold over 15 minutes. The overexposures call for dedicated treatment rooms (with adequate equipment and ventilation), more efficient anaesthetic practices, appropriate training, and regular checks.
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Affiliation(s)
- Marie-Agnès Denis
- Service de Médecine et de Santé au Travail, Pôle Santé Publique, Hospices Civils de Lyon, France
- Unité Mixte de Recherche Épidémiologique et de Surveillance Transport Travail Environnement (UMRESTTE), France
- Université de Lyon, France
- Université Lyon 1, France
| | - Charlotte Pete-Bonneton
- Service des Maladies Professionnelles, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, France
| | - Benjamin Riche
- Université de Lyon, France
- Université Lyon 1, France
- Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, France
- Équipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Évolutive, CNRS UMR 5558, France
| | - Robert Cadot
- Laboratoire de Toxicologie Professionnelle et Environnementale, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, France
| | - Amélie Massardier-Pilonchery
- Service de Médecine et de Santé au Travail, Pôle Santé Publique, Hospices Civils de Lyon, France
- Unité Mixte de Recherche Épidémiologique et de Surveillance Transport Travail Environnement (UMRESTTE), France
- Université de Lyon, France
- Université Lyon 1, France
- Service des Maladies Professionnelles, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, France
| | - Jean Iwaz
- Université de Lyon, France
- Université Lyon 1, France
- Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, France
- Équipe Biostatistique-Santé, Laboratoire de Biométrie et Biologie Évolutive, CNRS UMR 5558, France
| | - Barbara Charbotel
- Unité Mixte de Recherche Épidémiologique et de Surveillance Transport Travail Environnement (UMRESTTE), France
- Université de Lyon, France
- Université Lyon 1, France
- Service des Maladies Professionnelles, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, France
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Qin X, Kang L, Liu X, Jin J, Hu F, Lu W, Deng Y, Chen QY, Dang J. Acute nitrous oxide-induced neuropathy mimicking Guillain-Barré Syndrome. J Peripher Nerv Syst 2022; 27:189-196. [PMID: 35611446 DOI: 10.1111/jns.12503] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE The early clinical features of nitrous oxide (N2 O)-induced neuropathy were mimicking that of Guillain-Barré Syndrome (GBS). We aimed to explore clinical and laboratory characteristics of N2 O-induced neuropathy in comparison with GBS. METHODS We retrospectively reviewed data of 15 patients with N2 O-induced neuropathy and compared them with 15 GBS patients. RESULTS The age of the N2 O-induced neuropathy group was significantly younger than that in the GBS group (22 ± 5 vs 45 ± 17). Paresthesia was more common in N2 O-induced neuropathy group (100% vs 53.3%). The proportion of distal upper limbs weakness was lower than that in GBS group (20.0% vs 93.3%). There was no significant difference in distal weakness of the lower limbs (100% vs 80.0%). The incidence of motor conduction block and compound muscle action potential amplitude reduction in upper limbs was lower than that in GBS group (6.7% vs 60.0%; 26.7% vs 80.0%). The sensory nerve action potential amplitude drop in the lower limbs was more severe than that in GBS group (53.3% vs 0). The increase of Mean corpuscular volume (MCV) was more pronounced compared to GBS group (96.97 ± 6.00 vs 88.55 ± 5.41). High homocysteine levels were more common in N2 O-related group [29.80(11.60, 70.50) vs 14.35(9.22, 19.30)]. CONCLUSION Typical clinical features of the acute N2 O neuropathy appears to be a myeloneuropathy, affecting the lower limbs more than the upper limbs, mixed axonal-demyelinating electrophysiological performance, higher homocysteine level and larger MCV and common posterior spinal cord involvement in cervical segment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Xing Qin
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Li Kang
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Xiao Liu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Jiaoting Jin
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Fangfang Hu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Wenhui Lu
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Yongning Deng
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
| | - Qiao Yi Chen
- Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, PR China
| | - Jingxia Dang
- Department of Neurology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
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Inquimbert C, Maitre Y, Moulis E, Gremillet V, Tramini P, Valcarcel J, Carayon D. Recreational Nitrous Oxide Use and Associated Factors among Health Profession Students in France. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095237. [PMID: 35564631 PMCID: PMC9099944 DOI: 10.3390/ijerph19095237] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 02/04/2023]
Abstract
The first aim of this study was to investigate the recreational use of nitrous oxide (N2O) among health profession students at Montpellier University (France). The second aim was to identify the factors associated with N2O use. All students in medicine, dentistry, pharmacy and midwifery of the Montpellier University were contacted by email to participate in the survey. The students answered directly online by filling out anonymously a questionnaire including demographic information and questions about N2O, illicit drugs and alcohol use. Ethical approval was granted by the ethics committee of the Montpellier University. The sample comprised 593 students (mean age = 22.3 ± 2.6 yr), with 68.6% of females. Lifetime N2O use was reported by 76.6% and frequent alcohol use by 30.5% of the respondents. The lifetime use of cannabis, 'poppers', cocaine, ecstasy and LSD was 26.8%, 54.6%, 9.6%, 10.1% and 2.0% respectively. In multivariate analysis, the substances significantly associated with lifetime N2O were alcohol drinking and 'poppers' use. With respect to this self-nominated sample, our results indicate that respondents who were alcohol drinkers, were poppers users, follow longer studies, divert medical products for recreational use or were members of a students' corporation had higher odds of lifetime N2O use.
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Affiliation(s)
- Camille Inquimbert
- Department of Public Health, Faculty of Dental Medicine, University of Montpellier, 34000 Montpellier, France; (P.T.); (J.V.)
- Institut Desbrest d’Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, Université de Montpellier, 34093 Montpellier, France
- Correspondence: ; Tel.: +33-666957674
| | - Yoann Maitre
- EA 2415, Aide à la Décision pour une Médecine Personnalisée, Université de Montpellier, 34093 Montpellier, France;
| | - Estelle Moulis
- Department of Pediatric Dentistry, Faculty of Dental Medicine, University of Montpellier, 34000 Montpellier, France; (E.M.); (V.G.)
| | - Vincent Gremillet
- Department of Pediatric Dentistry, Faculty of Dental Medicine, University of Montpellier, 34000 Montpellier, France; (E.M.); (V.G.)
| | - Paul Tramini
- Department of Public Health, Faculty of Dental Medicine, University of Montpellier, 34000 Montpellier, France; (P.T.); (J.V.)
| | - Jean Valcarcel
- Department of Public Health, Faculty of Dental Medicine, University of Montpellier, 34000 Montpellier, France; (P.T.); (J.V.)
| | - Delphine Carayon
- Department of Prosthodontics, Faculty of Dental Medicine, University of Montpellier, 34000 Montpellier, France;
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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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Abstract
Of the water-soluble vitamins, vitamin B12 (B12) has the lowest daily requirement. It also has several unique properties including a complex pathway for its absorption and assimilation requiring intact gastric and terminal small intestinal function, an enterohepatic pathway, and several dedicated binding proteins and chaperons. The many causes of B12 deficiency include malabsorption and defects in cellular delivery and uptake, as well as limited dietary intake. B12 is required as a cofactor for only two reactions in humans, the cytosolic methionine synthase reaction and the mitochondrial methymalonyl CoA mutase reaction. Disruption of either of these reactions gives rise to B12 deficiency. Although more common with advancing age, because of the higher prevalence of malabsorptive disorders in the elderly, B12 deficiency is widely distributed across all age groups particularly where food insecurity occurs. The consequences and severity of B12 deficiency are variable depending on the degree of deficiency and its duration. Major organ systems affected include the blood, bone marrow and nervous system. Megaloblastic anemia results from a defect in thymidine and therefore DNA synthesis in rapidly dividing cells. Nervous system involvement is varied, some of which results from defective myelin synthesis and repair. Cognitive impairment and psychosis may also occur. Diagnosis of B12 deficiency rests on clinical suspicion followed by laboratory testing, which consists of a panel of tests, that together provide clinically reliable predictive indices. B12 metabolism and deficiency is closely intertwined with folate, another B-vitamin. This chapter explores the various aspects of a unique and fascinating micronutrient.
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Affiliation(s)
- Ralph Green
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, CA, United States.
| | - Joshua W Miller
- Department of Nutritional Sciences, Rutgers University, New Brunswick, NJ, United States
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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: 17] [Impact Index Per Article: 8.5] [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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