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case_report·neurology, emergency medicine, internal medicine, nutrition, micronutrients·PMC10438944

A Case Report of Nitrous Oxide-induced Myelopathy: An Unusual Cause of Weakness in an Emergency Department

Clinical Practice and Cases in Emergency Medicine · 4 authors, 1 centre

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TL;DR

This is a case report of a 33-year-old woman who developed progressive leg weakness and numbness from recreational nitrous oxide use, which caused a vitamin B12 deficiency and myeloneuropathy. After high-dose B12 therapy and stopping nitrous oxide, she had near-complete resolution of symptoms at one year.

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This case report describes a 33-year-old woman presenting to the emergency department with progressive bilateral lower extremity weakness after repeated recreational nitrous oxide use. An electromyography study was suggestive of myeloneuropathy, while brain and spine MRI imaging were normal. The patient was treated with high-dose vitamin B12 injections and instructed to stop nitrous oxide use. At eight-week follow-up, she could ambulate independently with normal strength. One year after onset, she maintained sobriety and had near-complete resolution of her neurological deficits. The case highlights that nitrous oxide toxicity is a reversible cause of weakness that should be considered, but it notes that neurological symptoms can occur with normal B12 levels and without abnormal imaging findings.

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case_report

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neurology

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ORIGINAL PAPER

PMC10438944

A Case Report of Nitrous Oxide-induced Myelopathy: An Unusual Cause of Weakness in an Emergency Department

Clinical Practice and Cases in Emergency Medicine

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ABSTRACT

Introduction Weakness is a common symptom that within itself does not indicate a specific diagnosis. Recreational inhalant use such as nitrous oxide (NO) may not often be disclosed. Additionally, professional or occupational history, such as being a dentist or dental assistant, should be determined because of higher reported rates of NO misuse. 1 Nitrous oxide can cause vitamin B 12 deficiency and resulting neuropathy. Nitrous oxide toxicity can have a wide variation of presentations with or without laboratory abnormalities or remarkable imaging findings, which can further complicate a diagnosis of weakness secondary to NO use. Case Report A 33-year-old female presented to the emergency department with progressive bilateral leg numbness and objective weakness after repeated recreational NO use. After an extensive workup, she was found to have vitamin B 12 deficiency and an electromyography study consistent with myeloneuropathy, despite normal imaging. She was prescribed high-dose vitamin B 12 therapy and stopped using NO. One year after diagnosis, our patient maintained NO sobriety and had near-complete resolution of prior neurologic deficits. Conclusion The use of recreational inhalant and the patient’s occupation should be considered when a patient presents with weakness. Obtaining vitamin B 12 and methylmalonic acid levels should be considered for diagnosis. However, NO-induced neuropathy can be seen in patients with normal vitamin B 12 and methylmalonic levels and patients do not always have abnormal imaging findings. The healthcare team should consider the varied presentations and findings of substance-induced conditions such as NO toxicity.

CITATION EXPORT

Madeleine S. Birch, Emmelyn J. Samones, Tammy Phan et al.. A Case Report of Nitrous Oxide-induced Myelopathy: An Unusual Cause of Weakness in an Emergency Department. Clinical Practice and Cases in Emergency Medicine. (2023). https://doi.org/10.5811/cpcem.1549

AUTHORS

4 · 1 CENTRES

Madeleine S. Birch, Emmelyn J. Samones, Tammy Phan, Mindi Guptill

Loma Linda University Medical Center, Department of Emergency Medicine, Loma Linda, California