title: Nitrous oxide misuse and vitamin B12 deficiency.
abstract: A 36-year-old man presented to hospital with a 5-week history of ascending limb paraesthesiae and balance difficulties. He had no medical or travel history of note, but admitted habitual nitrous oxide (N2O) inhalation. Neurological examination revealed a sensory ataxia with pseudoathetosis in the upper limbs and reduced vibration sensation to the hips bilaterally. Significant investigation results included a low serum vitamin B12 concentration, mild macrocytosis and raised serum homocysteine concentration. T2 MRI of the spinal cord demonstrated increased signal extending from C1 to T11 in keeping with a longitudinal myelitis. The patient was diagnosed with a myeloneuropathy secondary to vitamin B12 deficiency, resulting from heavy N2O inhalation. He was treated with intramuscular vitamin B12 injections and received regular physiotherapy. At discharge, he was able to mobilise short distances with the aid of a zimmer frame, and was independently mobile 8 weeks later.
authors.affiliation: Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK.
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Massey
authors.affiliation: Department of Neurology, Cardiff and Vale University Health Board, Cardiff, UK.
authors.forename: Trevor T
authors.initials: TT
authors.lastname: Pickersgill
authors.affiliation: Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, UK.
authors.forename: Kathryn
authors.initials: K
authors.lastname: J Peall
mesh_terms: D000328:Adult; D018685:Anesthetics, Inhalation / Q000009:adverse effects*; D003711:Demyelinating Diseases / Q000175:diagnosis / Q000209:etiology*; D003937:Diagnosis, Differential; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D009609:Nitrous Oxide / Q000009:adverse effects*; D010523:Peripheral Nervous System Diseases / Q000175:diagnosis / Q000209:etiology*; D013118:Spinal Cord Diseases / Q000000981:diagnostic imaging / Q000209:etiology*; D014806:Vitamin B 12 Deficiency / Q000139:chemically induced* / Q000150:complications
chemical_list: D018685:Anesthetics, Inhalation; D009609:Nitrous Oxide