Nitrous oxide-induced myeloneuropathy: a case series
D D Mair, Alvar Paris, Safiya A Zaloum, Laura M. White, Katherine Dodd, Christina Englezou, Farhin Patel, Siraj Abualnaja, James B Lilleker, David Gosal, Tom Hayton, Di Liang, Holger Allroggen, Mark Pucci, Stephen Keddie, Alastair J. Noyce
Abstract
Background Nitrous oxide (N 2 O) 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 N 2 O recreationally, but most information comes from small case series. Methods We describe 119 patients with N 2 O-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 N 2 O canisters consumed per week correlated with methylmalonic acid levels in the blood as a measure of functional B 12 deficiency (rho (ρ)=0.44, p=0.04). Conclusions Preventable neurological harm from N 2 O abuse is increasingly seen worldwide. Ease of access to canisters and larger cylinders of N 2 O has led to an apparent rise in cases of N 2 O-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.