A rise in cases of nitrous oxide abuse: neurological complications and biological findings

Abstract

Background: The recent lockdown due to the COVID-19 pandemic has been linked to a higher incidence of psychiatric manifestations and substance abuse. The recreative use of nitrous oxide is more and more widespread and neurological complications are frequent.

Methods: We report clinical characteristics and biological findings of five consecutive patients presenting to our tertiary care center between April 2020 and February 2021 with various neurological symptoms occurring after recent nitrous oxide abuse.

Results: Our patients presented with subacute combined degeneration of the spinal cord (4/5 patients) or with acute inflammatory demyelinating polyneuropathy (1/5 patients). No patient had reduced vitamin B-12 titer, but all had elevated blood levels of homocysteine and methylmalonic acid. This reflects the functional deficit in vitamin B-12 that can be linked to nitrous oxide consumption. After vitamin B-12 supplementation, clinical signs regressed at least partially in all 5 patients.

Conclusion: We report an elevated incidence of neurological complications of nitrous oxide abuse occurring during the recent COVID-19 lockdown. Nitrous oxide abuse should be tracked down in patients presenting with compatible neurological symptoms and elevated homocysteinemia. Vitamin B-12 should be supplemented as soon as the diagnosis is made.

Keywords: COVID-19; Nitrous oxide; Substance-related disorders; Toxicology; Vitamin B-12.

Fig.1

Spine MRI at admission. Left: sagittal T2-sequence of the cervical spinal cord, Right: axial View of the pathological segment, A = Patient 1: hyper-intensities of the posterior cervical spinal cord (C2-C6), B = Patient 2: hyper-intensities of the posterior cervical spinal cord (C1-C2) and C = Patient 5: hyper-intensities of the posterior cervical spinal cord (C3-C5)