Baylor University Medical Center Proceedings April 2017 - 172

for other causes of B12 deficiency, such as atrophic gastritis,
given his excessive use of nitrous oxide and improvement after
discontinuation of nitrous oxide.

aggressive vitamin B12 supplementation and nitrous oxide
cessation (4).
1.

DISCUSSION
Although our patient's vitamin B12 level was at the low
end of normal, his clinical presentation, elevated levels of
homocysteine and methylmalonic acid, and MRI findings
are consistent with a diagnosis of nitrous oxide-induced
vitamin B12 deficiency. Unfortunately, the accessibility and
low cost of whipped cream chargers have made nitrous oxide inhalation, or "whippets," increasingly popular among
teenagers and adults alike. While significant toxicities rarely
occur with occasional inhalation, heavy nitrous oxide abuse
can result in significant polyneuropathy and ataxia (5), as
seen in our patient. Provider recognition and early identification of nitrous oxide-induced vitamin B12 deficiency
is essential, as neurologic deficits are often reversible with

172

2.

3.

4.

5.

Substance Abuse and Mental Health Services Administration, Office
of Applied Studies. Results from the 2007 National Survey on Drug Use
and Health: National Findings (DHHS Publication No. SMA 08-4343).
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2008.
Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Harris WA,
Lowry R, McManus T, Chyen D, Whittle L, Lim C, Wechster H; Centers
for Disease Control and Prevention. Youth risk behavior surveillance-
United States, 2011. MMWR Surveill Summ 2012;61(4):1-162.
Kaufman B, Sutin KM, Wahlander S, Miller SM. Anesthetics and neuromuscular blocking agents. In Goldfrank LR, Flomenbaum NE, Lewin
NA, Howland MA, Nelson LS, Hoffman RS, eds. Goldfrank's Toxicologic
Emergencies, 6th ed. Stamford, CT: Appleton & Lange, 1998.
Vishnubhakat SM, Beresford HR. Reversible myeloneuropathy of
nitrous oxide abuse: serial electrophysiological studies. Muscle Nerve
1991;14(1):22-26.
Cheng HM, Park JH, Hernstadt D. Subacute combined degeneration of
the spinal cord following recreational nitrous oxide use. BMJ Case Rep
2013;2013:bcr2012008509.

Baylor University Medical Center Proceedings

Volume 30, Number 2



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