Abstract
A 24-year-old female, otherwise healthy, presented to the Emergency Department (ED)
with difficulty walking and bilateral leg pain. The patient was a recreational nitrous
oxide (NO2) user, also known as “whippets” or simply nitrous. Neurologic examination demonstrated
an unsteady gait and positive Romberg sign along with normal deep tendon reflexes
and normal muscle strength in upper and lower extremities. Laboratory results demonstrated
macrocytic erythropoiesis, reduced B12, elevated homocysteine, and elevated methylmalonic acid. Outpatient MRI later demonstrated
degeneration of the posterior spinal column. The patient was empirically treated in
the ED with intramuscular B12 and admitted to the evaluation unit for pain control and Physical Therapy (PT) evaluation.
Emergency Medicine (EM) physicians should be aware of this condition because NO2 is used both recreationally and in medicine. With the popularity of recreational
nitrous oxide, many emergency patients have experience with this drug. As in our case
report, the toxic effects can be profound and mimic other emergent conditions like
stroke. Emergency physicians should have a higher index of suspicion for the toxic
effects of this common drug. Elderly, vegetarians and patients with Irritable Bowel
Disease are at higher risk and may even experience toxicity from nitrous oxide used
therapeutically during routine anesthesia.
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Article Info
Publication History
Published online: May 24, 2018
Accepted:
May 13,
2018
Received:
May 4,
2018
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
