"The Silent Michigan Epidemic: Unraveling Neurological Changes Posed By" by Tabssum Chauhan, Mariam Jamil et al.
 

Document Type

Conference Proceeding

Publication Date

5-3-2024

Abstract

Introduction Nitrous oxide (N2O), traditionally considered a benign, odorless gas with analgesic and anesthetic properties, has seen a rise in abuse among young individuals in the United States. This abuse can lead to clinically significant neurological symptoms, including peripheral neuropathy and subacute combined degeneration of the spinal cord due to functional B12 deficiency induced by N2O. This case series examines four patients with N20 toxicity, and the functional recovery observed during subsequent follow-up visits after appropriate management. We will explore their motivation for abusing N20, their sources of access, and why its use is on the rise. Cases Description: The first two cases involve young females under 30 years old with a history of recreational nitrous oxide use for two months and a year, respectively. They presented with acute onset ascending bilateral upper and lower extremity weakness and numbness, one with concurrent urinary incontinence. Physical examinations revealed reduced motor strength and sensation of light touch and vibration in all extremities. Initial workup showed decreased Vitamin B12 levels, unremarkable CSF studies, and cervical MRI findings consistent with subacute-combined degeneration of the spinal cord. Both patients received four weeks of vitamin B12 supplementation, resulting in near-complete functional recovery. The next two cases involve adults in their 20s with approximately six-month history of recreational nitrous oxide use, presenting with bilateral upper and lower extremity numbness and paresthesia’s. Physical examinations revealed diminished light touch, pin prick and vibration sense in all extremities along with absent reflexes in bilateral lower extremities. Both had decreased serum vitamin B12 levels of < 200pg/ml, unremarkable CSF studies, and MRI findings. Treatment varied, with one patient receiving duloxetine and B12 injections, and the other managed with gabapentin and B12 injections. Both were instructed to complete a four-week course of B12 supplemental IM injections. One of the patients who was not able to complete a course of 4 weeks, did not have improvement in his symptoms on a follow-up phone call discussion. Clinical significance: Nitrous oxide oxidizes cobalt atom, inactivating methionine synthetase. This disruption impairs the production of methionine from homocysteine, which is needed during DNA synthesis. Subsequently, Methyl cobalamin cannot facilitate the production of S-adenosylmethionine interrupting myelin sheath formation as seen in subacute combined degeneration. Discussion This case series reveals a worrying emergence of recreational nitrous oxide use in Michigan especially after the Covid-19 Pandemic. Nitrous oxide is not categorized as a controlled substance by the United states federal Law and despite the state of Michigan passing legislation such as the 2022 Senate Bill 996 to regulate use in 2018, nitrous oxide cartridges and cannisters are easily accessible for purchase in large quantities from convenience stores, vape shops and Amazon in the form of metal cannisters disguised as propellant to make whipped cream and advertised as a “harmless” gas. This false perception of a “safe-high” and the short-lasting euphoric effects of N20 result in youngsters using multiple cartridges at once with the potential risk of significant neurological morbidity

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2024 Resident and Medical Student Day, May 3, 2024, Troy, MI

American College of Physicians (ACP) Michigan Chapter Scientific Meeting, Kalamazoo, MI, October 24-27, 2024.

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