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A woman presented with rapidly progressive flaccid tetraparesis, sensory ataxia, urinary retention and Lhermitte’s phenomenon that had developed over 3 days. Her symptoms had started within 24 hours of finishing a recreational nitrous oxide (N2O) binge during which she inhaled 200×125 mL N2O canisters over 72 hours. There was no history of prior N2O use. Examination showed weakness in the legs and arms (especially severe in hip and knee flexors), areflexia, bilateral extensor plantar responses, severely impaired proprioception and absent vibration sensation in the legs. She was bed-bound and required hoist transfers.
MR scan of cervical spine showed features of combined degeneration, with an inverted V-shaped T2 hyperintensity in the posterior columns of the cervical cord (figure 1). Investigations showed haemoglobin 128 g/L (normal 115–155), mean corpuscular volume 103 fL (80–99), low serum B12 117 pmol/L (170–800) and elevated methylmalonic acid 14.50 µmol/L (normal less than 0.40). …
Contributors TGS: background research; first draft of the manuscript; revision of the manuscript for intellectual content. WKD: background research; revision of the manuscript for intellectual content. IKLB: background research; revision of the manuscript for intellectual content. TE: revision of the manuscript for intellectual content. NEA: background research; revision of the manuscript for intellectual content.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally reviewed by Alexander Thompson, Oxford, UK.