Important reminder: nitrous oxide (N2O) as a cause of functional vitamin B12 deficiency

2021 ◽  
Vol 14 (7) ◽  
pp. e241414
Author(s):  
Abdullahi Elsheikh Mahgoub ◽  
Smit Sunil Deliwala ◽  
Ghassan Bachuwa
Keyword(s):  
Nitrous Oxide ◽  
Vitamin B12 Deficiency ◽  
Serum Markers ◽  
Cobalamin Deficiency ◽  
Vitamin B ◽  
Sensory Level ◽  
Significant Other ◽  
Lower Extremity Weakness ◽  
Fluid Analysis ◽  
B12 Deficiency

A 32-year-old woman who misused multiple substances, including nitrous oxide (N2O), sought medical advice after she subacutely developed bilateral lower extremity weakness without a sensory level but with ataxia—her significant other developed similar symptoms with vitamin B12 deficiency due to N2O intake. Laboratory results revealed macrocytic anaemia despite normal B12 and folate levels, with serum markers pointing towards functional cobalamin deficiency. Spinal MRIs and cerebrospinal fluid analysis were unremarkable. Our patient was treated with vitamin B12 supplementation with an encouraging response.

scholarly journals One month of nitrous oxide abuse causing acute vitamin B12 deficiency with severe neuropsychiatric symptoms

2019 ◽  
Vol 12 (2) ◽  
pp. bcr-2018-228001 ◽  
Author(s):  
Michael S Lundin ◽  
John Cherian ◽  
Michael Nyika Andrew ◽  
Richa Tikaria
Keyword(s):  
Nitrous Oxide ◽  
Neuropsychiatric Symptoms ◽  
Vitamin B12 Deficiency ◽  
Vitamin B ◽  
Lower Extremity Weakness ◽  
Studying Abroad ◽  
The Usa ◽  
B12 Deficiency ◽  
Whipped Cream ◽  
Brain And Spinal Cord

A 21-year-old university student studying abroad in the USA presented to the emergency department with double vision, lower extremity weakness with difficulty ambulating and other neuropsychiatric symptoms. MRI of the brain and spinal cord were normal. Vitamin B12 was 78 pg/mL (58 pmol/L, reference 211–911 pg/mL). The patient had been using nitrous oxide capsules used for whipped cream recharging, which she obtained from other students, a few times daily for a month for the purpose of anxiety relief. The patient was not a vegan or vegetarian. The patient was treated with intramuscular vitamin B12 repletion with partial resolution of neurologic symptoms and discharged on vitamin B12 supplementation.

Myeloradiculoneuropathy due to vitamin B12 deficiency: an unusual clinical and radiological presentation

2021 ◽  
Vol 14 (1) ◽  
pp. e239415
Author(s):  
Shambaditya Das ◽  
Souvik Dubey ◽  
Alak Pandit ◽  
Biman Kanti Ray
Keyword(s):  
Vitamin B12 Deficiency ◽  
Position Sense ◽  
Joint Position Sense ◽  
Vitamin B ◽  
Sensory Level ◽  
Intensity Changes ◽  
Syndromic Diagnosis ◽  
B12 Deficiency ◽  
Neuro Imaging ◽  
Parietal Cell Antibody

A 42-year-old man from rural India presented with asymmetric progressive paraparesis mimicking compressive dorsal myelopathy, followed by distal upper limb, truncal and neck-flexor weakness, further complicated by acute urinary retention. His sensory deficits were marked by loss of joint position sense (JPS) and graded loss of vibration sense, along with a definite sensory level. Deep tendon jerks were hypo-to-areflexic, plantar was bilaterally extensor. He had become less attentive and occasionally failed to keep track with conversations. A syndromic diagnosis of myeloradiculoneuropathy with cognitive impairments was made. Further tailored investigations revealed vitamin B12 deficiency with positive anti-parietal cell antibody. Diagnosis of subacute combined cord degeneration (SACD) was confirmed. Neuro-imaging revealed intramedullary intensity changes only along lateral aspect of spinal cord instead of characteristic posterior involvement. Following parenteral vitamin B12 supplementation, patient started showing improvement in motor power and subjective sensory symptoms. His bladder symptoms persisted initially, however recovered finally after 6 months.

Vitamin B12 Deficiency and Dementia

1995 ◽  
Vol 7 (1) ◽  
pp. 85-88 ◽  
Author(s):  
Ulisses Gabriel de Vasconcelos Cunha ◽  
Fábio Lopes Rocha ◽  
Josecy Maria de Souza Peixoto ◽  
Maria Flávia de Morão Motta ◽  
Maira Tonidandel Barbosa
Keyword(s):  
Vitamin B12 Deficiency ◽  
Cobalamin Deficiency ◽  
Vitamin B ◽  
Progressive Decline ◽  
Recent Onset ◽  
Beneficial Effects ◽  
History Of ◽  
B12 Deficiency ◽  
State Examination

We set out to investigate the possible beneficial effects on cognitive function of demented patients with cobalamin deficiency after cobalamin replacement. A total of 181 consecutive, demented (DSM-III or DSM-III-R criteria and score below 24 on the Mini-Mental State Examination [MMSE] outpatients (mean age 77.5 years) were prospectively evaluated and had their vitamin B12 level measured by radioimmunoassay. The frequency of vitamin B12 deficiency (less than 200 pg/mL) was 25% (46 patients). Treatment outcome was obtained in 19 patients (19 of 46). Despite cobalamin replacement, 16 of 19 patients persisted in showing progressive decline during follow-up visits (3 to 24 months). The nonresponse to vitamin B12 replacement in most cases seems to reflect the presence of associated irreversible dementia or a follow-up of shorter duration in a few patients. All of the patients who showed some improvement (MMSE returned to normal values) had mild dementia with a history of less than 2 years. Thus, screening for B12 deficiency should be considered in patients with recent onset of mild mental status changes.

scholarly journals High frequency of vitamin B12 deficiency in a Brazilian population

2010 ◽  
Vol 13 (8) ◽  
pp. 1191-1197 ◽  
Author(s):  
JM Xavier ◽  
FF Costa ◽  
JM Annichino-Bizzacchi ◽  
STO Saad
Keyword(s):  
High Frequency ◽  
Methylmalonic Acid ◽  
Vitamin B12 Deficiency ◽  
Cobalamin Deficiency ◽  
Vitamin B ◽  
Mean Cell Volume ◽  
Adult Participants ◽  
B12 Deficiency ◽  
Older Subjects ◽  
Brazilian Populations

AbstractObjectiveThere are few studies regarding vitamin B12 deficiency in developing countries. In Brazil, a late diagnosis of vitamin B12 deficiency progressing to severe neurological damage is common. Thus, the aim of the present study was to verify the frequency of vitamin B12 deficiency in two Brazilian populations (elderly and adult participants) and to compare different methods of vitamin B12 deficiency detection.DesignFive hundred participants were recruited from health centres from south-east Brazil and were separated into two groups: 60 years old or more and 30–59 years old. Vitamin B12 and folate concentrations were measured using electrochemiluminescence immunoassay (ECI) and RIA. Methylmalonic acid (MMA) was measured by LC coupled to tandem MS. Full blood counts were acquired using standard methods.ResultsAll participants had normal blood count results and mean cell volume less than 99 fl; none of them presented folate deficiency according to the results, which were all greater than 3 ng/ml. Cobalamin levels less than 200 pmol/l were identified by one of the two or by both methods in 7·2 % of the participants aged 60 years or more and 6·4 % of the participants aged 30–59 years. MMA levels were higher in older subjects (P = 0·007) compared with younger subjects. A greater correlation of MMA v. RIA was observed than of MMA v. ECI (P = 0·0017 v. P = 0·014). MMA quantification estimated that cobalamin deficiency was present in more than 11 % of the subjects for both studied groups.ConclusionsThe study shows that vitamin B12 deficiency is frequent in Brazilian adults and suggests that RIA is more sensitive than ECl for measuring cobalamin levels.

scholarly journals Encephalitis secondary to nitrous oxide and vitamin B12 deficiency

2019 ◽  
Vol 12 (12) ◽  
pp. e229380
Author(s):  
Gareth Hughes ◽  
Ed Moran ◽  
Martin J Dedicoat
Keyword(s):  
Cerebrospinal Fluid ◽  
Nitrous Oxide ◽  
Peripheral Neuropathy ◽  
Vitamin B12 ◽  
Tuberculous Meningitis ◽  
Vitamin B12 Deficiency ◽  
Vitamin B ◽  
Severe Vitamin ◽  
Elevated Protein ◽  
B12 Deficiency

A 27-year-old woman presented with confusion, agitation and fever. Having initially been treated as an infective encephalitis case her initial and subsequent lumbar punctures revealed cerebrospinal fluid with a worsening pleocytosis and elevated protein. It was initially felt she had been suffering from tuberculous meningitis and started on treatment it later became apparent that she had a severe vitamin B12 deficiency related to recreational nitrous oxide use. She also was noted to have a peripheral neuropathy. After replacing her vitamin B12 and later stopping her tuberculous medication once cultures were negative her cognition and peripheral neuropathy continued to improve.

scholarly journals Plasma amino acids and tissue methionine levels in fruit bats (Rousettus aegyptiacus) with nitrous oxide-induced vitamin B12 deficiency

1985 ◽  
Vol 53 (3) ◽  
pp. 657-662 ◽  
Author(s):  
Justin Van Der Westhuyzen ◽  
Suasn V. Van Tonder ◽  
Jayne E. Gibson ◽  
Terence A. Kilroe-smith ◽  
Jack Metz
Keyword(s):  
Nitrous Oxide ◽  
Vitamin B12 Deficiency ◽  
Dietary Supplementation ◽  
Basal Diet ◽  
Neurological Impairment ◽  
Vitamin B ◽  
Muscular Weakness ◽  
Fruit Bats ◽  
B12 Deficiency ◽  
Methionine Synthesis

1. The effect of methylcobalamin inactivation by the gas nitrous oxide on plasma amino acid and tissue methionine levels in fruit bats (Rousettus aegyptiacus) was examined.2. Animals exposed to N2O-oxygen (1:1, v/v) for 90 min daily received a fruit diet with or without methionine or betaine supplements. Exposure and diets were continued for up to 17 weeks or until neurological impairment and muscular weakness was established.3. All the groups exposed to N2O had significantly lower liver, brain and plasma methionine concentrations except the methionine-supplemented animals which showed significantly raised levels. Plasma homocysteine, which was absent in controls, was present in all the N2O-exposed groups.4. Betaine supplementation resulted in reduced accumulation of homocysteine in plasma. However, plasma and liver methionine levels were only slightly increased compared with animals on the basal diet, and brain methionine levels were the lowest of all the groups studied.5. These results support the hypothesis that reduced methionine synthesis is an important contributor to the development of neurological impairment in this species and suggest that dietary supplementation with the methionine precursor betaine cannot replace the loss of vitamin B12-dependent methionine synthesis.

scholarly journals Assessment of vitamin B12 deficiency and B12 screening trends for patients on metformin: a retrospective cohort case review

2021 ◽  
pp. bmjnph-2020-000193
Author(s):  
Darby Martin ◽  
Jeet Thaker ◽  
Maria Shreve ◽  
Lois Lamerato ◽  
Kartazyna Budzynska
Keyword(s):  
Retrospective Cohort ◽  
Protective Factor ◽  
Vitamin B12 Deficiency ◽  
Older Age ◽  
Secondary Outcome ◽  
Vitamin B ◽  
Case Review ◽  
Large Hospital ◽  
Hospital System ◽  
B12 Deficiency

ObjectivesOur study investigated the use of vitamin B12 testing in a large cohort of patients on metformin and assesses appropriateness and benefits of screening recommendations for vitamin B12 deficiency.DesignThis retrospective cohort study included insured adult patients who had more than 1 year of metformin use between 1 January 2010 and 1 October 2016 and who filled at least two consecutive prescriptions of metformin to establish compliance. The comparison group was not exposed to metformin. Primary outcome was incidence of B12 deficiency diagnosed in patients on metformin. Secondary outcome was occurrence of B12 testing in the patient population on metformin. Records dated through 31 December 2018 were analysed.SettingLarge hospital system consisting of inpatient and outpatient data base.ParticipantsA diverse, adult, insured population of patients who had more than 1 year of metformin use between 1 January 2010 and 1 October 2016 and who filled at least two consecutive prescriptions of metformin.ResultsOf 13 489 patients on metformin, 6051 (44.9%) were tested for vitamin B12 deficiency, of which 202 (3.3%) tested positive (vs 2.2% of comparisons). Average time to test was 990 days. Average time to test positive for deficiency was 1926 days. Factors associated with testing were linked to sex (female, 47.8%), older age (62.79% in patients over 80 years old), race (48.98% white) and causes of malabsorption (7.11%). Multivariable logistic regression showed older age as the only factor associated with vitamin B12 deficiency, whereas African-American ethnicity approached significance as a protective factor.ConclusionsBased on our study’s findings of vitamin B12 deficiency in patients on metformin who are greater than 65 years old and have been using it for over 5 years, we recommend that physicians consider screening in these populations.

Vitamin B12 deficiency is the dominant nutritional cause of hyperhomocysteinemia in a folic acid-fortified population

2005 ◽  
Vol 43 (10) ◽  
Author(s):  
Ralph Green ◽  
Joshua W. Miller
Keyword(s):  
United States ◽  
Folic Acid ◽  
Vitamin B12 Deficiency ◽  
The United States ◽  
Community Dwelling ◽  
Vitamin B ◽  
Prevalence Rates ◽  
Total Vitamin ◽  
Folic Acid Fortification ◽  
B12 Deficiency

AbstractPrevalence rates for folate deficiency and hyperhomocysteinemia have been markedly reduced following the introduction of folic acid fortification in the United States. We report the prevalence of hyperhomocysteinemia in a population of community-dwelling elderly Latinos in the post-folic acid fortification era. We measured homocysteine, total vitamin B

Ileocaecal tuberculosis: an under-recognised cause of vitamin B12 deficiency

2018 ◽  
Vol 49 (2) ◽  
pp. 143-144
Author(s):  
Ashok Kumar Pannu ◽  
Dinesh Raja Palanisamy
Keyword(s):  
Terminal Ileum ◽  
Vitamin B12 Deficiency ◽  
Abdominal Tuberculosis ◽  
Megaloblastic Anaemia ◽  
Vitamin B ◽  
Lower Quadrant ◽  
Abdominal Tenderness ◽  
B12 Deficiency ◽  
Clinical Triad ◽  
Right Lower Quadrant

A combination of anaemia and knuckle pigmentation should always raise concern for megaloblastic anaemia. As the terminal ileum is the site of vitamin B12 absorption and also the commonest site of abdominal tuberculosis, a clinical triad of prolonged fever, knuckle pigmentation and right lower quadrant abdominal tenderness should suggest ileocaecal tuberculosis in endemic areas.

scholarly journals The Level of Serum Pepsinogen in Diagnosing and Evaluating the Severity of Subacute Combined Degeneration Due to Vitamin B12 Deficiency

2021 ◽  
Vol 12 ◽  
Author(s):  
Xiaoyan Chen ◽  
Rong Wang ◽  
Xusheng Huang ◽  
Fei Yang ◽  
Shengyuan Yu
Keyword(s):  
Vitamin B12 ◽  
Neurological Complication ◽  
Vitamin B12 Deficiency ◽  
Inverse Correlation ◽  
Cobalamin Deficiency ◽  
Serum Pepsinogen ◽  
Roc Curve Analysis ◽  
Subacute Combined Degeneration ◽  
B12 Deficiency ◽  
Autoimmune Atrophic Gastritis

Subacute combined degeneration (SCD) is a neurological complication of cobalamin deficiency, which is usually caused by chronic autoimmune atrophic gastritis. Serum pepsinogen 1 and the ratio of pepsinogen 1/pepsinogen 2 (PG1/2) can reflect the severity of gastric atrophy.Objective: This work aims to investigate whether decreased serum PG1 and PG1/2 ratio are helpful in diagnosing SCD and reflecting the severity of SCD.Methods: We retrospectively analyzed the clinical and laboratory tests of 65 cases of SCD due to vitamin B12 deficiency and compared the laboratory parameters of SCD with 65 age- and sex-matched amyotrophic lateral sclerosis (ALS) patients.Results: PG1 and PG1/2 ratio were decreased in 80 and 52.3% of SCD patients, respectively. Compared to patients with PG1/2 ratio ≥3.0, patients with PG1/2 ratio <3.0 had more severe anemia, larger mean corpuscular volume (MCV), lower level of vitamin B12, higher folate and homocysteine (Hcy), more severe changes in somatosensory evoked potential (SEP), and higher rate of lesions in spinal MRI (P < 0.05). PG1 and PG1/2 ratio had inverse correlation with MCV and N20 latency in SEP examination (P < 0.05). PG1/2 ratio, RBC count, and Hcy were independent risk factors for SCD in logistic regression analyses. The ROC curve analysis revealed that the diagnostic accuracy of PG1 and PG1/2 ratio was 72.2 and 73.0%, respectively, while the cutoff values were 22.4 ng/ml and 2.43 for SCD, respectively.Conclusions: Decreased PG1 and PG1/2 ratio are helpful for the diagnosis and evaluation of the severity of SCD due to vitamin B12 deficiency.

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