Chronic Nitrous Oxide Toxicity Despite Elevated Serum Vitamin B₁₂ Level: A Case Report

Nitrous oxide (N₂O) toxicity is an uncommon but important-to-recognize presentation of neurologic deficits and hematologic abnormalities, which may never resolve in some patients. In the United States, nitrous oxide is legal to possess and easily obtainable for purchase in stores and online. Nitrous oxide abuse and its long-term sequelae must be recognized by the emergency physician to ensure proper follow-up and maximize neurologic outcomes.

A 28-year-old male with past medical history of alcoholism and polysubstance abuse presented to the emergency department with progressive paresthesias, shortness of breath, and neurologic complaints following daily inhalation of N₂O for three weeks. He was diagnosed with N₂O toxicity due to functional vitamin B₁₂ deficiency in the setting of elevated B₁₂ levels from prophylactic self-supplementation.

While most recreational users of nitrous oxide will experience transient neurologic symptoms resolving within minutes of cessation, frequent or heavy users may develop permanent neurotoxicity. Exposed patients require close follow-up with neurology and vitamin B₁₂ supplementation to maximize neurologic recovery. In this patient, there was persistence of neurologic symptoms over 24 hours after cessation of use despite self-supplementation of vitamin B₁₂.