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

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 B-12 was 78pg/mL (58pmol/L, reference 211-911pg/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 B-12 repletion with partial resolution of neurologic symptoms and discharged on vitamin B-12 supplementation.