He used to run several times a week. He could barely stand now.


When Ahmed read that this formerly healthy man suddenly had trouble walking, Guillain-Barré syndrome (GBS) was the first thing that came to mind. It’s an autoimmune disorder: Antibodies, often triggered by an infection, mistakenly attack healthy cells and confuse them with the invaders they’re there to control. Cells targeted in GBS are cells that form a protective shield around nerve fibers. Without this cover, the nerves are damaged and stop the transmission of sensory information between the body and the brain.

But as soon as Ahmed continued reading and saw the man using a whip, another, more likely diagnosis, came to mind. Nitrous oxide is considered a relatively safe drug unless used frequently, where it can cause persistent weakness and paralysis. The drug binds to the working part of vitamin B12, neutralizing this essential nutrient. Deficiency of functional B12 causes injury and eventual destruction of the protective sheath and underlying nerve, causing symptoms similar to those seen in GBS. Once enough nerve tissue is destroyed, the weakness becomes irreversible.

“If [his weakness] Because of the whip, she needs to come to the ER for IM vitamin B12,” Ahmed texted. Maslyn immediately called his friend back with urgent advice.

Dr. Matthew McIntosh was the doctor assigned to care for the patient at Buffalo General Hospital. When she saw the man, blood tests had been sent to measure her B12 level and she had received her first doses of the vitamin. McIntosh had heard of whips; Heard it was a popular recreational drug. However, because of this, he had not seen anyone in the hospital and was completely unaware of the vitamin B12 deficiency that could result from its misuse. And after hearing about this patient, McIntosh did what all doctors should do when faced with something new – he went online.

Uncovering the long and colorful history of nitrous oxide doesn’t take much work. It was first discovered in the late 18th century, and its recreational use and euphoric properties were described decades before its use as an anesthetic. The link between overuse and this type of B12 deficiency was not identified until 1978. However, it has since been well described in the medical literature.

Blood tests revealed that although the man had normal vitamin B12 levels, he was not doing his job. The nitrous oxide had rendered the vitamin in his body useless. Other blood tests and MRIs of the man’s brain and spine showed no other abnormalities. The man took several doses of vitamins over the next few days and recovered quickly. By the time he got to the hospital, he was too weak to stand. When he left, he was able to walk with the aid of a walker.

After a month of vitamin supplementation and intense physical therapy, the patient can now walk on his own. His gait is a little awkward, but he’s sure to get everything back in the end. He’s had the hounds on and off for ten years. The drug is not addictive, but it will tell you that you are completely addicted. He stopped using the drug many times over the years, but often relapsed when he was stressed or depressed. But this time she’s sure to let it go completely. There is no stress that will put him at risk of permanent disability. This time he was lucky. He enters rehab to make sure he’ll never get lucky again.


Lisa Sanders, MD, is a contributing author to the magazine. His most recent book is “Diagnostics: Solving the Most Surprising Medical Mysteries”. If you have a solved case to share, write to her at Lisa.Sandersmd@gmail.com.



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