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General Rehabilitation

Axonal Sensorimotor Polyneuropathy Induced by Recreational Nitrous Oxide Use: A Case Report

Saturday, October 25, 2025
12:00 PM - 1:30 PM MT
Location: Case Report Theater

    Primary Author(s)

  • Ryan Jensen, DO

    Resident Physician
    East Carolina University Health
    Winterville, North Carolina

    • Co-Author(s)

  • Harrison Jordan, DO

    Resident
    ECU Health (Vidant Medical Center/East Carolina University) PM&R Program
    Greenville, North Carolina

  • Samantha Greenman, DO

    Resident Physician
    ECU Health (Vidant Medical Center/East Carolina University) PM&R Program
    Greenville, North Carolina

  • MP

    Matthew Parker, MD

    Clinical Associate Professor
    East Carolina University
    Greenville, North Carolina

Disclosure(s):
Ryan Jensen, DO: No financial relationships to disclose
Harrison Jordan, DO: No financial relationships to disclose
Samantha Greenman, DO: No financial relationships to disclose
Case Diagnosis: We present a case of a 39-year-old male with axonal sensorimotor polyneuropathy due to recreational nitrous oxide use.

Case Description or Program Description: A 39-year-old male was admitted with an 8-month history of paresthesia and weakness, followed by confusion, expressive aphasia, and memory difficulties. Symptoms were most prominent in the bilateral lower extremities, leading to multiple falls. He inhaled nitrous oxide recreationally, commonly known as "whippets," using approximately 300 cartridges daily for 8 months. He was admitted to inpatient rehabilitation for ten days and discharged at an independent level with occasional supervision.

Setting: Inpatient Rehabilitation Unit

Assessment/Results: Electrodiagnostic studies revealed diminished amplitudes in sensory nerve conduction studies in a length-dependent pattern, no response in the bilateral lower extremity motor studies, normal motor latency and amplitudes in the upper extremities, and a normal median F-wave. MRI brain and spine were unremarkable. Initial vitamin B12 levels were 164 pg/mL, which increased to 790 pg/mL following 1000 mcg intramuscular vitamin B12 injections for 5 days, followed by oral supplementation.

Discussion (relevance): Nitrous oxide induces a short euphoric state and is a popular recreational drug among the younger population due to its legal status and easy availability. Its abuse can lead to central or peripheral nervous system pathology by inactivating vitamin B12, thus preventing the conversion of homocysteine to methionine. Laboratory findings may show low or deficient vitamin B12 levels, or elevated methylmalonic acid and homocysteine levels. Acutely, patients may present with altered cognition or hypoxemia. Chronically, symptoms typically include peripheral neuropathy, myelopathy, encephalopathy or anemia.

Conclusions: This case report highlights that recreational nitrous oxide use can result in length dependent axonal sensorimotor polyneuropathy and low vitamin B12 levels. Physiatrists should consider vitamin B12 supplementation to aid functional improvement during inpatient rehabilitation.