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Background: The recreational use of nitrous oxide is becoming increasingly common among teenagers and young adults. Since 2018, the use of nitrous oxide has increased exponentially and has become a public health problem. Case presentation: A 23-year-old patient was referred to accident and emergency (A&E) by his general practitioner for deterioration in general condition, vomiting, diarrhea and febrile headache at 39 °C. He reported that he had been partying for a month and consuming alcohol, cannabis and nitrous oxide. Three days before the consultation, he reported increased abdominal pain in the right iliac fossa. His homocysteine concentration was 51.9 μmol/L, and his plasma methyl malonate concentration increased to 4.45 μmol/L. A thoracic and abdominal CT scan revealed right iliac venous thrombosis associated with bilateral pulmonary embolism. Conclusion: Nitrous oxide inhibits the activity of methionine synthetase. We therefore observed an increase in plasma homocysteine and 5-methyl-THF. The increase in homocysteine could be responsible for the pro-thrombotic activity resulting from nitrous oxide intoxication. At present, no threshold or duration of exposure has been identified as being particularly likely to cause complications. It is likely that other factors coexist, such as coagulation disorders and polymorphisms of the MHTFR gene, which can lead to hyperhomocysteinaemia, cannabis consumption, inflammatory conditions and others. Treatment is based on vitamin B12 supplementation and curative anticoagulation. Some authors also recommend folate supplementation. Consumption of nitrous oxide could be associated with arterial and venous thromboembolic disease. [ABSTRACT FROM AUTHOR]

Abstract Background The recreational use of nitrous oxide is becoming increasingly common among teenagers and young adults. Since 2018, the use of nitrous oxide has increased exponentially and has become a public health problem. Case presentation A 23-year-old patient was referred to accident and emergency (A&E) by his general practitioner for deterioration in general condition, vomiting, diarrhea and febrile headache at 39 °C. He reported that he had been partying for a month and consuming alcohol, cannabis and nitrous oxide. Three days before the consultation, he reported increased abdominal pain in the right iliac fossa. His homocysteine concentration was 51.9 μmol/L, and his plasma methyl malonate concentration increased to 4.45 μmol/L. A thoracic and abdominal CT scan revealed right iliac venous thrombosis associated with bilateral pulmonary embolism. Conclusion Nitrous oxide inhibits the activity of methionine synthetase. We therefore observed an increase in plasma homocysteine and 5-methyl-THF. The increase in homocysteine could be responsible for the pro-thrombotic activity resulting from nitrous oxide intoxication. At present, no threshold or duration of exposure has been identified as being particularly likely to cause complications. It is likely that other factors coexist, such as coagulation disorders and polymorphisms of the MHTFR gene, which can lead to hyperhomocysteinaemia, cannabis consumption, inflammatory conditions and others. Treatment is based on vitamin B12 supplementation and curative anticoagulation. Some authors also recommend folate supplementation. Consumption of nitrous oxide could be associated with arterial and venous thromboembolic disease.

The recreatinal use of nitrous oxide has become more common in recent years, especially in adolescents and young adults. It has been mainly associated with medical conditions like megaloblastic anemia and (myelo)neuropathy. We report on the thromboembolic complications, a less known side effect, associated with recreational inhalation of nitrous oxide. An extensive literature search was performed for publications reporting on the thromboembolic complications associated with recreational nitrous oxide abuse. Data about sex, age, location of thrombosis, laboratory findings, therapy and outcome were collected. A total of 13 case reports or case series were identified comprising a total of 14 patients. The reported thromboembolic side effects included deep venous thrombosis, pulmonary embolism, mesenterial-, portal and splenic vein thrombosis, cerebral sinus thrombosis, cortical vein thrombosis, stroke, acute myocardial infarction and peripheral artery thromboembolism. These side effects are possibly mediated by the interaction of nitrous oxide with vitamin B12, a cofactor of the methionine synthase complex, which eventually results in elevation of plasma levels of homocysteine. Despite being a known risk factor for cardiovascular disease, the exact pathophysiological mechanism remains unclear. Cessation of nitrous oxide inhalation is necessary to prevent recurrent thrombosis. Nitrous oxide abuse may thus result in a wide spectrum of thromboembolic complications. One should be aware of this etiology, especially in a young person with no obvious risk factors for cardiovascular disease. Spreading awareness is important to inform people about the potentially serious side effects associated with nitrous oxide inhalation. [ABSTRACT FROM AUTHOR]