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BJA Advance Access published online on December 16, 2005
British Journal of Anaesthesia, doi:10.1093/bja/aei300
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© The Board of Management and Trustees of the British Journal of Anaesthesia 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Accepted November 6, 2005

Case Report

Reversible nitrous oxide myelopathy and a polymorphism in the gene encoding 5,10-methylenetetrahydrofolate reductase

H. J. Lacassie 1 *, C. Nazar 2, B. Yonish 3, P. Sandoval 4, H. A. Muir 5, and P. Mellado 4

1 Department of Anesthesiology, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
2 Department of Anesthesiology, Pontificia Universidad Católica de Chile, Santiago, Chile
3 Department of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC, USA
4 Department of Neurology, Pontificia Universidad Católica de Chile, Santiago, Chile
5 Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA

* To whom correspondence should be addressed.
H. J. Lacassie, E-mail: lacassie{at}med.puc.cl


  Abstract

We present a case of a patient who received nitrous oxide on two occasions within a period of 8 weeks and who subsequently developed a diffuse myelopathy, characterized by upper extremity paresis, lower extremity paraplegia and neurogenic bladder. Laboratory testing revealed hyperhomocysteinaemia and low levels of vitamin B12. Because of this uncommon clinical presentation, we analysed the patient's DNA, and found a polymorphism in the MTHFR gene that is associated with the thermolabile isoform of the 5,10-methylenetetrahydrofolate reductase enzyme, which explained the myelopathy experienced by the patient after being exposed to nitrous oxide. Soon after initiating supplementary therapy with folic acid and vitamin B12, the neurological symptoms subsided.

Keywords: anaesthesia, inhalation; anaesthetics gases, nitrous oxide; complications, myelopathy; enzymes, 5, 10-methylenetetrahydrofolate reductase; gene, MTHFR; vitamins, folic acid.
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