A fatal case of Ecstasy poisoning

A 21-year-old woman visited a rave in Toronto, Ontario. She took one tablet of the drug Ecstasy (3,4-methylenedioxymethamphetamine [MDMA]). She and a friend arrived home at 05:30. At 09:00 the girl could not be awakened, and was observed to be cold and had blue fingertips. She was immediately transferred to a nearby hospital.

The girl arrived unconscious (Glasgow Coma Scale was 3), and was intubated, ventilated and started on a dopamine infusion. She was pronounced brain dead two days later in the intensive care unit. Her laboratory results on admission illustrate two aspects of Ecstasy morbidity.

First, the patient was hyponatremic on arrival at hospital, with a sodium level of 126 mmol/L on admission, which rose to 134 mmol/L 3.5 h later. The hyponatremia played an important, if not crucial role, in the history of this girl because brain stem coning was detected during the postmortem. Hyponatremia is associated with Ecstasy use either because of an inappropriate secretion of antidiuretic hormone or because of sodium loss through excessive sweating during dancing combined with electrolyte-free water intake.

Secondly, the patient’s creatinine kinase levels were elevated (1028, 1542 and 1469 units/L, respectively), which is indicative of (moderate) rhabdomyolysis. Rhabdomyolysis is also a well described symptom of Ecstasy intoxication. The myoglobinuria resulting from rhabdomyolysis is believed to cause acute renal failure.

Reconstructing the events that led to the patient’s death, three mechanisms are possible. First, the patient could have died from a primary cardiac arrest following Ecstasy use, which has been described in literature. Secondly, the cardiac arrest could be secondary to other consequences of Ecstasy such as acute renal failure leading to hyperkalemia. Finally, looking at the patient’s sodium level on admission, she could have had a fatal hyponatremic seizure. The postmortem examination showed cerebral edema with evidence of herniation of cerebellar tonsils and necrosis, which suggest severe hyponatremia.

Measured postmortem levels of MDMA in the patient were 0.04 mg/100 mL. A reference in the literature, which is based on three deaths and used by the Centre of Forensic Sciences, Toronto identifies 0.04 mg/100 mL and higher as being fatal concentrations.

Still, it is unknown which Ecstasy concentration is safe and, even, whether there is a safe concentration. Different factors (individual susceptibility, circumstances at a party, nonlinear pharmacokinetics, purity of the pill) interact, promoting an unpredictable outcome and making Ecstasy a hazardous drug.

The Paediatric Death Review Committee of the Office of the Chief Coroner of Ontario recommends the following.

• Electrolytes and, more specifically, sodium values should be measured in patients in whom Ecstasy intoxication is suspected, especially when the patient presents with seizures. Fluid management is critical in Ecstasy patients. Patients with hyponatremia should not be resuscitated with hypotonic fluids because that will only aggravate their hyponatremia, putting them at risk for serious neurological consequences.

• Physicians, especially emergency department physicians and general practitioners, should be familiar with the morbidity of Ecstasy, which ranges from an increase in sympathetic tone (tachycardia, hypertension, sweating, mydriasis) to more severe symptoms such as hyponatremia, hyperthermia, rhabdomyolysis, acute renal failure and cardiac arrhythmias. The initial treatment should concentrate on these symptoms.

• The general opinion of Ecstasy’s reputed safety should be corrected. Among adolescents and the lay public, Ecstasy is still considered to be a safe drug. This myth is perpetuated by the media. Time magazine reported in June 2000 that “Ecstasy most probably won’t kill you” and “it takes fourteen of today’s purest pills to kill you”. The present case shows that only one Ecstasy tablet can have a fatal outcome. In fact, this case is one of a series of 14 Ecstasy-related deaths in a three-year time span in Ontario; all of the cases are being reviewed.

Raves and Ecstasy use are a notorious combination. Being both an amphetamine and a hallucinogen, Ecstasy apparently is an ideal ‘party drug’. The incidence of Ecstasy use is unknown, but literature references that are based on surveys in student populations suggest a rate somewhere between 5% and 40%. The most recent data suggest an increase in incidence. These facts, and especially the unpredictable and possibly fatal outcome, makes Ecstasy use a serious public health issue that concerns both adolescents and their parents.