MDMA Toxicity Clinical Presentation

  • Author: In-Hei Hahn, MD, FACEP; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Mar 9, 2011
 

History

The patient, friends, emergency medical services (EMS), or the authorities may provide history regarding the possibility of drug abuse. These patients usually present on weekends, often late at night or in the early morning hours after many hours of dancing at raves. Emergency Medical Services (EMS) or the authorities can provide information as to the setting in which they were found (eg, clubs, raves, bars). Sometimes, patients may be carrying MDMA tablets with motif symbols and rave paraphernalia such as neon glow sticks and "smart drinks," which are blended fruit juices with amino acids. However, in the absence of any history, always consider sympathomimetic drugs, such as amphetamines and cocaine, in any young patient who presents with altered mental status and autonomic hyperactivity.

Typically, patients present to the ED either immediately after an ingestion, indicating an acute adverse reaction, or, more commonly, after the euphoric high has subsided and they have tried repeated dosing or co-ingestion with other drugs. Often, patients have mixed toxidromic presentations because of co-ingestion with alcohol, marijuana, ketamine, gamma-hydroxybutyrate (GHB), heroin, or cocaine.

  • Central nervous system
    • Change in mental status, seizures
    • Anxiety, paranoia
    • Increased psychomotor activity, restlessness
    • Hyperthermia, hot flashes
    • Headache
    • Ataxia
    • Blurred vision, halos
    • Syncope
  • Cardiovascular
    • Palpitations
    • Chest pain
  • Gastrointestinal
    • Dry mouth
    • Nausea, vomiting
    • Abdominal cramping
    • Anorexia
  • Skin
    • Diaphoresis
    • Piloerection
  • Other - Pregnancy (Studies have shown that prenatal exposure to MDMA in pregnant rats induces transient and long-term neurochemical and behavioral modifications in dopaminergic and serotonergic functions.[6] )
  • Urinary retention, difficulty voiding
  • Sexual dysfunction
  • Dental - Bruxism (jaw clenching) is frequently observed in MDMA users resulting in enamel erosion and dental decay with consequent tooth fracture and gum recession.
Next

Physical

Physical examination findings demonstrate sympathomimetic hyperstimulation on various organ systems in the body; they can help focus on the most likely toxidrome; keep in mind that polysubstance abuse is the rule rather than the exception.

Pay particular attention to vital signs. MDMA toxicity results in tachycardia, hypertension, and hyperthermia. Obtain a rectal temperature along with frequent serial checks on the patient's neurologic status.

  • Head, ears, eyes, nose, and throat
    • Mydriasis
    • Nystagmus
    • Decreased visual acuity
    • Bruxism (ie, teeth grinding)
    • Trismus, jaw clenching
    • Eroded enamel
    • Dry mouth
  • Central nervous system
    • Hyperthermia
    • Increased psychomotor agitation
    • Hypervigilance
    • Agitation, anxiety
    • Ataxia
    • Hallucinations (very rare)
    • Hypertensive crisis (can lead to symptoms of stroke)
  • Cardiovascular
  • Respiratory
    • Respiratory distress (rare; patients are usually polysubstance abusers)
    • Respiratory failure, aspiration, noncardiogenic pulmonary edema
  • Other
    • Diaphoresis
    • Abdominal cramping
    • Muscle spasm
    • Sexual dysfunction (difficulty having orgasm)
    • Urinary retention
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

In-Hei Hahn, MD, FACEP  Attending Physician, Department of Emergency Medicine, Danbury Hospital Center, Assistant Professor, Department of Surgery, University of Vermont; St Lukes-Roosevelt Hospital Center; and Danbury Hospital Center; Assistant Clinical Professor, Department of Medicine, Columbia University College of Physicians and Surgeons.

In-Hei Hahn, MD, FACEP is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, and American College of Medical Toxicology

Disclosure: Nothing to disclose.

Specialty Editor Board

Peter MC DeBlieux, MD  Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans

Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John G Benitez, MD, MPH  Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author David Yew, MD, to the original writing and development of this article.

References

  1. Carvalho M, Pontes H, Remiao F, Bastos ML, Carvalho F. Mechanisms underlying the hepatotoxic effects of ecstasy. Curr Pharm Biotechnol. Aug 2010;11(5):476-95. [Medline].

  2. National Institute on Drug Abuse. MDMA (Ecstasy) Research Report Series. Electronic Version] http://nida.nih.gov/Research Reports/MDMA/. March 2006;[Full Text].

  3. Drug Abuse Warning Network (DAWN) Reports 2005. [Electronic Version]. Retrieved June 8, 2008 from http://dawninfo.samhsa.gov/.

  4. Cuomo MJ, Dyment PG, Gammino VM. Increasing use of "Ecstasy" (MDMA) and other hallucinogens on a college campus. J Am Coll Health. May 1994;42(6):271-4. [Medline].

  5. O'Shea E, Escobedo I, Orio L, et al. Elevation of ambient room temperature has differential effects on MDMA-induced 5-HT and dopamine release in striatum and nucleus accumbens of rats. Neuropsychopharmacology. Jul 2005;30(7):1312-23. [Medline].

  6. Galineau L, Belzung C, Kodas E, Bodard S, Guilloteau D, Chalon S. Prenatal 3,4-methylenedioxymethamphetamine (ecstasy) exposure induces long-term alterations in the dopaminergic and serotonergic functions in the rat. Brain Res Dev Brain Res. Feb 8 2005;154(2):165-76. [Medline].

  7. Grunau BE, Wiens MO, Brubacher JR. Dantrolene in the treatment of MDMA-related hyperpyrexia: a systematic review. CJEM. Sep 2010;12(5):435-42. [Medline].

  8. McElhatton PR, Bateman DN, Evans C, Pughe KR, Thomas SH. Congenital anomalies after prenatal ecstasy exposure. Lancet. Oct 23 1999;354(9188):1441-2. [Medline].

  9. Ames D, Wirshing WC. Ecstasy, the serotonin syndrome, and neuroleptic malignant syndrome--a possible link?. JAMA. Feb 17 1993;269(7):869-70. [Medline].

  10. Andreu V, Mas A, Bruguera M, et al. Ecstasy: a common cause of severe acute hepatotoxicity. J Hepatol. Sep 1998;29(3):394-7. [Medline].

  11. Burgess C, O'Donohoe A, Gill M. Agony and ecstasy: a review of MDMA effects and toxicity. Eur Psychiatry. Aug 2000;15(5):287-94. [Medline].

  12. Christophersen AS. Amphetamine designer drugs - an overview and epidemiology. Toxicol Lett. Mar 15 2000;112-113:127-31. [Medline].

  13. Cloud J. The lure of ecstasy. Time. Jun 5 2000;155(23):62-8. [Medline].

  14. Cunningham M. Ecstasy-induced rhabdomyolysis and its role in the development of acute renal failure. Intensive Crit Care Nurs. Aug 1997;13(4):216-23. [Medline].

  15. Fahal IH, Sallomi DF, Yaqoob M, Bell GM. Acute renal failure after ecstasy. BMJ. Jul 4 1992;305(6844):29. [Medline].

  16. Freudenmann RW, Oxler F, Bernschneider-Reif S. The origin of MDMA (ecstasy) revisited: the true story reconstructed from the original documents. Addiction. Sep 2006;101(9):1241-5. [Medline].

  17. Green AR, Cross AJ, Goodwin GM. Review of the pharmacology and clinical pharmacology of 3,4-methylenedioxymethamphetamine (MDMA or "Ecstasy"). Psychopharmacology (Berl). Jun 1995;119(3):247-60. [Medline].

  18. Henry JA, Fallon JK, Kicman AT, Hutt AJ, Cowan DA, Forsling M. Low-dose MDMA ("ecstasy") induces vasopressin secretion. Lancet. Jun 13 1998;351(9118):1784. [Medline].

  19. Holden R, Jackson MA. Near-fatal hyponatraemic coma due to vasopressin over-secretion after "ecstasy" (3,4-MDMA). Lancet. Apr 13 1996;347(9007):1052. [Medline].

  20. Joseph M. Ecstasy - Its History and Lore. Carlton Books; 2000:1-96.

  21. Lai TI, Hwang JJ, Fang CC, Chen WJ. Methylene 3, 4 dioxymethamphetamine-induced acute myocardial infarction. Ann Emerg Med. Dec 2003;42(6):759-62. [Medline].

  22. Maxwell DL, Polkey MI, Henry JA. Hyponatraemia and catatonic stupor after taking "ecstasy". BMJ. Nov 27 1993;307(6916):1399. [Medline].

  23. McCann UD, Eligulashvili V, Ricaurte GA. (+/-)3,4-Methylenedioxymethamphetamine ('Ecstasy')-induced serotonin neurotoxicity: clinical studies. Neuropsychobiology. 2000;42(1):11-6. [Medline].

  24. Office of Applied Studies. The Substance Abuse and Mental Health Services Administration (SAMHSA). Drug Abuse Warning Network. 2003.

  25. Randall T. 'Rave' scene, ecstasy use, leap atlantic. JAMA. Sep 23-30 1992;268(12):1506. [Medline].

  26. Reneman L, Booij J, Schmand B, van den Brink W, Gunning B. Memory disturbances in "Ecstasy" users are correlated with an altered brain serotonin neurotransmission. Psychopharmacology (Berl). Feb 2000;148(3):322-4. [Medline].

  27. Ricaurte GA, Martello AL, Katz JL, Martello MB. Lasting effects of (+-)-3,4-methylenedioxymethamphetamine (MDMA) on central serotonergic neurons in nonhuman primates: neurochemical observations. J Pharmacol Exp Ther. May 1992;261(2):616-22. [Medline].

  28. Saadat KS, O'shea E, Colado MI, Elliott JM, Green AR. The role of 5-HT in the impairment of thermoregulation observed in rats administered MDMA ('ecstasy') when housed at high ambient temperature. Psychopharmacology (Berl). Jun 2005;179(4):884-90. [Medline].

  29. Schwartz RH, Miller NS. MDMA (ecstasy) and the rave: a review. Pediatrics. Oct 1997;100(4):705-8. [Medline].

  30. Sporer KA. The serotonin syndrome. Implicated drugs, pathophysiology and management. Drug Saf. Aug 1995;13(2):94-104. [Medline].

  31. Steele TD, McCann UD, Ricaurte GA. 3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy"): pharmacology and toxicology in animals and humans. Addiction. May 1994;89(5):539-51. [Medline].

  32. Weir E. Raves: a review of the culture, the drugs and the prevention of harm. CMAJ. Jun 27 2000;162(13):1843-8. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.