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 emergency department (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 manifestations include the following:
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Change in mental status, seizures
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Anxiety, paranoia
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Increased psychomotor activity, restlessness
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Hyperthermia, hot flashes
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Headache
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Ataxia
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Blurred vision, halos
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Syncope
Cardiovascular manifestations include the following:
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Palpitations
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Chest pain
Gastrointestinal manifestations include the following:
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Dry mouth
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Nausea, vomiting
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Abdominal cramping
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Anorexia
Skin manifestations include the following:
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Diaphoresis
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Piloerection
Other manifestations include the following:
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Urinary retention, difficulty voiding
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Sexual dysfunction
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Dental - Bruxism (jaw clenching) is frequently observed in MDMA users; it results in enamel erosion and dental decay, with consequent tooth fracture and gum recession.
Although the causal relationship between MDMA and liver toxicity has not been shown definitively, case reports document hepatotoxicity resulting in self-limited hepatitis and fulminant liver failure following MDMA use. Always keep in mind the possibility of other drug ingestions. MDMA users often co-ingest other drugs, and ecstasy tablets can also contain other drugs. Heroin, ketamine, cocaine, alcohol, and marijuana have been implicated, and the patient may present with a mixed toxidromic clinical picture.
Physical Examination
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 findings include the following:
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Mydriasis
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Nystagmus
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Decreased visual acuity
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Bruxism (ie, teeth grinding)
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Trismus, jaw clenching
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Eroded enamel
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Dry mouth
Central nervous system findings include the following:
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Hyperthermia
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Increased psychomotor agitation
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Hypervigilance
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Agitation, anxiety
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Ataxia
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Hallucinations (very rare)
Cardiovascular findings include the following:
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Tachycardia
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Hypertensive crisis
Respiratory findings include the following:
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Respiratory distress (rare; such patients are usually polysubstance abusers)
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Respiratory failure, aspiration, noncardiogenic pulmonary edema
Other findings include the following:
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Diaphoresis
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Abdominal cramping
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Muscle spasm
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Sexual dysfunction (difficulty having orgasm)
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Urinary retention
