Introduction

MDMA, (3,4-Methylenedioxymethamphetamine) or ecstasy is an illicit drug used for recreational purposes, and has been initially introduced in 1912 as an appetite suppressant. In the 1950s it has been used as a drug which could lessen inhibitions in patients undergoing psychoanalysis. In the mid 1980s it became popular as a recreational drug used primarily among young adults.₁ No Lethal Dose ₅₀ (LD₅₀) studies in humans have been made. In patients with toxic MDMA abuse, LD₅₀ approaches or in some cases exceeds the primate LD₅₀ dose, which is 22 mg/kg.₂

Toxic effects of MDMA abuse include malignant hyperthermia, acute hepatic and renal failure, acute respiratory failure, cardiovascular collapse, cardiac arrythmias, hypertension, rhabdomyolysis, disseminated intravascular coagulation, hyponatremia, cerebral edema, inappropriate secretion of antidiuretic hormone syndrome, psychosis and depression. Little information is available regarding acute management or treatment of toxic ingestions.₃

Case Report

A 20 years old male was admitted to the Emergency Room, with confusion and profound sweating. His initial laboratory tests were normal. Soon thereafter a right hemiparesis, dysarthria, and subsequent deterioration of consciousness level were established. Babinski sign was positive in both legs. During the episode flumazenil, naloxone and corticosteroids were administered. Ophtalmoplegia, dysarthria, temperature of 39°C, cardiac arrhythmias, and rhabdomyolysis were also present. Urine analysis was proved positive for methylenedioxymethamphetamine cannabinoids and benzodiazepines. Until that time the patient denied any use of illegal narcotics. A head computed tomography scan (CT) upon his admission showed no abnormalities, but subsequent Magnetic Resonance Imaging (MRI) revealed an ischemic infarct in the brainstem. The patient has been transferred to the ICU. Two days later, a new CT scan confirmed the presence of the infarct. During his stay in the ICU the patient has been monitored for arrhythmias, was hydrated and rhabdomyolysis was appropriately managed. Five days latter following a partial recovery the patient was discharged. No other obvious causes that may have led to cerebral infarction, including potential cardiovascular pathology, abnormalities of blood coagulation or collagen vascular disease or others were found in extensive laboratory work up.

Because of its worldwide illicit use, MDMA merits a better understanding. The postmortem findings in deaths associated with ecstasy, include liver abnormalities, varying from foci of individual cell necrosis to hepatic necrosis, myocardial injuries consistent with catecholamine induced damage, whilst perivascular haemorrhagic and hypoxic changes have been identified in the brain₄. MDMA has been associated with cerebrovascular accidents, and although this fact is widely accepted, there are only few case reports described. From our search in bibliography we found only six relevant case reports of ischaemic stroke following ecstasy use. A possible interpretation of these incidents has been proposed from the work of Reneman and al who were based on single photon emission CT and have concluded that there is an altered regulation of 5HT2A receptors in MDMA users implicating that they may be at risk for cerebrovascular accidents due to abnormal vascular reactions. ₅

Available data imply a strong association between MDMA abuse and cerebral infraction. Our presentation, added to the previous relevant case reports on ecstasy adverse effects, aims at underlining the importance of drug abuse inclusion in the differential diagnosis of cerebral infraction in young adults.

Correspondence to

Dr A Fortis, Kerkis 71 Street, Petroupoli, Athens 132 31 Greece TEL: +302105014985 fax: +302102710019 Email: at40s@otenet.gr