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Ischemic Stroke In A Young Man Following Ecstasy Abuse: A Case Report

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Athanasios A. Fortis
Internist / Intesivist
Intensive Care Unit
Konstantopouleion Hospital

Harikleia D. Nikolaou
Internist /Intesivist
Intensive Care Unit
Konstantopouleion Hospital

Vassilios M. Zidianakis
Anaesthesiologist /Intesivist
Intensive Care Unit
Konstantopouleion Hospital

Nina M. Maguina M.D.
Pneumonologist /Intensivist
Intensive Care Unit
Konstantopouleion Hospital

Citation: A. A. Fortis, H. D. Nikolaou, V. M. Zidianakis & N. M. Maguina : Ischemic Stroke In A Young Man Following Ecstasy Abuse: A Case Report . The Internet Journal of Emergency and Intensive Care Medicine. 2005 Volume 8 Number 1

Introduction
Case Report
Address for Correspondence

Abstract

We report a case of a 20 years old male who was admitted to the Emergency Room, with confusion and profound sweating. Urine analysis was proved positive for methylenedioxymethamphetamine cannabinoids and benzodiazepines. 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. 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.

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.

Address for Correspondence

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

References

1. Shulgin AT. The backround and chemistry of MDMA. J Psychoactive Drugs 1986; 18: 291-4 (s)

2. Ricaurte GA, McCann UD. Neurotoxic amphetamine analogues: effects in monkeys and implications for humans. Ann NY Acad Sci 1992; 648:371-82 (s)

3. Capt James A. Rochester, MD, USAF, MC, Jeffrey T. Kirchner, DO Ecstasy (3,4-Methylenedioxymethamphetamine: History, Neurochemistry, and Toxicology. J Am Board Fam Pract 1999; 12(2): 137-42,. (s)

4. Milroy CM, Clark JC; Forrest AR. Pathology of deaths associated with "ecstasy" and "eve" misuse J Clin Pathol 1996; 49(2):149-53 (s)

5. Reneman L Habraken JB Majoie CB Booij J, den Heeten GJ () MDMA ("Ecstasy") and its association with cerebrovascular accidents: preliminary findings. AJNR Am J Neuroradiol 2000; 21(6):1001-7. (s)

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	The Internet Journal of Emergency and Intensive Care Medicine™ ISSN: 1092-4051 \| Home \| Editors \| Current Issue \| Archives \| Instructions for Authors \| Disclaimer \| Share with others \| Ischemic Stroke In A Young Man Following Ecstasy Abuse: A Case Report Read printer friendly Subscribe in a reader Share with others Athanasios A. Fortis Internist / Intesivist Intensive Care Unit Konstantopouleion Hospital Harikleia D. Nikolaou Internist /Intesivist Intensive Care Unit Konstantopouleion Hospital Vassilios M. Zidianakis Anaesthesiologist /Intesivist Intensive Care Unit Konstantopouleion Hospital Nina M. Maguina M.D. Pneumonologist /Intensivist Intensive Care Unit Konstantopouleion Hospital Citation: A. A. Fortis, H. D. Nikolaou, V. M. Zidianakis & N. M. Maguina : Ischemic Stroke In A Young Man Following Ecstasy Abuse: A Case Report . The Internet Journal of Emergency and Intensive Care Medicine. 2005 Volume 8 Number 1 Table of Contents Introduction Case Report Address for Correspondence Abstract We report a case of a 20 years old male who was admitted to the Emergency Room, with confusion and profound sweating. Urine analysis was proved positive for methylenedioxymethamphetamine cannabinoids and benzodiazepines. 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. 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. 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. Address for Correspondence Dr A Fortis, Kerkis 71 Street, Petroupoli, Athens 132 31 Greece TEL: +302105014985 fax: +302102710019 Email: [at40s@otenet.gr] References 1. Shulgin AT. The backround and chemistry of MDMA. J Psychoactive Drugs 1986; 18: 291-4 (s) 2. Ricaurte GA, McCann UD. Neurotoxic amphetamine analogues: effects in monkeys and implications for humans. Ann NY Acad Sci 1992; 648:371-82 (s) 3. Capt James A. Rochester, MD, USAF, MC, Jeffrey T. Kirchner, DO Ecstasy (3,4-Methylenedioxymethamphetamine: History, Neurochemistry, and Toxicology. J Am Board Fam Pract 1999; 12(2): 137-42,. (s) 4. Milroy CM, Clark JC; Forrest AR. Pathology of deaths associated with "ecstasy" and "eve" misuse J Clin Pathol 1996; 49(2):149-53 (s) 5. Reneman L Habraken JB Majoie CB Booij J, den Heeten GJ () MDMA ("Ecstasy") and its association with cerebrovascular accidents: preliminary findings. AJNR Am J Neuroradiol 2000; 21(6):1001-7. (s) This article was last modified on Fri, 13 Feb 09 13:26:16 -0600 This page was generated on Fri, 19 Mar 10 13:39:41 -0500, and may be cached.
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