CORONER’S CORNER
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 re-
sults 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 admis-
sion, which rose to 134 mmol/L 3.5 h later. The hy-
ponatremia played an important, if not crucial role, in
the history of this girl because brain stem coning was
detected during the postmortem. Hyponatremia is as-
sociated with Ecstasy use either because of an inap-
propriate 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, respec-
tively), which is indicative of (moderate) rhabdomyoly-
sis. 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 lit-
erature. Secondly, the cardiac arrest could be secon-
dary 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 necro-
sis, 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, circum-
stances at a party, nonlinear pharmacokinetics, pu-
rity of the pill) interact, promoting an unpredictable
outcome and making Ecstasy a hazardous drug.
Paediatr Child Health Vol 6 No 7 September 2001
The Paediatric Death Review Committee of the Office
of the Chief Coroner of Ontario recommends the follow-
ing.
· 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 popu-
lations suggest a rate somewhere between 5% and
40%. The most recent data suggest an increase in inci-
dence. 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.
Ewout J Hoorn for the Paediatric Death Review Committee,
Office of the Chief Coroner of Ontario, Toronto, Ontario
BIBLIOGRAPHY
Henry JA, Jeffries KJ, Dawling S. Toxicity and deaths from
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Holden R, Jackson MA. Near-fatal hyponatraemic coma due to
vasopressin over-secretion after “ecstasy” (3,4-MDMA). Lancet
1996;347:1052.
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