Severe Ecstasy poisoning in an 8-month-old infant

An unusual route of non-intentional intoxication by ecstasy in a toddler

We report a pediatric case of ecstasy intoxication via an unusual route. A mother called the emergency services after her daughter had inserted an ecstasy pill into her nose. During transportation, the child developed hypertension, tachycardia, and tachypnea. She was admitted to the nearest regional hospital, where a physical examination revealed psychomotor agitation, mydriasis, hypertension, tachycardia, and no hyperthermia. Blood tests showed no abnormalities. She was subsequently transferred to a tertiary-level pediatric hospital. During transportation, she was described as being intensely agitated with persistent mydriasis, tachycardia, and high blood pressure. Urinary toxicological screening confirmed the presence of MDMA. She was discharged after 24 h.

Ecstasy (3,4-methylenedioxymethamphetamine): Cardiovascular effects and mechanisms

3,4-methylenedioxymethamphetamine or MDMA (known as "ecstasy") is a recreational drug of abuse, popular worldwide for its distinctive psychotropic effects. Currently, the therapeutic potential of MDMA in psychotherapy has attracted a lot of interest from the scientific community, despite the multitude of effects that this drug of abuse elicits on the human body. While neuronal effects have been the most studied, cardiovascular effects have also been described, as increased blood pressure and heart rate are the most recognizable. However, other effects have also been described at the cardiac (impaired cardiac contractile function, arrhythmias, myocardial necrosis and valvular heart disease) and vascular (vasoconstriction, disruption of vascular integrity and altered haemostasis) levels. Several mechanisms have been proposed, from the interaction with monoamine transporters and receptors to the promotion of oxidative stress or the activation of matrix metalloproteinases (MMPs). This review provides an overview of the cardiovascular implications of MDMA intake and underlying mechanisms, relevant when considering its consumption as drug of abuse but also when considering its therapeutic potential in psychiatry. Moreover, the risk/benefit ratio of the therapeutic use of MDMA remains to be fully elucidated from a cardiovascular standpoint, particularly in patients with underlying cardiovascular disease.

A Paediatric Case of Acute Respiratory Distress Syndrome following Toxicity due to Ecstasy

Ecstasy, the street name for 3,4-methylenedioxyamphetamine, is a derivative of amphetamine with sympathomimetic effects and may cause life-threatening sudden cardiac arrhythmias, severe hyponatraemia, seizures and multiple organ failures. A three-year-old male child had been intubated after a seizure due to accidental intake of ecstasy when he presented to our paediatric emergency unit. On physical examination, the patient had poor health status and was unconscious and his pupils were mydriatic, his body temperature was 37.6 degree Celsius, his heart rate was 148/min, his blood pressure was 120/80 mmHg, his PaO2/FiO2 was 72 mmHg and his oxygen index was 18. Toxicological analyses showed 3,4-methylenedioxyamphetamine. The patient was diagnosed as acute respiratory distress syndrome. Appropriate ventilation strategies were used. On the ninth day after his admission, the patient had stabile vital signs and he was discharged. In this report, this three-year-old paediatric case of acute respiratory distress syndrome due to ecstasy intake will be presented. (Hong Kong j.emerg.med. 2016;23:238-241)

Contractile effects of 3,4-methylenedioxymethamphetamine on the human internal mammary artery

Since the late 1980s numerous reports have detailed adverse reactions to the use of 3,4-methylenedioxymethamphetamine (MDMA) associated with cardiovascular collapse and sudden death, following ventricular tachycardia and hypertension. For a better understanding of the effects of MDMA on the cardiovascular system, it is critical to determine their effects at the vasculature level, including the transporter or neurotransmitter systems that are most affected at the whole range of drug doses. With this purpose in mind, the aim of our study was to evaluate the contractile effect of MDMA in the human internal mammary artery, the contribution of SERT for this effect and the responsiveness of this artery to 5-HT in the presence of MDMA. We have also studied the possible involvement of 5-HT2 receptors on the MDMA contractile effect in this human blood vessel using ketanserin. Our results showed that MDMA contracted the studied human's internal mammary artery in a SERT-independent form, through activation of 5-HT2A receptors. Considering the high plasma concentrations achieved in heavy users or in situations of acute exposure to drugs, this effect is probably involved in the cardiovascular risk profile of this psychostimulant, especially in subjects with pre-existing cardiovascular disease.

Stimulant Toxicity in Children: A Retrospective Study on 147 Patients

OBJECTIVE

To evaluate the signs/symptoms of different stimulant toxicities in children to determine differences among them.

DESIGN

Observational, retrospective, single-center case-series.

SETTING

The only referral hospital for pediatric poisoned patients in Tehran, Iran, covering 12.5 million permanent and 6.5 million temporary residents.

PATIENTS

All children between 2007 and 2012 were evaluated. Their clinical findings, laboratory tests, electrocardiogram, and outcome were evaluated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 147 patients were enrolled (115, 24, three, and five with methamphetamine, methylphenidate, ecstasy, and unknown stimulant toxicities, respectively). Median (interquartile range) age of the methamphetamine- intoxicated children (16 mo [22-42 mo]) was significantly less than those with methylphenidate toxicity (66 mo [33-105 mo]). Almost 79% of the patients had ingested the stimulant, whereas 9% had passively been exposed to the methamphetamine smoke. The frequency of stimulant toxicity had significantly increased during the 5-year period of the study. Restlessness, mydriasis, stereotypic movements, and talkativeness were the most common signs and symptoms. Whereas bruxism only seen in 66.7% (95% CI, 21-94%) of ecstasy users, the prevalence of restlessness, sweating, and tremor was also more in this group of children. On the other hand, mydriasis and stereotypic movements were more common in crystal-meth patients by 76.5% (95% CI, 68-83%) and 53% (95% CI, 44-62%), respectively. A comparison between different routes of crystal-meth intoxication showed that flushing was more common in those who had passively/actively smoked/inhaled methamphetamine (odds ratio, 6.3 [95% CI, 1.5-26]). Palpitation was more seen in methylphenidate toxicity by 12.5% (95% CI, 4-31%). Restlessness was more detected in toddlers, whereas talkativeness and ataxia were more common in older children. Nineteen children (21%) had prolonged QTc according to normal values in different ages. None of them died.

CONCLUSIONS

More studies are warranted to evaluate the frequency and outcome of this poisoning in children. Educational preventive programs are also recommended.

Ecstasy intoxication as an unusual cause of epileptic seizures in young children

In light of the widespread use of ecstasy, it is surprising that only few cases of intoxicated young children have been reported. Patients almost invariably present with convulsions accompanied by sympathetic signs and symptoms such as hyperthermia. Two new cases of toddlers intoxicated with ecstasy are described. The first patient, a 19-month-old boy, presented with convulsions but no sympathetic signs. The pediatrician's suspicion was raised because of the absence of a postictal state. The second patient, a 20-month-old girl, had a more typical presentation with convulsions and hyperthermia. Her story illustrates the fact that immunoassays for toxicological screening can easily miss traces of additional illicit drugs present in the urine such as cocaine. The presence of other illicit drugs provides clues to the child's risky environment and should lead to further investigation. Finally, we review the available literature on ecstasy intoxication to summarize the key presenting manifestations.

Involvement of 5-HT2A receptors in the serotonin (5-HT) syndrome caused by excessive 5-HT efflux in rat brain

Previous studies have demonstrated that serotonin (5-HT) syndromes, particularly for the malignant cases, can be alleviated by ice water mists, cooling blankets and many other external cooling measures. In this study, we tested the hypothesis that external cooling measures reduce the responsivity of 5-HT(2A) receptors to excessive 5-HT efflux, which may be a possible mechanism underlying the treatment of serotonin syndrome. To test this, rat experiments were carried out in the standard and cool ambient temperature (T(amb) ) by administration of the 5-HT precursor 5-hydroxy-L-tryptophan combined with the monoamine oxidase inhibitor clorgyline. The first set of experiments was to assess severity of the syndromes by measuring body temperature responses. Consistent with the hypothesis, we found that the syndrome was malignant at the standard T(amb) of 22°C but alleviated at 12 or 6°C, these results being similar to those in rats pre-treated with the 5-HT(2A) receptor antagonist ketanserin. The second set of experiments was to utilize microdialysis to determine the relationship between the syndrome severity and 5-HT levels at the above-mentioned T(amb) . We found that excessive 5-HT efflux consisted of primary and secondary components through two distinct mechanisms. Furthermore, the secondary component efflux, which can be ascribed to 5-HT(2A) receptor activation, was proportionally reduced at the cool T(amb) of 12 and 6°C. In conclusion, results of this study support the hypothesis that cooling T(amb) reduces the functional activity of 5-HT(2A) receptors, thus alleviating the malignant syndrome.