A 20-year-old woman is brought to the emergency department from a college dorm. She attended a party earlier that night and was brought back to her room by her roommate. The roommate told paramedics that she called for an ambulance because the patient was agitated, combative, and "confused," and then appeared to have a seizure. The patient was obtunded by the time the paramedics arrived. She has a history of psychosis and takes risperidone and diphenhydramine nightly.
Temperature is 39.4 C (103 F), blood pressure is 179/108 mm Hg, pulse is 135/min, and respirations are 24/min. Physical examination shows a young diaphoretic woman who is warm to the touch. Pupils are dilated. There is no nystagmus. Occasional tremors are noted. She is hyperreflexic.
Laboratory results are as follows:
Which of the following is the most likely ingestion causing this patient's findings?

Question

A 20-year-old woman is brought to the emergency department from a college dorm.  She attended a party earlier that night and was brought back to her room by her roommate.  The roommate told paramedics that she called for an ambulance because the patient was agitated, combative, and "confused," and then appeared to have a seizure.  The patient was obtunded by the time the paramedics arrived.  She has a history of psychosis and takes risperidone and diphenhydramine nightly.
Temperature is 39.4 C (103 F), blood pressure is 179/108 mm Hg, pulse is 135/min, and respirations are 24/min.  Physical examination shows a young diaphoretic woman who is warm to the touch.  Pupils are dilated.  There is no nystagmus.  Occasional tremors are noted.  She is hyperreflexic.
Laboratory results are as follows:
 Which of the following is the most likely ingestion causing this patient's findings?

Quizplus · Accepted Answer

3,4-methylenedioxymethamphetamine (MDMA, ecstasy, Molly) is the most common stimulant used in dance clubs and raves. The ingestion of MDMA increases release of serotonin, dopamine, and norepinephrine from presynaptic neurons, preventing their metabolism by inhibiting monoamine oxidase. An oral dose can cause symptoms within 30-60 minutes and last up to 8 hours. Symptoms include euphoria with a sense of profound insight, intimacy, and well-being, but agitation and combativeness can also be present. Adverse effects resulting from sympathetic overload include tachycardia, mydriasis, diaphoresis, tremor, hypertension, arrhythmias, and urinary retention. Serotonin syndrome secondary to MDMA presents with delirium, hyperthermia, autonomic instability, and neuromuscular irritability. It may result in end-organ damage, rhabdomyolysis with acute renal failure, hepatic failure, acute respiratory distress syndrome, and coagulopathy from disseminated intravascular coagulation. Heat from the exertion of dancing in a crowded room coupled with the MDMA-induced hyperthermia can easily lead to excessive water intake and severe hyponatremia. Neurologic effects include confusion, agitation, and seizures due to both MDMA and hyponatremia. Treatment includes supportive care, benzodiazepines (for hypertension, seizures, and agitation), fluids for hyponatremia, and ice baths for hyperthermia. Serotonin syndrome (Choice B) Diphenhydramine overdose usually presents with anticholinergic overdose symptoms such as flushing (red as a beet), very dry skin without diaphoresis (dry as a bone), mydriasis (blind as a bat), agitation (mad as a hatter), and fever (hot as a hare). Sedation can also occur due to antihistaminic effect. MDMA toxicity causes diaphoresis instead of dry skin. (Choice C) Phencyclidine (PCP) intoxication may present with bizarre or violent behavior, psychomotor agitation, hallucinations, and incoordination. However, seizures (and rhabdomyolysis) are less common. PCP intoxication often presents with nystagmus (horizontal and vertical), which is not present in this patient. (Choice D) The ingestion of psilocybin (a hallucinogen found in certain mushrooms) can be associated with serotonergic effects. However, physical symptoms are usually mild. Significant sympathetic activation and seizures occur much less commonly with psilocybin. (Choice E) Risperidone overdose would likely cause muscle stiffness and/or oversedation. Neuroleptic malignant syndrome, which can occur at any antipsychotic dose, is characterized by mental status changes, severe hyperthermia (temperatures sometimes >40 C [104 F]), and generalized lead-pipe rigidity (rather than hyperreflexia). Educational objective: MDMA (3,4-methylenedioxymethamphetamine) is a stimulant used commonly at parties with overdose presenting as serotonin syndrome, severe hyperthermia, and hyponatremia. MDMA overdose can lead to seizures, coagulopathy, and renal and hepatic failure. __________ References: How MDMA's pharmacology and pharmacokinetics drive desired effects and harms. (http://www.ncbi.nlm.nih.gov/pubmed/24431106) Hallucinogen use disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27338969)

A 20-Year-Old Woman Is Brought to the Emergency Department from a College