A 21-year-old college student is brought to the emergency department by ambulance. The patient's friends saw him swallow an unknown substance at a concert party. Soon afterward, he appeared to be interacting with others at the party. A few hours later, however, the patient seemed disoriented, appeared flushed, and was sweating profusely. When emergency responders arrived, they found him having a seizure. He was stabilized en route to the emergency department, where his seizure stopped. The patient has no active illnesses except for a history of depression, for which he takes a selective serotonin reuptake inhibitor. He takes no other medications. Temperature is 40 C (104 F), blood pressure is 170/96 mm Hg, pulse is 120/min, and respirations are 18/min. On examination, the patient is flushed, diaphoretic, and hyperreflexive with occasional myoclonus, and he continues to be disoriented. Laboratory results are unremarkable except for a serum sodium level of 121 mEq/L. Which of the following substances is the most likely cause of this patient's condition?

Question

A 21-year-old college student is brought to the emergency department by ambulance.  The patient's friends saw him swallow an unknown substance at a concert party.  Soon afterward, he appeared to be interacting with others at the party.  A few hours later, however, the patient seemed disoriented, appeared flushed, and was sweating profusely.  When emergency responders arrived, they found him having a seizure.  He was stabilized en route to the emergency department, where his seizure stopped.  The patient has no active illnesses except for a history of depression, for which he takes a selective serotonin reuptake inhibitor.  He takes no other medications.  Temperature is 40 C (104 F), blood pressure is 170/96 mm Hg, pulse is 120/min, and respirations are 18/min.  On examination, the patient is flushed, diaphoretic, and hyperreflexive with occasional myoclonus, and he continues to be disoriented.  Laboratory results are unremarkable except for a serum sodium level of 121 mEq/L.  Which of the following substances is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

Explanation: This patient is exhibiting signs and symptoms of MDMA (3,4-methylenedioxy-methamphetamine) intoxication and serotonin syndrome. MDMA, formulated as Ecstasy or Molly, is a synthetic amphetamine with mild hallucinogenic properties. It causes an increase in synaptic norepinephrine, dopamine, and serotonin. Neurotoxicity may develop with long-term use. MDMA is often used by college students during parties to cause euphoria and increase sociability, empathy, and sexual desire. Intoxication may manifest as: Amphetamine toxicity: hypertension, tachycardia, and hyperthermia Serotonin toxicity: serotonin syndrome (characterized by autonomic dysregulation, high fever, altered mental status, neuromuscular irritability, and seizures) and hyponatremia (due to drug-induced inappropriate antidiuretic hormone secretion as well as excessive water intake to reduce hyperthermia) Coma and death may result. As in this patient, combining MDMA with other serotonergic drugs (eg, serotonergic antidepressants) further increases the risk of serotonin syndrome. Illicit synthetic amphetamines and analogs (such as MDMA and bath salts) may or may not show up as amphetamines in routine urine toxicology screens. (Choices A and C) Barbiturate and/or benzodiazepine intoxication can lead to dysarthria, ataxia, and sedation. These substances are likely to lower heart rate and blood pressure rather than elevate them, and they are anticonvulsants rather than proconvulsants. (Choice B) Bath salts are amphetamine analogs that can also cause serotonin syndrome. However, they are more likely to cause agitation (~80% of users), combativeness (>50% of users), and acute psychosis (>30% of users) and are less likely to be associated with hyponatremia. Bath salts are less commonly used than MDMA at college parties. (Choice D) Cocaine intoxication may cause euphoria, increased sexuality, agitation, psychosis, and increased heart rate and blood pressure; it can also cause serotonin syndrome. However, except for in areas where the coca plant grows, cocaine is not usually ingested orally (although it can be used topically on oral mucosa); it is typically used intranasally, smoked (eg, crack), or injected intravenously. (Choice F) Inhalants act as CNS depressants and can lead to slurred speech, dizziness, transient euphoria, and loss of consciousness. Effects typically last 15-45 minutes. Elevated vital signs are uncommon. Inhalants are not ingested orally. Educational objective: MDMA (3,4-methylenedioxy-methamphetamine) is a synthetic amphetamine with mild hallucinogenic properties. It can cause euphoria, increased sexual desire, and empathy. Intoxication may lead to hypertension, tachycardia, hyperthermia, serotonin syndrome, and hyponatremia. Coma, seizures, and death may occur. References: Ecstasy use and serotonin syndrome: a neglected danger to adolescents and young adults prescribed selective serotonin reuptake inhibitors. (http://www.ncbi.nlm.nih.gov/pubmed/24006318) Multiple MDMA (ecstasy) overdoses at a rave event: a case series. (http://www.ncbi.nlm.nih.gov/pubmed/22640978)

A 21-Year-Old College Student Is Brought to the Emergency Department