A death due to ecstasy – a case report

Introduction

People have used drugs of one sort or another for recreational purposes for thousands of years. It was only in the 19th century that the active substances such as morphine and cocaine were extracted. Later on, due to strict legal measures, designer drugs were made in the late 20th century.

Designer drugs such as MDMA, or ‘Ecstasy’, and 3,4-methylenedioxyethylamphetamine (MDEA, or ‘Eve’) have emerged as popular recreational drugs of abuse over the last decade. In Western Europe, due to the erroneous belief that these are relatively safe hallucinogens, the use of such substances as mood enhancers steadily increased, especially in discotheques, during the 1990s. ¹

These substances produce a mixture of central stimulant and psychedelic effects, many of which appear to be mediated by brain monoamines, particularly serotonin and dopamine. ² Nevertheless, ecstasy is still erroneously considered ‘harmless’ by most users. Cases of death directly related to MDMA abuse are uncommon, although there are reports of fatalities, especially in connection with vigorous physical activity (e.g. in events like rave or techno parties). ³ This has become increasingly common even in countries like India, especially in cosmopolitan cities like Bangalore. Here, we report one such case of death due to ecstasy overdose.

Case report

A 29 year-old-male, an event manager by profession, had partied all night and was found unresponsive by his friend. He was taken to a tertiary care centre with an alleged history of consumption of ecstasy tablets. He could not be revived and was declared dead.

Externally, the body measured 173 cm and was moderately built and nourished. Postmortem staining was present over the back of chest and abdomen and was fixed. Rigor mortis was setting in. The face was suffused. The lips had a bluish discolouration. Sub-conjunctival and sublingual haemorrhages (Figure 1) were noted. Bloodstained fluid was oozing from mouth and nostrils, and the nail beds were a bluish colour. An intravenous injection site was present over the front of right elbow with sub-epidermal extravasation. The left buttock showed a sub-epidermal bleed (Figure 4). OPEN IN VIEWER

Internal examination revealed bloodstained frothy fluid in the trachea. Both lungs were intensely congested and oedematous with numerous sub-pleural haemorrhages (Figure 2). Cut section exuded blood mixed with froth. The stomach contained 20 ml of pinkish cream fluid with a peculiar smell and the mucosa was congested. The heart surface showed petechial haemorrhages (Figure 3). All organs were intact and congested. The liver was enlarged with rounded borders. The bladder contained 10 ml of cloudy urine. Histopathological examination revealed congestion of all the organs with pulmonary oedema, hypertrophy of myocardial fibres and with foci of haemorrhage. There were haemorrhages over the epicardiac surface, micro vesicular steatosis of liver and cloudy changes in the kidneys. OPEN IN VIEWER

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Figure 3.

Petechial haemorrhages over surface.

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Figure 4.

Left buttock showing sub-epidermal bleed.

Hospital case records revealed that the deceased was brought with severe diaphoresis and was gasping; he was admitted in intensive care unit (ICU) with ventilator support. He was hypotensive and was started on inotropes. The liver function tests were deranged with elevated enzyme levels. There was a prolonged partial thromboplastin/activated partial thromboplastin (PT/aPTT) time. The platelet counts were 90,000/cu.mm (thrombocytopenia). The electrocardiogram (ECG) showed atrial flutter.

The chemical analysis report was positive for alcohol and methylenedioxymethamphetamine (MDMA) in blood, urine and viscera.

On perusal of the brief facts of case, autopsy findings, histopathology report and chemical analysis report, cause of death was considered to be due to respiratory failure as a result of disseminated intravascular coagulation (DIC) consequent upon consumption of MDMA with alcohol.

Discussion

MDMA is a member of a family of amphetamine derivatives known as MDA. Structurally, MDMA is similar to the stimulant methamphetamine and the hallucinogen mescaline. The effects of MDMA can be described as those of a hallucinogenic amphetamine, combining some effects of amphetamine (speed) with that of LSD (acid). However, many of the effects are dose dependent, and auditory and/or visual hallucinations are not commonly observed. Much of the abuse potential lies in its pleasurable subjective effects (e.g. empathy, euphoria, disinhibition, increased sensuality). Hence, MDMA is often described as the ‘hug drug’ due to the amplified desire to be touched and to socialise. ⁴

MDMA is available as a tablet, capsule, powder and liquid; however, it is most commonly used in tablet form. These tablets often are engraved with various motif symbols and brands, ranging from birds (e.g. doves) and animals (e.g. blue elephants), numbers (e.g. 8 × 1/2), cartoon characters (e.g. Bugs Bunny) and cars (e.g. Ferrari). It is usually swallowed, although reports of smoking, snorting and injecting MDMA have been found.

Tolerance to the psychoactive properties of MDMA develops rapidly, and the user is unable to restore the euphoric effects with repeated doses. Autonomic hyperactivity is a major feature in patients presenting with MDMA toxicity and is dose-dependent. Fatal dysrhythmias have been reported following MDMA use, resulting in ventricular fibrillation and asystole.

Vigorous dancing for long hours in these conditions can predispose patients to hyperthermia, dehydration, and muscle breakdown or rhabdomyolysis. Further complications include DIC, hepatotoxicity and acute renal failure. Most cases of toxicity have been idiosyncratic and did not depend on massive overdoses. ⁴

Clinical proofs of hyperthermia, rhabdomyolysis and DIC are also evident in deaths caused by MDEA intoxication with findings of sub-serous haemorrhage and severe poly visceral stasis.^5,6

DIC is evident at autopsy in the form of sub-serous haemorrhage and severe polyvisceral stasisin deaths caused by MDMA intoxication. In the present case, the pathological data are in accordance with a well-studied and documented clinical entity, i.e. hyperthermia and DIC. The possible mechanism of death in our case is over exertion, hyperthermia and electrolyte imbalance leading to dysrhythmia, acute DIC and pulmonary edema. Under appropriate circumstances, with no other convincing cause of death, the mere presence of methamphetamine may be considered the cause of death.

Conclusion

Deaths due to fatal intoxication with ecstasy are very rare. The problems with these street drugs are that the composition of the drug in these pills is unknown to the drug abusers and the unpredictable nature of these drugs may lead to fatality. Hence, it is important to highlight that these designer drugs are dangerous and can cause fatalities. Further, at autopsy an effort should be made to record the history of drug use and to take the necessary samples in such cases for analysis.