An announced suicide with ecstasy

Most cases of ecstasy overdose turn out to be accidental, whereas suicide attempts with designer drugs occur only sporadically. We report an announced suicide by means of a combination of 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyethylamphetamine (MDEA). During autopsy, sampling for toxicological investigation (peripheral blood, urine, cerebrospinal fluid, bile and gastric contents) occurred. Serum concentrations as high as 13.33 mg/l for MDMA, 7.32 mg/l for MDEA and 0.43 mg/l for 3,4-methylenedioxyamphetamine were found. Ecstasy tablets, which were confiscated by the police a few days earlier, showed also a combination of MDMA and MDEA. This fact suggests that the ingested tablets probably came from the same source as the seized pills.

MDMA and MDA Concentrations in Antemortem and Postmortem Specimens in Fatalities Following Hospital Admission

Over the last 15 years, numerous deaths involving "Ecstasy" (3,4-methylenedioxymethamphetamine, MDMA) have been reported and described in the literature. In most cases, either antemortem or postmortem concentration data are available. Because of the wide range of results and potential idiosyncratic nature of MDMA toxicity, interpretation of both antemortem and postmortem concentrations is difficult. The possible influence of postmortem redistribution may be an overlooked factor, but existing data involve postmortem concentrations from varying anatomical sites. However, this paper describes for the first time an evaluation of the concentrations of MDMA and 3,4-methylenedioxyamphetamine (MDA) found in five fatalities admitted to hospital where both antemortem and postmortem blood samples were available. Admission MDMA and MDA concentrations ranged between 0.55 and 4.33 mg/L and 0 and 0.10 mg/L, respectively, in antemortem serum/plasma. Postmortem blood MDMA and MDA concentrations ranged between 0.47 and 28.39 mg/L and 0.02 and 1.33 mg/L, respectively. Postmortem concentrations were higher than corresponding antemortem concentrations in all 5 cases with postmortem/antemortem ratios between 1.1 and 6.6 for MDMA and 1.5 and 13.3 for MDA. Differences in concentrations were also observed between anatomical sites, with central sites (e.g., heart) having much higher concentrations than peripheral sites (e.g., femoral). Overall, MDMA and MDA appear to exhibit postmortem redistribution and concentrations measured in postmortem specimens (even from peripheral sites) are not directly comparable with antemortem findings close to or prior to death.

The Epping Jaundice outbreak: mortality after 38�years of follow-up

OBJECTIVE

To investigate mortality in individuals exposed to 4,4'-methylenedianiline (MDA).

METHODS

The mortality of 84 individuals, accidentally poisoned with MDA during the "Epping Jaundice" outbreak of 1965, was compared with expected values based on national rates defined by age, period and sex, for the period 1965-2002. In addition, cancer registration data were analysed for the period 1971-2002.

RESULTS

The vital status of 83% of the group was established, with 37 deaths occurring before the end of follow-up. Mortality from all causes was close to expectation among females (Obs, 25; Exp, 30.3; SMR, 82), and below expectation among males (Obs, 12; Exp, 26.7; SMR, 45). There were no observed deaths from cancer of the liver or from nonmalignant liver disease.

CONCLUSIONS

This study has found no evidence to suggest that the ingestion of MDA had adversely affected mortality.

Interpretation of a 3,4-methylenedioxymethamphetamine (MDMA) blood level: discussion by means of a distribution study in two fatalities

The amphetamine derivative 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy" is a currently used or abused designer drug and fatalities are frequently encountered in forensic practice. However, the question remains open whether an MDMA blood level can be toxic or even potentially lethal. In order to provide insight in the interpretation of a detected MDMA concentration, the distribution of MDMA and its metabolite 3,4-methylenedioxyamphetamine (MDA) in various body fluids and tissues was studied and discussed in two different fatalities. Apart from peripheral blood samples (such as femoral and subclavian blood), various blood samples obtained centrally in the human body and several body fluids (such as vitreous humour) were examined. In addition, various tissues such as cardiac muscle, lungs, liver, kidneys, and brain lobes were analysed. In contrast to the peripheral blood levels, high MDMA and MDA levels were found in cardiac blood and the majority of the organs, except for the abdominal adipose tissue. The high concentrations observed in all lung lobes, the liver and stomach contents indicate that post-mortem redistribution of MDMA and MDA into cardiac blood can occur and, as a result, blood sampled centrally in the body should be avoided. Therefore, our data confirm that peripheral blood sampling remains "the golden standard". In addition, a distinct difference in peripheral blood MDMA concentrations in our two overdose cases was established (namely 0.271 and 13.508 microg/ml, respectively). Furthermore, our results suggest that, if a peripheral blood sample is not available and when putrefaction is not too pronounced, vitreous humour and iliopsoas muscle can be valuable specimens for toxicological analysis. Finally, referring to the various mechanisms of death following amphetamine intake, which can result in different survival times (e.g. cardiopulmonary complications versus hyperthermia), the anatomo-pathological findings and the toxicological results should be considered as a whole in arriving at a conclusion.

Death rates from ecstasy (MDMA, MDA) and polydrug use in England and Wales 1996-2002

The present study reports on all deaths related to taking ecstasy (alone, or in a polydrug combination) occurring in England and Wales in the time frame August 1996-April 2002. Data presented here are based on all information recorded in the National Programme on Substance Abuse Deaths (np-SAD) database. The np-SAD regularly receives all information on drug related deaths in addicts and non addicts from coroners. A total of 202 ecstasy-related fatalities occurred in the chosen time-frame, showing a steady increase in the number of deaths each year. The ratio male:female was 4:1 and 3 of 4 victims were younger than 29. In 17% of cases ecstasy was the sole drug implicated in death and in the remaining cases a number of other drugs (mostly alcohol, cocaine, amphetamines and opiates) have been found. According to toxicology results, MDMA accounted for 86% of cases and MDA for 13% of cases; single deaths were associated with MDEA and PMA. This is the largest sample of ecstasy related deaths so far; possible explanations are given for the observed steady increase in ecstasy-related deaths and a tentative 'rationale' for this polypharmacy combination is then proposed.

Tissue concentrations of MDMA and its metabolite MDA in three fatal cases of overdose

The recreational use of amphetamine derivatives has become increasingly popular in our country in past recent years. Their use is especially common among young people participating in dance parties known as "raves." As a direct consequence of their increased use, the number of fatal cases in which these compounds have been involved have increased dramatically since the second half of the last decade. In our laboratory, we have registered 25 cases related to amphetamine derivatives use since 1996. Three of them were deeply studied and the results obtained are presented in this paper. This information may be useful for the interpretation of the results obtained in toxicological analysis in the cases in which death may be attributed to MDMA use.

Fatality due to combined use of the designer drugs MDMA and PMA: a distribution study

We present a fatal case involving the combined ingestion of amphetamine, 3,4-methylenedioxymethylamphetamine, 3,4-methylenedioxyamphetamine, and paramethoxyamphetamine. Various postmortem specimens (e.g., several blood samples, urine, and tissue samples) were analyzed to study the distribution of the compounds and their metabolites in the human body. Quantitation took place using liquid chromatography-sonic spray ionization-mass spectrometry after pretreatment with a liquid-liquid extraction. The medico-legal findings were compatible with a disseminated intravascular coagulation induced by hyperthermia caused by the simultaneous intake of the amphetamine analogues.

Altered states: the clinical effects of Ecstasy

Ecstasy is the second most widely abused illegal drug in Europe. Ecstasy is the colloquial name for 3,4-methylenedioxymethamphetamine (MDMA), but not all Ecstasy tablets contain MDMA. When taken in hot, crowded environments, Ecstasy/MDMA users have developed acute complications that have had fatal consequences. Epidemiological evidence indicates that adverse reactions to Ecstasy/MDMA intoxication are rare and idiosyncratic. Potential mechanisms of action are reviewed. In animal studies, MDMA damages serotonergic fibres and reduces the number of serotonin transporter sites within the CNS. Demonstration of neurotoxicity in human users of Ecstasy is hampered by a number of confounds that the majority of published studies have failed to address. These confounds are reviewed and their impact is discussed.

Immunohistochemical demonstration of the amphetamine derivatives 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyamphetamine (MDA) in human post-mortem brain tissues and the pituitary gland

Abuse of amphetamine derivatives such as 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyamphetamine (MDA) is an important issue in current forensic practice and fatalities are not infrequent. Therefore, we investigated an immunohistochemical method to detect the amphetamine analogues MDMA and MDA in human tissues. For the staining procedure, the Catalysed Signal Amplification (CSA) method using peroxidase (HRP) provided by Dako and specific monoclonal antibodies were used. Appropriate controls for validation of the technique were included. The distribution of these designer drugs was studied in various brain regions including the four lobes, the basal ganglia, hypothalamus, hippocampus, corpus callosum, medulla oblongata, pons, cerebellar vermis and, additionally, in the pituitary gland. A distinct positive reaction was observed in all cortical brain regions and the neurons of the basal ganglia, the hypothalamus, the hippocampus and the cerebellar vermis but in the brainstem, relatively weak staining of neurons was seen. The reaction presented as a mainly diffuse cytoplasmic staining of the perikaryon of the neurons, and often axons and dendrites were also visualised. In addition, the immunoreactivity was present in the white matter. In the pituitary gland, however, distinct immunopositive cells were observed, with a prominent heterogeneity. The immunohistochemical findings were supported by the toxicological data. This immunostaining technique can be used as evidence of intake or even poisoning with MDMA and/or MDA and can be an interesting tool in forensic practice when the usual samples for toxicological analysis are not available. Furthermore, this method can be used to investigate the distribution of these substances in the human body.

Distribution study of 3,4-methylenedioxymethamphetamine and 3,4-methylenedioxyamphetamine in a fatal overdose

In this study, regional tissue distributions of the amphetamine analogue 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") and its metabolite 3,4-methylenedioxyamphetamine (MDA) in a fatal overdose are presented. Quantitation of MDMA and MDA levels occurred in blood samples taken centrally (right and left heart and main adjacent great vessels) and peripherally (subclavian and femoral blood). In addition, MDMA and MDA concentrations were determined in cardiac and iliopsoas muscle, both lungs, liver, both kidneys, spleen, the four brain lobes, cerebellum and brainstem, and adipose tissue. Finally, MDMA and MDA levels were determined in serum, vitreous humor, urine, and bile. For all samples, a fully validated high-pressure liquid chromatography procedure with fluorescence detection was used. The found substances were also identified with liquid chromatography-tandem mass spectrometry. Our data confirm that blood sampling from an isolated peripheral vein is recommended for MDMA and MDA. In addition, the vitreous humor MDMA level indicates that this fluid can be an interesting alternative when a suitable blood sample is missing. Considering the substantial differences in concentrations in blood samples taken from various sites in the body and the high levels in some tissues (e.g., in liver), we concluded that the influence of postmortem redistribution should be taken into account in the interpretation of toxicological data when an appropriate peripheral sample cannot be obtained or when blood samples are not available because of putrefaction.

Deaths associated with MBDB misuse

The use of phenethylamines in the dance scene is now well established. Apart from amphetamine, the commonest phenethylamine encountered in clinical and forensic settings is 3,4-methylenedioxymethamphetamine (MDMA) commonly known as ecstasy. Other phenethylamines, which have similar effects are encountered, such as 3,4-methylenedioxyethylamphetamine (MDEA) and their use has resulted in death. We report two deaths associated with another less commonly encountered member of the group, N-methyl-1-(3,4-methylenedioxyphenyl)-2-butanamine (MBDB), also known as Methyl-J and Eden.

Restraint as a stressor in mice: against the dopaminergic neurotoxicity of D-MDMA, low body weight mitigates restraint-induced hypothermia and consequent neuroprotection

In experimental studies of stress, restraint of laboratory rodents, perceived as easy to apply and believed to be reproducible, is a commonly used manipulation. The restraint manipulation is utilized as a technique to characterize the physiological, cellular and molecular consequences of stress as well as a tool to understand the ways in which stress may interact with toxic substances. In previous work, we utilized restraint in an examination of the effect of stress on the striatal dopaminergic neurotoxicity engendered by a series of substituted amphetamines. Contrary to our expectations, and most likely due to its body temperature-reducing properties in the mouse, restraint provided total or near total protection against the neurotoxicity of these agents. During subsequent studies utilizing C57Bl6/J female mice of varying weights and ages the degree of temperature reduction and the associated ability to block (20-100%) the dopamine depletion associated with the neurotoxic amphetamine 3,4-methylendioxyamphetamine (D-MDMA, 20 mg/kg of mouse body weight, every 2 h, s.c., total of four doses) were found to vary considerably more than had been previously observed. An in-depth analysis of the role mouse weight plays in the temperature reduction induced by restraint indicates mouse weight is a primary determinant of hypothermia and subsequent neuroprotection. It suggests the induction of stress in rodents by restraint is a complex effect that may lead to unanticipated results. The restraint manipulation is not as straight-forward a procedure as is commonly believed. Our data indicate that consistent application of restraint may require an adjustment of the restrainer device to mouse body weight.

Adam (MDMA) and Eve (MDEA) misuse: an immunohistochemical study on three fatal cases

Three fatal cases of MDMA/MDEA misuse have been examined. These referred to white males between 19 and 20 years of age, in which post-mortem toxicology showed the presence of MDMA (in one case), MDEA (in one case) and both (in one case). The clinical data were analysed and the histopathological findings were studied following immunohistochemical investigations. A complete immunohistochemical study has made it possible to demonstrate rhabdomyolysis and myoglobinuria with alterations of the organs typical of a DIC. Clinical, histopathological and toxicological data suggest that severe or fatal complications following ecstasy ingestion could be related to idiosyncratic response.

[Ecstasy--cool dope with long-lasting effects?]

The amphetamine derivative MDMA (3,4-methylenedioxymethamphetamine) was first synthesised in 1914 as an appetite suppressant, but was never used as such. MDMA is commonly known as "ecstasy" and has become a popular recreational drug of abuse at dance-clubs and rave parties, where it is combined with all-night dancing, crowded conditions, poor hydration and loud sound. This combination is probably the main reason why we have seen an upsurge in toxicity problems at rave parties, since all these factors are thought to promote or increase the toxicity of MDMA. The desired effects of MDMA are euphoria, increased energy and enhanced communication with others. Adverse effects are hyperthermia, rhabdomyolysis, acute renal failure, hepatotoxicity, depression and psychosis.

Intentional overdose and death with 3,4-methylenedioxyethamphetamine (MDEA; "Eve"): case report

We report a case of suicide following ingestion of a large dose of 3,4-methylenedioxyethamphetamine (MDEA, "Eve") in a 27-year-old woman with a history of depression. Several days before her death, she had attempted suicide with benzodiazepines resulting in a 24-hour hospital admission; at that time, no physiologic abnormalities were detected. Findings on autopsy were nonspecific. Toxicologic analysis showed a high concentration of MDEA and the appearance of benzodiazepines in body fluids. Ethanol and other drugs of abuse were not found. We discuss the clinical manifestations, toxicologic syndromes, and mechanisms of death with amphetamine intoxication. MDEA intoxication in young people may result in sudden death.

MDEA related death in Crete: a case report and literature review

"Designer drugs" are derivatives of approved drugs abused for recreational effect and created by underground laboratories to circumvent legal restriction. By far the most controversial drug has been MDMA (3,4-methylenedioxymethamphetamine) and the newer derivative MDEA (3,4-methylenedioxymethamphetamine) often called "Eve". MDEA-related deaths have not been reported in the US, but there have been a death of MDMA and MDEA severe poisonings. Convulsions, collapse, hyperpyrexia, disseminated intravascular coagulation rhabdomyolysis, and acute liver and renal damage result from the ingestion of the drug. Complications may occur and severity and death possibly result. The case of a 31-y-old male, the first victim of MDEA in Greece, is reported. Blood MDEA was 3.1 micrograms/mL; MDEA concentrations in liver, lung and kidney were 4.8, 5.2, and 4.8 micrograms/g respectively.

Accidental intoxication with methylene dianiline p,p'-diaminodiphenylmethane: acute liver damage after presumed ecstasy consumption

BACKGROUND

MDA is the abbreviation for methylene dianiline (p,p' diaminodiphenylmethane; 4,4'-methylenedianiline; CAS 101-77-9); and for methylendioxyamphetamine (MDMA, N, alpha-dimethyl-1,3-benzodioxole-5-ethanamine; CAS 42542-10-9). While the former is used for the production of polyurethane foams, the latter is a psychometric drug, which is becoming increasingly popular in the techno scene.

METHODS

We report six participants of a technoparty (1 female, 5 males, ages 17-25) who were admitted to the hospital with severe colicky abdominal pain and subsequently developed symptoms of hepatotoxicity. They had ingested an alcoholic beverage that had been spiked with a powdery substance they dubbed MDA.

RESULTS

All patients showed similar clinical symptoms, with an identical time course. Acute jaundice developed within 2 days after ingestion. Enzymes indicating cholestasis increased steadily over 7 days and reached peak values of 800 U/L (AP) and 380 U/L (GGT), whereas transaminases remained moderately elevated. Between days 5 and 7, all patients became febrile for one day, their body temperatures rising up to 40 degrees C. There was no evidence for hemolysis or an infectious hepatitis. Toxicological analysis revealed the presence of p,p'-diaminodiphenylmethane (4,4'-methylenedianiline) at a concentration of 130 mg/L in one of two urine extracts examined.

CONCLUSIONS

The analytical data indicate that the participants of the technoparty assumed the aniline-derivative, the cause of Epping Jaundice, was methylendioxyamphetamine because the same abbreviation, MDA, is used for both compounds. An overview of the acute liver toxicity of aniline derivatives is given and the possibility of amphetamine-induced liver damage is discussed.

Fatal poisoning by MDMA (ecstasy) and MDEA: a case report

The first observation of lethal recreational use of MDMA (ecstasy) and MDEA in Italy is reported, together with extensive toxicological and histopathological documentation. Findings such as disseminated intravascular coagulation, rarely reported before, are colocated in the framework of the toxic syndrome for a better definition of criteria for forensic diagnosis.

Acute poisoning with amphetamines (MDEA) and heroin: antagonistic effects between the two drugs

A case of oral ingestion of large doses of both the amphetamine-derivative 3,4-methylene dioxyethamphetamine (MDEA) and heroin is reported. Despite high serum levels of both drugs, the patient did not present with the classic signs and symptoms normally seen during intoxication with these drugs. The patient recovered after symptomatic treatment. The possibility that opposite pharmacological properties of the two drugs prevented the patients death is discussed.

"ADAM' or "EVE'?--a toxicological conundrum

The 3,4-methylenedioxy ring-substituted amphetamines, including "ADAM' and "EVE', are currently popular drugs of abuse. Adverse reactions are reported in the clinical literature but few fatal cases are documented and little toxicological data is available to guide those determining the cause or manner of death in such cases. We report two deaths presenting in a similar manner and with similar clinical features. Various body fluid samples were analysed for amphetamines by gas chromatography/mass spectrometry. In one case, amphetamine alone was detected at levels of 1.54 mg/l and 1.47 mg/l in postmortem blood and admission serum, respectively. The other involved several 3,4-methylenedioxy ring-substituted amphetamines, namely MDA, MDMA and MDEA, at levels of 0.25 mg/l, 0.43 mg/l and 0.3 mg/l, respectively in postmortem femoral blood and 0.24 mg/l, 0.55 mg/l and 0.49 mg/l in admission blood. The interpretation of these toxicological results and some novel legal issues are discussed.

Immunocytochemical evidence for serotonergic neurotoxicity of N-ethyl-methylenedioxyamphetamine (MDE)

N-ethyl-3,4-methylenedioxyamphetamine (MDE) is one of a group of substituted amphetamines which have effects on several serotonergic markers such as tissue levels of serotonin and activity of tryptophan hydroxylase. In this study we have compared its effects on the rat brain with those of p-chloroamphetamine (PCA) using serotonin immunocytochemistry with a primary 5-HT antibody and a secondary avidin-biotin-HRP antibody. Two weeks after multiple (40 mg/kg x 8), but not single, injections of MDE there was a pronounced reduction in the number of serotonin-immunoreactive axons seen. This reduction was most marked in areas innervated extensively by serotonergic axons with varicosities of the fine type (e.g., posterior cerebral cortex and area CA1 of hippocampus). The reduction was quantitatively less than but qualitatively similar to that produced by a single dose of PCA (10 mg/kg). In material from short (3 day) survival animals, a large number of morphologically highly abnormal forms could be seen, suggestive of degenerating axons. A parallel series of sections prepared using tyrosine hydroxylase immunocytochemistry showed no differences between saline controls and PCA- or MDE-treated animals. We conclude that multiple systemic injections of MDE reduce the number of serotonin-immunoreactive fibers in the rat brain 2 weeks after treatment.

3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy"): pharmacology and toxicology in animals and humans

(+/-)3,4-Methylenedioxymethamphetamine (MDMA, "Ecstasy"), a ring-substituted amphetamine derivative first synthesized in 1914, has emerged as a popular recreational drug of abuse over the last decade. Pharmacological studies indicate that MDMA produces a mixture of central stimulant and psychedelic effects, many of which appear to be mediated by brain monoamines, particularly serotonin and dopamine. In addition to its pharmacologic actions, MDMA has been found to possess toxic activity toward brain serotonin neurones. Serotonergic neurotoxicity after MDMA has been demonstrated in a variety of experimental animals (including non-human primates). In monkeys, the neurotoxic dose of MDMA closely approaches that used by humans. While the possibility that MDMA is also neurotoxic in humans is under investigation, other adverse effects of MDMA in humans have been documented, including various systemic complications and a number of untoward neuropsychiatric sequelae. Notably, many of the adverse neuropsychiatric consequences noted after MDMA involve behavioral domains putatively influenced by brain serotonin (e.g., mood, cognition and anxiety). Given the restricted status of MDMA use, retrospective clinical observations from suspecting clinicians will probably continue to be a primary source of information regarding MDMA's effects in humans. As such, this article is intended to familiarize the reader with the behavioral pharmacology and toxicology of MDMA, with the hope that improved recognition of MDMA-related syndromes will provide insight into the function of serotonin in the human brain, in health as well as disease.

A fatal overdose with 3,4-methylenedioxyamphetamine derivatives

Methylenedioxymethylamphetamine (MDMA or 'Ecstasy') is the best known of the 3,4-methylenedioxy ring-substituted amphetamines. Reports of serious adverse reactions and fatalities associated with its use emphasise hyperpyrexia, profuse sweating and subsequent rhabdomyolysis, although cardiac deaths and fatal accidents whilst intoxicated are also prominent. Other 3,4-methylenedioxy ring-substituted amphetamines are also available in the illicit market place and may have different spectra of activity. We report here a case of fatal ingestion of a variety of drugs of this group.

Ecstasy abuse in Ireland

Since the late 1970s, ecstasy (MDMA) has enjoyed increasing popularity as a recreational drug. We report a dramatic increase in reports of ecstasy ingestion to the National Poisons Information Centre from zero in January 1991 to thirty seven in June 1992. We have analysed these thirty seven cases retrospectively for age and sex distribution, clinical details and outcome. The patients involved were predominantly male (80%) and aged 10-30 years, the highest incidence being in the 16-25 year old age group. Thirty two (86%) patients were symptomatic. Symptoms in most cases were relatively mild. One death was reported due to congestive heart failure. The symptoms most frequently reported include dilated pupils, agitation, excitement, hallucinations, tachycardia, palpitations, CNS depression, incontinence and psychiatric symptoms.

Ecstasy and Whizz at a rave resulting in a major burn plus complications

A patient who sustained a major burn following abuse with Ecstasy and Whizz is described. His progress was complicated by hyperpyrexia, acute renal failure and convulsions, all of which have been recently recognized as potential side-effects of Ecstasy abuse. This report further highlights the dangers of substance abuse.

Hyperthermia associated with 3,4-methylenedioxyethamphetamine ('Eve')

A patient was admitted with hyperthermia, muscle rigidity, rhabdomyolysis and disseminated intravascular coagulation. He was initially thought to have taken 3,4-methylenedioxymethamphetamine (MDMA, 'Ecstasy'), but subsequent toxicology revealed the presence of 3,4-methylenedioxyethamphetamine (MDEA, 'Eve'), its sister drug, in his blood. Subsequent in vitro testing for malignant hyperthermia proved to be negative.

Fatal intoxication involving etryptamine

A case of fatal intoxication due to the ingestion of Etryptamine (ethyltryptamine) is reported. Toxicological findings included the following tissue distribution: blood (heart) 5.6 mg/L; urine 80.4 mg/L; vitreous 2.4 mg/L; bile 22.0 mg/L; stomach contents 52.9 mg, brain 16.2 mg/g; liver 18.3 mg/g and kidney 24.0 mg/g. Anatomic pathology showed pulmonary edema and generalized visceral congestion with some epicardial petechiae.

[Acute liver failure caused by methylenedioxymethamphetamine ('ecstasy')]

A female aged 18 years who had regularly taken 1-2 tablets of methylenedioxymethamphetamine ('ecstasy') every weekend developed acute liver failure. She recovered after two months hospitalization with conservative treatment. This is the 10th case of hepatotoxicity after use of ecstasy described in the literature. One patient died, another required liver transplantation. In young patients with jaundice and liver dysfunction a side effect of use of ecstasy should be considered as a possible cause.

Accidental ingestion of 'Ecstasy' (3,4-methylenedioxymethylamphetamine)

There is no report of the effects of 'Ecstasy' (3,4-methylenedioxymethylamphetamine) poisoning in childhood. The case of a 13 month old boy who ingested one capsule of Ecstasy is reported. Neurological and cardiovascular side effects predominated, which responded well to treatment with a chlormethiazole infusion.

Toxicity and deaths from 3,4-methylenedioxymethamphetamine ("ecstasy")

The risk of adverse reactions to 3,4-methylenedioxymethamphetamine (MDMA), more commonly known as "ecstasy", is now widely known in both the USA and UK, but the patterns of illness remain varied. We report our experience during 1990 and 1991. There has been a recent increase in cases of severe toxicity following recreational misuse of small amounts of MDMA. Among 7 fatalities, the pattern of toxicity included fulminant hyperthermia, convulsions, disseminated intravascular coagulation, rhabdomyolysis, and acute renal failure. Until now, there have been few reports of this type of toxicity from MDMA, which may be related both to the potential of the drug to alter thermoregulation and to the circumstances of misuse. In addition, we have monitored 7 cases of hepatotoxicity and suspect that the frequency of this complication is increasing; a history of MDMA misuse should be sought in young people presenting with unexplained jaundice or hepatomegaly. We also describe 5 subjects involved in road traffic accidents in whom MDMA was identified. Misuse of MDMA can have severe acute toxic effects; few data are available concerning long-term morbidity, and this deserves close monitoring in future.

Tissue Distribution of Methylenedioxymethamphetamine

Two cases of death involving methylenedioxymethamphetamine (MDMA) are reported; one case is a fatal acute overdose and the other is a drug-related death. The tissue distribution of MDMA is reported in both cases.

Death associated with abuse of a "designer drug"

A case of death is reported in a 26-year-old male previously thought to be healthy. At autopsy, the anterior descending branch of the left coronary artery was markedly atherosclerotic with a superimposed thrombus. Toxicologic analysis revealed 3,4 methylene dioxyamphetamine (MDA) in the blood at a concentration of 0.08 mg per deciliter. The authors draw attention to the reappearance of designer drugs in Kentucky and to the need for awareness of these deadly substance.

3,4-Methylenedioxymethamphetamine (MDMA) and other amphetamine derivatives

As various substances of abuse come under Drug Enforcement Administration (DEA) Schedule restrictions, slightly modified derivatives (designer drugs) replace them. A series of amphetamine derivatives are discussed in this presentation. Applicable analytical methods are presented. Details of cases handled by the office (hospital patients, driving while under the influence/driving under the influence of drugs [DWI/DUID], and medical examiner cases) are discussed.