(1670) The Cost of Euphoria: A Case of Refractory Shock From MDMA Toxicity

Tuesday, February 25, 2025

8:45am – 9:45am Eastern Time

Location: Connections Central - RST 07

First Author(s)

BP

Benjamin Pomy, MD

Trauma/Acute Care Surgery Fellow
George Washington University Hospital, United States

Co-Author(s)

KH

Katrina Hawkins, MD

Associate Professor of Anesthesiology and Critical Care Medicine
George Washington University, United States
LG

Leslie Gailloud, MD

Resident
George Washington University Hospital, United States
DY

David Yamane, MD,

Associate Professor
George Washington University, District of Columbia, United States
JW

Jeffrey Williams, MD

Assistant Professor
George Washington University., United States
Danielle Davison, MD

Associate Professor, Director of Intensive Care
George Washington University Medical Center
Washington, District of Columbia, United States

Introduction: 3,4-methylenedioxymethamphetamine (MDMA) is an amphetamine-related psychoactive substance often used recreationally with high abuse potential. Known for its euphoric effects, excessive use of MDMA can lead to neurotoxicity, catecholaminergic excess, and serotonin syndrome. We present a case of refractory shock from MDMA toxicity.

Description: A 27-year-old male presented from a nightclub after MDMA ingestion (confirmed by patient and urine drug screen). Initial vital signs were notable for fever of 42.5C, sinus tachycardia of 170 BPM, and hypotension. On exam he had spontaneous and inducible myoclonus. He was initially stabilized with volume resuscitation and beta blockade for severe tachycardia and active cooling measures for temperature management. His mental status deteriorated and he was intubated for airway protection. For serotonin syndrome, he was started on propofol and midazolam infusions and cyproheptadine. Continuous EEG was negative for seizures. Hypotension became refractory to volume and vasopressors, with an elevated troponin rising over 48 hours. Transthoracic echocardiogram exhibited a mildly-reduced ejection fraction, 40-45%, suggesting more distributive than cardiogenic shock. Despite maximum doses of norepinephrine, vasopressin, epinephrine, and angiotensin II he remained hypotensive and was treated with rescue therapy of methylene blue and epinephrine boluses with eventual stabilization. He also developed rhabdomyolysis and acute kidney injury, acute liver failure, and disseminated intravascular coagulation (DIC). With aggressive resuscitation his renal function recovered. His liver injury slowly corrected and DIC resolved with blood product replacement and supportive care. Ultimately vasopressors weaned off on hospital day 3. After stabilizing he awoke from sedation and followed commands on hospital day 6.

Discussion: Our case describes refractory shock in the setting of MDMA induced serotonin syndrome, requiring extensive resuscitation and vasoactive agents including methylene blue and angiotensin II. Contrary to previous cases he did not develop direct cardiotoxicity, rather profound vasoplegia from catecholamine depletion. This case illustrates a unique presentation of refractory serotonergic induced distributive shock secondary to MDMA overdose.