Acute complications

Cardiac complications

Cardiac arrhythmias are common—usually a marked sinus tachycardia, but ventricular tachycardia may occur. Deaths which occur soon after ingestion are usually due to cardiac arrhythmias such as ventricular fibrillation. Other cardiac problems induced by amphetamines include myocardial ischemia and infarction, left ventricular dysfunction, and acute cardiomyopathy.

Severe hyperthermia

Hyperthermia may result from muscular hyperactivity, prolonged convulsions, or a serotonin syndrome. Several deaths have occurred in the context of MDMA abuse as a dance drug at 'rave' parties (,a/ 1992). Once the organism has become overheated and fluid requirements are not met, a vicious cycle is set in motion giving rise to disseminated intravascular coagulation (DIC), rhabdomyolysis, and acute renal failure ( O'Connor.1994.).

Hyponatremic encephalopathy

Excessive fluid consumption in the absence of significant losses through prolonged exertion compounded by the presence of the syndrome of inappropriate ADH

secretion (SIADH) has led to acute symptomatic hyponatremia coagulation following MDMA abuse in a few cases (Hartung et,a/ 1998). Symptoms include nausea, vomiting, and a mute state with disorientation and convulsions; death due to cerebral edema is a rare complication.

Cerebrovascular accidents

Amphetamines are widely recognized as a cause of cerebrovascular accidents secondary to their potent sympathomimetic effects or to vasculitis. Most of these patients present with severe headache and nausea; they are usually conscious but confused and disorientated. Death may occur from cerebral infarction, cerebral hemorrhage, or subarachnoid hemorrhage.

Renal complications

Rarely, renal ischemia and infarction may occur due to vasculitis. More commonly, renal failure follows non-traumatic rhabdomyolysis. Hepatitis

Although isolated liver toxicity due to toxic hepatitis is uncommon, MDMA abuse should enter the differential diagnosis in young patients presenting with unexplained jaundice or hepatomegaly.

Intra-arterial injection

Injection of amphetamine into an artery usually occurs accidentally and may cause vasospasm and subsequent ischemia of the affected extremity. Chronic toxicity

Paranoid psychosis with visual, tactile, or olfactory hallucinations is a well-known manifestation of chronic amphetamine abuse. Dyskinesias, compulsive or repetitive behavior, and impaired performance are also recognized chronic sequelae. Recovery is usually rapid after withdrawal of the drug, but occasionally the condition becomes chronic. Poor dietary habits lead to nausea, vomiting, diarrhea, malnutrition, weight loss, dermatological changes, and various infectious complications. Paranoid reactions, anxiety and panic attacks, and depression can occur following MDMA abuse. Of even greater concern, its neurotoxic potential with destruction of serotoninergic neurons could cause mental illness after use of the drug has ceased.

Although tolerance occurs, withdrawal symptoms are not as severe as those with other drugs. The peak effect, with apathy, depression, lethargy, anxiety, sleep disturbances, myalgia, abdominal pain, and increased appetite, are seen 2 to 3 days after the last dose and can last for up to 6 days.

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