Acute dilated cardiomyopathy after recreational contaminated amphetamine use

Περιγραφή: Methylenedioxymetampetamine (MDMA), known initially with the brand name “Ecstasy” was originally developed in 1912 and was later promoted as a treatment for narcolepsy in selected patients. The drug was banned in 1985 due to safety concerns. In the late 1980s “Ecstasy” became an embracive term of pills that can contain a mixture of diverse substances including MDMA, such as LSD, cocaine, amphetamines, caffeine, heroine, rat poison, antiparasites etc. This is what makes “ecstasy” particularly dangerous since the user never really knows what combinations he is taking.

A 17 year old male presented to the Emergency Department of our hospital after ingesting one tablet of a substance, which he believed was a synthetic “ecstasy” combined with alchohol. He and his friends reportedly ingested the same substance at a party. He had no prior health problems and received no medication. After the initial euphoric effects subsided, he experienced lightheadedness, nausea, vomiting and diaphoresis. On arrival to the Emergency Department he had a decreased level of consciousness, hyperpyrexia (39,8 ̊C) and marked hypoglycemia (2 mg/dl). He was haemodynamically unstable with hypotension (BP 80/60 mmHg) and developed cardiogenic shock. He was immediately intubated and put under mechanical ventilatory support. Patient’s blood and urine samples were collected at the time of admission before any medication were administered for drug testing.

Electrocardiogram revealed sinus tachycardia ~130/min. Laboratory results reached a maximum value of white blood cells up to 44,5 K/μl, hematocrit 21,9 % platelets 92,2 K/μl, INR 2,06, D-dimers 4283 μg/l, SGOT 160 U/L SGPT 327 U/L, total bilirubin 28 mg/dl, CPK 1207 U/L, CRP 18,9 mg/L. Troponin I peaked at 5680 pg/ml. Chest X ray exhibited a normal cardiothoracic ratio with mild signs of pulmonary congestion. Echocardiography obtained at the day of admission revealed mild left ventricular dilatation with a severely impaired overall systolic function (EF~35%) and diffuse hypokinesis. The patient was transferred to the intensive care unit due to the developing polyorganic failure. He was put under inotropic and vasoconstrictory support. The patient developed rhabdomyolysis and acute renal failure that required continuous peritoneal dialysis. The patient also developed acute ischemic hepatitis with thrombocytopenia and transaminasemia with values 5 times above normal and total bilirubin up to 31 mg/dl that required plasmapheresis and fresh frozen plasma and platelet transfusions and prothrombin complex administration. Systolic dysfunction progressively improved and the patient was stabilized with an estimated ejection fraction approximately 55% three days later. They patient did no longer require pharmacological circulatory support.
Testing of toxicant exposure revealed the presence of 18 different substances, with predominant MDMA, MDA and benzoylecgonine. The pill included diverse substances including amphetamines, barbiturates, benzodiazepines, b blocker, paracetamol and caffeine (table 1). The patient is still hospitalized after hepatic transplantation. Cardiac and renal function have fully resumed, and the patient is heamodynamicallly stable.

Συμπέρασμα: Studies patients who received amphetamine derivatives at lowdoses for ADHD described a wide range of cardiac adverse effects, which did not include cardiomyopathy. This case demonstrates that street drug names can be misleading as the actual contents of the pills may be unknown both to the user as well as the clinician. In vitro human studies show that the metabolism of most psychostimulants is regulated by the cytochrome P450. This may explain individual differences in intensity of drug effects, susceptibility to acute toxicity and drug interactions. In our case a possible enzyme mutation and insufficiency could explain the severity of side effects experienced by our patient compared to his friends who demonstrated no toxicity after ingestion of the same pills.

Φαρμακευτική αγωγή: Ing Dobutamine IV
Ing Dopamine IV
amp Furosemide IV