A fatal case of myocardial damage due to misuse of the 'designer drug' MDMA

A 39-year-old woman collapsed after oral intake of 3,4-methylenedioxymethyl-amphetamine (MDMA, "ecstasy"). After ingestion of the drug, she had felt persistent discomfort in her anterior chest area, and lost consciousness for a few minutes on the following morning. She was transported to a hospital and died seven days after collapse. A serum sample obtained on admission revealed an MDMA concentration of 1.2mg/L, but no evidence of any other drug including amphetamine, methamphetamine, or other ring-substituted amphetamines. Microscopic examination at autopsy revealed striking changes in the heart, including small foci of myocyte necrosis with a surrounding macrophage inflammatory response, foci of fibrosis, and calcification accompanied by myocyte necrosis, these changes being predominant in the right ventricle. In the liver, hepatic necrosis was observed with fatty degeneration accompanied by inflammation. Myoglobinuria was demonstrated in the kidney by immunohistochemistry. Degeneration of neurons throughout the whole brain was also evident, in addition to haemorrhagic foci in the pons and medulla. Serious bronchopneumonia was also found in the right lung. These findings provide evidence that oral intake of MDMA can result in cardiotoxicity, inducing cardiac arrhythmia and cardiovascular collapse. As a consequence of the compromised blood supply, brain necrosis may occur, followed by severe bronchopneumonia. Ingestion of MDMA could also lead to liver damage as well as myoglobinuria resulting from rhabdomyolysis. These data suggest that death in this case had been caused largely by MDMA intoxication.