A 21-year-old man is brought to the emergency department by his friends due to severe agitation and confusion. His friends report that they were at an electronic music festival when he suddenly became profusely sweaty, disoriented, and collapsed. His medical history is significant for major depressive disorder, for which he takes fluoxetine daily. His temperature is 39.4°C (102.9°F), blood pressure is 170/105 mm Hg, pulse is 128/min, and respirations are 22/min. Physical examination shows diffuse diaphoresis, bilateral mydriasis, and tremors. Neurologic examination reveals prominent hyperreflexia and sustained clonus in the lower extremities. Which of the following illicit substances did this patient most likely consume?
- ACocaine
- BPhencyclidine
- 3,4-methylenedioxymethamphetamineAnswer
- DHeroin
- ECannabis
Answer
3,4-methylenedioxymethamphetamine
The correct answer is 3,4-methylenedioxymethamphetamine (MDMA). This patient is presenting with classic signs of serotonin syndrome: autonomic hyperactivity (hyperthermia, tachycardia, hypertension, diaphoresis), altered mental status (agitation, confusion), and neuromuscular irritability (hyperreflexia, sustained clonus). MDMA, also known as Ecstasy or Molly, is a common drug of abuse at electronic music festivals and clubs. It exerts its clinical effects primarily by causing massive release of serotonin into the synaptic cleft. When MDMA is used by a patient who is already taking a selective serotonin reuptake inhibitor (SSRI) like fluoxetine, the synergistic increase in serotonergic activity can precipitate life-threatening serotonin syndrome.
Step-by-Step Solution
Key Concept
Serotonin syndrome can be precipitated by the concomitant use of an SSRI and MDMA (Ecstasy), presenting with autonomic hyperactivity, altered mental status, and neuromuscular irritability (hyperreflexia, clonus).