In summary, our patient was a young man presenting with a seizure and subsequent multiorgan failure. Several hypotheses were considered to explain his presentation including aspiration pneumonitis, severe sepsis, neuroleptic malignant syndrome, rhabdomyolysis leading to AKI and collagen vascular disease with diffuse alveolar hemorrhage. There was no clear source of infection and all cultures including bronchoalveolar lavage were negative. Although he did receive one dose of haloperidol intravenously for his agitation on day 1, neuroleptic malignant syndrome was unlikely as he was only briefly febrile, there was no rigidity and creatine kinase levels were only mildly elevated. Collagen vascular disease seemed unlikely, as all his serologic markers were negative. Of interest, he had a complete and rapid recovery with just supportive treatment. This presentation could be explained by drug toxicity. The initial drug screen was negative for amphetamines. However, this was performed by routine immunoassay, which has a low sensitivity for detecting MDMA. Severity of patient presentation is not necessarily related to the ingested dose of MDMA [3, 4]. Our patient admitted taking multiple drugs along with “Molly”. However, it is unlikely that the other substances ingested concomitantly with “Molly” in our patient would have contributed to a rapid onset multisystem organ failure.

MDMA toxicity is due to release of neurotransmitters such as serotonin and dopamine causing hyperthermia, seizures and muscle breakdown leading to renal failure [1, 2]. Cardiac toxicity can lead to CHF, arrhythmias and myocardial infarction. The mechanism of cardiac toxicity is not clearly understood but can be related to oxidative stress from toxic metabolites of MDMA [5, 6]. In addition, other toxic effects include hyponatremia, disseminated intravascular coagulation, liver failure and cerebrovascular accidents [7, 8]. The development of hyponatremia is multifactorial and is thought to be primarily due to drug-induced excessive thirst and secretion of arginine vasopressin in the setting of fluid availability [6]. Various constellations of these manifestations have resulted in case reports of multisystem organ failure.

Several mechanisms of AKI associated with MDMA have been proposed with the most common etiology being seizure-precipitated rhabdomyolysis potentially accentuated by volume depletion and hypotension. These cases have pronounced levels of creatine kinase [6]. In our patient the cause of renal failure was not clear given only mildly elevated creatine kinase levels. As shown in Table 1, a creatine kinase level of 863 units/L was the highest level recorded during his entire hospitalization. Retrospectively, he most probably developed drug-induced renal artery vasoconstriction leading to renal hypoperfusion and reversible acute tubular necrosis. Severe symptomatic hyponatremia is another serious complication of MDMA that can present with mental status changes and seizures. Although our patient presented with a seizure, it did not appear to be related to hyponatremia nor to hyperthermia. His confusion and agitation prior to intubation could be interpreted as drug withdrawal but was more probably attributable to encephalopathy in the setting of AKI and hypoxemia. Acute respiratory failure in the context of multisystem failure is due to acute lung injury in most cases discussed in the literature [9]. In our patient this appeared more related to fluid overload as a consequence of CHF and AKI.

Based on a review of case reports, Liechti et al. described two common presentations of ecstasy-related death: the first being multiorgan failure precipitated by hyperthermia and the second, hyponatremia-induced brain edema [10]. Our patient had only a transient fever spike with minimally decreased sodium; he does not appear to fit into either of these categories.

Contrary to the belief that “Molly” is pure MDMA, it is often adulterated with so-called designer drugs, for example methylenedioxypyrovalerone also known as bath salts. These compounds inhibit norepinephrine-dopamine reuptake and have a side-effect profile similar to MDMA including AKI [11]. It is possible that our patient unknowingly ingested bath salts with “Molly”.