Fatal brain oedema after ingestion of ecstasy and benzylpiperazine

History and admission findings: A 23-year-old woman was hospitalized with h eadache, malaise and somnolence 11 hours after ingestion of AZ (benzylpiper azine), 7 hours after ingestion of ecstasy (MDMA), and large volume of flui ds. On admission she had bradycardia (heart rate 48/min), hypertension (blo od pressure 154/95 mm Hg), and reduced consciousness with diminished tendon reflexes and non-reacting pupils (Glasgow Coma Score 6). Investigations: Serum sodium was markedly decreased (115 mmol/l [normal 135 -145]) with low plasma osmolality (246 mosm/kg [normal 280-300]). Other lab oratory findings were within normal limits. Treatment and course: The patient had severe hypervolaemic hypotonic hypona traemia. 40 minutes after admission she seized twice and was intubated. Bra in CT scan showed massive cerebral oedema with beginning tonsillar herniati on. Serum sodium concentration returned to normal within 38 hours, but the patient deteriorated neurologically with increasing tonsillar herniation de tected in a second brain CT scan. The patient died 57 hours after admission . Conclusion: 13 cases of MDMA-associated severe hyponatraemia are reported. Intake of fluids after MDMA ingestion may lead to potentially fatal hypervo laemic hypotonic hyponatraemia with cerebral oedema. Symptoms appear about 8 hours (range 4-18) after MDMA ingestion. Even low doses of MDMA and fluid s may lead to a serious outcome. The only risk factor is female gender. Mea surement of serum sodium and brain CT scan is recommended in all patients w ith altered mental status after MDMA consumption.