Ecstasy-associated acute severe hyponatremia and cerebral edema: a role for osmotic diuresis?

Ecstasy, or 3,4-methylenedioxymethamphetamine (MDMA), is a drug of abuse with a wide range of toxicity affecting the brain, heart, and liver. Renal toxicity of MDMA is due either to acute kidney injury (e.g., non-traumatic rhabdomyolysis) or to water and electrolyte imbalance (i.e., hyponatremia). Although syndrome of inappropriate secretion of antidiuretic hormone has been recognized as a major mechanism for MDMA-associated hyponatremia, other factors (e.g., MDMA-induced polydipsia) have also been proposed.

Hypertonic saline has been used by most authors to treat MDMA-associated acute symptomatic hyponatremia. Our case is the second published report in which mannitol was chosen for management of this pathologic phenomenon.

We present a case of MDMA-associated acute severe hyponatremia and cerebral edema in a young female, and analyze the underlying pathophysiology, the therapeutic strategy, and the course of disease.

Based on this observation, coupled with the previous report and the complex pathophysiology of this phenomenon, we suggest that osmotic diuresis be considered a possible therapeutic option for MDMA-associated acute symptomatic hyponatremia.