The Case of Ecstasy Confusion
By Emily Allen
Department of Math and Science
Gloucester County College, Sewell NJ
_____________________________________________________________________________
Sally, Nick and Jane are good friends. Jane and Nick are regular users of the drug, ecstasy.
Sally has never tried this drug but feels pressured to give it a try. She is a bit nervous about its
side effects and decides to do some web research. She discovers it is a synthetic, psychoactive
drug chemically similar to the stimulant methamphetamine and known as MDMA (3-4
methylenedioxymethamphetamine). Sally also reads it is often linked to heat stoke and
dehydration with recommendations to drink large quantities of fluids.
Sally, Nick and Jane attend a party on Saturday night. Sally decides to try ecstasy with the rest
of the group. Sally, Nick and Jane all consume their ecstasy pills after using their home testing
kit to determine the ecstasy contains no hidden substances.
Sally has been heeding the internet advisories to be aware of fluid intake. She has consumed a
very large bottle of water already. She hasn’t had to go to the bathroom and thinks she may need
more water so she starts on a second bottle. Jane and Nick are just eating potato chips by the
handful on the couch thinking about how silly and paranoid Sally is about her water drinking.
About two hours after taking the pills, Sally starts complaining of being tired and having a
headache. Despite the water Sally drank she still feels thirsty. Nick and Jane are very alert and
feel fine. Sally seems more and more disoriented.
Questions to Ponder:
1. Before taking the ecstasy and drinking the second bottle of water, Sally was fully
hydrated. What do you think may be occurring?
2. Hypothesize on what body systems may be involved in Sally’s symptoms?
3. What’s different about Nick and Jane’s behavior that could account for the fact that they
are not having the same symptoms as Sally?
Emily Allen, Gloucester County College, HAPS: Renal Physiology Course
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The Case of Ecstasy Confusion Part II
By Emily Allen
Department of Math and Science
Gloucester County College, Sewell NJ
_____________________________________________________________________________
Sally’s friends decide she needs to go to the emergency room. She doesn’t appear to be hot and
overheating just confused. Sally drinks an additional glass of water still complaining that she is
thirsty. She continues to appear more and more confused and her headache worse. Her friends
do not want to tell the doctors at the emergency room of their drug use so they just say she is
feeling sick. The doctors run some tests and obtain the following results:
Test
Blood sodium concentration
Blood chloride concentration
Blood bicarbonate
concentration
Serum osmolarity
Urine Specific Gravity
Sally’s Results
117 mmol/L
87 mmol/L
15 mmol/L
Normal Range
135-145 mmol/L
98-108 mmol/L
22-30 mmol/L
245 mOsm/kg
1.015
285-295 mmol/L
1.002 -1.028
Questions to Answer:
1. Is Sally’s extracellular fluid electrolyte concentration for the three ions high or low?
2. Are Sally’s cells in a hypertonic, hypotonic or isotonic solution? What direction is water
moving by osmosis? Explain why?
3. Urine specific gravity is an indicator of urine osmolarity. Given Sally’s blood sodium
and osmolarity, is the urine specific gravity what you would expect, near the upper end of
normal osmolarity?
4. What organ is affected causing the confusion? Why?
Emily Allen, Gloucester County College, HAPS: Renal Physiology Course
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The Case of Ecstasy Confusion Part III
By Emily Allen
Department of Math and Science
Gloucester County College, Sewell NJ
_____________________________________________________________________________
The doctors note Sally’s decreased extracellular sodium, chloride, and bicarbonate concentration
and decreased plasma osmolarity. The doctors give Sally an IV solution. The doctors believe
that Sally has consumed more water than necessary but that there may be inappropriate hormonal
function to blame for her symptoms.
Nick believes the doctors should know about Sally’s ecstasy use so they can properly treat her.
He speaks up and tells them about their drug use.
Questions to Answer:
1. What hormone regulates normal extracellular fluid osmolarity and is most likely altered?
Would an abnormally high or low level be expected?
2. Would an IV solution be the proper treatment? What type (hypertonic, hypotonic,
isotonic) IV solution would they give Sally? Why?
3. What should have Sally consumed other than water?
Emily Allen, Gloucester County College, HAPS: Renal Physiology Course
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The Case of Ecstasy Confusion Part IV
By Emily Allen
Department of Math and Science
Gloucester County College, Sewell NJ
_____________________________________________________________________________
A few hours later Sally has urinated and is feeling better. The doctors gather Nick, Sally and
Jane around to talk about the situation.
One doctor begins “Drug use is not a good idea under any circumstance, but there is so much
information available at our fingertips. It is not always the correct information. We have to be
aware of the sources and interpret the information for ourselves.”
“I was trying to be safe.” Sally squeaks into the conversation.
“Most websites advise you to drink plenty of water because ecstasy use is often combined with
dancing and fluid loss due to sweating. But ecstasy releases abundant quantities of serotonin
which is closely associated with antidiuretic hormone (ADH) release. So when serotonin is
overproduced, unnecessary release of ADH may lead to hyponatremia” says another doctor.
Jane asks “So why didn’t Nick and I get hyponatremia?”
“There are probably many reasons! You too may have had slight hyponatremia, but it was mild
enough to be asymptomatic. Sally intensified her problem by drinking so much water. There are
other situations where normal water balance deviations become exacerbated by seemingly
preventative behavior. Many people participate in marathons and know they must
conscientiously stay hydrated. But just last week we had someone who was in the hospital with
hyponatremia, with symptoms just like Sally had been experiencing. Or you may have heard of
the woman who died of water intoxication following a "Hold your wee for a Wii" contest where
individuals drank water and tried to avoid urinating.” says the same doctor.
Questions to Answer:
1. How could a marathon runner experience hyponatremia?
2. Why would a marathon runner on a hot day drinking the same quantity of water be less
likely to experience this condition than a marathon runner on a cold day?
Emily Allen, Gloucester County College, HAPS: Renal Physiology Course
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The Case of Ecstasy Confusion Answer Key
Part I
1. Before taking the ecstasy and drinking the second bottle of water, Sally was fully
hydrated. What do you think may be occurring?
There is not enough information to fully answer the question of what is occurring to Sally.
Students should debate the possibilities of what may be occurring to her based on the limited
information but students should recognize that more information must be given before
making a diagnosis. Many potential answers may be discussed. This discussion begins the
students thinking about the symptoms involved in the case and helps the group members to
get involved in the case.
2. Hypothesize on what body systems may be involved in Sally’s symptoms?
There may be many answers for this question. There is not enough information to come up
with a definitive list but students may think about the possibilities.
1. Renal system due to the high water intake and no urination.
2. Neural due to the headache and disorientation
3. What’s different about Nick and Jane’s behavior that could account for the fact that they
are not having the same symptoms as Sally?
Nick and Jane are regular ecstasy users and this was Sally’s first time using the drug. Sally
consumed a large quantity of water and Nick and Jane ate potato chips. Later in the case
study it will be revealed that their food and water consumption differences were a major
component of the different symptoms.
Part II
1. Is Sally’s extracellular fluid electrolyte concentration for the three ions high or low? Low
2. Are Sally’s cells in a hypertonic, hypotonic or isotonic solution? What direction is water
moving by osmosis? Explain why?
Sally’s cells are in a hypotonic solution. Water is moving into the cells because the
osmolarity in the cells is higher than the extracellular fluid.
3. Urine specific gravity is an indicator of urine osmolarity. Given Sally’s blood sodium
and osmolarity, is the urine specific gravity what you would expect, near the upper end of
normal osmolarity?
Yes, the urine specific gravity appears near the upper end of normal osmolarity. If excessive
fluid intake was diluting Sally’s plasma causing her increase in blood sodium and osmolarity
you would expect to see a decrease in the specific gravity. Sally’s blood sodium and
osmolarity being high and a low specific gravity indicates interference with urinary dilution
that the kidneys are unable to excrete water as they should be doing. An inappropriate
secretion of ADH would cause this interference with urinary dilution.
4. What organ is affected causing the confusion? Why?
All of the tissue cells of the body will swell due to the hypotonic extracellular fluid. The
neurons in the brain are tightly packed in the skull and given virtually no room to expand.
This brain edema causes the confusion.
Part III
1. What hormone regulates normal extracellular fluid osmolarity and is most likely altered?
Would an abnormally high or low level be expected?
Emily Allen, Gloucester County College, HAPS: Renal Physiology Course
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ADH is the major regulator of ECF osmolarity and secondarily regulates ECF volume. A high
level of ADH would be expected. Even small amounts of ecstasy have been shown to cause
increases in ADH secretion and ADH stimulates thirst. Thus ecstasy is a cause of the syndrome
of inappropriate ADH secretion.
2. Would an IV solution be the proper treatment? What type (hypertonic, hypotonic,
isotonic) IV solution would they give Sally? Why?
A 3% NaCl hypertonic IV solution would be the proper treatment. Students may think that the
problem is too much fluid and thus think initially an IV solution would be adding more fluid. But
adding a hypertonic solution to the bloodstream would pull the water out of the swelled cells into
the bloodstream.
3. What should have Sally consumed other than water?
Sally should have consumed a salty food rather than water that would have elevated her sodium
levels and kept the sodium balanced to the water levels she was adding. Sports drinks would
have been better than water but still would not have prevented her problem if she drank
excessive levels of sports drinks as they are still a hypotonic solution.
Part IV
1. How could a marathon runner experience hyponatremia?
If a marathon runner consumed too much fluid in the form of water or sports drinks.
2. Why would a marathon runner on a hot day drinking the same quantity of water be less
likely to experience this condition than a marathon runner on a cold day?
The runner would be more likely to experience hyponatremia on a cold day than on a hot day.
Increased sweating on a hot day would increase hypo-osmotic fluid loss in sweat, thereby
increasing ECF osmolarity and requiring larger quantities of water ingested to over-hydrate and
dilute the ECF. On a cold day, due to decreased fluid loss, it would take less water/beverage
ingestion to dilute the ECF and cause hyponatremia.
Ecstasy References
Greer G, Tolbert R: Subjective reports of the effects of MDMA in a clinical setting. J
Psychoactive Drugs 18:319,1986.
Henry JA, et al.: Toxicity and deaths from 3,4-methylenedioxymethamphetamine ("ecstasy").
Lancet 340:384,1992.
Henry JA, et al.: Low-dose MDMA ("ecstasy") induces vasopressin secretion. Lancet
351:1784,1998.
Hew-Butler, et al: Consensus Statement of 1st International Exercise-Associated Hyponatremia
Consensus Development converence. Clin J Sport Med 15:208,2005
Marieb E: Anatomy and Physiology Second Edition. San Francisco: Pearson Benjamin
Cummings, 2005.
Navar G: “Renal System Physiology Update” Presentation. Human Anatomy and Physiology
Society Conference. San Diego. 27 May 2007.
Emily Allen, Gloucester County College, HAPS: Renal Physiology Course
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