Ting-I Lai

Methylene 3, 4 dioxymethamphetamine-induced acute myocardial infarction.

Methylene 3, 4 dioxymethamphetamine (MDMA) has been gaining popularity as a recreational drug over the past few decades around the globe. Although once thought to be safer than its mother compound, amphetamine, several life-threatening adverse reactions have been reported. Among the cardiovascular toxicities documented, MDMA commonly causes various forms of arrhythmia and heart failure. However, MDMA-induced acute myocardial infarction is rarely reported. We report a case of acute myocardial infarction in a young man shortly after taking MDMA. Massive thrombosis over the right coronary artery was demonstrated by means of emergency angiography. After treatment with intravenous glycoprotein IIb/IIIa inhibitor and intracoronary urokinase infusion, the coronary artery was shown to be patent without any apparent stenotic lesions. The mechanism of MDMA-induced acute myocardial infarction was discussed.

Spontaneous hemopneumothorax: an overlooked life-threatening condition

Spontaneous hemopneumothorax is a rare clinical entity. A large spontaneous hemopneumothorax is life-threatening, and mortality increases with delayed recognition and intervention. The initial chest radiography and the amount of blood drained from the inserted chest tube frequently underestimates the actual blood loss from the active bleeder around the ruptured apical bullae, leading to failed recognition of a potentially life-threatening condition until unexpected hemodynamic collapse develops. We report 2 cases of spontaneous hemopneumothorax to emphasize the importance of early recognition and prompt surgical intervention by video-assisted thoracoscopic surgery (VATS).

Ring down artefacts on abdominal sonography to predict pulmonary abnormalities in the emergency department

Ring down artefacts are sometimes found when emergency physicians perform abdominal ultrasound to differentiate between various abdominal problems. We describe a patient who presented with right upper quadrant abdominal pain and whose ultrasound examination showed ring down artefacts posterior to the right hemidiaphragm, which led to the eventual diagnosis of pneumonia. Ring down artefacts on ultrasound may be used to predict pulmonary abnormalities. Awareness of this sonographic finding may assist in accurate diagnosis and administration of appropriate treatment without delay.

The sandwich sign of nonlymphomatous origin

To investigate the etiologies of the sandwich sign other than lymphoma.

Ecstasy poisoning in a toddler.

Received: May 18, 2006 Revised: July 5, 2006 Accepted: August 1, 2006 *Correspondence to: Dr Cheng-Chung Fang, Department of Emergency Medicine, National Taiwan University Hospital, 7, Chung-Shan South Road, Taipei 100, Taiwan. E-mail: conrad@ha.mc.ntu.edu.tw Sir, We found the article “Accidental Ingestion of Ecstasy in a Toddler” by Chang et al1 in the December 2005 issue of the Journal of the Formosan Medical Association interesting, and we have a few questions and comments. The authors stated that the patient’s urine contained 2111 ng/mL of amphetamine without mentioning the method of measurement. As 3,4-methylenedioxymethamphetamine (MDMA; slang term “ecstasy”) is different from amphetamine, how did the authors arrive at the diagnosis of MDMA poisoning instead of amphetamine poisoning? When encountering a patient suspected of substance abuse, the most popular screening method is immunoassay. By using this method, there is a cross-reaction among the derivatives of amphetamines, namely methamphetamine, MDMA, 3,4-methylenedioxyamphetamine, 3,4-methylenedioxy-N-ethylamphetamine, etc. If the authors had used the immunoassay to examine the urine sample, this patient might have been suffering from MDMA poisoning despite a positive amphetamine urine examination. Therefore, the authors should try to confirm the presence of MDMA by gas chromatography (GC)/mass spectrometry (MS). After GC/MS testing, the exact amount of MDMA could be identified and the authors would then be able to conclude that the patient was intoxicated by MDMA. Ecstasy is a common substance of abuse and is rarely formulated as pure MDMA, but rather a mixture of various substances. A report from the US suggests that ecstasy commonly contains substances other than MDMA.2 According to a study from Taiwan’s National Bureau of Controlled Drugs,3 an illegal MDMA tablet may contain as many as 10 ingredients. Although the patient’s history showed that a tablet of ecstasy was taken, we still need to examine the boy’s urine for other abuse substances in addition to amphetamine and its derivatives. Therefore, there is a high possibility that this patient may have suffered from mixed poisoning. At the very least, the urine sample should have been examined to exclude ketamine, which is commonly combined with MDMA in tablet form and causes similar symptoms as MDMA poisoning. A The authors discussed the concentration of MDM in the second paragraph of their Discussion. However, the case report only provided the urine level of amphetamine, which does not correlate well with the clinical picture. The MDMA concentration in urine is usually much higher than that in blood. As demonstrated in our previf ous case report of MDMA poisoning, the urine level o MDMA is about 90 times higher than that of plasma.4 f Furthermore, the authors only provided the urine level o A “amphetamine”, which cannot directly represent MDM levels as we have already stated in the second paragraph. t Last but not least, this case report raised importan ethical and legal issues, which were not clarified in the Discussion. According to Taiwan’s Law of Children’s y Welfare, health care providers are obligated to notif law enforcement agents when coming across and treating children using abuse substances. This boy was improperly treated by his parents, and it is the duty of the f health care providers to prevent further possibility o child abuse by reporting the situation to the authorities.