Acute cholestatic hepatitis syndrome caused by ecstasy

Introduction: Drug induced liver disease should be considered in the background of any form of liver diseases. Use of psychoactive drugs, including ecstasy (3,4-methylenedioxy-methamphetamin, MDMA), have become more frequent in Hungary recently. Fatal consequences of ecstasy including liver failure have been reported. We report on a case of acute cholestatic hepatitis caused by ecstasy.

Case report: 33 year old man was seen by the outpatient unit with the clinical signs of fatigue, vomiting, and deep jaundice (se bi: 691, di bi: 465 umol/l) and itching. The elevated transaminase levels (AST: 212, ALT: 573, GGT: 206 U/l), dark urine and light-colored stool referred to hepatitis syndrome with cholestatis. The negative serologic markers (antiHAV, HBsAg, antiHCV, EBV-IgM) and the lack of auto-antibodies (ANA, AMA, SMA, ANCA) did not prove viral or autoimmune causes. Mutation analysis did not refer to Wilson-disease or hemochromatosis in the background. Although serum copper and ferritin levels were high, they were considered as consequence of acute phase reaction. The ultrasound and computer tomography examinations showed moderate hepatomegaly, but no other pathological signs. ERCP did not prove any biliary obstruction. At the first visit, ingestion of toxic agents were denied by the patient, but after the examinations he was asked repeatedly, and finally he admitted taking two tablets of ecstasy pills first time in his life, three weeks before the initial symptoms. He was not a drug addict. The result of histological finding of liver biopsy was in concordance with toxic liver disease.

Slow, continuous recovery was observed. He did not receive any medicine. After five months his jaundice disappeared, the levels of serum bilirubin and transaminases and cholestasic markers returned to the normal range.

Conclusion: This case draws attention, to that ingestion of only two ecstasy tablets can cause severe acute hepatitis syndrome. We emphasize the importance of careful, repeated history taking with empathy especially in case of drug users.