Background: 3,4-Methylenedioxymethamphetamine (MDMA; ecstasy), a compound chemically related to stimulant and hallucinogenic drugs, has been found to induce a state of euphoria and increased selfawareness. MDMA has been increasingly used for recreational purposes, especially among college students and other young adults, and has been associated with multiple toxic effects.Methods: Using MEDLINE, the medical literature was searched from 1986 using the key words "ecstasy," "MDMA," and "designer drugs." Articles dating before 1986 were accessed from cross-reference of the more recent articles. A case report is described.Results: MDMA was developed in 1912 as an appetite suppressant but never became commercially successful. It resurfaced in the 1950s as a psychotherapeutic agent. In 1985 MDMA was classified as a schedule 1 drug by the Food and Drug Administration after reports of neurotoxicity in laboratory animals. It again resurfaced in the mid 1980s as a recreational drug used primarily among college students and other young adults. There are a number of case reports describing toxic effects from MDMA, including hyperthermia, rhabdomyolysis, coagulopathy, and acute renal failure. Little information is available regarding acute management or treatment of toxic ingestions.Conclusions: MDMA ingestion has been associated with severe toxic effects. Although the literature describes numerous cases of toxic ingestion, there are no published recommendations or suggestions to guide physicians in the evaluation and treatment of such cases. By reviewing the history, neurochemistry, and tOxicology of MDMA, as well as providing some guidance regarding management of toxic ingestion, we can arm the provider with valuable information for use in the acute setting. In addition, this information will assist providers in counseling young adults regarding the possible consequences of using this substance.

Infectious mononucleosis is common in adolescents and young adults. Although the syndrome is most often associated with Epstein-Barr virus, several other organisms can also cause infectious mononucleosis. Diagnosis is based on clinical findings and the presence of heterophil antibodies and atypical lymphocytes. Diagnosis may be more difficult in older adults because the presenting symptoms often differ from those seen in children. Symptoms usually resolve in 2 to 3 weeks. Treatment of uncomplicated infectious mononucleosis is supportive, but corticosteroids may be beneficial for the treatment of several complications associated with Epstein-Barr virus. Physically active patients should be counseled about the risks of splenic injury.

Preview The increasing number of patients surviving with advanced HIV infection presents new challenges to physicians who care for them. As a patient's CD4+ T-lymphocyte count declines, susceptibility to opportunistic fungal infections increases. In this article, Dr Kirchner discusses two commonly encountered pathogens, Cryptococcus neoformans and Histoplasma capsulatum.

Data from the 1970s first suggested that vitamin E may be effective in decreasing mortality from cardiovascular disease. As the understanding of the antioxidant effect of this vitamin evolved, researchers began to further study the biologic effects of vitamin E. In vitro studies have shown vitamin E to have several potentially cardioprotective effects, including antagonizing the oxidation of low-density lipoproteins, inhibiting platelet aggregation and adhesion, preventing smooth muscle proliferation, and preserving normal coronary dilation. Several prospective studies, including the US Nurses' Health Study and the US Health Professionals' Follow-up Study, found a 34% and 39% reduction, respectively, in the risk of having a cardiac event for those taking vitamin E supplements. The Iowa Women's Health Study found a 47% reduction in cardiac mortality. Results of randomized, controlled clinical trials have not found consistent benefit, however. The best known of these trials, the Cambridge Heart Antioxidant Study, found a 47% reduction in fatal and nonfatal myocardial infarction in patients with proven coronary atherosclerosis who were given 400 or 800 IU of vitamin E daily. There was, however, no effect on mortality. While emerging and promising data suggest the potential benefit of vitamin E for high-risk cardiac patients, physicians should be alert to the results of randomized, controlled clinical trials already in progress.

Gonorrhea has been declining since its 1975 peak. Risk factors include age 15 to 19 years, multiple or casual sexual contacts, sexual activity related to drug use, and low socioeconomic status. Infection is usually mild but may be asymptomatic. While no physical signs are specific to the gonococcus, pelvic inflammatory disease is a common complication and cause of infertility and should be treated if it is suspected. Diagnosis of gonorrhea is typically by culture. Newer, more accurate tests are available but are more expensive. For treatment, the CDC recommends only highly effective regimens. Patients need to refer recent sexual partners for treatment and abstain from sexual intercourse until completion of therapy and resolution of symptoms. The incidence of syphilis appears to be declining in the United States, but it should be considered if an ulcer is found in the genital region. If untreated, the disease progresses through primary, secondary, latent, and tertiary phases, and systemic symptoms can mimic other conditions. Positive standard screening tests should be confirmed by fluorescent treponemal antibody absorption testing. Darkfield microscopy is appropriate for diagnosis of an ulcer. The treatment of choice for all phases of syphilis is a single dose of intramuscular benzathine penicillin. Other components of therapy include partner notification and patient follow-up. The spread of HIV is closely linked to STD transmission. Therefore, testing for HIV is strongly encouraged when another STD has been diagnosed.