title: Catecholaminergic polymorphic ventricular tachycardia found in an adolescent after a methylenedioxymethamphetamine and marijuana-induced cardiac arrest.
abstract: OBJECTIVE
  To illustrate the challenges of managing patients with acute, undiagnosed arrhythmias through a case that demonstrates a possible association between catecholaminergic polymorphic ventricular tachycardia, a genetically determined severe arrhythmia disorder that often presents as either syncope or sudden death, and 3,4-Methylenedioxymethamphetamine ("Ecstasy") combined with marijuana, which are often considered safe drugs by users.
  
  
  METHODS
  Case report.
  
  
  METHODS
  Pediatric intensive care unit.
  
  
  METHODS
  A 15-yr-old male collapsed suddenly after ingesting an unknown substance and smoking marijuana. He was successfully resuscitated by first-responder chest compressions and rescue breaths along with a single 100-J shock by paramedics. He was intubated and transferred to a pediatric intensive care unit. Initial cardiac workup was negative but severe instability on vasopressors and a family history of intermittent palpitations and syncope in his brother raised suspicion for catecholaminergic polymorphic ventricular tachycardia. Identification of the unknown substance required coordination with a toxicology laboratory.
  
  
  METHODS
  The patient had extremely labile cardiovascular responses to vasopressors. On day 5, his blood pressure was stable and he was extubated. A full cardiac workup, including a catheterization (preadmission to pediatric intensive care unit), electrocardiogram, cardiac magnetic resonance imaging were done to screen out most structural arrythmogenic diseases. A specific genetic test for catecholaminergic polymorphic ventricular tachycardia was sent.
  
  
  RESULTS
  The patient's methylenedioxymethamphetamine blood level was 87 ng/mL approximately 12 hrs after ingestion. Given the 3-8 hr half-life of methylenedioxymethamphetamine, it is likely that levels were toxic at the time of ingestion (>110 ng/mL). Marijuana may have provided a synergistic critical catecholamine release to trigger an arrhythmia. Genetic testing showed a ryanodine receptor-2 mutation that was consistent with catecholaminergic polymorphic ventricular tachycardia.
  
  
  CONCLUSIONS
  While an initial cardiac workup for an acute, undiagnosed arrhythmia may be negative, family history may be a simple, essential component of patient management and disease diagnosis. This case demonstrates a possible association between methylenedioxymethamphetamine, marijuana, and catecholaminergic polymorphic ventricular tachycardia. All genetic and structural arrythmogenic disorders should be considered when working up a patient with presumed toxin-induced arrhythmias.
authors.affiliation: Medical Education Department, Children's Hospital, Oakland, CA, USA.
authors.forename: Matt
authors.initials: M
authors.lastname: Diffley
authors.forename: Patil
authors.initials: P
authors.lastname: Armenian
authors.forename: Roy
authors.initials: R
authors.lastname: Gerona
authors.forename: Olaf
authors.initials: O
authors.lastname: Reinhartz
authors.forename: Kishor
authors.initials: K
authors.lastname: Avasarala
mesh_terms: D000293:Adolescent; D019943:Amino Acid Substitution; D006213:Hallucinogens / Q000008:administration & dosage / Q000009:adverse effects / Q000097:blood; D006323:Heart Arrest / Q000139:chemically induced*; D006801:Humans; D015278:Intensive Care Units, Pediatric; D008297:Male; D008385:Marijuana Smoking / Q000009:adverse effects*; D009154:Mutation; D018817:N-Methyl-3,4-methylenedioxyamphetamine / Q000008:administration & dosage / Q000009:adverse effects* / Q000097:blood; D019837:Ryanodine Receptor Calcium Release Channel / Q000235:genetics; D017180:Tachycardia, Ventricular / Q000235:genetics*
chemical_list: D006213:Hallucinogens; D019837:Ryanodine Receptor Calcium Release Channel; D018817:N-Methyl-3,4-methylenedioxyamphetamine