A 24-year-old woman arrived at the emergency department with altered mental status. Tests showed severe hyponatremia (serum sodium 116 mmol/L) and diffuse brain edema, but no history of drug use was reported. The correct diagnosis of MDMA-induced hyponatremic coma was delayed until six days later, when a toxicology screen revealed a high urine concentration of MDMA (7,767 ng/ml). This case illustrates how the absence of exposure history and typical stimulant effects can make MDMA-related hyponatremic coma easy to overlook. A high index of suspicion and prompt toxicological screening are essential for diagnosing such cases.
Two patients developed N,N-dimethyltryptamine (DMT) poisoning after consuming an herbal stew made from Syrian rue seeds (containing monoamine oxidase inhibitors) and Acacia tree bark (containing DMT). Laboratory analysis confirmed DMT and harmaline in their blood and urine. One patient had detectable DMT in serum (25 ng/mL) and more severe symptoms, including altered consciousness, rhabdomyolysis, and elevated liver enzymes, while the other had undetectable serum DMT and milder effects. The combination mimics taking DMT with a monoamine oxidase inhibitor, producing sympathomimetic toxicity. Physicians should consider unusual herbal preparations as potential causes of drug-drug interactions and poisoning.