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It is uncommon for younger patients to develop herpes zoster ophthalmicus (HZO) without underlying immunocompromise.
3,4-Methylenedioxymethamphetamine (MDMA, “ecstasy”) is a widely abused psychomotor stimulant shown to cause a transient immunosuppression.1–4 In this report, we present the relation between MDMA induced immune dysfunction and the development of HZO in a previously healthy young male.
A 24 year old African-American male without significant past medical history presented with an eruptive, vesicular rash on his left forehead and eyelid consistent with the diagnosis of herpes zoster ophthalmicus (fig 1). Although he reported using safe sexual practice and denied injecting drug use, he admitted using an oral drug, ecstasy, three times a day for 4 days before the development of his symptoms. He tested negative for HIV and underlying malignancy, and slowly improved on intravenous aciclovir during his admission
Varicella zoster reactivation is a potential complication of immunosuppression. Predisposing factors to reactivation include increasing age, neoplastic diseases, HIV, immunosuppressive therapy, or debilitating systemic disease.5 Since zoster in patients under 50 years old is uncommon, a search for predisposing factors is indicated. It has been shown, in short term studies, that ecstasy use results in immune suppression.1–4 Therefore, we believe that our patient’s prolonged use of ecstasy facilitated the development of HZO.
3,4-Methylenedioxymethamphetamine is a widely abused psychomotor stimulant with behavioural effects similar to those elicited by amphetamines and hallucinogens. MDMA has become a popular drug of abuse over the past two decades.3 A study in 1988 found that 39% of students on a college campus admitted to having taken the drug at least once in the previous year.6 Surveys have also shown a steady increase in MDMA use in 8th, 10th, and 12th graders.7 MDMA produces a profound euphoria, heightened feelings of empathy, emotional warmth, and self acceptance.7 Adverse effects include hyperthermia, seizures, cardiac arrhythmias, hepatotoxicity, and many psychiatric disorders.8 There has been an increase in reports of presumed ecstasy related fatalities and severe adverse effects such as aortic dissection and myocardial infarction.9,10
Connor et al1,3,4 demonstrated that acute MDMA administration produced a variety of time dependent neurochemical, endocrine, and immune alterations in rats. Their studies provided evidence that a single administration of MDMA induces a rapid and sustained suppression of induced lymphocyte proliferation and a decrease in circulating lymphocytes. The alterations in immune function were accompanied by a significant increase in plasma corticosterone concentrations. They hypothesised that users of MDMA may have reduced immunocompetence and therefore display increased susceptibility to both infectious and neoplastic disease.1
In a study by Pacifici et al2 it was shown that MDMA administered to humans at doses compatible with its recreational use caused rapid changes in certain immunological parameters. They demonstrated that 1 hour after administration, there was a significant reduction in CD4 T cell count and an increase in natural killer cell count. These changes in immune function were also linked to increased cortisol concentration.2
The studies discussed above provide evidence for the relation between MDMA and immune dysfunction. We have demonstrated a case where MDMA abuse led to the development of herpes zoster ophthalmicus. This relation has important implications for the examination of an atypical infectious process. Given the rising use of MDMA, especially among high school and college students, this consequence is a significant public health concern. Not only is it important to gather history regarding the use of illicit drugs, but also to stress the negative impact this drug can have on potential users. We anticipate more reports of infectious diseases related to MDMA use. Further studies are necessary to define the mechanisms by which MDMA causes immune dysfunction and to determine long term effects in humans.