Severe 3,4-Methylenedioxymethamphetamine (MDMA)-Associated Rhabdomyolysis in Crohn's Disease: Direct Toxicity and Inflammatory Susceptibility in the Absence of Hyperthermia.

Rhabdomyolysis is a recognized complication of 3,4-methylenedioxymethamphetamine (MDMA), usually driven by severe hyperthermia and agitation. We describe a previously healthy 45-year-old man who developed profound rhabdomyolysis (creatine kinase (CK) 160,000 U/L) and intrinsic acute kidney injury requiring hemodialysis after ingesting 1.5 g of "Molly" (pure MDMA), despite remaining afebrile throughout. In the literature review, the first reported case of severe MDMA-associated rhabdomyolysis without hyperthermia and the third-highest CK values was documented. He later received a new diagnosis of Crohn's disease, raising the possibility that inflammatory bowel disease-related myositis created an "immune-primed" susceptibility to muscle injury. In contrast to typical MDMA cases, there was no hyperthermia, exertion, serotonin syndrome, or significant electrolyte abnormality to explain the muscle breakdown. This case, therefore, supports an under-recognized, non-hyperthermic mechanism of MDMA toxicity involving direct mitochondrial and oxidative skeletal muscle injury, potentially amplified by occult Crohn's disease, and highlights the need to consider MDMA toxicity even in afebrile patients presenting with severe rhabdomyolysis.