MDMA is thought to cause potent and possibly permanent neurotoxicity in the serotonin (5HT) pathways. These pathways are the same ones that underlie chronic neuropsychiatric illnesses such as major depressive disorder, psychosis, and panic disorder, supporting the view that MDMA can lead to prolonged neuropsychiatric problems. As in our patient, recovery from the neuropsychiatric complications of MDMA tends to be slow and tedious. Improvement may be explained by compensatory metabolic changes within remaining 5HT and non 5HT neurons, or regeneration of damaged neurons. These mechanisms serve to reverse the 5HT deficit and lead to clinical improvement. MDMA has gained popularity recently as a recreational drug in the high school and college populations. It is commonly referred to as``ecstasy'',``X'',``E'', or``Adam''. It has hallucinogenic and stimulant properties. Due to its potential for severe and chronic complications, it must be considered in the differential diagnosis of new onset psychiatric illness, especially in adolescents and young adults. DISCUSSION: He was discharged home after alcohol counseling. DISCUSSION: Hyponatremia is the most common electrolyte abnormality in hospitalized patients. Symptoms are related to CNS dysfunction and include headache, nausea, vomiting, anorexia, disorientation and depressed reflexes. Symptom severity is correlated with how rapidly the hyponatremia developed. Coma and seizures can occur with acute drops to less than 120 meq/L. The initial approach to diagnosis is measurement of serum and urine osmolality and urine sodium. The most common finding is hypotonic hyponatremia, which is further subdivided by volume status. Our patient was hypovolemic, and low urine sodium implied appropriate renal sodium retention. The diagnosis of beer potomania was also considered, although this is classically a euvolemic state with a low urine osmolality. Treatment should be initiated in all symptomatic patients and those with levels less than 120mEq/L. For hypovolemic hyponatremia, the treatment of choice is normal saline. Overly rapid correction is avoided to prevent central pontine myelinolysis. year-old male with a longstanding history of steroid-dependent asthma and recurrent sinusitis presented with bilateral upper extremity weakness, beginning during a steroid taper. Symptoms then progressed to generalized weakness, malaise, anorexia, and a peripheral eosinophilia. He was given stress dose steroids with prompt resolution of both symptoms and eosinophilia and kept on prednisone 10 mg a day. He then began to develop wasting of his forearms, difficulty in performing tasks using his hands, and difficulty arising from a chair. Medications included salmeterol, fluticasone 220 mcg MDI, and prednisone. On physical examination, he was cushingoid. Lungs were clear. Pertinent neurologic findings included moderate proxminal muscles weakness and motor weakness with atrophy in distribution of the left and right median and ulnar nerve, left radial nerve and bilateral peroneal nerves. Deep tendon reflexes were absent in the right biceps, brachioradialis and left achilles. White count was 22,000 with 30% eosinophils. ACTH stim test was consistent with adrenal insufficiency. Chest X-ray was clear. EMG was consistent with a mixed motor and sensory loss in the ulnar and median nerve distribution. Peroneal muscle biopsy showed eosinophilic infiltration of a blood vessel consistent with a vasculitis. DISCUSSION: Our patient presented with adult-onset asthma, peripheral eosinophilia, and mononeuropathy multiplex. These features are consistent with Churg-Strauss Syndrome (CSS). The muscle biopsy showing eosinophilic infiltration of a blood vessel ensured the diagnosis. The American College of Rheumatology has developed classification criteria by comparing 20 patients who had CSS to 787 control patients with other forms of vasculitis. The six criteria more typical of CSS include: asthma, eosinophilia of greater than 10% , mononeuropathy or polyneuropathy, nonfixed pulmonary infiltrates on CXR, paranasal sinus abnormalities, and biopsy containing a blood vessel with extravascular eosinophils. The presence of any four or more yielded a sensitivity of 85% and a specificity of 99.7%. The natural history of the syndrome follows three clinical phases: (1) prodromal allergic phase (2) allergic rhinitis, nasal polyposis, and asthma and (3) peripheral and tissue eosinophilia. The differential diagnosis includes Wegener's granulomatosis, hypereosinophilic syndromes, polyarteritis nodosa, and microscopic polyangiitis. LEARNING OBJECTIVES: 1) Recognize that an asymptomatic mass on an extremity can be a soft tissue sarcoma. 2) Consider an incisional biopsy in an extremity lesion, particularly if it is larger than 5 cm in diameter. CASE INFORMATION: A 32-year-old African American woman with no significant past medical history presented with a 4 week history of right thigh pain, swelling and hemoptysis. She noted that her right thigh had been swollen without pain for several weeks prior to her presentation. On examination she had a swollen, tender, firm right thigh with right inguinal adenopathy. She had no skin lesions, clear lungs, and a normal pelvic exam. A pap smear was normal. Laboratory data were notable for a hematocrit of 27.7% and a serum iron of 24 ug/dl. Doppler ultrasound studies of the legs were negative for deep venous thrombosis. Chest x-ray showed multiple pulmonary nodules of variable sizes in both lungs, confirmed by a CT scan of the chest which also showed no mediastinal or hilar lymphadenopathy. MRI studies revealed a 6.5Â4.5Â4.5 cm soft tissue mass in the right thigh with lymphadenopathy in the right inguinal, external iliac and common iliac chains, and retrocaval region at the level of the renal veins. A biopsy of the right thigh mass revealed sheets of large monomorphic epithelioid cells which were positive by immunohistochemical studies for cytokeratin and vimentin. These findings were consistent with a diagnosis of epithelioid sarcoma metastatic to the lungs. DISCUSSION: Soft tissue sarcomas account for fewer than one percent of all malignancies and often present as an asymptomatic mass on the extremities of young adults, most often in the third decade of life. Fewer than 20% present as metastatic disease. Because of their slow-growth (over months) and initial presentation, they may be mistaken for other entities (eg. lipomas). Compression of a nerve or blood vessel can cause symptoms. Sarcomas usually spread hematogenously to the lungs, although epithelioid sarcomas can also metastasize through the lymphatic system. Patients with soft tissue sarcomas < 5 cm in diameter have a metastasis-free 5year survival rate of 81%, regardless of tumor grade, depth, and location. In contrast, there is only a 20% 5-year survival rate for patients with lung metastasis. Diagnostic workup should include radiographs, MRI, referral for an incisional biopsy, and chest x-ray or chest CT to search for possible metastatic disease. Because sarcomas are rare and histological interpretation can be difficult, a primary care physician should refer patients to surgeons or centers experienced in the diagnosis of soft tissue sarcomas. The early consideration of this diagnosis can greatly improve patient outcome.