This is an examination of a case series of fatalities found in the records of the New York City Office of the Chief Medical Examiner recorded between January 1997 and July 2000 wherein MDMA was detected in the tissues of the deceased person. Out of 19,366 toxicological analyses performed in 20,881 deaths, 22 (or 0.001%) were considered ecstasy-related deaths, indicating their relative rarity. However, MDMA or ecstasy-related deaths may have been underreported, as autopsies do not routinely test for MDMA or substituted amphetamines. 3 ecstasy-related fatalities occurred in 1997, 3 in 1998, 11 in 1999 and 5 in the first half of 2000. 59% (13) died of "acute intoxication," (unspecified, frequently found dead in bed), 32% (7) died from mechanical injury (falls, vehicular accidents, homicide), and 9% (2) died from "natural disease" in combination with MDMA intoxication (e.g. coronary disease). 81% of the MDMA-related fatalities were men, and all of them were white. The most frequent co-intoxicants detected were opiates (32%), ethanol (32%), ketamine (27%) and cocaine (22%). Fatalities reported in New York are compared with 45 ecstasy-related deaths reported in the medical literature. Perhaps due to greater familiarity with heat stroke and hyperthermia in New York than in the UK, ecstasy-induced hyperthermia was less liable to lead to death in New York City than it was in the UK. The authors speculate that opiates and cocaine might exacerbate ecstasy-related adverse effects, leading to death. The authors also note that the case series suggests that ecstasy-related fatalities may not be purely dose-dependent. Without reference to the frequency with which users combine ecstasy with other drugs, it is difficult to assess the strength of claims of increased mortality after specific drug combinations. This case series is more a catalog of fatalities occurring after MDMA ingestion than a model explaining the distribution of fatalities, but it does offer a hypothesis for geographic differences in the causes of ecstasy-related fatalities.