View source for Amanita mushrooms

==Background==
[[File:Amanita phalloides.png|thumb|''Amanita phalloides'' aka "death cap"]]
*''Amanita phalloides''
*Not to be confused with ''Amanita muscaria''

{{Anticholinergic types}}

==Clinical Features==
===Stage 1 (GI)===
*Occurs 6-24hr after ingestion and lasts 12-24hr
*The later the onset of symptoms the better the outcome
*GI predominant symptoms:
**[[Abdominal pain]], [[vomiting]] and [[diarrhea]] (which may become bloody)

===Stage 2 (convalescent)===
*Occurs 48hr after ingestion and lasts 12-24hr
*Symptoms subside and patient appears better
*Liver deteriorates silently and precipitously (LFTs begin to rise)

===Stage 3 (failure)===
*Occurs 2-4 days after ingestion
*Fulminant [[liver failure]]
**[[Hyperbilirubinemia]], [[coagulopathy]], [[hepatic encephalopathy]], [[hepatorenal syndrome]]
*Death (may occur in 3-7 days)

==Differential Diagnosis==
{{Acute hepatitis causes}}
{{Mushroom toxicity DDX}}
{{SLUDGE DDX}}

==Evaluation==
===Workup<ref>Garcia J, Costa VM, Carvalho A, Baptista P, de Pinho PG, de Lourdes Bastos M, et al. Amanita phalloides poisoning: Mechanisms of toxicity and treatment. Food Chem Toxicol. 2015 Sep 12. 86:41-55.</ref>===
*Blood sugar
*BMP
*[[LFTs]]
*Lipase
*Coags, [[DIC]] labs
*CBC with differential
*LDH, haptoglobin, reticulocyte
*CK
*Thyroid studies
*[[Methemoglobin]] level
*Urine drug screen
*[[Urinalysis]]

===Diagnosis===
*Typically based on history and laboratory findings

==Management==
===Immediate therapy===
*[[Activated charcoal]]
**Some advocate repeated doses during the first 24hr
***Amatoxin undergoes enterohepatic circulation
*[[Penicillin]]
**High doses 1 mil units/kg/d effective in animal studies (inhibits amatoxin uptake)
*Silibinin (milk thistle derivative)
**'''Mortality benefit'''
**Free radical scavenger used successfully in Europe
**5mg/kg over 1 hr, then 25-50mg/kg/d<ref>Saller, R., Brignoli, R., Melzer, J. and Meier, R. (2008) ‘An Updated Systematic Review with Meta-Analysis for the Clinical Evidence of Silymarin’, Forschende Komplementärmedizin / Research in Complementary Medicine, 15(1), pp. 9–20</ref>
*[[N-acetylcysteine]] admin much like in acetaminophen toxicity<ref>Lee DS et al. Amatoxin Toxicity Medication. July 21, 2015. http://emedicine.medscape.com/article/1008902-medication#2.</ref>
**'''Mortality benefit'''
**Load 150mg/kg IV over 15min in 200 cc D5W
**Then 50mg/kg in 500cc D5W over 4hrs
**Followed by 100mg/kg in 1000cc D5W over 16hrs
*Extracorporeal albumin dialysis<ref>Faybik, P., Hetz, H., Baker, A., Bittermann, C., Berlakovich, G., Werba, A., Krenn, C.-G. and Steltzer, H. (2003) ‘Extracorporeal albumin dialysis in patients with Amanita phalloides poisoning’, Liver International, 23pp. 28–33.</ref>
**Allow hepatic regeneration or forestall transplantation

===Ongoing therapy===
*Glucose monitoring
**[[Hypoglycemia]] is one of the most common causes of death in early mushroom toxicity
*Liver/renal failure monitoring
**Serial LFTs, chem, coags
*Prepare for liver transplant
**Progressive [[coagulopathy]], [[encephalopathy]], renal failure are indications for transplant

==Medication Dosing==
{{MedicationDose
| drug = N-Acetylcysteine
| dose = 150mg/kg IV over 15min, then 50mg/kg over 4hr, then 100mg/kg over 16hr
| route = IV
| context = Hepatoprotective, mortality benefit
| indication = Amanita mushrooms
| population = Adult
}}
{{MedicationDose
| drug = Penicillin G
| dose = 1 million units/kg/day IV divided q4hr
| route = IV
| context = Inhibits amatoxin uptake
| indication = Amanita mushrooms
| population = Adult
}}

==Disposition==
*Admit all suspected of ingesting amatoxin containing mushrooms for at least 48hr
*Referral to liver transplant service

==See Also==
*[[Mushroom toxicity]]
*[[Anticholinergic toxicity]]

==External Links==

==References==
<references/>

[[Category:Toxicology]]