Mushroom toxicity: Difference between revisions

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==Background==
==Background==
===Major Categories===
Clinically broken into two main categories:
*Early-Onset Poisoning
#Early-Onset Poisoning (toxicity begins within 2hr of ingestion)
**Toxicity begins within 2hr of ingestion; clinical course is usually benign
#*Clinical course is usually benign
*Late-Onset Poisoning
#*Comprises majority of mushroom-induced intoxications
**Toxicity begins 6hr after ingestion; clinical course is often serious/ possibly fatal
#Late-Onset Poisoning (toxicity begins 6hr after ingestion)
#*Clinical course is often serious/ possibly fatal
#*Amanita species causes 95% of deaths
#**Most frequent species: ''[[A. phalloides]], bisporigera, magnivelaris, ocreata, verna, virosa''<ref>Enjalbert F et al. Treatment of Amatoxin Poisoning: 20 year retrospective analysis. J tox Clin Tox 2002 40(6):715-767.</ref>
#**Toxin inhibits formation of mRNA and is heat stable


{| class="wikitable"
{{Mushroom identification images}}
| align="center" style="background:#f0f0f0;"|'''Mushroom Toxin'''
| align="center" style="background:#f0f0f0;"|'''Pathologic Effect'''
|-
| Amatoxin||Hepatotoxicity
|-
| Coprine||Disulfiram-like
|-
| Gyromitrin||Seizures
|-
| Ibotenic Acid||Anticholinergic
|-
| Muscarine||Cholinergic
|-
| Orellanin||Nephrotoxicity
|-
| Psilocybin||Hallucinations
|}


==Differential Diagnosis==
==Clinical Features==
{{Acute hepatitis causes}}
===Early-Onset===
 
''Depends on the type of mushroom ingested''
==Early-Onset Poisoning==
*Comprises majority of mushroom-induced intoxications
*Symptom onset 30-90 min with hallucinations, lasting 6-8 hrs<ref>Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.</ref>:
**Isoxazoles (ibotenic acid and muscimol) - dsyarthria, ataxia, muscle cramps
**Psilocybin - euphoria, visual hallucinations, agitation, sympathomimetic Sxs
 
===Clinical Features===
*Depends on the type of mushroom ingested
*GI
*GI
**Nausea/vomiting/diarrhea
**[[Nausea/vomiting]], diarrhea
**Resolves within 24hr
**Resolves within 24hr
*CNS
*CNS<ref>Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.</ref>
**Euphoria, hallucinations
**Isoxazoles (ibotenic acid and muscimol) - [[dysarthria]], [[ataxia]], muscle cramps
**Lasts 4-6hr
**Psilocybin - euphoria, visual [[hallucinations]], [[agitation]], [[sympathomimetic]] symptoms
**Lasts 4-8hrs
*Muscarinic  
*Muscarinic  
**SLUDGE symptoms
**SLUDGE symptoms
**Diaphoresis, muscle fasciculations, miosis, bradycardia, bronchorrhea
**Diaphoresis, muscle fasciculations, miosis, [[bradycardia]], bronchorrhea
**Resolves in 4-12hr
**Resolves in 4-12hr
*Disulfiram-like effect  
*Disulfiram-like effect  
** Usually when drinking alcohol
**Usually when drinking alcohol
** Flushing, tachycardia, diaphoresis, hypotension
**Flushing, [[tachycardia]], diaphoresis, [[hypotension]]
 
===Delayed-Onset===
''Four Stages <ref>Brayer AF, Froula L. Mushroom poisoning. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2016:(Ch) 219.</ref> <ref>Shih RD. Plants, mushrooms and herbal medications. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:(Ch) 164.</ref>''
#Latent (symptom free, up to 24 hours)
#Symptomatic (GI distress)
#Convalescent (feel better, but LFT's increasing)
#Fulminant (day 2-4)
 
==Differential Diagnosis==
{{Mushroom toxicity DDX}}
{{SLUDGE DDX}}
{{Acute hepatitis causes}}
 
==Evaluation==
===Early-Onset===
 
===Delayed-Onset===
*[[Hypoglycemia]] is common cause of death and needs close monitoring


===Treatment===
==Management==
===Early-Onset===
*GI predominant symptoms:
*GI predominant symptoms:
**Activated charcoal 0.5-1gm/kg
**[[Activated charcoal]] 0.5-1gm/kg
**Do not give antidiarrheal meds
**Do ''not'' give antidiarrheal meds
*CNS predominant symptoms:
*CNS predominant symptoms:
**Place in dark, quiet room
**Place in dark, quiet room
**Benzos may be given to pts who are agitated
**[[Benzos]] may be given to patients who are agitated
**Consider [[pyridoxine]] for refractory seizures, especially if suspecting [[gyromitra]]<ref> Berger KJ, Guss DA. Mycotoxins revisited: Part II. J Emerg Med. 2005;28(2):175. </ref>
*Muscarinic predominant symptoms:
*Muscarinic predominant symptoms:
**Consider atropine for severe symptoms; 0.5-1mg IV for adults; 0.01mg/kg IV for peds
**Consider [[atropine]] for severe symptoms; 0.5-1mg IV for adults; 0.01mg/kg IV for peds
 
===Delayed-Onset===
Consider [[Amanita mushrooms|Amatoxin-specific treatments]]:
*[[Activated charcoal]]
*[[N-Acetylcysteine|N-Acetylcysteine (NAC)]]: 150 mg/kg over one hour, 50 mg/kg over 4 hours, 100 mg/kg over 16 hours
*Call poison control, consider:
**[[Penicillin G]]
**Silibinin dihemisuccinate
**[[Cimetidine]]
**Vitamin C


===Disposition===
==Disposition==
===Early-Onset===
*Discharge once symptoms have subsided
*Discharge once symptoms have subsided


==Delayed-Onset Poisoning==
===Delayed-Onset===
*Amanita species causes 95% of deaths
*Admit
**Toxin inhibits formation of mRNA and is heat stable
**Most frequent species: ''A. phalloides, bisporigera, magnivelaris, ocreata, verna, virosa''<ref>Enjalbert F et al. Treatment of Amatoxin Poisoning: 20 year retrospective analysis. J tox Clin Tox 2002 40(6):715-767.</ref>
 
===''Amanita phalloides''===
[[File:Amanita phalloides.png|thumb|Amanita phalloides aka death cap]]
====Clinical Findings====
*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:
***Abd pain, vomiting and diarrhea (which may become bloody)
*Stage 2 (convalescent)
**Occurs 48hr after ingestion and lasts 12-24hr
**Symptoms subside and pt appears better
**Liver deteriorates silently and precipitously (LFTs begin to rise)
*Stage 3 (failure)
**Occurs 2-4d after ingestion
**Fulminant liver failure
***Hyperbilirubinemia, coagulopathy, hepatic encephalopathy, hepatorenal syndrome
 
====Treatment====
*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; 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 150 mg/kg IV over 15min in 200 cc D5W
***Then 50 mg/kg in 500cc D5W over 4hrs
***Followed by 100 mg/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
 
====Disposition====
*Admit all pts suspected of ingesting amatoxin containing mushrooms for at least 48hr
 
===''Gyromitra'' mushrooms===
[[File:Gyromitra_mushrooms.jpg|thumb|Gyromitra mushrooms]]
*Also known as "brain fungi"
*Fruit in the spring and early summer
*Frequently mistaken for morel mushrooms<ref>Brozen R et al. Gyromitra Mushroom Toxicity. Apr 14, 2015. http://emedicine.medscape.com/article/817931-treatment#showall.</ref>
*Inhibits formation of Vitamin B6 and GABA via hydrazine metabolite
 
====Clinical findings====
*GI upset, fatigue, muscle cramps
*Can present with refractory seizures due to GABA deficiency
*Hemolysis usually mild
*Rarely methemoglobinemia
 
====Treatment====
*Supportive care
*High dose pyridoxine for refractory seizures (5g IV initially)
*Avoid phenobarbital, especially in liver failure
*Methylene blue for severe methemoglobinemia
*Folinic acid supplementation (hydrazines inhibit MTHF production)
 
===''Crotinarius'' mushrooms===
[[File:Cortinarius_mushroom.jpg|thumb|Cortinarius mushroom]]
* contain toxin Orellanine
 
====Clinical findings====
* Headache, chills, malaise, nausea and vomiting over days
* Can see delayed renal failure 1-3 weeks after exposure
 
====Treatment====
* Supportive
* If renal failure from mushroom exposure, recovery can take several weeks. May need temporary hemodialysis.


==References==
==References==
*Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose
<references/>
<references/>


[[Category:Tox]]
[[Category:Toxicology]]

Latest revision as of 19:11, 22 August 2019

Background

Clinically broken into two main categories:

  1. Early-Onset Poisoning (toxicity begins within 2hr of ingestion)
    • Clinical course is usually benign
    • Comprises majority of mushroom-induced intoxications
  2. Late-Onset Poisoning (toxicity begins 6hr after ingestion)
    • Clinical course is often serious/ possibly fatal
    • Amanita species causes 95% of deaths
      • Most frequent species: A. phalloides, bisporigera, magnivelaris, ocreata, verna, virosa[1]
      • Toxin inhibits formation of mRNA and is heat stable

Mushroom Identification

Clinical Features

Early-Onset

Depends on the type of mushroom ingested

Delayed-Onset

Four Stages [3] [4]

  1. Latent (symptom free, up to 24 hours)
  2. Symptomatic (GI distress)
  3. Convalescent (feel better, but LFT's increasing)
  4. Fulminant (day 2-4)

Differential Diagnosis

Mushroom toxicity by Type

Mushroom Toxin Pathologic Effect
Amanita Amatoxin Hepatotoxicity
Coprine Disulfiram-like
Crotinarius Orellanine Delayed renal failure
Gyromitra Gyromitrin Seizures
Ibotenic Acid Anticholinergic
Muscarine Cholinergic
Orellanin Nephrotoxicity
Psilocybin Hallucinations

SLUDGE Syndrome

Causes of acute hepatitis

Evaluation

Early-Onset

Delayed-Onset

  • Hypoglycemia is common cause of death and needs close monitoring

Management

Early-Onset

  • GI predominant symptoms:
  • CNS predominant symptoms:
    • Place in dark, quiet room
    • Benzos may be given to patients who are agitated
    • Consider pyridoxine for refractory seizures, especially if suspecting gyromitra[6]
  • Muscarinic predominant symptoms:
    • Consider atropine for severe symptoms; 0.5-1mg IV for adults; 0.01mg/kg IV for peds

Delayed-Onset

Consider Amatoxin-specific treatments:

Disposition

Early-Onset

  • Discharge once symptoms have subsided

Delayed-Onset

  • Admit

References

  1. ↑ Enjalbert F et al. Treatment of Amatoxin Poisoning: 20 year retrospective analysis. J tox Clin Tox 2002 40(6):715-767.
  2. ↑ Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.
  3. ↑ Brayer AF, Froula L. Mushroom poisoning. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2016:(Ch) 219.
  4. ↑ Shih RD. Plants, mushrooms and herbal medications. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier; 2018:(Ch) 164.
  5. ↑ Ostapowicz G, Fontana RJ, Schiodt FV, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med. 2002 Dec 17; 137(12): 947-54.
  6. ↑ Berger KJ, Guss DA. Mycotoxins revisited: Part II. J Emerg Med. 2005;28(2):175.
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