Mushroom toxicity: Difference between revisions

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==Background==
==Background==
Clinically broken into two main categories:
#Early-Onset Poisoning (toxicity begins within 2hr of ingestion)
#*Clinical course is usually benign
#*Comprises majority of mushroom-induced intoxications
#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


{{Mushroom identification images}}


Amatoxin
==Clinical Features==
===Early-Onset===
''Depends on the type of mushroom ingested''
*GI
**[[Nausea/vomiting]], diarrhea
**Resolves within 24hr
*CNS<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) - [[dysarthria]], [[ataxia]], muscle cramps
**Psilocybin - euphoria, visual [[hallucinations]], [[agitation]], [[sympathomimetic]] symptoms
**Lasts 4-8hrs
*Muscarinic
**SLUDGE symptoms
**Diaphoresis, muscle fasciculations, miosis, [[bradycardia]], bronchorrhea
**Resolves in 4-12hr
*Disulfiram-like effect
**Usually when drinking alcohol
**Flushing, [[tachycardia]], diaphoresis, [[hypotension]]


- inhibits rna polymerase and interfers c dna rna transcriptn. -
===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)


- Disruption of protein synthesis causes fatal intestinal hepatic renal dz.
==Differential Diagnosis==
{{Mushroom toxicity DDX}}
{{SLUDGE DDX}}
{{Acute hepatitis causes}}


- Is heat stable- not affected by cooking
==Evaluation==
===Early-Onset===


- delayed tox- 6-24 hrs
===Delayed-Onset===
*[[Hypoglycemia]] is common cause of death and needs close monitoring


- liver and kidney failure
==Management==
===Early-Onset===
*GI predominant symptoms:
**[[Activated charcoal]] 0.5-1gm/kg
**Do ''not'' give antidiarrheal meds
*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]]<ref> Berger KJ, Guss DA. Mycotoxins revisited: Part II. J Emerg Med. 2005;28(2):175. </ref>
*Muscarinic predominant symptoms:
**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


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


- oxidizes hemoglobin- can cause methemoglobinemia
===Delayed-Onset===
*Admit


- inhibits glutamic acid decarboxylase- leads to low GABA level - neuro sxs
==References==
<references/>


-delayed 6-8 hrs -
[[Category:Toxicology]]
 
- hepatitis
 
- cns changes
 
- hemolysis
 
- metHb
 
 
Orellanine and orelline
 
 
Coprine
 
- if ingested c etoh can lead to Beta adrenergic stimulation like disulfiram rxn
 
 
Ibotenic acid and muscimol
 
- anticholinergic activity and hallucinatns,
 
 
Muscarine
 
- cholinergic stimulatn- blurred vision, sweating, HA, lacrimation, salivation, urinary freq
 
 
Psilocybin and psilocin
 
- nv, hallucination, flashbacks
 
 
==Diagnosis==
 
 
- if > 6h from ingestion to sxs suggests amatoxin, gyromitrin, orellenine, oreline. Do LFT, PT
 
- if < 3h is ibotenic acid, muscimol, muscarine, psilocin
 
- temporal assoc c etoh and sxs suggest coprine poisoning
 
 
==Treatment==
 
 
- charcoal
 
- no antiemetic or imodium since will cause increased toxin absorption
 
- golightly whole bowel irrigation
 
- if amatoxn, gyromitrin, orellanine admit for observatn
 
 
TOXIN SPECIFIC TX-
 
Amatoxn-
 
- forced diuresis
 
- charcoal hemoperfusion
 
- high dose penicilin- inhibits amatoxn uptake by hepatocytes. One million units/kg in divided doses per day for 2- 3 days. Sz is complicatn.
 
- high dose cimetidine- inhibits P450 enzyme. 2 gms q 4h iv
 
- liver xplant
 
- hyperbaric O2
 
- high dose ascorbic acid
 
- N- acetylcysteine
 
Gyromitrin poisoning-
 
- pyridoxin 25mg/kg iv over 30min. Repeat up to 4 times in 24 hrs if sxs persist.
 
- benzos
 
- diuresis
 
- blood xfusion
 
- methylene blue
 
Orellanine
 
- fluids
 
Coprine- etoh
 
- dopamine for hypotn
 
Ibotenil- muscimol
 
- control neuromuscular hyperactivity- benzos. Consider physostigmine if refractory agitation and tachy and perif anticholinergic findings
 
Muscarine poisoning
 
- atropine
 
- albuterol
 
- anti histamines,
 
 
==Source==
 
 
6/06 MISTRY
 
 
 
 
[[Category:Tox]]

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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