Mushroom toxicity: Difference between revisions
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**Toxin inhibits formation of mRNA and is heat stable
**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>
**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


==References==
==References==

Revision as of 15:30, 2 February 2016

Background

Major Categories

  • Early-Onset Poisoning
    • Toxicity begins within 2hr of ingestion; clinical course is usually benign
  • Late-Onset Poisoning
    • Toxicity begins 6hr after ingestion; clinical course is often serious/ possibly fatal
Mushroom Toxin Pathologic Effect
Amatoxin Hepatotoxicity
Coprine Disulfiram-like
Gyromitrin Seizures
Ibotenic Acid Anticholinergic
Muscarine Cholinergic
Orellanin Nephrotoxicity
Psilocybin Hallucinations

Specific Mushroom Type Ingestions

Differential Diagnosis

Causes of acute hepatitis

Early-Onset Poisoning

  • Comprises majority of mushroom-induced intoxications
  • Symptom onset 30-90 min with hallucinations, lasting 6-8 hrs[2]:
    • 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
    • Nausea/vomiting/diarrhea
    • Resolves within 24hr
  • CNS
    • Euphoria, hallucinations
    • Lasts 4-6hr
  • Muscarinic
    • SLUDGE symptoms
    • Diaphoresis, muscle fasciculations, miosis, bradycardia, bronchorrhea
    • Resolves in 4-12hr
  • Disulfiram-like effect
    • Usually when drinking alcohol
    • Flushing, tachycardia, diaphoresis, hypotension

Treatment

  • 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 pts who are agitated
  • Muscarinic predominant symptoms:
    • Consider atropine for severe symptoms; 0.5-1mg IV for adults; 0.01mg/kg IV for peds

Disposition

  • Discharge once symptoms have subsided

Delayed-Onset Poisoning

  • Amanita species causes 95% of deaths
    • Toxin inhibits formation of mRNA and is heat stable
    • Most frequent species: A. phalloides, bisporigera, magnivelaris, ocreata, verna, virosa[3]

References

  1. ↑ 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.
  2. ↑ Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.
  3. ↑ Enjalbert F et al. Treatment of Amatoxin Poisoning: 20 year retrospective analysis. J tox Clin Tox 2002 40(6):715-767.
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