Mushroom toxicity: Difference between revisions

Revision as of 22:34, 20 September 2011

Background

Two categories:
1. Early-Onset Poisoning
  1. Toxicity begins within 2hr of ingestion; clinical course is usually benign
2. Late-Onset Poisoning
  1. Toxicity begins 6hr after ingestion; clinical course is often serious/ possibly fatal

Early-Onset Poisoning

Comprises majority of mushroom-induced intoxications

Clinical Features

Depends on the type of mushroom ingested
GI
1. Nausea/vomiting/diarrhea
2. Resolves within 24hr
CNS
1. Euphoria, hallucinations
2. Lasts 4-6hr
Muscarinic
1. SLUDGE symptoms
2. Diaphoresis, muscle fasciculations, miosis, bradycardia, bronchorrhea
3. Resolves in 4-12hr

Treatment

GI predominant symptoms:
1. Activated charcoal 0.5-1gm/kg
2. Do not give antidiarrheal meds
CNS predominant symptoms:
1. Place in dark, quiet room
2. Benzos may be given to pts who are agitated
Muscarinic predominant symptoms:
1. 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
1. Toxin inhibits formation of mRNA

Clinical Findings

Stage 1 (GI)
1. Occurs 6-24hr after ingestion and lasts 12-24hr
  1. The later the onset of symptoms the better the outcome
2. GI predominant symptoms:
  1. Abd pain, vomiting and diarrhea (which may become bloody)
Stage 2 (convalescent)
1. Occurs 48hr after ingestion and lasts 12-24hr
2. Symptoms subside and pt appears better
3. Liver deteriorates silently and precipitously (LFTs begin to rise)
Stage 3 (failure)
1. Occurs 2-4d after ingestion
2. Fulminant liver failure
  1. Hyperbilirubinemia, coagulopathy, hepatic encephalopathy, hepatorenal syndrome

Treatment

Immediate therapy
1. Activated charcoal
  1. Some advocate repeated doses during the first 24hr
    1. Amatoxin undergoes enterohepatic circulation
2. Penicillin
  1. High doses 1 mil units/kg/d effective in animal studies (inhibits amatoxin uptake)
3. Silibinin
  1. Free radical scavenger used successfully in Europe; 25-50mg/kg/d
Ongoing therapy
1. Glucose monitoring
  1. Hypoglycemia is one of the most common causes of death in early mushroom toxicity
2. Liver/renal failure monitoring
  1. Serial LFTs, chem, coags
3. Prepare for liver transplant
  1. Progressive coagulopathy, encephalopathy, renal failure are indications for transplant

Disposition

Admit all pts suspected of ingesting amatoxin containing mushrooms for at least 48hr

Source

Tintinalli

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
-*Onset of diarrhea <8hr after ingestion is sensitive marker for fatality
+#Two categories:
-===Stages===
+##Early-Onset Poisoning
-*First stage (6-24hr after ingestion)
+###Toxicity begins within 2hr of ingestion; clinical course is usually benign
-**Abd pain, fever, N/V, diarrhea, tachycardia, hyperglycemia, hypotension
+##Late-Onset Poisoning
-*Second stage (48hr after ingestion)
+###Toxicity begins 6hr after ingestion; clinical course is often serious/ possibly fatal
-**Symptoms subside (even though liver deteriorates precipitously)
-*Third stage
-**Fulminant liver failure
-Amatoxin
+==Early-Onset Poisoning==
+*Comprises majority of mushroom-induced intoxications
-- inhibits rna polymerase and interfers c dna rna transcriptn. -
+===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
-- Disruption of protein synthesis causes fatal intestinal hepatic renal dz.
+===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
-- Is heat stable- not affected by cooking
+===Disposition===
+#Discharge once symptoms have subsided
-- delayed tox- 6-24 hrs
+==Delayed-Onset Poisoning==
+#Amanita species causes 95% of deaths
+##Toxin inhibits formation of mRNA
-- liver and kidney failure
+===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
+###Free radical scavenger used successfully in Europe; 25-50mg/kg/d
+#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
-Gyromitrins
+===Disposition===
+#Admit all pts suspected of ingesting amatoxin containing mushrooms for at least 48hr
-- oxidizes hemoglobin- can cause methemoglobinemia
-- inhibits glutamic acid decarboxylase- leads to low GABA level - neuro sxs
--delayed 6-8 hrs -
-- 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==
+Tintinalli
-/06 MISTRY
 [[Category:Tox]]