Mushroom toxicity: Difference between revisions

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**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''===
==''Amanita phalloides''==
[[File:Amanita phalloides.png|thumb|Amanita phalloides aka death cap]]
[[File:Amanita phalloides.png|thumb|Amanita phalloides aka death cap]]
====Clinical Findings====
===Clinical Findings===
*Stage 1 (GI)
*Stage 1 (GI)
**Occurs 6-24hr after ingestion and lasts 12-24hr
**Occurs 6-24hr after ingestion and lasts 12-24hr
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***Hyperbilirubinemia, coagulopathy, hepatic encephalopathy, hepatorenal syndrome
***Hyperbilirubinemia, coagulopathy, hepatic encephalopathy, hepatorenal syndrome


====Treatment====
===Treatment===
*Immediate therapy
*Immediate therapy
**Activated charcoal
**Activated charcoal
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***Progressive coagulopathy, encephalopathy, renal failure are indications for transplant
***Progressive coagulopathy, encephalopathy, renal failure are indications for transplant


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


Revision as of 01:30, 11 January 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

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]

Amanita phalloides

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[4]
    • N-acetylcysteine admin much like in acetaminophen toxicity[5]
      • 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[6]
      • 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

Gyromitra mushrooms
  • Also known as "brain fungi"
  • Fruit in the spring and early summer
  • Frequently mistaken for morel mushrooms[7]
  • 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

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

  • Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose
  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.
  4. ↑ 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
  5. ↑ Lee DS et al. Amatoxin Toxicity Medication. July 21, 2015. http://emedicine.medscape.com/article/1008902-medication#2.
  6. ↑ 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.
  7. ↑ Brozen R et al. Gyromitra Mushroom Toxicity. Apr 14, 2015. http://emedicine.medscape.com/article/817931-treatment#showall.
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