Mushroom toxicity: Difference between revisions

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#*Clinical course is often serious/ possibly fatal
#*Clinical course is often serious/ possibly fatal
#*Amanita species causes 95% of deaths
#*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>
#**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
#**Toxin inhibits formation of mRNA and is heat stable
{{Mushroom toxicity DDX}}


{{Mushroom identification images}}
{{Mushroom identification images}}
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''Depends on the type of mushroom ingested''
''Depends on the type of mushroom ingested''
*GI
*GI
**Nausea/vomiting/diarrhea
**[[Nausea/vomiting]], diarrhea
**Resolves within 24hr
**Resolves within 24hr
*CNS<ref>Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.</ref>
*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) - dsyarthria, ataxia, muscle cramps
**Isoxazoles (ibotenic acid and muscimol) - [[dysarthria]], [[ataxia]], muscle cramps
**Psilocybin - euphoria, visual hallucinations, agitation, sympathomimetic Sxs
**Psilocybin - euphoria, visual [[hallucinations]], [[agitation]], [[sympathomimetic]] symptoms
**Lasts 4-8hrs
**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===
===Delayed-Onset===
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==Differential Diagnosis==
==Differential Diagnosis==
{{Mushroom toxicity DDX}}
{{SLUDGE DDX}}
{{Acute hepatitis causes}}
{{Acute hepatitis causes}}


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===Delayed-Onset===
===Delayed-Onset===
*Hypoglycemia is common cause of death and needs close monitoring
*[[Hypoglycemia]] is common cause of death and needs close monitoring


==Management==
==Management==
===Early-Onset===
===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 patients 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>
**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:
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*[[N-Acetylcysteine|N-Acetylcysteine (NAC)]]: 150 mg/kg over one hour, 50 mg/kg over 4 hours, 100 mg/kg over 16 hours
*[[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:
*Call poison control, consider:
**Penicillin G
**[[Penicillin G]]
**Silibinin dihemisuccinate
**Silibinin dihemisuccinate
**Cimetidine
**[[Cimetidine]]
**Vitamin C
**Vitamin C



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.