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 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 | **[[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) - | **Isoxazoles (ibotenic acid and muscimol) - [[dysarthria]], [[ataxia]], muscle cramps | ||
**Psilocybin - euphoria, visual hallucinations, agitation, sympathomimetic | **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: | ||
Line 65: | Line 65: | ||
*[[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:
- 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[1]
- Toxin inhibits formation of mRNA and is heat stable
Mushroom Identification
Clinical Features
Early-Onset
Depends on the type of mushroom ingested
- GI
- Nausea/vomiting, diarrhea
- Resolves within 24hr
- CNS[2]
- 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
Delayed-Onset
- Latent (symptom free, up to 24 hours)
- Symptomatic (GI distress)
- Convalescent (feel better, but LFT's increasing)
- 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
- Carbamate toxicity
- Mushroom toxicity, especially:
- Organophosphate toxicity
- Nerve agent
- Nicotine toxicity (look alike)
- Acetylcholinesterase inhibitor overdose (e.g in myasthenia gravis or post anesthesia reversal)
Causes of acute hepatitis
- Acetaminophen toxicity (most common cause of acute liver failure in the US[5])
- Viral hepatitis
- Toxoplasmosis
- Acute alcoholic hepatitis
- Toxins
- Ischemic hepatitis
- Autoimmune hepatitis
- Wilson's disease
Evaluation
Early-Onset
Delayed-Onset
- Hypoglycemia is common cause of death and needs close monitoring
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[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:
- Activated charcoal
- 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
Disposition
Early-Onset
- Discharge once symptoms have subsided
Delayed-Onset
- Admit
References
- ↑ Enjalbert F et al. Treatment of Amatoxin Poisoning: 20 year retrospective analysis. J tox Clin Tox 2002 40(6):715-767.
- ↑ Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Berger KJ, Guss DA. Mycotoxins revisited: Part II. J Emerg Med. 2005;28(2):175.