Mushroom toxicity: Difference between revisions
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===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 | ||
==References== | ==References== | ||
Revision as of 01:49, 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
- Acetaminophen toxicity (most common cause of acute liver failure in the US[1])
- Viral hepatitis
- Toxoplasmosis
- Acute alcoholic hepatitis
- Toxins
- Ischemic hepatitis
- Autoimmune hepatitis
- Wilson's disease
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
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
- Some advocate repeated doses during the first 24hr
- 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
- Activated charcoal
- 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
- Glucose monitoring
Disposition
- Admit all pts suspected of ingesting amatoxin containing mushrooms for at least 48hr
References
- Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose
- ↑ 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.
- ↑ Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.
- ↑ Enjalbert F et al. Treatment of Amatoxin Poisoning: 20 year retrospective analysis. J tox Clin Tox 2002 40(6):715-767.
- ↑ 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
- ↑ Lee DS et al. Amatoxin Toxicity Medication. July 21, 2015. http://emedicine.medscape.com/article/1008902-medication#2.
- ↑ 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.