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Mushroom Poisoning, Emergency Medicine

Basics

Description

- Mechanism: - Inhibits pyridoxal phosphate - Damage to RBCs, hepatocytes, neurons

- Amanitin/phalloidin: - Nausea - Vomiting - Abdominal cramps - Bloody diarrhea - Clinical course: - Onset of symptoms delayed 6 " 36 hr with development of GI symptoms - Transient latent phase may last 2 days (no pain/symptoms) - Can progress to hepatic or renal failure and death in 2 " 6 days - Most lethal mushroom toxins

- Coprine: - Disulfiram-like reaction within minutes to hours when combined with alcohol: - Flushing - Sweating - Nausea/vomiting - Palpitations

- Ibotenic acid/muscimol: - Relatively rapid onset of 30 " 120 min - GABA agonist effects include: - Hallucinations - Dysarthria - Ataxia - Somnolence/coma

- Glutamatergic effects (mainly pediatrics): - Seizures - Muscle cramps/myoclonic movements

- Psilocin/psilocybin: - Rapid onset, usually resolves in 6 " 12 hr - Visual hallucinations - Alteration of perception - Mydriasis - Tachycardia - Fever and seizures in children

- T. equestre: - Acute rhabdomyolysis: - Myalgias/arthralgias - Hematuria/dark urine - Decreased urine output

- Psilocin/psilocybin: - Self-limited toxicity - Dark, quiet room and reassurance - Benzodiazepines for agitation - External cooling measures if needed in children

- Orellanine and A. smithiana: - Closely monitor BUN, creatinine, electrolytes, and urine output. - Forced diuresis with Lasix contraindicated - Diuresis with alkalinization of urine with NaHCO3 if signs of rhabdomyolysis - Hemodialysis/renal transplantation may be needed.

- T. equestre ( "man on horse " ): - Fluid hydration - Check and follow CPK. - Monitor urine output.

  • Amanitin/phalloidin:Species:Amanita phalloides ( "death cap " )Amanita virosa/Amanita verna ( "destroying angel " )Galerina marginata, Galerina venenataMechanism:Cyclopeptide toxins inhibit RNA polymerase 2, which kills GI epithelium, hepatocytes, nephrocytes
  • Gyromitrin:Species:Gyromitra esculenta ( "false morels " )Other Gyromitra spp.Mechanism:Inhibits pyridoxal phosphateDamage to RBCs, hepatocytes, neurons
  • Muscarine:Species:Inocybe (several species)Clitocybe (several species)Mechanism:
  • Coprine:Species:Coprinus atramentarius ( "inky caps " )Mechanism:Blocks acetaldehyde dehydrogenaseCauses disulfiram-like reaction if mixed with alcohol
  • Ibotenic acid/muscimol:Species:Amanita pantherina ( "the panther " )Amanita muscaria ( "fly agaric " )Mechanism:
  • Psilocin/psilocybin:Species:Psilocybe and Panaeolus spp. as well as othersMechanism:Similar structure to lysergic acid diethylamide, effect serotonin receptor
  • Gastric irritants:Many various mushrooms, including those normally considered edible
  • Orellanine:Species:Cortinarius (several species)Mechanism:
  • Tricholoma equestre ( "man on horse " ):Rhabdomyolysis-inducing mushroomsUnidentified myotoxin

Diagnosis

Signs and Symptoms

  • Amanitin/phalloidin:NauseaVomitingAbdominal crampsBloody diarrheaClinical course:Onset of symptoms delayed 6 " 36 hr with development of GI symptomsTransient latent phase may last 2 days (no pain/symptoms)Can progress to hepatic or renal failure and death in 2 " 6 daysMost lethal mushroom toxins
  • Gyromitrin:1st 5 " 10 hr:Abdominal crampsNausea/vomitingWatery diarrheaLater symptoms:WeaknessCyanosisConfusionSeizuresComa
  • Muscarine:Cholinergic symptoms include:MiosisSalivationLacrimationSweatingDiarrheaFlushed skinNauseaBradycardiaBronchoconstrictionOnset usually within 1 hr (may be delayed)
  • Coprine:Disulfiram-like reaction within minutes to hours when combined with alcohol:FlushingSweatingNausea/vomitingPalpitations
  • Ibotenic acid/muscimol:Relatively rapid onset of 30 " 120 minGABA agonist effects include:HallucinationsDysarthriaAtaxiaSomnolence/comaGlutamatergic effects (mainly pediatrics):SeizuresMuscle cramps/myoclonic movements
  • Psilocin/psilocybin:Rapid onset, usually resolves in 6 " 12 hrVisual hallucinationsAlteration of perceptionMydriasisTachycardiaFever and seizures in children
  • Gastric irritants:Group of toxins that cause nausea, vomiting, intestinal cramps, and watery diarrheaOnset 30 min to 3 hr, usually resolved in 6 " 12 hr
  • Orellanine/Amanita smithiana:Nausea/vomitingHeadacheSweatingChillsLow-back painPolydipsiaClinical course:May progress to oliguria and acute renal failureMarkedly delayed onset of symptoms (2 " 14 days)
  • T. equestre:Acute rhabdomyolysis:Myalgias/arthralgiasHematuria/dark urineDecreased urine outputDehydration

History

  • Time of ingestion
  • Time of symptom onset
  • Quantity ingested
  • Preparation: Raw or cooked
  • Picked in the wild or store-bought
  • Coingestants, other mushrooms
  • Alcohol/drug use history
  • Symptoms of family members, friends

Physical Exam

  • Vital signs
  • Changes in mental status
  • Pupillary response
  • Cardiopulmonary exam
  • Abdominal exam
  • Neurologic exam

Essential Workup

  • Mushroom description:Pileus (cap); margin shapeStipe (stem)Lamellae (gills)VeilAnnulus (ring)Volva
  • Store mushroom in brown paper bag for future identification:<3% of cases result in an exact mushroom identification.Digital photography and electronic image transfer to poison control center or regional mycologist

Diagnosis Tests & Interpretation

Lab

  • CBC
  • Prothrombin time (PT), partial thromboplastin time (PTT)
  • Electrolytes, BUN, creatinine, glucose
  • Urinalysis
  • LFTs, creatine phosphokinase (CPK)
  • Imaging
  • Spore print: Mycologist needed for specific genus/species interpretation

Differential Diagnosis

  • Very broad differential
  • Gastroenteritis
  • Hepatitis/acetaminophen hepatotoxicity
  • Acute renal failure (many causes)
  • Rhabdomyolysis (many causes)
  • Cholinergic syndrome (e.g., organophosphates)
  • Anticholinergic syndrome
  • Seizures (many causes)

Treatment

Pre-Hospital

Bring any unconsumed mushrooms or mushroom pieces to hospital to aid in diagnosis:

  • Refrigerate specimens if possible, place in brown paper bag.

Initial Stabilization/Therapy

  • ABCs
  • Establish IV 0.9% NS saline
  • Monitor
  • Naloxone, D50W (or Accu-Chek), and thiamine for altered mental status

Ed Treatment/Procedures

General Measures

  • Decontamination:Activated charcoal (50 " 100 g)Gastric decontamination if early after ingestion and patient:Has not yet vomited.Has normal mental and respiratory statusIs not undergoing hallucinations
  • Fluid rehydration and electrolyte replacement as necessary
  • Call local poison control center at 800-222-1222 and request mycologist " digital picture may be electronically sent for identification.
  • Obtain specimens (vomitus if needed) for identification.

Mushroom-specific Therapy

  • Amanitin/phalloidin:Administer activated charcoal PO q2 " 4h.Hypoglycemia and elevated PT:Signs of liver failureAdminister fresh-frozen plasma and vitamin K for coagulation disorders with active bleeding.Administer calcium in presence of hypocalcemia.Liver transplant for severe hepatic necrosisConsider N-acetylcysteine, high-dose penicillin G, or silibinin if available (thioctic acid controversial)
  • Gyromitrin:Treat seizure with benzodiazepines.Administer pyridoxine (vitamin B6) in severely symptomatic patients.Treat liver dysfunctions as outlined for amanitin/phalloidin group.Dialysis for renal failure
  • Muscarine:Administer atropine in severe cases.
  • Coprine:Self-limited toxicity " supportive careAvoid syrup of ipecac (contains alcohol) ²-Blockers for cardiac dysrhythmias
  • Ibotenic acid/muscimol:Usually self-limited toxicityProvide supportive careMonitor for hypotensionTreat moderate symptoms with benzodiazepines, if severe anticholinergic symptoms; consider physostigmine.
  • Psilocin/psilocybin:Self-limited toxicityDark, quiet room and reassuranceBenzodiazepines for agitationExternal cooling measures if needed in children
  • GI Irritants:When poisoning from above groups not suspected, administer fluids and antiemetics.Provide supportive care
  • Orellanine and A. smithiana:Closely monitor BUN, creatinine, electrolytes, and urine output.Forced diuresis with Lasix contraindicatedDiuresis with alkalinization of urine with NaHCO3 if signs of rhabdomyolysisHemodialysis/renal transplantation may be needed.
  • T. equestre ( "man on horse " ):Fluid hydrationCheck and follow CPK.Monitor urine output.

Medication

  • Activated charcoal slurry: 1 " 2 g/kg up to 100 g PO
  • Atropine: 0.5 mg (peds: 0.02 mg/kg) IV; repeat 0.5 " 1 mg IV (peds: 0.04 mg/kg) q10min if secretions recur, to max. 1 mg/kg in children and 2 mg/kg in adults
  • Dextrose: D50W 1 amp: 50 mL or 25 g (peds: D25W 2 " 4 mL/kg) IV
  • Diazepam (benzodiazepine): 5 " 10 mg (peds: 0.2 " 0.5 mg/kg) IV
  • Lorazepam (benzodiazepine): 2 " 6 mg (peds: 0.03 " 0.05 mg/kg) IV
  • Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  • Physostigmine: 0.5 " 2 mg IM or IV in adults
  • Propranolol: 1 mg (peds: 0.01 " 0.1 mg/kg) IV
  • Pyridoxine: 25 mg/kg IV over 30 min
  • Thiamine (vitamin B1): 100 mg (peds: 50 mg) IV or IM

Follow-Up

Disposition

Admission Criteria

  • All symptomatic patients:Protracted vomiting, dehydration, liver or renal toxicity, or seizures
  • Transfer to tertiary medical center for early signs of renal or hepatic failure.
  • Symptomatic infants and young children found with mushrooms:
  • ICU admission for known ingestion of an amanitin-containing mushroom:Early liver service consultation

Discharge Criteria

Asymptomatic during 6 " 8 hr with 24 hr of close home observation and close follow-up (if reliable caregivers)

Issues for Referral

Potential liver or renal transplantation

Followup Recommendations

Drug detoxification programs if chronic recreational use

Pearls and Pitfalls

  • There are old mushroom pickers, and bold mushroom pickers; but there are no old, bold mushroom pickers.
  • Symptoms with late onset (>6 hr) generally indicate more lethal toxins.
  • Lack of proper mycologic identification
  • Timely organ transplant referrals when indicated

Additional Reading

  • Beuhler MC, Sasser HC, Watson WA. The outcome of North American pediatric unintentional mushroom ingestions with various decontamination treatments: An analysis of 14 years of TESS data. Toxicon. 2009;53(4):437 " 443.
  • Diaz JH. Syndromic diagnosis and management of confirmed mushroom poisonings. Crit Care Med. 2005;33(2):427 " 436.
  • Goldfrank LR. Mushrooms In: Goldfrank LR, ed. Goldfranks Toxicologic Emergencies. 9th ed. New York, NY: McGraw-Hill, 2011:1522 " 1536.
  • Matsuura M, Saikawa Y, Inui K, et al. Identification of the toxic trigger in mushroom poisoning. Nat Chem Biol. 2009;5(7):465 " 467.
  • West PL, Lindgren J, Horowitz BZ. Amanita smithiana mushroom ingestion: A case of delayed renal failure and literature review. J Med Toxicol. 2009;5(1):32 " 38.

Codes

ICD9

988.1 Toxic effect of mushrooms eaten as food

ICD10

T62.0X1A Toxic effect of ingested mushrooms, accidental, init

SNOMED

  • 86505009 Toxic effect from eating mushrooms (disorder)
  • 216771005 Accidental poisoning from mushrooms (disorder)
  • 242358002 Accidental ingestion of hallucinogenic mushrooms (disorder)