Mushroom Poisoning, Emergency Medicine

Basics

Description

Amanitin/phalloidin:
- Species:
  - Amanita phalloides ( "death cap " )
  - Amanita virosa/Amanita verna ( "destroying angel " )
  - Galerina marginata, Galerina venenata
- Mechanism:
  - Cyclopeptide toxins inhibit RNA polymerase 2, which kills GI epithelium, hepatocytes, nephrocytes
Gyromitrin:
- Species:
  - Gyromitra esculenta ( "false morels " )
  - Other Gyromitra spp.
- Mechanism:
  - Inhibits pyridoxal phosphate
  - Damage to RBCs, hepatocytes, neurons
Muscarine:
- Species:
  - Inocybe (several species)
  - Clitocybe (several species)
- Mechanism:
  - Parasympathomimetic
Coprine:
- Species:
  - Coprinus atramentarius ( "inky caps " )
- Mechanism:
  - Blocks acetaldehyde dehydrogenase
  - Causes disulfiram-like reaction if mixed with alcohol
Ibotenic acid/muscimol:
- Species:
  - Amanita pantherina ( "the panther " )
  - Amanita muscaria ( "fly agaric " )
- Mechanism:
  - GABA agonists
Psilocin/psilocybin:
- Species:
  - Psilocybe and Panaeolus spp. as well as others
- Mechanism:
  - 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:
  - Direct renal toxicity
Tricholoma equestre ( "man on horse " ):
- Rhabdomyolysis-inducing mushrooms
- Unidentified myotoxin

Diagnosis

Signs and Symptoms

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
Gyromitrin:
- 1st 5 " 10 hr:
  - Abdominal cramps
  - Nausea/vomiting
  - Watery diarrhea
- Later symptoms:
  - Weakness
  - Cyanosis
  - Confusion
  - Seizures
  - Coma
Muscarine:
- Cholinergic symptoms include:
  - Miosis
  - Salivation
  - Lacrimation
  - Sweating
  - Diarrhea
  - Flushed skin
  - Nausea
  - Bradycardia
  - Bronchoconstriction
- Onset usually within 1 hr (may be delayed)
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
Gastric irritants:
- Group of toxins that cause nausea, vomiting, intestinal cramps, and watery diarrhea
- Onset 30 min to 3 hr, usually resolved in 6 " 12 hr
Orellanine/Amanita smithiana:
- Nausea/vomiting
- Headache
- Sweating
- Chills
- Low-back pain
- Polydipsia
- Clinical course:
  - May progress to oliguria and acute renal failure
  - Markedly delayed onset of symptoms (2 " 14 days)
T. equestre:
- Acute rhabdomyolysis:
  - Myalgias/arthralgias
  - Hematuria/dark urine
  - Decreased urine output
- Dehydration

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 shape
- Stipe (stem)
- Lamellae (gills)
- Veil
- Annulus (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 status
  - Is 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 failure
  - Administer fresh-frozen plasma and vitamin K for coagulation disorders with active bleeding.
- Administer calcium in presence of hypocalcemia.
- Liver transplant for severe hepatic necrosis
- Consider 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 care
- Avoid syrup of ipecac (contains alcohol)
- ²-Blockers for cardiac dysrhythmias
Ibotenic acid/muscimol:
- Usually self-limited toxicity
- Provide supportive care
- Monitor for hypotension
- Treat moderate symptoms with benzodiazepines, if severe anticholinergic symptoms; consider physostigmine.
Psilocin/psilocybin:
- Self-limited toxicity
- Dark, quiet room and reassurance
- Benzodiazepines for agitation
- External 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 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.

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:
- Assume ingestion.
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)

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