Mushroom Poisoning

1
Mushroom Poisoning

• Adam Oster
• Dr. Mark Yarema
• March 21, 2002

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Mushroom Poisoning
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Case 1

• 22 male student from SAIT presents with severe
  abdominal pain and profuse non-bloody vomitting.
  States that he ate a pizza with shrooms his
  friend had put on it approximately 2 hours ago.
• Looks unwell
• 120, 110/90, 10, 96 RA, 37.9
• Management plan
• initial resuscitation
• identify mushroom, if possible (toxicologist or
  mycologist)
• further care if necessary

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Mushroom Poisoning

• 5 exposures per 100 000 population
• most exposures are relatively benign
• approx 5 result in moderate poisoning
• approx 3 deaths per year

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Mushroom Poisoning

• Prognosis is dependent on the specific species of
  mushroom
• if a specimen is available store at room temp in
  a bag
• can collect vomitus as well
• species ingested remains unknown in approx 90 of
  cases
• amanita species responsible for the majority of
  fatal ingestions
• identification efforts should be spent
  identifying this high risk species.

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Mushroom Poisoning
Early Onset
Late onset
cyclopeptides
Ibotenic and muscimol
coprine
gyromitrin
psilocybin
GI toxin
orellanine
muscarine
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Mushroom Poisoning

• Early onset symptoms
• usually develop lt4 hours
• GI symptoms common and usually predominate
• include hallucinogenic mushrooms
• can last upto 24h
• treatment is supportive
• good outcome is the general rule

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Case 2

• 16 girl brought in by EMS. Friends describe a
  seizure at their house about 1 hours after eating
  5 mushrooms. When EMS arrived they witnessed a
  30 sec tonic-clonic seizure.
• O/E
• GCS 11, drowsy and dehydrated
• Vitals
• 150, 12, 99 RA, 38.6, 130/90
• Management?

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Mushroom Poisoning

• Early onset symptoms
• CNS effects
• psilocybin and ibotenic acid/muscimol group
• eg Psilocybe cubenesis (Gold caps)
• found in Florida, Lousianna and Texas.
• grow in cow dung
• structurally related to LSD and serotonin
• remain active when dried or cooked

Early Onset
Ibotenic and muscimol
coprine
psilocybin
GI toxin
muscarine
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Mushroom Poisoning

• Early onset symptoms
• ibotenic acid and muscimol
• eg amanita muscaria
• structurally related to GABA and glutamate
• lethargy, hallucination, seizures and agitiation
  usually begin within 2hr
• usually produce anticholinergic not cholinergic
  symptoms
• do not use atropine

Early Onset
Ibotenic and muscimol
coprine
psilocybin
GI toxin
muscarine
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Case 3

• 28 male river guide. Presents with emesis and
  diarrhea 3 hrs after sampling edible mushrooms
  from the river bank.
• O/E
• VSS, afebrile, not jaundiced.
• eyes are tearing and he is salivating
• no RUQ or abdominal pain.

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Mushroom Poisoning

• Muscarine containing
• eg Clitocybe dealbata
• cholinergic toxidrome
• does not cross BBB
• atropine can be used for severe symptoms

Early Onset
Ibotenic and muscimol
coprine
psilocybin
GI toxin
muscarine
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Case 4
Early Onset

• 30 male chef. Presents with 2 hours of severe
  nausea and vomitting. He ate mushrooms on a dare
  3 hours ago and has been drinking beer since then
  to get the taste out of his mouth. States he has
  never felt this sick in his life.
• Vitals 38.0, 110, 12, 99, 120/80
• O/E
• looks ill and flushed
• vomits during exam
• exam within normal

Ibotenic and muscimol
coprine
psilocybin
GI toxin
muscarine
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Mushroom Poisoning

• Coprine-containing mushrooms
• only cause symptoms with the simultaneous
  ingestion of ethanol
• a dislfiram-type reaction caused by ADH
  antagonism

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Case 5

• 50 woman, previously healthy. Presents with 10
  hours of N/V and abdominal cramping. States that
  she was on a nature walk with a friend yesterday
  morning and they sampled some of the mushrooms
  along the route. Felt well until this am.
• Vitals -- 130, 100/60, 16, 97 RA, 37.0
• O/E
• looks ill and dehydrated, not jaundiced.
• Lab
• INR 3.4, PTT 80, ALT 3500, Cr 265

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Mushroom Poisoning
Early Onset
Late onset
cyclopeptides
Ibotenic and muscimol
coprine
gyromitrin
psilocybin
GI toxin
orellanine
muscarine
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Red Flag Cases

• A 32-year-old man gathered and ate wild mushrooms
  that he believed were similar to other mushrooms
  he had previously gathered and eaten. Eight hours
  later, he developed vomiting and profuse
  diarrhea he was admitted to a hospital 19 hours
  after ingestion.
• A 30-year-old man used a guidebook to assist in
  the collection of wild mushrooms. Twelve hours
  after eating the mushrooms he had gathered, he
  developed vomiting and severe diarrhea. He was
  admitted to a hospital 17 hours after ingestion
  because of orthostatic hypotension and
  dehydration

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Mushroom Poisoning

• Late onset symptoms
• Cyclopeptide Mushrooms
• 3 main types of toxins amatoxins, virotoxins,
  phallotoxins
• amanita phalloides (Death Cap) most well known
  species
• contains amatoxins
• responsible for the vast majority of deaths
• easily misdiagnosed as gastroenteritis
• patients may not associate symptoms with mushroom
  ingestions because of the delayed onset

Late onset
cyclopeptides
gyromitrin
orellanine
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Amanita Phalloides

• Found primarily in the cool coastal regions of
  the west coast, but it also grows in several
  other regions, including the mid-Atlantic coast
  and in the northeast.
• Reported ingestions in the pacific Northwest, the
  Gulf Coast region, and even in suburban New York
• Flourish in favorable weather conditions during
  the fall or the rainy season.
• Toxin not destroyed by cooking or drying

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Amanita Phalloides

• 4 stage disease process
• Stage 1 incubation phase (upto 12 hrs)
• Stage 2 GI stage (lasts 12-24h). N/V/D abd
  cramps, dehydration, fever and hypoglycemia
• Stage 3 quiescent stage
• Stage 4 hepatocellular and renal damage with
  coagulopathy
• death from A. phalloides poisoning usually
  results from hepatic and/or renal failure and may
  occur 4-9 days after ingestion.
• fatality rate among persons treated for A.
  phalloides poisoning is 20-30.
• median lethal dose is 0.1 mg to 0.3 mg of the
  toxin per kg of body weight.

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Amanita Phalloides

• Investigations and Management
• CBC, lytes, Cr, BUN, PTT, INR, LFTs, bili
• ?HPLC for the amatoxin in serum and urine
• TLC of the mushroom itself

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Amanita Phalloides

• Investigations and Management
• lavage
• MDAC (?interrupt enterohepatic circulation)
• hydration and supportive care
• correction of any coagulopathy
• empiric vit K and FFP
• unproven but attempted therapies incllude
• non-invasive
• high-dose penicillin (500 000-1000 000U/Kg/d)
• dexamethasone
• NAC
• invasive
• dialysis (must initiate within first 24hr)
• transplantation

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Mushroom Myths

• A mushroom is safe to eat if it does not turn a
  silver spoon black when boiled together.
• No deadly mushrooms grow on wood.
• If an animal eats it, the mushroom is safe.
• Boiling, drying, and salting will detoxify the
  mushroom.
• Poisonous mushrooms will turn rice-water red.
• Mushrooms are safe toadstools are poisonous.
• A mushroom is safe to eat if the cap has been
  peeled.