Mushroom toxicity
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
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
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
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Hepatitis D
- Hepatitis E
- HSV
- Epstein-Barr virus
- Varicella zoster virus
- Toxoplasmosis
- Acute alcoholic hepatitis
- Toxins
- Ischemic hepatitis
Evaluation
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.
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