Adam Oster Dr. Mark Yarema March 21, 2002 Mushroom Poisoning Adam Oster Dr. Mark Yarema March 21, 2002

Mushroom Poisoning

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

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

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.

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

Mushroom Poisoning Early onset symptoms usually develop <4 hours GI symptoms common and usually predominate include hallucinogenic mushrooms can last upto 24h treatment is supportive good outcome is the general rule

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?

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

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

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.

Mushroom Poisoning Muscarine containing Early Onset Ibotenic and eg Clitocybe dealbata cholinergic toxidrome does not cross BBB atropine can be used for severe symptoms Early Onset Ibotenic and muscimol coprine GI toxin psilocybin muscarine

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

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

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

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

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

Mushroom Poisoning Late onset cyclopeptides gyromitrin orellanine 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

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

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.

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

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

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.