1. Hussein Unwala, Dr. Ingrid Vicas February 4, 2010

2.  Pretest  Overview of Different Classes  Approach to clinical classification  Management of the unknown mushroom ingestion  Cases

3.  Ten are identifiable: ◦ Cyclopeptides ◦ Gyromitrin ◦ Muscarine ◦ Coprine ◦ ibotenic acid and muscimol ◦ psilocybin ◦ general GI irritants ◦ Orellinine ◦ allenic norleucine ◦ Myotoxins

4.  Amanita species, including A. verna, A. virosa, and A. phalloides  Galerina spp, including G. autumnalis, G. marginata,and Galerina venenata  Lepiota species, including L. helveola, L. josserandi, and L. brunneoincarnata.

5.  Phase 1: ◦ Severe gastroenteritis, 5-24 hours post ingestion  Phase 2: ◦ Quiescent phase, 12-36 hours post ingestion  Phase 3: ◦ Hepatic, renal toxicity, death; 2-5 days post ingestion ◦ Endocrine malfunction - TSH, Ca, Insulin

6.  Activated charcoal 1g/kg q 2-4 hours, antiemetics  Correct fluid, electrolyte abnormalities  Forced diuresis and hemodialysis techniques  Penicillin G 1g/kg/day IV, administered 5 days post ingestion  Silibinin 20-50 mg/kg/day ◦ May modify cell membrane receptor sites ◦ safe ◦ Worked in dogs, but...  Extracorporeal albumin dialysis as a bridge to liver transplant

7.  Gyromitrin  Monomethydrazine ◦ (Inhibits pyridoxine) Disrupts GABA

8.  Common : GI toxicity 5-10 hours post ingestion  Rare: ◦ delirium, stupor, convulsions, coma ◦ Hepatorenal syndrome

9.  Activated Charcoal 1g/kg  Benzo’s for seizures ◦ Pyrodixine 70mg/kg

10.  SLUDGEM/DUMBELLS  No central muscarinic effects  Usually mild effects, develop 0.5-2hrs post  Atropine rarely needed

11.  Disulfuram effect, inhibiting acetaldehyde dehydrogenase for up to 48-72 hours EtOH Alcohol Dehydrogenase Acetaldehyde Acetaldehyde Dehydrogenase Acetic Acid  tachycardia, flushing, nausea, and vomiting  Fomepizole theoretic benefit

12.  GABAergic in adults, ◦ Somnolence, hallucinations, dysphoria, delerium  Glumatamatergic in kids ◦ Myoclonic movements, seizures  Onset 0.5-2hrs  Benzo prn  http://www.youtube.com/watch?v=MkCS9eP WuLU http://www.youtube.com/watch?v=MkCS9eP WuLU

13.  Aka magic mushrooms  Toxicity common  Thought to act at 5-HT2 receptors  Rapidly (within 1 hour) : ataxia, hyperkinesis, visual hallucinations, and illusions.  Rare : renal failure, seizures, cardiopulmonary arrest  Benzo prn

14.  Hundreds of mushrooms fall in this group (“Little Brown Mushrooms”)  GI toxicity occurs 0.5-3 hours post ingestion; clinical course is brief (6-24hours)  Rare : hypovolemic shock, immune-mediated hemolytic anemia  Supportive care

15.  Nephrotoxic  Symptoms 24-36 hours post ingestion: headache, chills, flank/abdo pain, polydypsia, anorexia, nausea/vomitting  Oliguric renal failure develops several days to weeks later  Treatment : hemodialysis, renal transplantation.  No evidence suggests plasmapheresis/hemoperfusion is of any benefit in preventing chronic renal failure even when initiated in the first 48 hours.

16.  Associated with ingestion of Amanita smithiana  Symptoms noted 30min – 12hours  Often GI initially  Then ARF 4-6 days later, azotemia  Suggest treat with activated charcoal, early hemodialysis

17.  All reported cases in Europe  Tricholoma equestre  All 15 cases led to subsequent death

18.  Determine whether ingestion was a deadly variety; ie Amatotoxin ◦ if outside southwestern Canada, onset of GI symptoms within 3 hours rules out amatoxin  Attempt collection of mushrooms, detailed description  Dry paper bag; gastric contents?  Consult a mycologist! If not available,  Melzer reagent : 20mL H20, 1.5g KI, 0.5g I, 20g chloral hydrate. Amatoxin turns dark blue upon contact

19. Symptoms < 3 h Muscarine, Coprine, Ibotenic Acid, Psilocybin, GI Irritants No tests essential, monitor fluids and electrolyte status Activated Charcoal If Hallucinating/seizures, benzos prn If Hypotension, fluid resuscitation, Dopamine 5-20 mcg/kg/min, then NE Electrolyte Repletion Discharge once GI/psychadelic symptoms resolve, volume depletion corrected Symptoms > 6 h Cyclopeptides, Gyromitra Activated Charcoal initially, then q 4h/continuous Electrolyte, Glucose Repletion Penicillin G Consultation with liver transplant specialist Methylene blue for methemoglobinemia, Blood transfusion if hemolysis Pyridoxine/benzos if seizures Mycologist if available ELFT’s If suspecting Gyromitra, check methemoglobin levels Symptoms > 24 h orelline Assess Renal Function Activated Charcoal Electrolyte Repletion Amanita Smithsiana can present 0.5-12 hours Mixed Ingestions can present any time