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

2. Mushroom Poisoning

3. 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

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

5. 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.

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

7. 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

8. 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?

9. 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

10. 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

11. 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.

12. 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

13. 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

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

15. 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 , 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

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

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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 ( U/Kg/d)
dexamethasone
NAC
invasive:
dialysis (must initiate within first 24hr)
transplantation

23. 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.