Mushroom poisoning - Revision history

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Ostermayer: Created page with "Mushroom poisoning encompasses a spectrum of clinical syndromes caused by ingestion of toxic mushroom species. The key distinction for the emergency physician is between '''early-onset''' (<6 hours) and '''delayed-onset''' (>6 hours) symptoms, as delayed presentations are far more likely to be life-threatening.Diaz JH. Amatoxin-Containing Mushroom Poisonings: Species, Toxidromes, Treatments, and Outcomes. ''Wilderness Environ Med''. 2018;29(1):111-11..."

2026-03-17T23:06:35Z

Created page with "Mushroom poisoning encompasses a spectrum of clinical syndromes caused by ingestion of toxic mushroom species. The key distinction for the emergency physician is between '''early-onset''' (<6 hours) and '''delayed-onset''' (>6 hours) symptoms, as delayed presentations are far more likely to be life-threatening.<ref name="Diaz2018">Diaz JH. Amatoxin-Containing Mushroom Poisonings: Species, Toxidromes, Treatments, and Outcomes. ''Wilderness Environ Med''. 2018;29(1):111-11..."

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Mushroom poisoning encompasses a spectrum of clinical syndromes caused by ingestion of toxic mushroom species. The key distinction for the emergency physician is between '''early-onset''' (<6 hours) and '''delayed-onset''' (>6 hours) symptoms, as delayed presentations are far more likely to be life-threatening.<ref name="Diaz2018">Diaz JH. Amatoxin-Containing Mushroom Poisonings: Species, Toxidromes, Treatments, and Outcomes. ''Wilderness Environ Med''. 2018;29(1):111-118. doi:10.1016/j.wem.2017.10.002</ref>

==Background==
*There are over 5,000 species of mushrooms; approximately 50-100 are toxic to humans<ref name="StatPearls">Amatoxin Mushroom Toxicity. ''StatPearls''. 2023. PMID: 28613706</ref>
*'''95% of mushroom-related deaths worldwide''' are caused by amatoxin-containing mushrooms (''Amanita'', ''Galerina'', ''Lepiota'' species)<ref name="Diaz2018"/>
*Most poisonings occur in foragers who misidentify wild mushrooms as edible species
**Immigrants may mistake toxic local species for edible ones from their home country
**Recreational users may confuse toxic species for hallucinogenic ''Psilocybe'' mushrooms
*'''Children''' and '''elderly''' are more susceptible to volume depletion and toxicity
*Amatoxins are '''heat-stable''' — cooking does not eliminate the toxin<ref name="StatPearls"/>
*Most mushroom ingestions are benign GI irritants; the challenge is identifying the dangerous minority

===Critical clinical pearl===
*'''Symptom onset >6 hours after ingestion should be considered potentially lethal until proven otherwise'''<ref name="Diaz2018"/>
*Early-onset GI symptoms (<6 hours) are generally self-limited
*Delayed-onset GI symptoms (6-24+ hours) suggest amatoxin, gyromitrin, or orellanine poisoning and carry significant morbidity and mortality

==Clinical features==
Classified by onset and predominant toxidrome:<ref name="Medscape">Mushroom Toxicity. ''Medscape''. 2024.</ref>

===Early-onset syndromes (<6 hours)===

====GI irritant syndrome (most common)====
*Caused by many species (e.g. ''Chlorophyllum molybdites'', ''Entoloma'', ''Boletus'')
*Nausea, vomiting, abdominal cramps, diarrhea within 1-3 hours
*Self-limited; resolves with supportive care
*Rarely life-threatening unless severe dehydration

====Muscarinic (cholinergic) syndrome====
*Caused by ''Inocybe'' and ''Clitocybe'' species
*Onset 15-30 minutes
*'''SLUDGE/DUMBELS:''' salivation, lacrimation, urination, diarrhea, GI cramping, emesis; diaphoresis, urination, miosis, bronchospasm/bronchorrhea, emesis, lacrimation, salivation
*[[Bradycardia]], [[Hypotension|hypotension]]
*Treatment: '''[[Atropine|atropine]]'''

====Isoxazole (anticholinergic/GABAergic) syndrome====
*Caused by ''Amanita muscaria'' (fly agaric), ''A. pantherina''
*Onset 30 min - 2 hours
*Confusion, agitation, hallucinations, [[Ataxia|ataxia]], myoclonus, [[Seizure|seizures]]
*'''Mydriasis''', tachycardia, dry skin
*Alternating sedation and excitation
*No hepatic or renal injury
*Treatment: supportive; [[Benzodiazepines|benzodiazepines]] for agitation/seizures

====Psilocybin syndrome====
*Caused by ''Psilocybe'', ''Panaeolus'', ''Gymnopilus'' species
*Onset 30 min - 1 hour
*Hallucinations (visual), euphoria, anxiety, agitation, tachycardia, mydriasis, hyperthermia
*Self-limited (4-6 hours)
*Treatment: supportive; benzodiazepines for agitation; reassurance

====Coprine (disulfiram-like) syndrome====
*Caused by ''Coprinus atramentarius'' (inky cap)
*Symptoms occur only when mushroom ingestion is combined with '''alcohol''' (within 2-72 hours of mushroom ingestion)
*Flushing, tachycardia, headache, nausea, vomiting, [[Hypotension|hypotension]]
*Treatment: supportive; IV fluids; avoid alcohol; '''fomepizole''' may be considered in severe cases<ref name="Medscape"/>

====GI with early renal toxicity====
*Caused by ''Amanita smithiana''
*GI symptoms as early as 2-4 hours; renal injury follows
*May present earlier than other serious syndromes — do not assume safety based on early onset alone

===Delayed-onset syndromes (>6 hours) — potentially life-threatening===

====Amatoxin syndrome (most dangerous)====
*Caused by ''Amanita phalloides'' (death cap), ''A. virosa'' (destroying angel), ''A. verna'', ''A. bisporigera'', ''Galerina'' spp., ''Lepiota'' spp.
*'''Phase 1 (6-24 hours):''' severe cholera-like vomiting and watery diarrhea → dehydration, electrolyte derangement
*'''Phase 2 (24-48 hours):''' apparent clinical improvement ('''"false recovery"''' or "quiescent phase") — transaminases begin rising
*'''Phase 3 (48-96 hours):''' fulminant [[Acute liver failure|hepatic failure]] — markedly elevated AST/ALT, coagulopathy, hypoglycemia, [[Hepatic encephalopathy|encephalopathy]], [[Hepatorenal syndrome|hepatorenal syndrome]], [[DIC]], multiorgan failure, death<ref name="Diaz2018"/>
*Mortality 10-30% overall; higher in children and delayed presentations<ref name="StatPearls"/>
*Mechanism: alpha-amanitin inhibits RNA polymerase II → arrests protein synthesis → hepatocellular necrosis
*Amatoxin undergoes '''enterohepatic recirculation''', which is the rationale for multi-dose activated charcoal

====Gyromitrin syndrome====
*Caused by ''Gyromitra esculenta'' (false morel) and related species
*Onset 6-12 hours
*GI symptoms followed by '''hepatic failure''' (similar to amatoxin)
*Also causes '''[[Methemoglobinemia|methemoglobinemia]]''', hemolysis, [[Seizure|seizures]] (via GABA inhibition)
*Mechanism: gyromitrin metabolized to monomethylhydrazine (rocket fuel analog)
*Treatment: '''pyridoxine (vitamin B6)''' 25 mg/kg IV for seizures refractory to benzodiazepines; folinic acid; methylene blue for methemoglobinemia<ref name="Medscape"/>

====Orellanine syndrome====
*Caused by ''Cortinarius'' species
*Onset '''delayed 1-3 days''', sometimes up to 2 weeks
*GI symptoms followed by '''progressive [[Acute kidney injury|renal failure]]'''
*Renal injury may be irreversible, requiring long-term hemodialysis or transplant
*No specific antidote; supportive care

====Norleucine (allenic norleucine) syndrome====
*Caused by ''Amanita smithiana'', ''A. proxima''
*Onset 4-12 hours (may overlap with early-onset range)
*GI symptoms followed by '''renal failure''' (typically reversible)
*Mild hepatotoxicity may accompany

==Differential diagnosis==
===Other causes of acute gastroenteritis===
*[[Acute gastroenteritis]] (viral, bacterial)
*[[C. difficile]]

===Other causes of acute liver failure===
*[[Acetaminophen toxicity]]
*[[Viral hepatitis]]
*[[Wilson disease]]
*Other [[Hepatotoxicity|drug-induced liver injury]]

===Other toxic ingestions===
*[[Iron toxicity]]
*[[Copper sulfate toxicity]]
*[[Caustic ingestion]]
*[[Organophosphate toxicity]] (for muscarinic symptoms)

==Evaluation==
===Workup===
*'''Detailed history is the most critical diagnostic tool:'''
**Timing of symptom onset relative to ingestion (early vs. delayed)
**Type of mushroom (save specimens if available; photograph; consult mycologist)
**Geographic location and season of foraging
**Preparation method (raw, cooked)
**Number of people who shared the meal and their symptoms
**Co-ingestion (especially alcohol for coprine syndrome)
*'''Attempt mushroom identification:'''
**Save any remaining mushroom specimens (including spore prints)
**Contact local [[Poison control]] center — may have access to mycologists
**Telemedicine/photograph-based identification resources
*'''Labs (for all symptomatic patients):'''
**CBC, BMP, hepatic function panel (AST, ALT, total bilirubin, albumin), coagulation studies (PT/INR), lipase
**Blood glucose (hypoglycemia may signal hepatic failure)
**Urinalysis
**Lactate
*'''Additional labs for suspected amatoxin or serious poisoning:'''
**Serial LFTs and coagulation studies every 6-12 hours for at least 48-72 hours (transaminases may be initially normal during Phase 1)
**Ammonia (for hepatic encephalopathy)
**Blood type and screen (anticipate possible liver transplant)
**Urine amatoxin assay — available at some specialty/reference labs; may be positive within 24-48 hours of ingestion; not widely available or rapid enough to guide acute management<ref name="StatPearls"/>
*'''Additional labs for specific syndromes:'''
**Methemoglobin level (gyromitrin poisoning)
**CK (rhabdomyolysis)
**Serial creatinine (orellanine, norleucine syndromes)
*'''Salicylate, acetaminophen, ethanol levels''' — if intentional ingestion suspected

===Diagnosis===
*Primarily clinical, based on timing of symptom onset and symptom constellation
*'''Key diagnostic rule:''' GI symptoms >6 hours post-ingestion = assume amatoxin poisoning until proven otherwise
*Rising AST/ALT after initial GI illness is highly concerning for amatoxin or gyromitrin hepatotoxicity
*The '''"false recovery"''' period in amatoxin poisoning (GI symptoms improve before liver failure manifests) is a dangerous diagnostic trap — do not discharge patients during this window

==Management==
===All patients===
*IV fluid resuscitation; correct electrolyte abnormalities and hypoglycemia
*Continuous cardiac monitoring
*Contact [[Poison control]] and attempt mushroom identification
*Anti-emetics (ondansetron) for persistent vomiting

===GI decontamination===
*'''Activated charcoal''' (1 g/kg, max 50 g) if presenting within 1-2 hours of ingestion<ref name="Medscape"/>
*For suspected '''amatoxin poisoning:''' give '''multi-dose activated charcoal''' (even if presenting late) to interrupt enterohepatic recirculation<ref name="StatPearls"/>
**Repeat dosing every 2-4 hours
*Gastric lavage generally not recommended beyond 1 hour post-ingestion
*Whole-bowel irrigation may be considered for amatoxin ingestion

===Amatoxin-specific management===
No proven antidote exists; all therapies are supportive and based on limited evidence:<ref name="StatPearls"/><ref name="Diaz2018"/>
*'''N-acetylcysteine (NAC):''' IV per [[Acetaminophen toxicity|acetaminophen]] protocol — provides glutathione, hepatoprotective; widely recommended
*'''Silibinin (IV):''' 5 mg/kg IV over 1 hour, then 20 mg/kg/day as continuous infusion — thought to block hepatic amatoxin uptake; used in Europe; not FDA-approved in the US
**'''Silymarin (oral):''' milk thistle extract, 1 g PO QID — available over-the-counter in North America as surrogate for IV silibinin
*'''High-dose penicillin G:''' 300,000-1,000,000 units/kg/day IV (commonly 4 million units q4h) — may compete with hepatic uptake of amatoxin; evidence is limited
*'''Multi-dose activated charcoal''' — interrupts enterohepatic recirculation (see above)
*'''Aggressive fluid resuscitation''' — maintain urine output to enhance renal amatoxin clearance
*'''Liver transplant evaluation:''' early referral to a transplant center for patients with progressive hepatic failure
**King's College criteria or Clichy criteria may guide transplant listing
**Approximately 50% of patients who develop fulminant hepatic failure will require transplantation<ref name="Diaz2018"/>

===Gyromitrin-specific management===
*'''Pyridoxine (vitamin B6):''' 25 mg/kg IV — for seizures refractory to benzodiazepines (gyromitrin depletes pyridoxal phosphate/GABA)<ref name="Medscape"/>
*'''Folinic acid''' — adjunctive (hydrazines inhibit folic acid conversion)
*'''Methylene blue''' 1-2 mg/kg IV — for [[Methemoglobinemia|methemoglobinemia]]
*Supportive care for hepatic failure similar to amatoxin poisoning

===Muscarinic syndrome management===
*'''[[Atropine]]''' 0.5-1 mg IV (adults), 0.01-0.02 mg/kg IV (children); titrate to effect (drying of secretions, resolution of bradycardia)
*May need repeated dosing

===Isoxazole/psilocybin syndrome management===
*Supportive care
*'''[[Benzodiazepines]]''' for agitation, anxiety, or seizures
*Reassurance and calm environment (especially psilocybin)
*Avoid restraints if possible (risk of rhabdomyolysis with agitation)

===Orellanine syndrome management===
*No specific antidote
*Supportive care with nephrology consultation
*Hemodialysis for renal failure; renal transplant if no recovery

==Disposition==
*'''Early-onset GI symptoms only (<6 hours), known non-toxic species, mild symptoms:'''
**Observe 4-6 hours; if tolerating PO and clinically well, may discharge with return precautions
*'''Symptom onset >6 hours post-ingestion, unknown mushroom species, or suspected amatoxin:'''
**'''Admit all patients''' — ICU if hemodynamically unstable or evidence of organ injury
**Serial labs (LFTs, coagulation, renal function, glucose) every 6-12 hours for minimum 48-72 hours
**'''Do NOT discharge during the "false recovery" phase''' (24-48 hours post-ingestion when GI symptoms improve but hepatic injury is evolving)
**Early contact with liver transplant center for amatoxin poisoning<ref name="Diaz2018"/>
*'''Patients with isoxazole/psilocybin syndromes:'''
**Observe until symptoms resolve (typically 4-8 hours); discharge if stable and safe
**Psychiatric evaluation if intentional ingestion
*'''Orellanine suspected:'''
**Admit; serial renal function monitoring; nephrology consultation
*'''All intentional ingestions:''' psychiatric evaluation mandatory prior to discharge
*'''All patients:''' contact [[Poison control]] (1-800-222-1222 in the US)

==See Also==
*[[Acute liver failure]]
*[[Acetaminophen toxicity]]
*[[Methemoglobinemia]]
*[[Organophosphate toxicity]]
*[[Caustic ingestion]]
*[[Copper sulfate toxicity]]
*[[Rhabdomyolysis]]
*[[Acute kidney injury]]

==External Links==
*[https://www.ncbi.nlm.nih.gov/books/NBK431052/ StatPearls — Amatoxin Mushroom Toxicity]
*[https://emedicine.medscape.com/article/167398-overview Medscape — Mushroom Toxicity]
*[https://www.poison.org/ American Association of Poison Control Centers (1-800-222-1222)]
*[https://journals.sagepub.com/doi/10.1016/j.wem.2017.10.002 Diaz JH — Amatoxin-Containing Mushroom Poisonings: Species, Toxidromes, Treatments, and Outcomes (2018)]

==References==
<references/>

[[Category:Toxicology]]
[[Category:GI]]

← Older revision		Revision as of 09:30, 22 March 2026
Line 7:		Line 7:
	**Immigrants may mistake toxic local species for edible ones from their home country		**Immigrants may mistake toxic local species for edible ones from their home country
	**Recreational users may confuse toxic species for hallucinogenic ''Psilocybe'' mushrooms		**Recreational users may confuse toxic species for hallucinogenic ''Psilocybe'' mushrooms
	* Children and ~~'''~~elderly~~'''~~ are more susceptible to volume depletion and toxicity		* Children and elderly are more susceptible to volume depletion and toxicity
	*Amatoxins are '''heat-stable''' — cooking does not eliminate the toxin<ref name="StatPearls"/>		*Amatoxins are '''heat-stable''' — cooking does not eliminate the toxin<ref name="StatPearls"/>
	*Most mushroom ingestions are benign GI irritants; the challenge is identifying the dangerous minority		*Most mushroom ingestions are benign GI irritants; the challenge is identifying the dangerous minority

	===Critical clinical pearl===		===Critical clinical pearl===
	*~~'''~~Symptom onset >6 hours after ingestion should be considered potentially lethal until proven otherwise~~'''~~<ref name="Diaz2018"/>		*Symptom onset >6 hours after ingestion should be considered potentially lethal until proven otherwise<ref name="Diaz2018"/>
	*Early-onset GI symptoms (<6 hours) are generally self-limited		*Early-onset GI symptoms (<6 hours) are generally self-limited
	*Delayed-onset GI symptoms (6-24+ hours) suggest amatoxin, gyromitrin, or orellanine poisoning and carry significant morbidity and mortality		*Delayed-onset GI symptoms (6-24+ hours) suggest amatoxin, gyromitrin, or orellanine poisoning and carry significant morbidity and mortality
Line 32:		Line 32:
	* SLUDGE/DUMBELS: salivation, lacrimation, urination, diarrhea, GI cramping, emesis; diaphoresis, urination, miosis, bronchospasm/bronchorrhea, emesis, lacrimation, salivation		* SLUDGE/DUMBELS: salivation, lacrimation, urination, diarrhea, GI cramping, emesis; diaphoresis, urination, miosis, bronchospasm/bronchorrhea, emesis, lacrimation, salivation
	*[[Bradycardia]], [[Hypotension\|hypotension]]		*[[Bradycardia]], [[Hypotension\|hypotension]]
	*Treatment: ~~'''~~[[Atropine\|atropine]]~~'''~~		*Treatment: [[Atropine\|atropine]]

	====Isoxazole (anticholinergic/GABAergic) syndrome====		====Isoxazole (anticholinergic/GABAergic) syndrome====
Line 52:		Line 52:
	====Coprine (disulfiram-like) syndrome====		====Coprine (disulfiram-like) syndrome====
	*Caused by ''Coprinus atramentarius'' (inky cap)		*Caused by ''Coprinus atramentarius'' (inky cap)
	*Symptoms occur only when mushroom ingestion is combined with ~~'''~~alcohol~~'''~~ (within 2-72 hours of mushroom ingestion)		*Symptoms occur only when mushroom ingestion is combined with alcohol (within 2-72 hours of mushroom ingestion)
	*Flushing, tachycardia, headache, nausea, vomiting, [[Hypotension\|hypotension]]		*Flushing, tachycardia, headache, nausea, vomiting, [[Hypotension\|hypotension]]
	*Treatment: supportive; IV fluids; avoid alcohol; ~~'''~~fomepizole~~'''~~ may be considered in severe cases<ref name="Medscape"/>		*Treatment: supportive; IV fluids; avoid alcohol; fomepizole may be considered in severe cases<ref name="Medscape"/>

	====GI with early renal toxicity====		====GI with early renal toxicity====
Line 66:		Line 66:
	*Caused by ''Amanita phalloides'' (death cap), ''A. virosa'' (destroying angel), ''A. verna'', ''A. bisporigera'', ''Galerina'' spp., ''Lepiota'' spp.		*Caused by ''Amanita phalloides'' (death cap), ''A. virosa'' (destroying angel), ''A. verna'', ''A. bisporigera'', ''Galerina'' spp., ''Lepiota'' spp.
	* Phase 1 (6-24 hours): severe cholera-like vomiting and watery diarrhea → dehydration, electrolyte derangement		* Phase 1 (6-24 hours): severe cholera-like vomiting and watery diarrhea → dehydration, electrolyte derangement
	* Phase 2 (24-48 hours): apparent clinical improvement (~~'''~~"false recovery"~~'''~~ or "quiescent phase") — transaminases begin rising		* Phase 2 (24-48 hours): apparent clinical improvement ("false recovery" or "quiescent phase") — transaminases begin rising
	* Phase 3 (48-96 hours): fulminant [[Acute liver failure\|hepatic failure]] — markedly elevated AST/ALT, coagulopathy, hypoglycemia, [[Hepatic encephalopathy\|encephalopathy]], [[Hepatorenal syndrome\|hepatorenal syndrome]], [[DIC]], multiorgan failure, death<ref name="Diaz2018"/>		* Phase 3 (48-96 hours): fulminant [[Acute liver failure\|hepatic failure]] — markedly elevated AST/ALT, coagulopathy, hypoglycemia, [[Hepatic encephalopathy\|encephalopathy]], [[Hepatorenal syndrome\|hepatorenal syndrome]], [[DIC]], multiorgan failure, death<ref name="Diaz2018"/>
	*Mortality 10-30% overall; higher in children and delayed presentations<ref name="StatPearls"/>		*Mortality 10-30% overall; higher in children and delayed presentations<ref name="StatPearls"/>
	*Mechanism: alpha-amanitin inhibits RNA polymerase II → arrests protein synthesis → hepatocellular necrosis		*Mechanism: alpha-amanitin inhibits RNA polymerase II → arrests protein synthesis → hepatocellular necrosis
	*Amatoxin undergoes ~~'''~~enterohepatic recirculation~~'''~~, which is the rationale for multi-dose activated charcoal		*Amatoxin undergoes enterohepatic recirculation, which is the rationale for multi-dose activated charcoal

	====Gyromitrin syndrome====		====Gyromitrin syndrome====
	*Caused by ''Gyromitra esculenta'' (false morel) and related species		*Caused by ''Gyromitra esculenta'' (false morel) and related species
	*Onset 6-12 hours		*Onset 6-12 hours
	*GI symptoms followed by ~~'''~~hepatic failure~~'''~~ (similar to amatoxin)		*GI symptoms followed by hepatic failure (similar to amatoxin)
	*Also causes ~~'''~~[[Methemoglobinemia\|methemoglobinemia]]~~'''~~, hemolysis, [[Seizure\|seizures]] (via GABA inhibition)		*Also causes [[Methemoglobinemia\|methemoglobinemia]], hemolysis, [[Seizure\|seizures]] (via GABA inhibition)
	*Mechanism: gyromitrin metabolized to monomethylhydrazine (rocket fuel analog)		*Mechanism: gyromitrin metabolized to monomethylhydrazine (rocket fuel analog)
	*Treatment: ~~'''~~pyridoxine (vitamin B6)~~'''~~ 25 mg/kg IV for seizures refractory to benzodiazepines; folinic acid; methylene blue for methemoglobinemia<ref name="Medscape"/>		*Treatment: pyridoxine (vitamin B6) 25 mg/kg IV for seizures refractory to benzodiazepines; folinic acid; methylene blue for methemoglobinemia<ref name="Medscape"/>

	====Orellanine syndrome====		====Orellanine syndrome====
	*Caused by ''Cortinarius'' species		*Caused by ''Cortinarius'' species
	*Onset ~~'''~~delayed 1-3 days~~'''~~, sometimes up to 2 weeks		*Onset delayed 1-3 days, sometimes up to 2 weeks
	*GI symptoms followed by ~~'''~~progressive [[Acute kidney injury\|renal failure]]~~'''~~		*GI symptoms followed by progressive [[Acute kidney injury\|renal failure]]
	*Renal injury may be irreversible, requiring long-term hemodialysis or transplant		*Renal injury may be irreversible, requiring long-term hemodialysis or transplant
	*No specific antidote; supportive care		*No specific antidote; supportive care
Line 90:		Line 90:
	*Caused by ''Amanita smithiana'', ''A. proxima''		*Caused by ''Amanita smithiana'', ''A. proxima''
	*Onset 4-12 hours (may overlap with early-onset range)		*Onset 4-12 hours (may overlap with early-onset range)
	*GI symptoms followed by ~~'''~~renal failure~~'''~~ (typically reversible)		*GI symptoms followed by renal failure (typically reversible)
	*Mild hepatotoxicity may accompany		*Mild hepatotoxicity may accompany