Mushroom toxicity: Difference between revisions

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==Background==
==Background==
#Two categories:
Clinically broken into two main categories:
##Early-Onset Poisoning
#Early-Onset Poisoning (toxicity begins within 2hr of ingestion)
###Toxicity begins within 2hr of ingestion; clinical course is usually benign
#*Clinical course is usually benign
##Late-Onset Poisoning
#*Comprises majority of mushroom-induced intoxications
###Toxicity begins 6hr after ingestion; clinical course is often serious/ possibly fatal
#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''<ref>Enjalbert F et al. Treatment of Amatoxin Poisoning: 20 year retrospective analysis. J tox Clin Tox 2002 40(6):715-767.</ref>
#**Toxin inhibits formation of mRNA and is heat stable


==Early-Onset Poisoning==
{{Mushroom identification images}}
*Comprises majority of mushroom-induced intoxications


===Clinical Features===
==Clinical Features==
#Depends on the type of mushroom ingested
===Early-Onset===
#GI
''Depends on the type of mushroom ingested''
##Nausea/vomiting/diarrhea
*GI
##Resolves within 24hr
**[[Nausea/vomiting]], diarrhea
#CNS
**Resolves within 24hr
##Euphoria, hallucinations
*CNS<ref>Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.</ref>
##Lasts 4-6hr
**Isoxazoles (ibotenic acid and muscimol) - [[dysarthria]], [[ataxia]], muscle cramps
#Muscarinic  
**Psilocybin - euphoria, visual [[hallucinations]], [[agitation]], [[sympathomimetic]] symptoms
##SLUDGE symptoms
**Lasts 4-8hrs
##Diaphoresis, muscle fasciculations, miosis, bradycardia, bronchorrhea
*Muscarinic  
##Resolves in 4-12hr
**SLUDGE symptoms
**Diaphoresis, muscle fasciculations, miosis, [[bradycardia]], bronchorrhea
**Resolves in 4-12hr
*Disulfiram-like effect
**Usually when drinking alcohol
**Flushing, [[tachycardia]], diaphoresis, [[hypotension]]


===Treatment===
===Delayed-Onset===
#GI predominant symptoms:
''Four Stages <ref>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.</ref> <ref>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.</ref>''
##Activated charcoal 0.5-1gm/kg
#Latent (symptom free, up to 24 hours)
##Do not give antidiarrheal meds
#Symptomatic (GI distress)
#CNS predominant symptoms:
#Convalescent (feel better, but LFT's increasing)
##Place in dark, quiet room
#Fulminant (day 2-4)
##Benzos may be given to pts who are agitated
#Muscarinic predominant symptoms:
##Consider atropine for severe symptoms; 0.5-1mg IV for adults; 0.01mg/kg IV for peds


===Disposition===
==Differential Diagnosis==
#Discharge once symptoms have subsided
{{Mushroom toxicity DDX}}
{{SLUDGE DDX}}
{{Acute hepatitis causes}}


==Delayed-Onset Poisoning==
==Evaluation==
#Amanita species causes 95% of deaths
===Early-Onset===
##Toxin inhibits formation of mRNA


===''Amanita phalloides''===
===Delayed-Onset===
====Clinical Findings====
*[[Hypoglycemia]] is common cause of death and needs close monitoring
#Stage 1 (GI)
##Occurs 6-24hr after ingestion and lasts 12-24hr
###The later the onset of symptoms the better the outcome
##GI predominant symptoms:
###Abd pain, vomiting and diarrhea (which may become bloody)
#Stage 2 (convalescent)
##Occurs 48hr after ingestion and lasts 12-24hr
##Symptoms subside and pt appears better
##Liver deteriorates silently and precipitously (LFTs begin to rise)
#Stage 3 (failure)
##Occurs 2-4d after ingestion
##Fulminant liver failure
###Hyperbilirubinemia, coagulopathy, hepatic encephalopathy, hepatorenal syndrome


====Treatment====
==Management==
#Immediate therapy
===Early-Onset===
##Activated charcoal
*GI predominant symptoms:
###Some advocate repeated doses during the first 24hr
**[[Activated charcoal]] 0.5-1gm/kg
####Amatoxin undergoes enterohepatic circulation
**Do ''not'' give antidiarrheal meds
##Penicillin
*CNS predominant symptoms:
###High doses 1 mil units/kg/d effective in animal studies (inhibits amatoxin uptake)
**Place in dark, quiet room
##Silibinin (milk thistle)
**[[Benzos]] may be given to patients who are agitated
###Free radical scavenger used successfully in Europe; 25-50mg/kg/d
**Consider [[pyridoxine]] for refractory seizures, especially if suspecting [[gyromitra]]<ref> Berger KJ, Guss DA. Mycotoxins revisited: Part II. J Emerg Med. 2005;28(2):175. </ref>
#Ongoing therapy
*Muscarinic predominant symptoms:
##Glucose monitoring
**Consider [[atropine]] for severe symptoms; 0.5-1mg IV for adults; 0.01mg/kg IV for peds
###Hypoglycemia is one of the most common causes of death in early mushroom toxicity
##Liver/renal failure monitoring
###Serial LFTs, chem, coags
##Prepare for liver transplant
###Progressive coagulopathy, encephalopathy, renal failure are indications for transplant


====Disposition====
===Delayed-Onset===
#Admit all pts suspected of ingesting amatoxin containing mushrooms for at least 48hr
Consider [[Amanita mushrooms|Amatoxin-specific treatments]]:
*[[Activated charcoal]]
*[[N-Acetylcysteine|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


==Source==
==Disposition==
Tintinalli
===Early-Onset===
*Discharge once symptoms have subsided


[[Category:Tox]]
===Delayed-Onset===
*Admit
 
==References==
<references/>
 
[[Category:Toxicology]]

Latest revision as of 19:11, 22 August 2019

Background

Clinically broken into two main categories:

  1. Early-Onset Poisoning (toxicity begins within 2hr of ingestion)
    • Clinical course is usually benign
    • Comprises majority of mushroom-induced intoxications
  2. 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

Mushroom Identification

Clinical Features

Early-Onset

Depends on the type of mushroom ingested

Delayed-Onset

Four Stages [3] [4]

  1. Latent (symptom free, up to 24 hours)
  2. Symptomatic (GI distress)
  3. Convalescent (feel better, but LFT's increasing)
  4. Fulminant (day 2-4)

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

Causes of acute hepatitis

Evaluation

Early-Onset

Delayed-Onset

  • Hypoglycemia is common cause of death and needs close monitoring

Management

Early-Onset

  • GI predominant symptoms:
  • 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:

Disposition

Early-Onset

  • Discharge once symptoms have subsided

Delayed-Onset

  • Admit

References

  1. ↑ Enjalbert F et al. Treatment of Amatoxin Poisoning: 20 year retrospective analysis. J tox Clin Tox 2002 40(6):715-767.
  2. ↑ Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ Berger KJ, Guss DA. Mycotoxins revisited: Part II. J Emerg Med. 2005;28(2):175.
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