Amanita mushrooms: Difference between revisions
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==Background== | ==Background== | ||
[[File:Amanita phalloides.png|thumb|''Amanita phalloides'' aka "death cap"]] | |||
[[File:Amanita phalloides.png|thumb|Amanita phalloides aka death cap]] | *''Amanita phalloides'' | ||
*Not to be confused with ''Amanita muscaria'' | |||
{{Anticholinergic types}} | |||
==Clinical Features== | ==Clinical Features== | ||
| Line 8: | Line 11: | ||
*The later the onset of symptoms the better the outcome | *The later the onset of symptoms the better the outcome | ||
*GI predominant symptoms: | *GI predominant symptoms: | ||
**Abdominal pain, vomiting and diarrhea (which may become bloody) | **[[Abdominal pain]], [[vomiting]] and [[diarrhea]] (which may become bloody) | ||
===Stage 2 (convalescent)=== | ===Stage 2 (convalescent)=== | ||
| Line 16: | Line 19: | ||
===Stage 3 (failure)=== | ===Stage 3 (failure)=== | ||
*Occurs 2- | *Occurs 2-4 days after ingestion | ||
*Fulminant liver failure | *Fulminant [[liver failure]] | ||
**Hyperbilirubinemia, coagulopathy, hepatic encephalopathy, hepatorenal syndrome | **[[Hyperbilirubinemia]], [[coagulopathy]], [[hepatic encephalopathy]], [[hepatorenal syndrome]] | ||
*Death (may occur in 3-7 days) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Acute hepatitis causes}} | {{Acute hepatitis causes}} | ||
{{Mushroom toxicity DDX}} | {{Mushroom toxicity DDX}} | ||
{{SLUDGE DDX}} | |||
== | ==Evaluation== | ||
===Workup<ref>Garcia J, Costa VM, Carvalho A, Baptista P, de Pinho PG, de Lourdes Bastos M, et al. Amanita phalloides poisoning: Mechanisms of toxicity and treatment. Food Chem Toxicol. 2015 Sep 12. 86:41-55.</ref>=== | ===Workup<ref>Garcia J, Costa VM, Carvalho A, Baptista P, de Pinho PG, de Lourdes Bastos M, et al. Amanita phalloides poisoning: Mechanisms of toxicity and treatment. Food Chem Toxicol. 2015 Sep 12. 86:41-55.</ref>=== | ||
*Blood sugar | *Blood sugar | ||
*BMP | *BMP | ||
* | *[[LFTs]] | ||
*Lipase | *Lipase | ||
*Coags, DIC labs | *Coags, [[DIC]] labs | ||
*CBC with differential | *CBC with differential | ||
*LDH, haptoglobin, reticulocyte | *LDH, haptoglobin, reticulocyte | ||
*CK | *CK | ||
*Thyroid studies | *Thyroid studies | ||
* | *[[Methemoglobin]] level | ||
*Urine drug screen | *Urine drug screen | ||
*Urinalysis | *[[Urinalysis]] | ||
===Diagnosis=== | |||
*Typically based on history and laboratory findings | |||
==Management== | ==Management== | ||
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*[[Penicillin]] | *[[Penicillin]] | ||
**High doses 1 mil units/kg/d effective in animal studies (inhibits amatoxin uptake) | **High doses 1 mil units/kg/d effective in animal studies (inhibits amatoxin uptake) | ||
* | *Silibinin (milk thistle derivative) | ||
**'''Mortality benefit''' | **'''Mortality benefit''' | ||
**Free radical scavenger used successfully in Europe | **Free radical scavenger used successfully in Europe | ||
** | **5mg/kg over 1 hr, then 25-50mg/kg/d<ref>Saller, R., Brignoli, R., Melzer, J. and Meier, R. (2008) ‘An Updated Systematic Review with Meta-Analysis for the Clinical Evidence of Silymarin’, Forschende Komplementärmedizin / Research in Complementary Medicine, 15(1), pp. 9–20</ref> | ||
*[[N-acetylcysteine]] admin much like in acetaminophen toxicity<ref>Lee DS et al. Amatoxin Toxicity Medication. July 21, 2015. http://emedicine.medscape.com/article/1008902-medication#2.</ref> | *[[N-acetylcysteine]] admin much like in acetaminophen toxicity<ref>Lee DS et al. Amatoxin Toxicity Medication. July 21, 2015. http://emedicine.medscape.com/article/1008902-medication#2.</ref> | ||
**'''Mortality benefit''' | **'''Mortality benefit''' | ||
**Load | **Load 150mg/kg IV over 15min in 200 cc D5W | ||
**Then | **Then 50mg/kg in 500cc D5W over 4hrs | ||
**Followed by | **Followed by 100mg/kg in 1000cc D5W over 16hrs | ||
*Extracorporeal albumin dialysis<ref>Faybik, P., Hetz, H., Baker, A., Bittermann, C., Berlakovich, G., Werba, A., Krenn, C.-G. and Steltzer, H. (2003) ‘Extracorporeal albumin dialysis in patients with Amanita phalloides poisoning’, Liver International, 23pp. 28–33.</ref> | *Extracorporeal albumin dialysis<ref>Faybik, P., Hetz, H., Baker, A., Bittermann, C., Berlakovich, G., Werba, A., Krenn, C.-G. and Steltzer, H. (2003) ‘Extracorporeal albumin dialysis in patients with Amanita phalloides poisoning’, Liver International, 23pp. 28–33.</ref> | ||
**Allow hepatic regeneration or forestall transplantation | **Allow hepatic regeneration or forestall transplantation | ||
| Line 73: | Line 80: | ||
==See Also== | ==See Also== | ||
*[[Mushroom toxicity]] | *[[Mushroom toxicity]] | ||
*[[Anticholinergic toxicity]] | |||
==External Links== | ==External Links== | ||
Latest revision as of 22:01, 27 March 2024
Background
- Amanita phalloides
- Not to be confused with Amanita muscaria
Anticholinergic toxicity Causes
- Medications[1]
- Atropine
- Antihistamines
- Antidepressants
- Antipsychotics
- Muscle relaxants
- Anti-Parkinsonians
- Plants
- Jimson weed (Devil's trumpet)
- Amanita mushroom
Clinical Features
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:
- Abdominal pain, vomiting and diarrhea (which may become bloody)
Stage 2 (convalescent)
- Occurs 48hr after ingestion and lasts 12-24hr
- Symptoms subside and patient appears better
- Liver deteriorates silently and precipitously (LFTs begin to rise)
Stage 3 (failure)
- Occurs 2-4 days after ingestion
- Fulminant liver failure
- Death (may occur in 3-7 days)
Differential Diagnosis
Causes of acute hepatitis
- Acetaminophen toxicity (most common cause of acute liver failure in the US[2])
- Viral hepatitis
- Toxoplasmosis
- Acute alcoholic hepatitis
- Toxins
- Ischemic hepatitis
- Autoimmune hepatitis
- Wilson's disease
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
- Carbamate toxicity
- Mushroom toxicity, especially:
- Organophosphate toxicity
- Nerve agent
- Nicotine toxicity (look alike)
- Acetylcholinesterase inhibitor overdose (e.g in myasthenia gravis or post anesthesia reversal)
Evaluation
Workup[3]
- Blood sugar
- BMP
- LFTs
- Lipase
- Coags, DIC labs
- CBC with differential
- LDH, haptoglobin, reticulocyte
- CK
- Thyroid studies
- Methemoglobin level
- Urine drug screen
- Urinalysis
Diagnosis
- Typically based on history and laboratory findings
Management
Immediate therapy
- Activated charcoal
- Some advocate repeated doses during the first 24hr
- Amatoxin undergoes enterohepatic circulation
- Some advocate repeated doses during the first 24hr
- Penicillin
- High doses 1 mil units/kg/d effective in animal studies (inhibits amatoxin uptake)
- Silibinin (milk thistle derivative)
- Mortality benefit
- Free radical scavenger used successfully in Europe
- 5mg/kg over 1 hr, then 25-50mg/kg/d[4]
- N-acetylcysteine admin much like in acetaminophen toxicity[5]
- Mortality benefit
- Load 150mg/kg IV over 15min in 200 cc D5W
- Then 50mg/kg in 500cc D5W over 4hrs
- Followed by 100mg/kg in 1000cc D5W over 16hrs
- Extracorporeal albumin dialysis[6]
- Allow hepatic regeneration or forestall transplantation
Ongoing therapy
- Glucose monitoring
- 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
- Admit all suspected of ingesting amatoxin containing mushrooms for at least 48hr
- Referral to liver transplant service
See Also
External Links
References
- ↑ Dawson AH, Buckley NA. Pharmacological management of anticholinergic delirium – theory, evidence and practice. Br J Clin Pharmacol. 2015;81(3):516-24.
- ↑ 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.
- ↑ Garcia J, Costa VM, Carvalho A, Baptista P, de Pinho PG, de Lourdes Bastos M, et al. Amanita phalloides poisoning: Mechanisms of toxicity and treatment. Food Chem Toxicol. 2015 Sep 12. 86:41-55.
- ↑ Saller, R., Brignoli, R., Melzer, J. and Meier, R. (2008) ‘An Updated Systematic Review with Meta-Analysis for the Clinical Evidence of Silymarin’, Forschende Komplementärmedizin / Research in Complementary Medicine, 15(1), pp. 9–20
- ↑ Lee DS et al. Amatoxin Toxicity Medication. July 21, 2015. http://emedicine.medscape.com/article/1008902-medication#2.
- ↑ Faybik, P., Hetz, H., Baker, A., Bittermann, C., Berlakovich, G., Werba, A., Krenn, C.-G. and Steltzer, H. (2003) ‘Extracorporeal albumin dialysis in patients with Amanita phalloides poisoning’, Liver International, 23pp. 28–33.