Mushroom toxicity

Background

1. Two categories:
   1. Early-Onset Poisoning
      1. Toxicity begins within 2hr of ingestion; clinical course is usually benign
   2. Late-Onset Poisoning
      1. Toxicity begins 6hr after ingestion; clinical course is often serious/ possibly fatal

Early-Onset Poisoning

• Comprises majority of mushroom-induced intoxications

Clinical Features

1. Depends on the type of mushroom ingested
2. GI
   1. Nausea/vomiting/diarrhea
   2. Resolves within 24hr
3. CNS
   1. Euphoria, hallucinations
   2. Lasts 4-6hr
4. Muscarinic
   1. SLUDGE symptoms
   2. Diaphoresis, muscle fasciculations, miosis, bradycardia, bronchorrhea
   3. Resolves in 4-12hr

Treatment

1. GI predominant symptoms:
   1. Activated charcoal 0.5-1gm/kg
   2. Do not give antidiarrheal meds
2. CNS predominant symptoms:
   1. Place in dark, quiet room
   2. Benzos may be given to pts who are agitated
3. Muscarinic predominant symptoms:
   1. Consider atropine for severe symptoms; 0.5-1mg IV for adults; 0.01mg/kg IV for peds

Disposition

1. Discharge once symptoms have subsided

Delayed-Onset Poisoning

1. Amanita species causes 95% of deaths
   1. Toxin inhibits formation of mRNA

Amanita phalloides

Clinical Findings

1. Stage 1 (GI)
   1. Occurs 6-24hr after ingestion and lasts 12-24hr
      1. The later the onset of symptoms the better the outcome
   2. GI predominant symptoms:
      1. Abd pain, vomiting and diarrhea (which may become bloody)
2. Stage 2 (convalescent)
   1. Occurs 48hr after ingestion and lasts 12-24hr
   2. Symptoms subside and pt appears better
   3. Liver deteriorates silently and precipitously (LFTs begin to rise)
3. Stage 3 (failure)
   1. Occurs 2-4d after ingestion
   2. Fulminant liver failure
      1. Hyperbilirubinemia, coagulopathy, hepatic encephalopathy, hepatorenal syndrome

Treatment

1. Immediate therapy
   1. Activated charcoal
      1. Some advocate repeated doses during the first 24hr
         1. Amatoxin undergoes enterohepatic circulation
   2. Penicillin
      1. High doses 1 mil units/kg/d effective in animal studies (inhibits amatoxin uptake)
   3. Silibinin (milk thistle)
      1. Free radical scavenger used successfully in Europe; 25-50mg/kg/d
2. Ongoing therapy
   1. Glucose monitoring
      1. Hypoglycemia is one of the most common causes of death in early mushroom toxicity
   2. Liver/renal failure monitoring
      1. Serial LFTs, chem, coags
   3. Prepare for liver transplant
      1. Progressive coagulopathy, encephalopathy, renal failure are indications for transplant

Disposition

1. Admit all pts suspected of ingesting amatoxin containing mushrooms for at least 48hr

Source

Tintinalli