Amanita mushrooms

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Background

Amanita phalloides

Amanita phalloides aka death cap

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:
      • 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

Differential Diagnosis

Diagnosis

Treatment

  • Immediate therapy
    • Activated charcoal
      • Some advocate repeated doses during the first 24hr
        • Amatoxin undergoes enterohepatic circulation
    • 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; 25-50mg/kg/d[1]
    • N-acetylcysteine admin much like in acetaminophen toxicity[2]
      • Mortality benefit
      • Load 150 mg/kg IV over 15min in 200 cc D5W
      • Then 50 mg/kg in 500cc D5W over 4hrs
      • Followed by 100 mg/kg in 1000cc D5W over 16hrs
    • Extracorporeal albumin dialysis[3]
      • 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

See Also

External Links

References

  1. 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
  2. Lee DS et al. Amatoxin Toxicity Medication. July 21, 2015. http://emedicine.medscape.com/article/1008902-medication#2.
  3. 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.