Mushroom toxicity: Difference between revisions

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==Background==
==Background==
===Major 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


{| class="wikitable"
{{Mushroom identification images}}
| align="center" style="background:#f0f0f0;"|'''Mushroom Toxin'''
| align="center" style="background:#f0f0f0;"|'''Pathologic Effect'''
|-
| Amatoxin||Hepatotoxicity
|-
| Coprine||Disulfiram-like
|-
| Gyromitrin||Seizures
|-
| Ibotenic Acid||Anticholinergic
|-
| Muscarine||Cholinergic
|-
| Orellanin||Nephrotoxicity
|-
| Psilocybin||Hallucinations
|}


===Specific Mushroom Type Ingestions===
==Clinical Features==
*[[Cortinarius mushrooms]]
===Early-Onset===
*[[Gyromitra mushrooms]]
''Depends on the type of mushroom ingested''
*[[Amanita mushrooms]]
 
==Differential Diagnosis==
{{Acute hepatitis causes}}
 
==Diagnosis==
<gallery mode="packed">
File:Cortinarius_mushroom.jpg|[[Cortinarius mushroom]]
File:Gyromitra_mushrooms.jpg|[[Gyromitra mushrooms]]
File:Amanita phalloides.png|[[Amanita phalloides mushroom]]
</gallery>
 
==Early-Onset Poisoning==
*Comprises majority of mushroom-induced intoxications
*Symptom onset 30-90 min with hallucinations, lasting 6-8 hrs<ref>Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.</ref>:
**Isoxazoles (ibotenic acid and muscimol) - dsyarthria, ataxia, muscle cramps
**Psilocybin - euphoria, visual hallucinations, agitation, sympathomimetic Sxs
 
===Clinical Features===
*Depends on the type of mushroom ingested
*GI
*GI
**Nausea/vomiting/diarrhea
**Nausea/vomiting/diarrhea
**Resolves within 24hr
**Resolves within 24hr
*CNS
*CNS<ref>Rolston-Cregler L et al. Hallucinogenic Mushroom Toxicity. Apr 08, 2015. http://emedicine.medscape.com/article/817848-overview.</ref>
**Euphoria, hallucinations
**Isoxazoles (ibotenic acid and muscimol) - dsyarthria, ataxia, muscle cramps
**Lasts 4-6hr
**Psilocybin - euphoria, visual hallucinations, agitation, sympathomimetic Sxs
**Lasts 4-8hrs
*Muscarinic  
*Muscarinic  
**SLUDGE symptoms
**SLUDGE symptoms
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**Resolves in 4-12hr
**Resolves in 4-12hr
*Disulfiram-like effect  
*Disulfiram-like effect  
** Usually when drinking alcohol
**Usually when drinking alcohol
** Flushing, tachycardia, diaphoresis, hypotension
**Flushing, tachycardia, diaphoresis, hypotension
 
===Delayed-Onset===
''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>''
#Latent (symptom free, up to 24 hours)
#Symptomatic (GI distress)
#Convalescent (feel better, but LFT's increasing)
#Fulminant (day 2-4)
 
==Differential Diagnosis==
{{Mushroom toxicity DDX}}
{{SLUDGE DDX}}
{{Acute hepatitis causes}}
 
==Evaluation==
===Early-Onset===
 
===Delayed-Onset===
*Hypoglycemia is common cause of death and needs close monitoring


===Treatment===
==Management==
===Early-Onset===
*GI predominant symptoms:
*GI predominant symptoms:
**Activated charcoal 0.5-1gm/kg
**Activated charcoal 0.5-1gm/kg
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*CNS predominant symptoms:
*CNS predominant symptoms:
**Place in dark, quiet room
**Place in dark, quiet room
**Benzos may be given to pts who are agitated
**Benzos may be given to patients who are agitated
**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>
*Muscarinic predominant symptoms:
*Muscarinic predominant symptoms:
**Consider atropine for severe symptoms; 0.5-1mg IV for adults; 0.01mg/kg IV for peds
**Consider [[atropine]] for severe symptoms; 0.5-1mg IV for adults; 0.01mg/kg IV for peds
 
===Delayed-Onset===
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


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


==Delayed-Onset Poisoning==
===Delayed-Onset===
*Amanita species causes 95% of deaths
*Admit
**Toxin inhibits formation of mRNA and is heat stable
**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>


==References==
==References==

Revision as of 21:28, 13 September 2018

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

  • GI
    • Nausea/vomiting/diarrhea
    • Resolves within 24hr
  • CNS[2]
    • Isoxazoles (ibotenic acid and muscimol) - dsyarthria, ataxia, muscle cramps
    • Psilocybin - euphoria, visual hallucinations, agitation, sympathomimetic Sxs
    • Lasts 4-8hrs
  • Muscarinic
    • SLUDGE symptoms
    • Diaphoresis, muscle fasciculations, miosis, bradycardia, bronchorrhea
    • Resolves in 4-12hr
  • Disulfiram-like effect
    • Usually when drinking alcohol
    • Flushing, tachycardia, diaphoresis, hypotension

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:
    • Activated charcoal 0.5-1gm/kg
    • Do not give antidiarrheal meds
  • 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:

  • Activated charcoal
  • 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

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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