Amanita mushrooms

(Redirected from A. phalloides)

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:

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)

Differential Diagnosis

Causes of acute hepatitis

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

Evaluation

Workup[2]

  • Blood sugar
  • BMP
  • LFTs
  • Lipase
  • Coags, DIC labs
  • CBC with differential
  • LDH, haptoglobin, reticulocyte
  • CK
  • Thyroid studies
  • Methemoglobin level
  • Urine drug screen
  • Urinalysis

Management

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
    • 5mg/kg over 1 hr, then 25-50mg/kg/d[3]
  • N-acetylcysteine admin much like in acetaminophen toxicity[4]
    • 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[5]
    • 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

Disposition

  • Admit all suspected of ingesting amatoxin containing mushrooms for at least 48hr
  • Referral to liver transplant service

See Also

External Links

References

  1. 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.
  2. 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.
  3. 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
  4. Lee DS et al. Amatoxin Toxicity Medication. July 21, 2015. http://emedicine.medscape.com/article/1008902-medication#2.
  5. 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.