Amanita mushrooms

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Amanita phalloides aka "death cap"
  • Amanita phalloides
  • Not to be confused with Amanita muscaria

Anticholinergic toxicity Causes

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



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


  • Typically based on history and laboratory findings


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[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


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

See Also

External Links


  1. Dawson AH, Buckley NA. Pharmacological management of anticholinergic delirium – theory, evidence and practice. Br J Clin Pharmacol. 2015;81(3):516-24.
  2. 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.
  3. 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.
  4. 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
  5. Lee DS et al. Amatoxin Toxicity Medication. July 21, 2015.
  6. 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.