II. Epidemiology
- Prepared foods with toxic mushrooms is most common type of lethal exposure
III. Types
- Neurotoxic mushrooms
- Amanita muscaria and pantherina (Cholinergic Toxicity)
- Inocybe and Clitocybe species (parasympathetic)
- Coprinus atramentarius (Antabuse-like Alcohol effect)
- Psilcybe (Hallucinogen)
- Gyromitra esculenta or false morel: severe Neurotoxin
- Hepatotoxic mushrooms (Cyclopeptide Mushrooms)
- Background
- Amatoxins (cyclic peptides) are heat stabile with high bioavailability
- Amatoxins inhibit RNA polymerase II and suppress protein synthesis
- Amanita phalloides (severe hepatotoxicity)
- White cap and white gills
- Stem ascends from a cup at the base of the mushroom
- Stem encircled by a white skirt below the cap
- Amanita Virosa
- Amanita Verna
- Galerina Species
- Lepiota Species
- Background
- Nephrotoxic mushrooms
- Norleucine mushrooms (includes Amanita smithiana)
- Orellanine mushrooms
IV. Findings: Hepatotoxic mushrooms (Cyclopeptide Mushrooms, Amatoxins)
- Phase 1: Gastrointestinal (5-24 hours after ingestion)
- Phase 2: Liver Injury (12-36 hours after ingestion)
- Increased Liver Function Tests
- Increased INR
- Phase 3: Liver Failure (2-6 days after ingestion)
V. Management: Approach
- See Unknown Ingestion
- Call poison control for any suspected ingestion
- Consulting mycologists may be available in some regions if mushroom ingested is brought to ED
- Initial general management
- Intravenous hydration and Anti-emetics are typically the only management needed
- Decontamination if recent ingestion
- Oral Activated Charcoal may absorb amatoxins
- Symptom presentation may be more accurate than mushroom identification
- Vomiting within 1-2 hours of ingesting a single mushroom
- Gastrointestinal irritation is more likely
- Intravenous hydration and Anti-emetics are typically the only management needed
- Vomiting with later onset may suggest hepatotoxic mushroom ingestion
- See Hepatotoxic mushroom ingestion
- Liver Transaminases (AST, ALT) are typically increased by the onset of gastrointestinal symptoms
- Vomiting within 1-2 hours of ingesting a single mushroom
- Hepatotoxic mushroom ingestion suspected
- Admit all patients
- Obtain baseline Liver Function Tests and follow serial levels
- First-line management
- Additional management
- High dose Penicillin (Benzylpenicillin) 0.5 to 1.0 MU/kg/day IV
- Cimetidine
- Other medications used
- Silymarin (Milk Thistle extract)
- Thioctic Acid
- Consider for liver transplant
- Indicated in acute toxic fulminant liver failure
- Nephrotoxic mushrooms
- Present with Acute Renal Failure starting 2-5 days after ingestion (presentation may be delayed 2 weeks)
- May require Dialysis
- Renal Function returns in most cases
-
Hallucinogenic mushooms
- Supportive care
- Resolves without residua
-
Cholinergic mushrooms
- See Cholinergic Toxicity
- Muscarinic effects (Excessive Salivation, eye tearing, Diarrhea)
- Typically do not cause nicotinic effects (paralysis or Seizures)
VI. References
- Swadron and Nordt in Majoewsky (2013) EM:Rap 13(3):2
- Tomaszewski (2021) Crit Dec Emerg Med 35(3):24
