This document discusses mushroom poisoning from ingesting the deadly Amanita phalloides mushroom. It presents the clinical features of poisoning including delayed gastrointestinal symptoms and progressive liver failure. Treatment involves supportive care, administering silibinin intravenously to block toxin uptake in the liver, N-acetylcysteine to increase glutathione levels, and penicillin which may decrease the effectiveness of silibinin. Prognosis depends on early treatment and liver transplantation may be required for survival if treatment is delayed.
5. Presentations
Often eat multiple mushrooms
GI Sx most common - usually within 2-3/24
Toxin not clear
Kids vs Adults
“Magic Mushrooms”
6. Key Questions
Number mushrooms ingested by how many
people?
Time since ingestion
Time onset GI Sx + period of Sx
Location (Canberra/SA/Vic)
?Near Oak trees
Risk for simple gastroenteritis
9. Clinical Features
Delayed GI toxicity (6-24/24) with severe
fluid losses from Cholera-like diarrhoea
Hepatorenal toxicity from 18-36/24
Often minimal Sx “Honeymoon Period”
Progressive Hepatic Failure from 36-96/24
often with associated hepatorenal
syndrome and pancreatitis
10. Toxinokinetics
Amatoxins - particularly alpha-amatoxin
H2O insoluble, heat stable - not safe post parboiling
Absorbed from GI tract, transported to Liver
Actively transported into hepatocytes
Binds to RNA polymerase Type II
Halts protein synthesis
Organs with rapid cell turnover - GI, Prox tubules
11. Treatment
Fluids for GI Sx
Important Questions
Ongoing Fluids/BSL control
Screening + Specific
Charcoal
MDAC +/- Plasmapheresis
Start within 24/24 (if possible)
Transplant after 4/7
Resus
R
S
I
D
E
A
D
12. Silibinin
Loading: 5mg/kg iv over 1/24
Infusion 20mg/kg/day for 3/7
Blocks hepatocyte uptake of amatoxin
OATP 1B3 + Na Taurocholate
Can use Silymarin po if Silibinin not
available
approx 10g/day NB: Side Fx Diarrhoea +
+
14. NAC
Same dosing as for paracetamol
150mg/kg load (15-60 min)
50mg/kg over 4/24
100mg/kg over 16/24 then repeat...
Glutathione magic...
15. What doesn’t work
Fab - increased renal toxicity
Dialysis/Charcoal Haemoperfusion
- doesn’t clear the toxin effectively
Thioctic Acid - no benefit
16. Six Point Plan
Call a friend
Charcoal
Good supportive care
Silybinin +/- Penicillin
NAC
Stop the boats
17. References
1. Faulstich H, Kirchner K, Derenzini M. Strongly enhanced toxicity of the mushroom
toxin alpha-amanitin by an amatoxin-specific Fab or monoclonal antibody. Toxicon.
1988;26(5):491-9.
2. Diaz JH. Syndromic diagnosis and management of confirmed mushroom poisonings.
Crit Care Med. 2005 Feb;33(2):427-36.
3. Jander S, Bischoff J. Treatment of Amanita phalloides poisoning: I. Retrospective
evaluation of plasmapheresis in 21 patients. Ther Apher. 2000 Aug;4(4):303-7.
4. Becker CE, Tong TG, Boerner U, et al: Diagnosis and treatment of Amanita
phalloides-type mushroom poison- ing-Use of thioctic acid. West J Med 125:100-109,
Aug 1976
5. Murray L, Daly FFS, Little M, and Cadogan M. Toxicology Handbook (2nd edition),
Elsevier Australia 2011
UptoDate:
1. Amatoxin-containing mushroom poisoning including ingestion of Amanita phalloides
2. Management of mushroom poisoning
3. Clinical manifestations and evaluations of mushroom poisoning
4. Magdalan J, Ostrowska A, Piotrowska A, et al. Benzylpenicillin, acetylcysteine and
silibinin as antidotes in human hepatocytes intoxicated with alpha-amanitin. Exp
Toxicol Pathol 2010; 62:367.
5. Thomas J. Duffy, MD Toxic Fungi of Western North America
http://www.mykoweb.com/TFWNA/P-17.html
Notas del editor
Kids - more likely to partially sample single mushrooms, less likely to eat a significant amount
Magic Mushrooms - Psilocybin
10 Patients - 7 were recent immigrants or visitors
8 hepatotoxicity 4 died
Natural Selection ... with low P volumes
GI Toxicity - Vomiting with Severe Diarrhoea (like Cholera)
The earlier the GI Sx, or the higher the lactate the worse the toxicity
Transported by OATP 1B3 and Na Taurocholate co-transporter
Does not appear to cross placenta
Specific Ix: LFTs 18-24/24 post ingestion
Meixner Test: conc HCl onto newspaper (contains lignin) - blue colour
NB: +ve for psilocybin as well
Rx Charcoal - best evidence for reduction in mortality, not specifically stated
In vitro studies using cultured human hepatocytes
Systematic review + observational study - less effective if commenced > 24/24 post ingestion
Less effective than Silibinin in vitro studies
Systematic review: mortality 6.8% vs 11.6% average