Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 38-47: Mushrooms Poisoning + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Vomiting, diarrhea, and abdominal cramps after ingestion of many different toxic mushrooms Amatoxin-type Delayed-onset severe gastroenteritis, followed by severe hepatic injury +++ General Considerations ++ There are thousands of toxic mushroom species Ingestion of even a portion of an amatoxin-containing mushroom may be sufficient to cause death Cooking amatoxin-type cyclopeptides does not prevent the poisoning + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Amatoxin-type cyclopeptides (Amanita phalloides, Amanita ocreata, Amanita verna, Amanita virosa, and Galerina species) After a latent interval of 8–12 h, severe abdominal cramps and vomiting begin and progress to profuse diarrhea Acute kidney injury, hepatic necrosis, and hepatic encephalopathy, occur 1–2 days after onset Gyromitrin type (Gyromitra and Helvella species) Toxicity is more common following ingestion of uncooked mushrooms Vomiting, diarrhea, hepatic necrosis, convulsions, coma, and hemolysis may occur after a latent period of 8–12 h Muscarinic type (Inocybe and Clitocybe species) Vomiting, diarrhea, bradycardia, hypotension, salivation, miosis, bronchospasm, and lacrimation occur shortly after ingestion Cardiac arrhythmias may occur Anticholinergic type (Amanita muscaria, Amanita pantherina) Excitement Delirium Flushed skin Dilated pupils Muscular jerking tremors Gastrointestinal irritant type (Boletus, Cantharellus) Nausea, vomiting, and diarrhea occur shortly after ingestion Disulfiram type (Coprinus species) Disulfiram-like sensitivity to alcohol may persist for several days Toxicity is characterized by flushing, hypotension, and vomiting after coingestion of alcohol Hallucinogenic (Psilocybe and Panaeolus species) Mydriasis, nausea and vomiting, and intense visual hallucinations occur 1–2 h after ingestion Cortinarius orellanus May cause acute kidney injury due to tubulointerstitial nephritis +++ Differential Diagnosis ++ Differential diagnosis of Amatoxin-type mushroom poisoning Acetaminophen poisoning Acute viral hepatitis + Diagnosis Download Section PDF Listen +++ +++ Diagnostic Procedures ++ There are no readily available laboratory tests for mushroom toxins Local mycologist may help identify suspect fungi Amatoxin-type mushrooms Typical delay of 8–12 hours before gastrointestinal symptoms occur Hepatic transaminases elevated after 24 hours Necrosis of the liver, massive and acute Metabolic acidosis, hypoglycemia, elevated ammonia suggest severe hepatic failure + Treatment Download Section PDF Listen +++ +++ Medications +++ EMERGENCY MEASURES ++ Administer activated charcoal (60–100 g orally or via gastric tube, mixed in aqueous slurry) for any recent ingestion Give intravenous fluids to replace losses from vomiting and diarrhea Monitor central venous pressure, urinary output, and kidney function tests to help guide volume replacement After the onset of symptoms, efforts to remove the toxic agent are probably useless, especially in cases of amatoxin or gyromitrin poisoning, in which there is usually a delay of 12 h or more before symptoms occur +++ SPECIFIC MEASURES ++ Amatoxin-type cyclopeptides Aggressive fluid replacement for diarrhea and intensive supportive care for hepatic failure (including liver transplant if needed) are the mainstays of treatment Silymarin (silibinin) Often used in Europe Currently only commercially available in the United States as a nutritional supplement given orally Liver transplant may be the only hope for survival in gravely ill patients—contact a liver transplant center early Gyromitrin type: Give pyridoxine, 25 mg/kg intravenously Muscarinic type Give atropine, 0.005–0.01 mg/kg intravenously Repeat as needed Anticholinergic type Physostigmine, 0.5–1.0 mg intravenously May calm extreme agitation and reverse peripheral anticholinergic manifestations However, may also cause bradycardia, asystole, and seizures Alternately, use lorazepam, 1–2 mg intravenously Gastrointestinal irritant type: Treat with antiemetics and intravenous or oral fluid Disulfiram type: Avoid alcohol and treat acetaldehyde reaction with fluids and supine position Hallucinogenic type Provide a quiet, supportive atmosphere Diazepam or haloperidol may be used for sedation Cortinarius Provide supportive care Hemodialysis as needed for acute kidney injury + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Fatalities are rare with Muscarinic type Anticholingeric type Gastrointestinal irritant type Hallucinogenic mushrooms +++ When to Refer ++ Liver transplant may be necessary, particularly for amatoxin-type cyclopeptides Contact a transplant center early + References Download Section PDF Listen +++ + +Bonacini M et al. Features of patients with severe hepatitis due to mushroom poisoning and factors associated with outcome. Clin Gastroenterol Hepatol. 2017 May;15(5):776–9. [PubMed: 28189696] + +Diaz JH. Amatoxin-containing mushroom poisonings: species, toxidromes, treatments, and outcomes. Wilderness Environ Med. 2018 Mar;29(1):111–8. [PubMed: 29325729] + +Kim T et al. Predictors of poor outcomes in patients with wild mushroom-induced acute liver injury. World J Gastroenterol. 2017 Feb 21;23(7):1262–7. [PubMed: 28275306] + +White J et al. Mushroom poisoning: a proposed new clinical classification. Toxicon. 2019 Jan;157:53–65. [PubMed: 30439442]