Pediatric Amatoxin Toxicity Clinical Presentation

  • Author: Douglas S Lee, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Mar 30, 2012
 

History

Collect important information about the ingestion of wild mushrooms in patients with suspected amatoxin poisoning, which generally occurs at least 6 hours before the onset of symptoms. Attempt to determine the following:

  • Time of ingestion
  • Time of onset of symptoms
    • Phalloidin causes GI symptoms about 6-12 hours after ingestion.
    • Renal and liver toxicity caused by amanitin is evident 24-48 hours after ingestion. A recent pattern of delayed-onset renal toxic mushroom ingestion is emerging in Western North America.[4]
  • Description of mushrooms
  • Location at which mushrooms were obtained
  • Other mushrooms and co-ingestants: GI symptoms may occur earlier than 6 hours due to other mushrooms ingested at the same time; however, symptoms from isolated A phalloides usually begin at least 6-12 hours after the ingestion. Make efforts to identify other toxins ingested during an attempted suicide.

Toxicity from A phalloides occurs over several days and is usually divided into the following stages:

  • Stage I: Sudden onset of nausea, vomiting, watery diarrhea, and cramping abdominal pain occurs 6-12 hours after ingestion. Patients may become dehydrated and hypotensive during this episode. Patients often present during this stage, and, if misdiagnosed, may be erroneously discharged without further care.
  • Stage II: Clinical improvement occurs with supportive care. Despite the resolution of symptoms, hepatic and renal damage is ongoing, which is evident by rising laboratory test values.
  • Stage III: If discharged, patients may return to the hospital 2-6 days later with severe coagulopathy, renal failure, and encephalopathy.
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Physical

The examination depends on the stage of the poisoning. Due to profuse vomiting and watery diarrhea, the patient may present in hypovolemic shock during the GI phase.

  • Vital signs
    • Tachycardia
    • Hypotension
  • Head, ears, eyes, nose, and throat: Epistaxis or scleral icterus that is related to hepatic failure may appear in a patient with delayed presentation.
  • Abdominal: The patient can have mild diffuse tenderness, and a rectal examination reveals occult bloody stool. Hepatomegaly results from hepatitis late in the course of the disease.
  • Neurologic: Effects are related to hepatic failure. Depending on the time that elapses after ingestion, the examination findings may vary from normal to agitation, somnolence, seizures, or coma.
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Causes

  • Causes include ingestion by any of the following:
    • Amateur mushroom hunters seeking a fresh picked meal
    • Adults and adolescents seeking psychotropic mushrooms
    • Unsupervised children in suburban or rural areas
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Contributor Information and Disclosures
Author

Douglas S Lee, MD  Attending Physician, Department of Emergency Medicine, Naples Community Hospital

Douglas S Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Suzanne Bentley, MD  Clinical Instructor, Department of Emergency Medicine, Elmhurst Hospital, Mount Sinai School of Medicine

Suzanne Bentley, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Medical Women's Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Theodore Bania, MD  Program Director, Assistant Director of Research, Department of Emergency Medicine, Division of Toxicology, Assistant Professor, St Luke's-Roosevelt Hospital Center, Columbia University

Theodore Bania, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, New Mexico Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Matthew R Denny, MD, MPH  Staff Physician, Department of Emergency Medicine, Santa Clara Valley Medical Center; Clinical Instructor, Department of Emergency Medicine, Stanford University School of Medicine

Matthew R Denny, MD, MPH is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael E Mullins, MD  Assistant Professor, Division of Emergency Medicine, Washington University in St Louis School of Medicine; Attending Physician, Emergency Department, Barnes-Jewish Hospital

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD  Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Paul D Petry, DO, FACOP, FAAP  Consulting Staff, Freeman Pediatric Care, Freeman Health System

Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

References

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Amanita phalloides.
 
 
 
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