Toxicity, Mushrooms - Amatoxin 

  • Author: Douglas S Lee, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Jun 16, 2009
 

Background

The Greek poet Euripedes recorded the first documented deaths due to mushroom poisoning, or mycetismus, upon describing a family's fatal mushroom ingestion. Today, most reports of deadly mushroom ingestion come from central and Eastern Europe. Almost 50 of the more than 5000 species of mushrooms are poisonous to humans. The Amanita species are reputed to be responsible for 90% of fatal mushroom poisonings worldwide; however, Amanita poisonings are uncommon in North America and were responsible for 2 of 6 deaths caused by mushroom poisoning in a 5-year period in the United States.

Amanita muscaria.Amanita muscaria.

Even experts can mistake Amanita phalloides, also known as the death cap, for similar-looking nontoxic mushrooms.

Amanita phalloides.Amanita phalloides.

The mushroom has no characteristic odor or offensive taste. It is large, with a hemispherical cap 5-15 cm in diameter located on a central stem that is 8-15 cm long and 1-2 cm in diameter. The weight of an average intact mushroom is approximately 25 g. The cap is usually dry and shiny, with a light green-yellow color darkening towards the center. Gills are located under the cap and are not attached to the stem. Incomplete excavation of the entire mushroom may leave behind the vulva, or cup, at the base of the stem.

In the United States, Amanita species most commonly are found in the Pacific Northwest and the Blue Ridge Mountains of the Northeast but are becoming increasingly recognized in Pennsylvania, New Jersey, and Ohio. They tend to grow near filbert (hazelnut), chestnut, or oak trees. Peak season is late summer into fall; however, mushrooms can be found in early winter.

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Pathophysiology

The clinical manifestations of an A phalloides ingestion are the result of the cyclopeptide toxins, phalloidin and amatoxin. Phalloidin causes gastroenteritislike effects 6-12 hours after initial ingestion. Phalloidin, a cyclic heptapeptide, interrupts the actin polymerization-depolymerization cycle and impairs cell membrane function. Phalloidin has limited gastrointestinal absorption, and symptoms improve within hours of supportive care.

Amanitins, primarily alpha-amanitin, are responsible for the hepatic, renal, and encephalopathic effects. Amatoxin, an octapeptide, inhibits RNA polymerase II, therefore interfering with DNA and RNA transcription. The toxin mainly affects tissues with high rates of protein synthesis, including the liver, kidneys, brain, pancreas, and testes.

About 60% of absorbed alpha-amanitin is excreted into the bile. The liver is exposed to high concentrations of toxin through the portal system and via the enterohepatic circulation. Hepatocytes are damaged early, with sparing of the hepatic sinusoids. In these cases, fatty degeneration of the hepatic parenchyma and patterns of centrilobular necrosis with hemorrhage are typical.

Amatoxin is eliminated in the urine, gastroduodenal fluids, and feces for several days after ingestion. A single gram of fresh A phalloides can yield approximately 0.2-0.4 mg of alpha-amanitin. The lethal dose is less than 0.1 mg/kg. The toxins of A phalloides are stable to cooking and remain active in dried mushrooms.

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Epidemiology

Frequency

United States

The 2003 American Association of Poison Control Centers (AAPCC) annual report lists 8,252 mushroom exposures, 60% of which were in children younger than 6 years, and species were only identified in 17% of the cases.[1] Forty three of the 8,252 exposures were known to be from cyclopeptides-containing mushrooms. This is likely an underestimation due to underreporting because of the difficulty in identifying the offending agent, delayed patient presentation after ingestion, and difficulty in recognition of the symptoms of mycetismus.[2]

Mortality/Morbidity

In 1998, no deaths in the United States were attributed to cyclopeptides. Most mortality statistics are from Europe, where the number of victims is larger. With current therapies, mortality from A phalloides is 20-30%. In general, the mortality rate is higher in children than adults. One case series reports mortality of 51% in patients younger than 10 years. This may be due to the lower body weight of children.

Age

Mycetismus commonly is due to amateur mushroom picking or accidental ingestions by unsupervised children.

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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  Resident Physician, Department of Emergency Medicine, Mount Sinai School of 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, Mt Sinai Hospital

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, Department of Emergency Medicine, Washington University School of Medicine

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 Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine

Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

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

Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society

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.

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Amanita muscaria.
Amanita phalloides.
 
 
 
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