Pediatric Amatoxin Toxicity Workup

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

Laboratory Studies

The following studies may be indicated in patients with mushroom poisoning:

  • Electrolyte, glucose, BUN, and creatinine levels
    • Abnormalities may be due to vomiting, diarrhea, and dehydration.
    • Progression to renal failure causes a further rise in BUN and creatinine levels.
  • Liver function test results: These may be normal upon presentation; however, elevation may occur after 24-48 hours.
    • Aspartate transaminase
    • Alanine transaminase
    • Lactic acid dehydrogenase
    • Bilirubin
  • Prothrombin time (PT) and/or activated partial thromboplastin time (aPTT)
    • Severe coagulopathy may develop as the toxicity progresses to later stages.
    • PT is considered a reliable prognostic indicator for Amanita poisoning.
  • Urinalysis
    • Microscopic hematuria may occur in stage I.
    • Oliguria and anuria develop with renal failure.
  • Amylase and lipase levels: A phalloides can directly induce pancreatitis.
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Imaging Studies

  • Specific studies are not indicated with the history of amatoxin ingestion.
  • If the history is unknown, abdominal radiography may be obtained to rule out obstruction.
  • Ultrasound and CT scanning are performed to narrow the differential but do not have positive findings.
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Other Tests

  • Meixner test
    • This test can detect amatoxin concentrations as low as 0.2 mg/mL.
    • Place uneaten mushrooms in a dry paper bag for transport.
    • If the patient can provide a sample of the mushrooms that were ingested, a drop of liquid from a fresh mushroom can be expressed onto a lignin-containing paper (eg, print-free newspaper). After the paper has dried, a drop of concentrated hydrochloride (10-12 N) is added. If amatoxins are present, a blue color develops within 2 minutes.
    • A dried mushroom may be tested by crushing it in pure methanol and using a drop of the methanol before adding the hydrochloride. This test is not valid on stomach contents.
    • Determining if a test result is positive can be difficult, and the clinical use of the Meixner test is questionable.
  • Spore analysis in stomach contents
    • Spores can be examined by light microscopy using an oil immersion lens after isolation and concentration via centrifuge.
    • The spores are examined in both water and Melzer solution.
    • The spores of amatoxin-containing Amanita mushrooms are smooth and turn blue in Melzer solution.
    • Whether the spores of Amanita species survive the digestive process and pass into the stool is unknown.
  • Radioimmunoassay, thin-layer chromatography, and high-performance liquid chromatography
    • These tests can measure the toxin in the serum, although these methods are generally not available.
    • Amatoxins are eliminated very rapidly from the serum. Levels have no prognostic significance.
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Histologic Findings

  • Excised livers from patients with Amanita poisoning reveal massive hepatic centrilobular necrosis with resultant hemorrhage.
  • If allowed to progress, the poisoning causes lobular collapse and regenerative changes.
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Proceed to Treatment & Management
 
 
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

  1. Watson WA, Litovitz TL, Rodgers GC Jr, et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2005;23(5):589-666. [Medline].

  2. Flammer R, Schenk-Jager KM. [Mushroom poisoning--the dark side of mycetism]. Ther Umsch. May 2009;66(5):357-64. [Medline].

  3. Kintziger KW, Mulay P, Watkins S, Schauben J, Weisman R, Lewis-Younger C, et al. Wild mushroom exposures in Florida, 2003-2007. Public Health Rep. Nov-Dec 2011;126(6):844-52. [Medline]. [Full Text].

  4. West PL, Lindgren J, Horowitz BZ. Amanita smithiana mushroom ingestion: a case of delayed renal failure and literature review. J Med Toxicol. Mar 2009;5(1):32-8. [Medline].

  5. [Guideline] Murray KF, Carithers RL Jr. AASLD practice guidelines: Evaluation of the patient for liver transplantation. Hepatology. Jun 2005;41(6):1407-32. [Medline]. [Full Text].

  6. Mengs U, Pohla RT, Mitchell T. Legalon® Sil: The Antidote of Choice in Patients with Acute Hepatotoxicity from Amatoxin Poisoning. Curr Pharm Biotechnol. Feb 20 2012;[Medline].

  7. Barbato MP. Poisoning from accidental ingestion of mushrooms. Med J Aust. Jun 21 1993;158(12):842-7. [Medline].

  8. Becker CE, Tong TG, Boerner U, et al. Diagnosis and treatment of Amanita phalloides-type mushroom poisoning: use of thioctic acid. West J Med. Aug 1976;125(2):100-9. [Medline].

  9. Berger KJ, Guss DA. Mycotoxins Revisited: Part I. The Journal of Emergency Medicine. 2005;28:53-62. [Medline].

  10. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline].

  11. Broussard CN, Aggarwal A, Lacey SR, Post AB, Gramlich T, Henderson JM, et al. Mushroom poisoning--from diarrhea to liver transplantation. Am J Gastroenterol. Nov 2001;96(11):3195-8. [Medline].

  12. Cappell MS, Hassan T. Gastrointestinal and hepatic effects of Amanita phalloides ingestion. J Clin Gastroenterol. Oct 1992;15(3):225-8. [Medline].

  13. Diaz JH. Evolving global epidemiology, syndromic classification, general management, and prevention of unknown mushroom poisonings. Crit Care Med. Feb 2005;33(2):419-26. [Medline].

  14. Diaz JH. Syndromic diagnosis and management of confirmed mushroom poisonings. Crit Care Med. Feb 2005;33(2):427-36. [Medline].

  15. Enjalbert F, Gallion C, Jehl F, Monteil H. Toxin content, phallotoxin and amatoxin composition of Amanita phalloides tissues. Toxicon. Jun 1993;31(6):803-7. [Medline].

  16. Enjalbert F, Rapior S, Nouguier-Soule J, et al. Treatment of amatoxin poisoning: 20-year retrospective analysis. J Toxicol Clin Toxicol. 2002;40(6):715-57. [Medline].

  17. Feinfeld DA, Mofenson HC, Caraccio T, Kee M. Poisoning by amatoxin-containing mushrooms in suburban New York--report of four cases. J Toxicol Clin Toxicol. 1994;32(6):715-21. [Medline].

  18. Floersheim GL. Treatment of human amatoxin mushroom poisoning. Myths and advances in therapy. Med Toxicol. Jan-Feb 1987;2(1):1-9. [Medline].

  19. Galler GW, Weisenberg E, Brasitus TA. Mushroom poisoning: the role of orthotopic liver transplantation. J Clin Gastroenterol. Oct 1992;15(3):229-32. [Medline].

  20. Ganzert M, Felgenhauer N, Zilker T. Indication of liver transplantation following amatoxin intoxication. Journal of Hepatology. 2005;42:202-209. [Medline].

  21. Goldfrank LR. Mushrooms: Toxic and hallucinogenic. In: Goldfrank LR, Flomenbaum NE, Lewin NA, eds. Goldfrank's Toxicologic Emergencies. 6th ed. 1998:1207-19.

  22. Homann J, Rawer P, Bleyl H, et al. Early detection of amatoxins in human mushroom poisoning. Arch Toxicol. Oct 1986;59(3):190-1. [Medline].

  23. Jaeger A, Jehl F, Flesch F, et al. Kinetics of amatoxins in human poisoning: therapeutic implications. J Toxicol Clin Toxicol. 1993;31(1):63-80. [Medline].

  24. Klein AS, Hart J, Brems JJ, et al. Amanita poisoning: treatment and the role of liver transplantation. Am J Med. Feb 1989;86(2):187-93. [Medline].

  25. Lampe KF, McCann MA. Differential diagnosis of poisoning by North American mushrooms, with particular emphasis on Amanita phalloides-like intoxication. Ann Emerg Med. Sep 1987;16(9):956-62. [Medline].

  26. Litovitz TL, Klein-Schwartz W, Caravati EM, et al. 1998 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1999;17(5):435-87. [Medline].

  27. Olson KR, Pond SM, Seward J, et al. Amanita phalloides-type mushroom poisoning. West J Med. Oct 1982;137(4):282-9. [Medline].

  28. Rubik J, Pietraszek-Jezierska E, Sergiusz J, et al. Successful treatment of a child with fulminant liver failure and coma caused by Amanita phalloides intoxication with albumin dialysis without liver transplantation. Pediatric Transplantation. 2004;8:295-300. [Medline].

  29. Schneider SM, Borochovitz D, Krenzelok EP. Cimetidine protection against alpha-amanitin hepatotoxicity in mice: a potential model for the treatment of Amanita phalloides poisoning. Ann Emerg Med. Oct 1987;16(10):1136-40. [Medline].

 
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