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Toxicity, Mushroom - Muscarine: Differential Diagnoses & Workup
Updated: Oct 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Asthma
Gastroenteritis
Heart Failure, Congestive
Hypoglycemia
Toxicity, Organophosphate
Other Problems to Be Considered
Poisoning with cholinergic agents
Poisoning with mushrooms containing muscarine such as Clitocybe cerrusata, C dealbata, Clitocybe nubulosa, Inocybe fastigiata, Inocybe geophylla, Inocybe rimosus, and Omphalotus olearius (jack-o'lantern mushroom).
Omphalotus olearius (jack o'lantern mushroom).
Organophosphate insecticides: Patients may exhibit similar cholinergic symptoms as those of muscarine poisonings, but muscle fasciculations and weakness, respiratory paralysis, decreased level consciousness, and an insecticide odor are usually also present.
Poisoning with cholinergic and anticholinesterase drugs
Bethanechol (Urecholine)
Carbachol (Miostat intraocular solution, Isopto Carbachol)
Cevimeline
Methacholine (Amechol eye drops, Provocholine)
Pilocarpine
Physostigmine
Neostigmine
Pyridostigmine
Workup
Laboratory Studies
- Several texts, such as Goldfrank's Toxicological Emergencies,5 describe how to determine if the suspect botanical contains amatoxin, a potent toxin found in some of the Amanita species. However, for symptomatic patients, identification of the mushroom by a mycologist is desirable. (See Consultations.)
- Obtain a complete blood count because some mushroom toxins (eg, gyromitrin) can cause hemolytic anemia.
- Baseline liver function studies are indicated because possible ingestion of other toxic mushrooms, such as cyclopeptide-type mushrooms, can cause hepatotoxicity.
- Baseline renal function studies are indicated because some mushrooms are nephrotoxic, such as Amanita smithiana ( in Northwestern US) and orelline mushrooms.
- Consider evaluation for rhabdomyolysis if signs and symptoms warrant because some mushrooms, Tricholoma equestre, may cause muscle toxicity.
- Obtain a basic serum metabolic profile (sodium, potassium, chlorine, carbon dioxide, creatinine, glucose, and calcium) to evaluate fluid and electrolyte disturbances.
- Urine drug screening should be considered, especially if the patient has unexplained behavioral changes; if suicidal intent, substance abuse, or foul play is suspected; or if ingestion of unknown toxins is suspected.
- Chromatographic techniques (eg, thin-layer chromatography [TLC], gas-liquid chromatography [GLC], high-pressure liquid chromatography [HPLC]) are available to detect amanitins, orellanine, muscimol and ibotenic acid, psilocybin, muscarine, and the gyromitrins. However, these techniques are typically unavailable to the general practitioner because they are limited to laboratories conducting research on these compounds.
Imaging Studies
- Chest radiography may be helpful in evaluating pulmonary edema.
Other Tests
- Gastric contents may be examined. A mycologist may be able to microscopically identify the spores recovered from the patient's gastric contents.
- Obtain an electrocardiogram to evaluate the presence of atrioventricular (AV) nodal disease and heart block.
Procedures
No particular diagnostic procedures are available or needed for most patients with toxicity from mushrooms containing muscarine.
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 Differential Diagnoses & Workup: Toxicity, Mushroom - Muscarine |
| Treatment & Medication: Toxicity, Mushroom - Muscarine |
| Follow-up: Toxicity, Mushroom - Muscarine |
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References
Benjamin DR. Muscarine poisoning. In: Mushrooms: Poisons and Panaceas. New York, NY: WH Freeman; 1995:340-50.
Poisindex managements, mushrooms – muscarine / histamine. In: Poisindex System, internet database online [database online]. Greenwood Village (CO): Thomson Reuters (Healthcare); February 27, 2009.
Berger KJ, Guss DA. Mycotoxins revisited: Part I. J Emerg Med. Jan 2005;28(1):53-62. [Medline].
Berger KJ, Guss DA. Mycotoxins revisited: Part II. J Emerg Med. Feb 2005;28(2):175-83. [Medline].
Goldfrank LR. Mushrooms. In: Flomenbaum NE, Goldfrank LR, Hoffman RS, Howland MA, Lewin NA, Nelson LS. Goldfrank's Toxicologic Emergencies. 8th. New York: McGraw-Hill; 2006:1564-76.
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].
Diaz JH. Syndromic diagnosis and management of confirmed mushroom poisonings. Crit Care Med. Feb 2005;33(2):427-36. [Medline].
Bronstein AC, Spyker DA, Cantilena Jr LR, 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. 2008;46:927-1057.
Pauli JL, Foot CL. Fatal muscarinic syndrome after eating wild mushrooms. Med J Aust. Mar 21 2005;182(6):294-5. [Medline].
NAMA (North American Mycological Association). Annual reports. North American Mycological Association, Toxicology Section. Available at http://www.namyco.org/toxicology. Accessed March 4, 2009.
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].
Fischbein CB, Mueller GM, Leacock PR, Wahl MS, Aks SE. Digital imaging: a promising tool for mushroom identification. Acad Emerg Med. Jul 2003;10(7):808-11. [Medline].
Beuhler MC, Sasser HC, Watson WA. The outcome of North American pediatric unintentional mushroom ingestions with various decontamination treatments: an analysis of 14 years of TESS data. Toxicon. 2009;53:437-43.
Chyka PA, Seger D, Krenzelok EP, Vale JA, ,. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila). 2005;43(2):61-87. [Medline].
Further Reading
Keywords
muscarine, mushroom poisoning, mushroom poisoning symptoms, cholinergic syndrome, jack o'lantern mushroom, sweating mushroom
