eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Mushroom - Muscarine: Treatment & Medication

Author: Peter A Chyka, PharmD, FAACT, DABAT, Professor and Executive Associate Dean, College of Pharmacy, University of Tennessee Health Science Center
Coauthor(s): William Banner Jr, MD, PhD,, Medical Director, Oklahoma Poison Control Center; Clinical Professor of Pharmacy, Oklahoma University College of Pharmacy-Tulsa; Adjunct Clinical Professor of Pediatrics, Oklahoma State University College of Osteopathic Medicine
Contributor Information and Disclosures

Updated: Oct 14, 2009

Treatment

Medical Care

  • Symptomatic patients may be treated with supportive measures.
  • The entire episode usually subsides in 6-8 hours; some symptoms may take up 24 hours to fully resolve.
  • Consider using atropine when excessive bronchial secretions compromise breathing and cause shortness of breath.
  • Monitor with pulse oximetry.
  • Be prepared to support the airway and perform orotracheal suctioning if needed.2

Consultations

  • Consult a mycologist to assist with mushroom identification. A mycologist can be contacted through the local poison center (in the United States, call 800-222-1222), a mycology club, the North American Mycological Association, a botanical garden, or local university.
  • Consultation with a medical toxicologist may be helpful, if available.
  • Consult a psychiatrist when the ingestion may have been a suicidal gesture.

Medication

Most patients with poisoning due to mushrooms containing muscarine can be treated without medications. If patients exhibit excessive bronchial secretions or other symptoms of cholinergic excess (bradycardia) that are of significant concern, atropine may decrease these symptoms. If the patient presents within 1 hour of ingestion oral administration of activated charcoal may be considered,13 but adsorption to activated charcoal has not been demonstrated for these constituents.14 No evidence suggests that routine administration of multiple doses of activated charcoal is useful. Ipecac syrup should generally be avoided because vomiting often occurs spontaneously and evidence for effectiveness is lacking.

Anticholinergic agents

Atropine is a competitive inhibitor of acetylcholine and muscarine in the autonomic nervous systems and relieves the muscarinic effects, especially bronchorrhea. Inhaled anticholinergic agents (eg, ipratropium) may also be considered.


Ipratropium (Atrovent)

Chemically related to atropine. Has antisecretory properties and, when applied locally, inhibits secretions from serous, and seromucous glands lining the nasal mucosa.

Adult

Nebulizer: 1 vial (500 mcg) inhaled via nebulizer tid/qid
MDI: 2 actuations PO qid; not to exceed 12 inhalations/24 h

Pediatric

Nebulizer: 250 mcg inhaled via nebulizer tid
Metered dose inhaler: 1-2 actuations PO tid; not to exceed 6 inhalations/24 h

Drugs with anticholinergic properties, such as dronabinol, may increase toxicity; albuterol increases effects of ipratropium

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not indicated for acute episodes of bronchospasm; caution in narrow-angle glaucoma, prostatic hypertrophy, and bladder neck obstruction


Atropine sulfate injection

Acts at parasympathetic receptor sites to block the actions of acetylcholine and muscarine.

Adult

0.4-1 mg IV/IM; repeat q20-30min prn to control bronchial secretions and titrate the dose to response

Pediatric

0.02 mg/kg IV/IM; minimal dose is 0.1 mg; repeat q10-20min prn to control secretions and titrate the dose to response

Additive effects in the presence of other anticholinergics; may increase pharmacologic effects of atenolol and digoxin; may decrease antipsychotic effects of phenothiazines; tricyclic antidepressants with anticholinergic activity may increase effects

Documented hypersensitivity; benefits may outweigh risks if cholinergic symptoms life-threatening toxicity; thyrotoxicosis, narrow-angle glaucoma, tachycardia, obstructive uropathy, paralytic ileus, toxic megacolon, asthma, and myasthenia gravis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid prophylactic use and only when significant symptoms are present; avoid in Down syndrome and brain damage to prevent hyperreactive response; avoid in coronary heart disease, tachycardia, congestive heart failure (CHF), cardiac arrhythmias, and hypertension; caution in peritonitis, ulcerative colitis, hepatic disease, and hiatal hernia with reflux esophagitis; in prostatic hypertrophy, prostatism can cause dysuria (catheterization may be required)

More on Toxicity, Mushroom - Muscarine

Overview: Toxicity, Mushroom - Muscarine
Differential Diagnoses & Workup: Toxicity, Mushroom - Muscarine
Treatment & Medication: Toxicity, Mushroom - Muscarine
Follow-up: Toxicity, Mushroom - Muscarine
Multimedia: Toxicity, Mushroom - Muscarine
References
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References

  1. Benjamin DR. Muscarine poisoning. In: Mushrooms: Poisons and Panaceas. New York, NY: WH Freeman; 1995:340-50.

  2. Poisindex managements, mushrooms – muscarine / histamine. In: Poisindex System, internet database online [database online]. Greenwood Village (CO): Thomson Reuters (Healthcare); February 27, 2009.

  3. Berger KJ, Guss DA. Mycotoxins revisited: Part I. J Emerg Med. Jan 2005;28(1):53-62. [Medline].

  4. Berger KJ, Guss DA. Mycotoxins revisited: Part II. J Emerg Med. Feb 2005;28(2):175-83. [Medline].

  5. 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.

  6. 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].

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

  8. 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.

  9. Pauli JL, Foot CL. Fatal muscarinic syndrome after eating wild mushrooms. Med J Aust. Mar 21 2005;182(6):294-5. [Medline].

  10. NAMA (North American Mycological Association). Annual reports. North American Mycological Association, Toxicology Section. Available at http://www.namyco.org/toxicology. Accessed March 4, 2009.

  11. 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].

  12. 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].

  13. 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.

  14. Chyka PA, Seger D, Krenzelok EP, Vale JA, ,. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila). 2005;43(2):61-87. [Medline].

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Further Reading

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Keywords

muscarine, mushroom poisoning, mushroom poisoning symptoms, cholinergic syndrome, jack o'lantern mushroom, sweating mushroom

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Contributor Information and Disclosures

Author

Peter A Chyka, PharmD, FAACT, DABAT, Professor and Executive Associate Dean, College of Pharmacy, University of Tennessee Health Science Center
Peter A Chyka, PharmD, FAACT, DABAT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Clinical Pharmacy, and American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Coauthor(s)

William Banner Jr, MD, PhD,, Medical Director, Oklahoma Poison Control Center; Clinical Professor of Pharmacy, Oklahoma University College of Pharmacy-Tulsa; Adjunct Clinical Professor of Pediatrics, Oklahoma State University College of Osteopathic Medicine
William Banner Jr, MD, PhD, is a member of the following medical societies: American College of Medical Toxicology
Disclosure: Nothing to disclose.

Medical Editor

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

Pharmacy Editor

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

Managing Editor

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

CME Editor

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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