eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Mushroom: Differential Diagnoses & Workup

Author: Rania Habal, MD, Assistant Professor, Department of Emergency Medicine, New York Medical College
Coauthor(s): Jorge A Martinez, MD, JD, Clinical Professor, Department of Internal Medicine, Louisiana State University School of Medicine; Clinical Instructor, Department of Surgery, Tulane School of Medicine
Contributor Information and Disclosures

Updated: Jun 25, 2009

Differential Diagnoses

Acute Liver Failure
Gastroenteritis, Viral
Acute Renal Failure
Hallucinogens
Adrenal Crisis
Hepatorenal Syndrome
Encephalopathy, Hepatic
Isoniazid Hepatotoxicity
Food Allergies
Septic Shock
Food Poisoning
Shock, Hemorrhagic
Gastroenteritis, Bacterial

Workup

Laboratory Studies

  • Arterial blood gas analysis may demonstrate hypoxia and acidosis.
  • Glucose: Hypoglycemia may develop suddenly during the gastroenteritis phase of gyromitrin poisoning, as well as during the hepatic failure phase of both gyromitrin and amatoxin poisoning. Hypoglycemia in the setting of liver failure signals a grim prognosis.
  • Electrolytes: Electrolyte disturbances, such as hypokalemia, may occur in patients with severe gastroenteritis. Hypocalcemia may occur with orellanine-induced renal failure and in both gyromitrin and amatoxin poisoning. Hypophosphatemia may occur with amatoxin and gyromitrin poisoning, especially in children.
  • Renal function tests: Blood urea nitrogen, creatinine level, and urinalysis are used as screening tools for renal function. Renal insufficiency occurs as a result of circulatory collapse from any cause, and, in the setting of amatoxin and gyromitrin toxicity, it may be part of the hepatorenal syndrome. A serum creatinine level greater than 1.4 mg/dL in the setting of amatoxin-induced hepatic failure is associated with a fatal course. Orellanine is a direct nephrotoxin and may induce oliguric renal failure several days or weeks after ingestion of the toxic mushroom. Mild renal insufficiency also may be observed with intravenous injection of psilocybin.
  • Liver function tests: Hepatic failure is a common complication in amatoxin and gyromitrin ingestions. Biomarkers of hepatocellular necrosis include aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and lactic dehydrogenase. With amatoxin- and gyromitrin-induced hepatic necrosis, these biomarkers begin to rise exponentially 36-72 hours after the ingestion of these mushrooms. Severe hyperbilirubinemia also occurs, as do the prothrombin and activated partial thromboplastin time. An elevated ammonia heralds hepatic encephalopathy, and a bilirubin level exceeding 4.6 mg/dL is associated with a lethal course.
  • CBC count: Anemia may be secondary to acute blood loss, which may complicate hemorrhagic gastroenteritis or may be secondary to hemolysis observed with gyromitrin poisoning. Anemia may also be secondary to renal failure observed in orellanine poisoning.
  • Methemoglobin: Methemoglobinemia may be observed with gyromitrin poisoning and occasionally after an intravenous injection of psilocybin.
  • Creatinine phosphokinase (CPK): Elevated CPK levels are a manifestation of rhabdomyolysis, which may be noted with Tricholoma and Russula species.
  • Toxicology laboratory: Acetaminophen levels should be obtained for all patients with an unknown ingestion and should be suspected in all patients with fulminant hepatic failure. Toxicology screening for barbiturates, benzodiazepines, opiates, and alcohol should be obtained to help differentiate the cause of coma. Toxicology screening for phencyclidine, LSD, and cocaine may help differentiate the cause of hallucinations and agitation. Toxicology screening for phenothiazines may help differentiate the cause of hepatic failure or anticholinergic toxicity.
  • Enzyme-linked immunosorbent assay (ELISA): ELISA analysis of urinary Amanitin appears efficacious in diagnosing amatoxin poisoning.
  • Chromatography–mass spectrometry have been used to identify monomethyhydrazines (gyromitrin mushrooms), phenyethyleneamine (Psilocybe mushrooms), and orellanine (Cortinarius mushrooms).
  • Hemagglutination inhibition has been used to detect anti-Paxillus immunoglobulin G (IgG).

Imaging Studies

  • Radiography: Bilateral reticulonodular infiltrates may be seen with puffball-induced allergic bronchoalveolitis. A chest radiograph may reveal aspiration pneumonia or pulmonary edema. A CT scan of the brain is indicated in all patients with encephalopathy in order to rule out structural disease.
  • Sonography: Renal ultrasound may show enlarged kidneys in orellanine poisoning.

Other Tests

  • Electrocardiography: An electrocardiogram may reveal signs of hyperkalemia, which may complicate orellanine-induced renal failure.
  • Mushroom toxicology
    • The most reliable method of identifying the mushroom involved in poisoning remains botanical identification of the fungus that was ingested. When no sample of the mushroom is available, postingestion analyses may be performed, but these are time consuming, and, by the time the results are available, the patient has recovered. The toxin may be recovered from the cooking water, gastric contents, blood, and urine of the poisoned patient.
    • Meixner test: When the mushroom specimen is available, the Meixner test provides a rapid method of identifying amatoxins. False-positive results may occur with psilocybin. The test consists of expressing a drop of mushroom juice onto a lignin paper (newspaper) and allowing it to air dry. A drop of hydrochloric acid (10-12 N) then is placed on the same spot, and the area is observed for any color change. The presence of amatoxin is suggested by a bluish discoloration of the area.

Procedures

  • Liver biopsy
    • Gyromitrin toxicity - Diffuse hepatocellular damage
    • Amatoxin toxicity - Fatty degeneration of the liver, with extensive central zone necrosis and centrilobular hemorrhage
  • Renal biopsy
    • Gyromitrin - Interstitial nephritis
    • Orellanine - Binds to tubular cells and may be detected as long as 6 months after ingestion
    • Renal biopsy reveals acute tubular necrosis and dedifferentiation of the proximal tubule. Electron microscopy reveals vacuolization of the tubular cells with loss of the brush border.

Histologic Findings

  • Histologic examination of the liver reveals diffuse hepatocellular damage with gyromitrin toxicity and fatty degeneration of the liver with extensive central zone necrosis and centrilobular hemorrhage in amatoxin poisoning.
  • Electron microscopy reveals changes consistent with extensive lipid peroxidation of the cytoplasm as well as the nucleus, vacuolization of the mitochondria, and clumping of the nucleolar chromatin.
  • Renal biopsy findings may reveal interstitial nephritis in gyromitrin toxicity, acute tubular necrosis, and dedifferentiation of the proximal tubule in orellanine toxicity.
  • Electron microscopy reveals vacuolization of the tubular cells with loss of the brush border.

More on Toxicity, Mushroom

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

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Keywords

mushroom toxicity, mushroom poisoning, mycetism, toadstool poisoning, amatoxins, gyromitrins, orellanine, muscarine, psilocybin, muscimol/ibotenic acid, coprine, general GI irritants, neurotoxins, nephrotoxins, myotoxins, phallotoxins, virotoxins, destroying angel, autumn skullcap, Amanita phalloides, Amanita virosa, Amanita verna, Galerina autumnalis, false morel, Gyromitra esculenta, Gyromitra ambigua, Gyromitra gigas, Gyromitra infula, early false morel, Verpa bohemica, webcap, Cortinarius orellanus, Cortinarius speciosissimus, Cortinarius gentilis, Cortinarius callisteus, Cortinarius rainierensis, Cortinarius splendens, Amanita proxima, fly agaric, panthercap, Amanita muscaria, Amanita pantherine, Psilocybe, Panaeolus, Gymnopilus, Copelandia, Conocybe, Psathyrella Pluteus, sweater mushroom, Clitocybe dealbata, Paxillus involutus, green gill, Chlorophyllum molybdates, jack-o'-lantern, Omphalotus illudens, pepper bolete, Boletus piperatus, horse mushroom, Agaricus arvensis

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Contributor Information and Disclosures

Author

Rania Habal, MD, Assistant Professor, Department of Emergency Medicine, New York Medical College
Disclosure: Nothing to disclose.

Coauthor(s)

Jorge A Martinez, MD, JD, Clinical Professor, Department of Internal Medicine, Louisiana State University School of Medicine; Clinical Instructor, Department of Surgery, Tulane School of Medicine
Jorge A Martinez, MD, JD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Cardiology, American College of Emergency Physicians, American College of Physicians, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Laurie Robin Grier, MD, Medical Director of MICU, Associate Professor of Medicine, Section of Pulmonary and Critical Care Medicine, Louisiana State University Health Science Center at Shreveport
Laurie Robin Grier, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Society for Parenteral and Enteral Nutrition, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Daniel R Ouellette, MD, FCCP, Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System
Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM, Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair, Academic Affairs, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center
Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, Shock Society, and Society of Critical Care Medicine
Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

 
 
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