eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Mushroom: Follow-up

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

Follow-up

Further Inpatient Care

  • Amatoxin poisoning: Further inpatient care of patients who survive focuses on the management of direct complications of poisoning and on the management of the liver transplant.
  • Gyromitrin poisoning: Further inpatient care of patients who survive focuses on the management of complications of poisoning, such as rhabdomyolysis, methemoglobinemia, and hemolysis, and on management of the liver transplant.
  • Orellanine poisoning: Further inpatient care of patients focuses on the management of complications such as renal failure.

Transfer

Transfer to a liver transplant facility should occur early in the course of FHF and prior to the development of stage III hepatic encephalopathy.

Deterrence/Prevention

Education regarding the poisonous nature of wild mushrooms may act as a deterrent to mushroom foraging and ingestion.

Complications

  • Respiratory complications: Aspiration pneumonia common to all poisonings involves loss of airway protective reflexes. Noncardiogenic pulmonary edema may complicate poisonings.
  • CNS complications: Convulsions are common in gyromitrin poisoning, but they also may be due to hypoxia, acidosis, and metabolic abnormalities. Cerebral edema may be a complication of hypoxia, acidosis, trauma, and hepatic failure.
  • Hepatic complications: Fulminant hepatic failure (FHF) is a complication for amatoxin and gyromitrin poisoning.
  • Renal failure is a common complication of orellanine poisoning but also may be due to hypoperfusion and shock and may be part of the hepatorenal syndrome.
  • Methemoglobinemia may complicate gyromitrin poisoning.
  • Hemolysis may complicate gyromitrin poisoning.
  • Hypoglycemia is a common complication of hepatic failure caused by poisoning with gyromitrins and amatoxins.
  • Trauma may complicate hallucinogenic mushroom poisoning.
  • Hypovolemia and electrolyte disturbances may complicate any mushroom poisoning.

Prognosis

  • Amatoxin poisoning: With good supportive care, the mortality rate for amatoxin poisoning may be reduced from 60% to less than 10%.  In a retrospective analysis of amatoxin poisoned patients, Giannini found found that the evolution of hepatic transaminases and prothrombin time over the initial 4 days were highly predictive of recovery or death.5
  • Gyromitrin poisoning: Most patients recover; death is rare in the United States, but, in some areas of Europe, mushrooms containing gyromitrins account for the most mushroom fatalities.
  • Orellanine poisoning: Although it is not found in the United States, in some areas of Europe, mushrooms containing orellanine account for the most mushroom fatalities. A shorter time course between ingestion and toxicity portends a worse prognosis. Mild renal insufficiency may resolve a few months after the ingestion.
  • Psilocybin poisoning: Prognosis is excellent; no fatalities were reported in the United States in 2004.

Patient Education

  • Education regarding the poisonous nature of wild mushrooms may act as a deterrent to mushroom foraging and ingestion.
  • Patients ingesting coprine-containing mushrooms should be educated regarding the interaction with alcohol.
  • For excellent patient education resources, visit eMedicine's Poisoning Center and Poisoning - First Aid and Emergency Center. Also, see eMedicine's patient education articles Poisoning and Activated Charcoal.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the diagnosis of mushroom poisoning
  • Failure to recognize that more than one species of mushroom was ingested
  • Failure to institute supportive therapy prior to the identification of the mushroom
  • Failure to recognize and treat complications
  • Failure to consider liver transplant, when indicated

Special Concerns

  • Children are more susceptible to volume depletion and mushroom toxicity (mushroom poisoning) than are healthy adults.
  • Elderly patients are more susceptible to volume depletion than are healthy adults.
  • Patients with comorbidities have worse prognoses.
 


More on Toxicity, Mushroom

Overview: Toxicity, Mushroom
Differential Diagnoses & Workup: Toxicity, Mushroom
Treatment & Medication: Toxicity, Mushroom
Follow-up: Toxicity, Mushroom
Multimedia: Toxicity, Mushroom
References
[ CLOSE WINDOW ]

References

  1. Dhabolt John. Mushroom Poisons and Poisonous Mushrooms. The Puffball (Newsletter of the Willamette Valley Mushroom Society. 1993;16, No. 3:[Full Text].

  2. 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].

  3. Beug MW, Shaw M, Cochran KW. Summary of approximately 2000 reports in the NAMA registry. NAMA Case registry.

  4. Tong TC, Hernandez M, Richardson WH 3rd, et al. Comparative treatment of alpha-amanitin poisoning with N-acetylcysteine, benzylpenicillin, cimetidine, thioctic acid, and silybin in a murine model. Ann Emerg Med. Sep 2007;50(3):282-8. [Medline].

  5. Giannini L, Vannacci A, Missanelli A, et al. Amatoxin poisoning: a 15-year retrospective analysis and follow-up evaluation of 105 patients. Clin Toxicol (Phila). Jun-Aug 2007;45(5):539-42. [Medline].

  6. Amanita phalloides mushroom poisoning--Northern California, January 1997. MMWR Morb Mortal Wkly Rep. Jun 6 1997;46(22):489-92. [Medline].

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

  8. Beckurts KT, Holscher AH, Heidecke CD, et al. [The role of liver transplantation in the treatment of acute liver failure following Amanita phalloides poisoning]. Dtsch Med Wochenschr. Mar 21 1997;122(12):351-5. [Medline].

  9. Bedry R, Baudrimont I, Deffieux G, et al. Wild-mushroom intoxication as a cause of rhabdomyolysis. N Engl J Med. Sep 13 2001;345(11):798-802. [Medline].

  10. Bektas H, Schlitt HJ, Boker K, et al. [Indications for liver transplantation in severe amanita phalloides mushroom poisoning]. Chirurg. Oct 1996;67(10):996-1001. [Medline].

  11. Benjamin DR. Mushroom poisoning in infants and children: the Amanita pantherina/muscaria group. J Toxicol Clin Toxicol. 1992;30(1):13-22. [Medline].

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

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

  14. Bouget J, Bousser J, Pats B, et al. Acute renal failure following collective intoxication by Cortinarius orellanus. Intensive Care Med. 1990;16(8):506-10. [Medline].

  15. Butera R, Locatelli C, Coccini T, et al. Diagnostic accuracy of urinary amanitin in suspected mushroom poisoning: a pilot study. J Toxicol Clin Toxicol. 2004;42(6):901-12. [Medline].

  16. Danel VC, Saviuc PF, Garon D. Main features of Cortinarius spp. poisoning: a literature review. Toxicon. Jul 2001;39(7):1053-60. [Medline].

  17. de Haro L, Jouglard J, Arditti J, et al. [Acute renal insufficiency caused by Amanita proxima poisoning: experience of the Poison Center of Marseille]. Nephrologie. 1998;19(1):21-4. [Medline].

  18. 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].

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

  20. 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].

  21. Fischbein CB, Mueller GM, Leacock PR, et al. Digital imaging: a promising tool for mushroom identification. Acad Emerg Med. Jul 2003;10(7):808-11. [Medline].

  22. Goldfrank LR. Mushrooms. Goldfrank's Toxicologic Emergencies. Eighth Edition. Goldfrank LR, Flom. 2006:1564-1575.

  23. Haddad LM, Winchester JF. Mushrooms. Clinical Management of Poisoning and Drug Overdose. 1998;365-374.

  24. Hall AH, Spoerke DG, Rumack BH. Mushroom poisoning: identification, diagnosis, and treatment. Pediatr Rev. Apr 1987;8(10):291-8. [Medline].

  25. Horn S, Horina JH, Krejs GJ, et al. End-stage renal failure from mushroom poisoning with Cortinarius orellanus: report of four cases and review of the literature. Am J Kidney Dis. Aug 1997;30(2):282-6. [Medline].

  26. Karlson-Stiber C, Persson H. Cytotoxic fungi--an overview. Toxicon. Sep 15 2003;42(4):339-49. [Medline].

  27. Kuwabara T, Arai A, Honma N, et al. [Acute encephalopathy among patients with renal dysfunction after ingestion of "sugihiratake", angel's wing mushroom--study on the incipient cases in the northern area of Niigata Prefecture]. Rinsho Shinkeigaku. Mar 2005;45(3):239-45. [Medline].

  28. Köppel C. Clinical symptomatology and management of mushroom poisoning. Toxicon. Dec 1993;31(12):1513-40. [Medline].

  29. 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].

  30. Leathem AM, Purssell RA, Chan VR, et al. Renal failure caused by mushroom poisoning. J Toxicol Clin Toxicol. 1997;35(1):67-75. [Medline].

  31. Lincoff G, Mitchell DH. Toxic and Hallucinogenic Mushroom Poisoning: A Handbook For Physicians and Mushroom Hunters.

  32. McPartland JM, Vilgalys RJ, Cubeta MA. Mushroom poisoning. Am Fam Physician. Apr 1997;55(5):1797-800, 1805-9, 1811-2. [Medline].

  33. Montanini S, Sinardi D, Pratico C, et al. Use of acetylcysteine as the life-saving antidote in Amanita phalloides (death cap) poisoning. Case report on 11 patients. Arzneimittelforschung. Dec 1999;49(12):1044-7. [Medline].

  34. Pinson CW, Daya MR, Benner KG, et al. Liver transplantation for severe Amanita phalloides mushroom poisoning. Am J Surg. May 1990;159(5):493-9. [Medline].

  35. Respiratory illness associated with inhalation of mushroom spores--Wisconsin, 1994. MMWR Morb Mortal Wkly Rep. Jul 29 1994;43(29):525-6. [Medline].

  36. Rubik J, Pietraszek-Jezierska E, Kaminski A, et al. Successful treatment of a child with fulminant liver failure and coma caused by Amanita phalloides intoxication with albumin dialysis without liver transplantation. Pediatr Transplant. Jun 2004;8(3):295-300. [Medline].

  37. Saviuc P, Flesch F. [Acute higher funghi mushroom poisoning and its treatment]. Presse Med. Sep 20 2003;32(30):1427-35. [Medline].

  38. Saviuc PF, Danel VC, Moreau PA, et al. Erythromelalgia and mushroom poisoning. J Toxicol Clin Toxicol. 2001;39(4):403-7. [Medline].

  39. Schneider SM, Vanscoy G, Michelson EA. Failure of cimetidine to affect phalloidin toxicity. Vet Hum Toxicol. Feb 1991;33(1):17-8. [Medline].

  40. Schneider SM. Mushroom Toxicity. In: Auerbach PS, Geehr EC, eds. Management of Wilderness and Environmental Emergencies. 1988:891-907.

  41. Shakil AO, Mazariegos GV, Kramer DJ. Fulminant hepatic failure. Surg Clin North Am. Feb 1999;79(1):77-108. [Medline].

  42. Shi Y, He J, Chen S, et al. MARS: optimistic therapy method in fulminant hepatic failure secondary to cytotoxic mushroom poisoning--a case report. Liver. 2002;22 Suppl 2:78-80. [Medline].

  43. Warden CR, Benjamin DR. Acute renal failure associated with suspected Amanita smithiana mushroom ingestions: a case series. Acad Emerg Med. Aug 1998;5(8):808-12. [Medline].

  44. Warden CR, Benjamin DR. Acute renal failure associated with suspected Amanita smithiana mushroom ingestions: a case series. Acad Emerg Med. Aug 1998;5(8):808-12. [Medline].

  45. Winkelmann M, Stangel W, Schedel I, et al. Severe hemolysis caused by antibodies against the mushroom Paxillus involutus and its therapy by plasma exchange. Klin Wochenschr. Oct 1 1986;64(19):935-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

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

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.