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Toxicity, Mushroom: Treatment & Medication
Updated: Jun 25, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
In the absence of a definitive identification of the mushroom, all ingestions should be considered serious and possibly lethal. Once diagnosed, treatment of mushroom poisoning is largely supportive.
Endotracheal intubation is recommended in all patients at risk of aspiration, and mechanical ventilation should be initiated in all patients with hypoxia, hypercarbia, acidemia, and shock. Aggressive rehydration in the ICU may be necessary in patients with choleralike gastroenteritis, and infusions of large amounts of electrolytes with dextrose solutions may be necessary to maintain vital functions.
Blood transfusions may be required in patients with hemorrhagic diarrhea, blood loss, and severe hemolytic anemia.
Blood pressure support with dopamine and norepinephrine may be required when crystalloids and colloid infusions fail. Hypoglycemia is treated with infusions of 10% dextrose with thiamine.
Cerebral edema is also treated in a conventional manner, which is aimed at reducing intracerebral pressure and preventing herniation. Hyperventilation, fluid restriction, osmotic diuresis, positioning the head of the bed at 30° from the horizontal plane, barbiturate coma, and anticonvulsants may be necessary.
GI decontamination, including whole-bowel irrigation, may be necessary. Beyond the first postprandial hour, orogastric lavage is not recommended because of the procedure's questionable efficacy. Activated charcoal plays a much more important role in limiting absorption of most toxins and is indicated for all patients with mushroom poisoning, regardless of the timing of presentation. When amatoxins are suspected, repeated doses of activated charcoal should be administered for 3-4 days to interrupt enterohepatic circulation of these toxins.
Once absorbed, the toxin may be neutralized with inhibition of the tissue uptake of the toxin, inhibition of the metabolic pathways involved in the development of toxicity, or enhanced elimination of the toxin. Specific therapy depends on the presumed toxin ingested.
Other complications of mushroom poisoning are treated in a standard manner.
Methemoglobinemia, which may occur after the ingestion of gyromitrins and, occasionally, after an intravenous injection of psilocybin, is treated with intravenous methylene blue.
Hemolysis, which may occur with gyromitrin toxicity, is usually mild, requires the administration of large amounts of intravenous fluids only to prevent renal complications, and rarely requires blood transfusions. Hemolysis due to Paxillus species may be more severe and may result in acute renal failure.
Agitation, commonly observed with hallucinogenic mushrooms, is treated with benzodiazepines. Phenothiazines are best avoided in this setting. Other causes of agitation (eg, hypoxia, hypovolemia, shock) should also be sought and corrected.
Anticholinergic poisoning may be treated with benzodiazepines and rarely requires physostigmine.
Severe muscarinic symptoms may require the infusion of small doses of atropine.
Patients with severe poisoning from disulfiram-containing mushrooms may benefit from fomepizole (4-methylpyrazole), which blocks alcohol dehydrogenase and, hence, the formation of the toxic aldehyde.
Renal failure, commonly observed with orellanine poisoning, may require hemodialysis. Patients with orellanine and orelline poisoning may benefit from hemoperfusion when it is performed within a week of ingestion, prior to the development of renal failure. Acute renal failure may also follow the ingestion of Amanita smithiamna and A proxima. Conventional indications for dialysis include uremic encephalopathy, fluid overload (with pulmonary edema), severe hyperkalemia, and acidosis. Patients with unremitting renal failure are candidates for renal transplantation.
Fulminant hepatic failure is a common complication observed with amatoxin and gyromitrin poisoning, and it should be treated aggressively because it commonly follows a fatal course.
The development of hepatic encephalopathy, hyperbilirubinemia greater than 4.6 mg/dL, prolongation of the prothrombin time to greater than twice the reference range, and a serum creatinine level greater than 1.4 mg/dL signal a fatal course. For these patients, orthotopic liver transplantation may be the only life-saving therapy. Therefore, transfer to a liver transplant center should be undertaken early in the setting of amanita poisoning and prior to the development of stage III encephalopathy, jaundice, or renal failure. Patients who develop shock, acidosis, hypoglycemia, and coagulopathy with hemorrhage and those who exhibit marked elevations of liver transaminases also should be considered for immediate orthotopic liver transplantation, even in the absence of hepatic encephalopathy, azotemia, and hyperbilirubinemia.
While waiting for an orthotopic liver transplant, patients with fulminant hepatic failure should be intubated early in order to prevent the added burden of aspiration pneumonia and hypoxia. Hypovolemia is treated with crystalloids. Hemorrhage is treated with blood transfusions and, when accompanied by coagulopathy, infusions of fresh frozen plasma. Lactulose may be administered to patients who exhibit hepatic encephalopathy.
The development of renal failure in patients with fulminant hepatic failure warrants an attentive search for the etiology of the renal failure. Patients with hepatorenal syndrome are candidates for liver transplantation. Prerenal azotemia may be treated with cautious infusions of crystalloids, albumin, and fresh frozen plasma. Low-dose dopamine occasionally may aid in reversing renal failure. Should hemodialysis be required, continuous renal replacement therapy (CRRT) is the dialysis mode of choice because standard hemodialysis can cause rapid elevations in intracranial pressure and decreased cerebral perfusion.
Specific therapies include the following:
- Amatoxin
- In addition to intensive airway and fluid therapy, correction of coagulation factors, multiple dose activated charcoal, a number of therapeutic options have been proposed, but to date, no controlled studies comparing the efficacy of different modalities have been published.
- The most frequently recommended therapy for amatoxin poisoning is intravenous benzyl penicillin, combined with silibinin (an extract of milk thistle) and cimetidine. N -acetylcysteine (NAC) has also been frequently recommended. Benzyl penicillin and silibinin appear to reduce the uptake of amatoxin by hepatocytes. Of the 2 modalities, silibinin has been purported to offer a better survival advantage compared to benzyl penicillin.
- Cimetidine (a cytochrome P-450 inhibitor) is used to inhibit the uptake of amatoxins by the mixed function oxidase system, thereby reducing toxicity. N -acetylcysteine, a glutathione precursor, capable of binding amatoxin-related free radicals, has been found in one case series to be efficacious.
- In a murine model, however, none of the proposed antidotal therapies were found to significantly affect the hepatic aminotransferase levels compared with controls; nor did any of them demonstrate an important decrease in hepatic necrosis histologically.4
- The intravenous form of silibinin is not currently available in the United States; however, an oral form (ie, silymarin) may be obtained. Silymarin is a dietary supplement found in health food stores.
- Corticosteroids, vitamin C, kutkin, aucubin, and thioctic acid have been used in the past but have no proven benefit and are no longer recommended. Charcoal hemoperfusion and hemodialysis are also ineffective in removing toxins because, once formed, the toxin is excreted rapidly by the kidneys.
- Plasma exchange transfusions have also been used with some success, but controlled studies are lacking. MARS (Molecular Absorbent Regenerating System), a new extracorporeal liver-assistance method that uses an albumin dialysate for the removal of albumin-bound toxins, has shown promising survival results in amatoxin-related hepatic failure. Hyperbaric oxygen therapy has been advocated for amatoxin poisoning and should be considered, when available.
- In the case of gyromitrin poisoning, in which systemic toxicity results from reduced concentrations of GABA, seizures may be overcome by the infusions of pyridoxine if they do not respond to benzodiazepines. Phenobarbital increases the metabolism of hydrazines to toxic compounds and should be avoided in the treatment of seizures in this setting. Hydrazines also inhibit the transformation of folic acid to tetrahydrofolic acid. Therefore, patients with gyromitrin toxicity should receive folinic acid.
Surgical Care
- Indications for immediate orthotopic liver transplant include the following:
- Stage III hepatic encephalopathy
- Serum bilirubin levels greater than 4.6 mg/dL
- Prothrombin time prolongation greater than twice the reference range and unresponsive to fresh frozen plasma infusions (Patients with a prothrombin time >100 s should be considered for transplant.)
- Quick-test value less than 20%
- Other suggested indications include age younger than 12 years, serum creatinine level greater than 1.4 mg/dL, hemorrhage, shock, acidosis, hypoglycemia, and factor V deficiency (concentration <10% of the reference range).
Consultations
- Identification of the mushroom: Specialists from the regional poison center, toxicologists, botanists, and mycologists may assist in the identification of the mushroom. The Internet may also provide answers. However, decontamination and treatment should not await the identification of the mushroom.
- Transplant surgery: Consultation is indicated as soon as the diagnosis of amanita-induced fulminant hepatic liver failure is entertained.
- Nephrology: Consultation is indicated for renal failure or when dialysis or hemoperfusion is required.
Diet
- Hepatic failure: The catabolic rate of patients with fulminant hepatic failure (FHF) is quadruple the reference range catabolic rate, and patients in FHF should receive adequate protein and carbohydrates so that hepatocyte regeneration may be optimized. Limiting protein in patients with FHF is associated with an increased mortality rate. Patients with acute FHF also are at risk for hypoglycemia and require close monitoring of their glucose levels along with infusions of 10% dextrose solutions. Patients receiving high-carbohydrate solutions also must receive thiamine.
- Renal failure: Use of essential amino acids is not associated with better outcomes than is the use of standard amino acids. Nutrition of patients with acute renal failure should include amino acids and glucose, with a relatively normal calorie-to-nitrogen ratio.
Medication
The goals of pharmacotherapy are to neutralize the toxin, to reduce morbidity, and to prevent complications.
Anticonvulsants
These agents prevent seizure recurrence and terminate clinical and electrical seizure activity.
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life.
By increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, it may depress all levels of CNS, including limbic and reticular formation.
Monitor patient's blood pressure after administering dose. Adjust as necessary.
Adult
2 mg/dose IV slowly over 2-5 min; not to exceed 8 mg/dose
Pediatric
0.05-0.1 mg/kg IV slowly over 2-5 min; not to exceed 2 mg/dose
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, MAOIs, narcotics, valproate, oral contraceptives, and antihistamines
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, respiratory depression, or Parkinson disease
Diazepam (Valium)
Depresses all levels of CNS (eg, limbic, reticular formation), possibly by increasing activity of GABA.
Adult
5-10 mg IV q10-15min; not to exceed 30 mg/8h period
Pediatric
0.05-0.3 mg/kg IV q10-15min; not to exceed 5 mg/dose
Effects potentiated with alcohol, barbiturates, MAOIs, narcotics, valproate, oral contraceptives, and antihistamines
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with other CNS depressants, low albumin levels, hepatic disease (may increase toxicity), impaired renal function, and respiratory depression
Phenobarbital (Barbita, Luminal)
Interferes with transmission of impulses from thalamus to cortex of brain.
Adult
Loading dose: 15-20 mg/kg IV at 25-50 mg/min
Maintenance dose: 1-5 mg/kg/d
Pediatric
Administer as in adults
May decrease effects of chloramphenicol, digitoxin, corticosteroids, carbamazepine, theophylline, verapamil, metronidazole, and anticoagulants (patients stabilized on anticoagulants may require dosage adjustments if added to or withdrawn from their regimen); coadministration with alcohol may produce additive CNS effects and death; chloramphenicol, valproic acid, and MAOIs may increase phenobarbital toxicity; rifampin may decrease phenobarbital effects; induction of microsomal enzymes may result in decreased effects of oral contraceptives in women (must use additional contraceptive methods to prevent unwanted pregnancy; menstrual irregularities also may occur)
Documented hypersensitivity; severe respiratory disease; marked impairment of liver function; nephritis
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
In prolonged therapy, evaluate hematopoietic, renal, hepatic, and other organ systems; caution in fever, hyperthyroidism, diabetes mellitus, and severe anemia because adverse reactions can occur; caution in myasthenia gravis and myxedema
Antiemetics
These agents block the dopamine receptors in the chemoreceptor trigger zone.
Prochlorperazine (Compazine)
May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system.
Not recommended in children <20 lb due to high incidence of extrapyramidal effects.
Adult
5-10 mg IV slowly; not to exceed 40 mg/d
Pediatric
Not established
Coadministration with other CNS depressants or anticonvulsants may cause additive effects; administration with epinephrine may cause hypotension; cardiovascular effects are potentiated with use of diuretics
Documented hypersensitivity; bone marrow suppression; narrow-angle glaucoma; severe liver or cardiac disease
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
Drug-induced parkinsonian syndrome or pseudoparkinsonism occurs quite frequently; akathisia is the most common extrapyramidal reaction in elderly patients; lowers seizure threshold; caution in patients with history of seizures; caution in cardiovascular disease (may cause arrhythmias and hypotension)
Metoclopramide (Reglan)
Works as antiemetic by blocking dopamine receptors in the chemoreceptor trigger zone of the CNS.
Adult
10 mg IV slowly up to 1 mg/kg
Pediatric
2.5 mg IV slowly up to 1-2 mg/kg IV q2-4h
Anticholinergic agents may antagonize effects of metoclopramide; opiate analgesics may increase metoclopramide toxicity in CNS
Documented hypersensitivity; pheochromocytoma; Parkinson disease; GI obstruction; GI bleed
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in history of mental illness and Parkinson disease; may induce seizures, changes in mental status, extrapyramidal symptoms, and arrhythmias
GI decontaminants
These agents are empirically used to minimize systemic absorption of the toxin.
Activated charcoal (Liqui-Char)
Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal absorbs 100-1000 mg of drug per g of charcoal. Does not dissolve in water. For maximum effect, administer within 30 min after ingesting poison. The first dose of activated charcoal generally is used with a cathartic (eg, sorbitol 1 g/kg PO). Additional doses of sorbitol are not administered to children due to resultant excessive intraintestinal osmotic shifts, electrolyte imbalance, and intravascular volume depletion.
Adult
1-2 g/kg PO; repeat q4h
Pediatric
<1 year: 1 g/kg PO, without sorbitol
1-12 years: 1-2 g/kg PO; repeat q4h; use sorbitol for only 1-2 doses
>12 years: Administer as in adults
May inactivate syrup of ipecac if used concomitantly; effectiveness of other medications decrease with coadministration; do not mix charcoal with sherbet, milk, or ice cream (decreases absorptive properties of activated charcoal)
Documented hypersensitivity; poisoning or overdosage of mineral acids and alkalies
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
May result in intestinal obstruction; aspiration may result in tracheal obstruction and bronchiolitis obliterans; combination with a cathartic in children may result in hemodynamic instability; not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administering activated charcoal; after emesis with ipecac, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black
Polyethylene glycol (GoLYTELY)
Laxative with strong electrolyte and osmotic effects that has cathartic actions in GI tract.
Adult
1-2 L/h PO until rectal effluent is clear
Pediatric
50-250 mL/kg/h PO until rectal effluent is clear
Reduces effectiveness and absorption of oral medications
Documented hypersensitivity; colitis; megacolon; bowel perforation; gastric retention; GI obstruction
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
Caution in ulcerative colitis and hot loop polypectomy
Antidotes
Most amatoxin antidotes are experimental and based on animal studies and/or anecdotal reports of success in humans.
Penicillin G (Pfizerpen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. Blocks amanitin uptake by hepatocytes and prevents amanitin from binding to RNA polymerase.
Adult
1 million U/kg/d IV
Pediatric
<15 kilograms: 600,000 U IV
15-30 kilograms: 1 million U IV
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function; high doses are associated with seizures
Silibinin (Silibinin Plus)
Compound made of silymarin, an extract of the milk thistle plant Silybum marianum. May act as a free radical scavenger or may interrupt enterohepatic circulation. Blocks amanitin uptake by hepatocytes. Available in Europe but not the United States.
Adult
Intravenous loading: 5 mg/kg over 1 h, followed by continuous IV infusion of 20/mg/kg for 3 d
Pediatric
Not established
Decreased efficacy when activated charcoal is administered concomitantly; may decrease effectiveness of oral contraceptives
Documented hypersensitivity
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
None reported
N-acetylcysteine (Mucosil, Mucomyst)
May provide substrate for conjugation with toxic metabolite.
Adult
Loading dose: 140 mg/kg PO
Maintenance dose: 70 mg/kg PO q4h
Pediatric
Administer as in adults
Absorption is reduced by charcoal
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
GI distress may occur
Pyridoxine (Nestrex)
May be used in conjunction with benzodiazepines for the treatment of convulsions that develop with gyromitrin toxicity. Involved in synthesis of GABA within the CNS.
Adult
25 mg/kg up to 5 g IV over 30 min
Pediatric
Administer as in adults
Pyridoxine may decrease levodopa, phenytoin, and phenobarbital serum levels
Documented hypersensitivity
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
Doses >70 mg/kg are associated with increased toxicity; long-term use of high doses of pyridoxine may result in neuropathy manifested by numbness, paresthesias, or unsteady gait
Methylene blue (Urolene Blue)
In reduced form, leukomethylene blue is an electron donor to reduce methemoglobin. Reduction of methylene blue is by NADPH generated by G-6-PD.
Adult
1-2 mg/kg IV over 5 min
Pediatric
Not established
None reported
Documented hypersensitivity; renal insufficiency
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
In G-6-PD deficiency, can cause profound anemia; do not inject into CNS
Fomepizole (Antizol)
Anticortinarius antidote with better safety profile than ethanol. Easier to dose and administer. In contrast to ethanol, 4-MP levels do not need to be monitored during therapy.
Adult
15 mg/kg IV over 30 min, then 10 mg/kg q12h for 4 doses
Pediatric
Not established
Inhibitory effects on alcohol dehydrogenase are increased in presence of ethanol
Documented hypersensitivity
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
Do not administer as bolus; caution in breastfeeding women because no information on excretion of this medication in breast milk is available; caution in renal impairment; may induce seizures
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Further Reading
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
