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Hallucinogenic Mushroom Toxicity Clinical Presentation

  • Author: Louis Rolston-Cregler, MD; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Apr 08, 2015
 

History

Obtain a history of the exposure that includes the following:

  • Quantity of mushrooms ingested – The concentration of active substances is low in any individual mushroom, but as a general rule, toxic symptoms result from the consumption of about 1 mushroom by young children and 3 or more by adolescents and adults [14] ; an amount as small as a mouthful can cause symptoms [13]
  • Preparation of the mushroom (eg, raw or cooked) – The effects of mushrooms vary greatly, and cooking may not alter toxicity
  • Source of the mushroom (eg, outdoors or the Internet)
  • Time of ingestion
  • Symptoms seen after ingestion and time between ingestion and onset – Symptoms tend to appear more quickly after ingestion of hallucinogenic mushrooms than after ingestion of more lethal mushrooms
  • Prehospital treatment, including home remedies
  • Medications regularly taken and any co-ingestants

The timing of symptom onset is important for distinguishing life-threatening or severe mushroom poisonings from less serious ones, which typically have an onset of symptoms well within 5 hours of ingestion (as is the case for poisonings involving hallucinogenic mushrooms). If symptoms such as vomiting, diarrhea, and abdominal pain begin 5 hours or more after ingestion, mushrooms that can cause potentially life-threatening or severe toxicity (eg, A phalloides or Cortinarius spp) should be considered.[20, 21, 22, 23, 24]

Note, however, that Amanita smithiana, a mushroom found in the northwestern United States, is characterized by the onset of GI distress within 1-12 hours after ingestion.[25] For mushroom ingestions in the Pacific Northwest, patients who have early-onset symptoms (< 3 hours after ingestion) and remain symptomatic should be fully evaluated in a hospital until the mushroom identity is confirmed or the patient’s condition improves.[24]

Identification of the actual mushroom consumed is important but is typically impossible because the mushroom in question has already been digested. (See Identification of Mushroom Specimens.) Collecting the patient’s gastric contents by means of gastric lavage or after emesis might yield identifiable spores. Remote viewing of digital images of an unknown mushroom may facilitate its identification by a mycologist.[26]

For more information on differentiating among various mushroom poisonings, see Mushroom Toxicity.

Mushrooms containing ibotenic acid and muscimol

Symptoms of poisoning with ibotenic acid or muscimol typically begin 30 minutes to 1 hour after ingestion; in rare cases, however, symptom onset may be delayed as long as 3 hours.

Hallucinations may be accompanied by dysarthria, ataxia, and muscle cramps and may persist for as long as 8 hours. However, a case report described an otherwise healthy 48-year-old man who accidentally ingested A muscaria mushrooms and experienced a 5-day paranoid psychosis accompanied by visual and auditory hallucinations.[16] By day 6, his condition had returned to baseline, with no long-term adverse effects reported.

Central nervous system (CNS) effects range from agitation to coma. Heavy intoxication may cause vomiting, diarrhea, and seizures.

Fatal A pantherina poisonings have been reported in the Pacific Northwest region of the United States.[4, 18, 27]

Mushrooms containing psilocybin

Alterations in perception begin within 30 minutes of ingestion of psilocybin-containing mushrooms and generally subside after 6 hours.

Widely varying CNS manifestations (eg, euphoria, visual and religious hallucinations, and feeling closer to nature) have been reported. Visual hallucinations may include perceived motion of stationary objects or surfaces.[28] Patients presenting in the emergency department (ED) may experience more unpleasant effects, such as fear, agitation, confusion, delirium, psychosis, and schizophrenialike syndromes.

Symptoms may include nausea and sympathomimetic activity such as mydriasis and tachycardia. Symptoms in children include hyperpyrexia and seizures.

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Physical Examination

Physical examination typically yields the following findings:

  • Vital signs – Pulse and blood pressure are usually unchanged.
  • Respiration – Breathing is slow and regular, similar to that in deep sleep
  • Gastrointestinal (GI) – GI upset and vomiting occur but are not common; when vomiting or diarrhea does occur, fluid and electrolyte changes are uncommon
  • Integumentary – Skin may be reddened and warm to the touch
  • Musculoskeletal – Muscle spasms may occur
  • Neurologic (eg, ataxia, incoordination, confusion, delirium, and psychosis) – Agitation and CNS depression may occur; especially in children, tonic-clonic seizures, fasciculations, and myoclonic jerking lasting 6-9 hours have been reported [13] ; seizures in adults are uncommon

In these intoxications, neurologic findings predominate. Initial excitation leads to stupor, then coma; severe lethargy alternating with agitation is common, and a deep sleep may occur. Agitation, babbling, confusion, screaming, irritability, hallucinations, dizziness, ataxia, euphoria progressing to muscle jerks, spasms, delirium, racing thoughts, and giddiness may be seen. Headache may last several days. Illusions of sight and sound are produced by misinterpretation of sensory input. Fever, tachycardia, and hypotension may occur because of agitation.

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Complications

In addition to CNS sequelae, hallucinogenic mushrooms may affect other organ systems. In one case of psilocybin intoxication, an 18-year-old man developed a cardiac dysrhythmia and myocardial infarction.[29]

Another case report described a 25-year-old man who developed rhabdomyolysis and acute renal failure followed by posterior encephalopathy and cortical blindness after ingesting hallucinogenic mushrooms.[30, 31]

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Contributor Information and Disclosures
Author

Louis Rolston-Cregler, MD Resident Physician, Department of Emergency Medicine, SUNY Downstate Medical Center, Kings County Hospital Center

Louis Rolston-Cregler, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Medical Student Association/Foundation, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association, Student National Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Acknowledgements

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.

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.

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.

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Clinical Toxicologists, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association

Disclosure: Nothing to disclose.

Diane F Giorgi, MD, FACEP Attending Physician, Department of Emergency Medicine, Brooklyn Hospital Center

Diane F Giorgi, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American Association of Women Emergency Physicians, American College of Emergency Physicians, and American College of Physicians

Disclosure: Nothing to disclose.

Michael Hodgman, MD Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare

Michael Hodgman, MD is a member of the following medical societies: American College of Medical Toxicology, American College of Physicians, Medical Society of the State of New York, and Wilderness Medical Society

Disclosure: Nothing to disclose.

C Crawford Mechem, MD, MS, FACEP Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department

C Crawford Mechem, MD, MS, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Fly agaric (Amanita muscaria).
Amanita pantherina.
Amanita muscaria.
Amanita muscaria var. guessowii with yellow cap surface, from Massachusetts.
Amanita muscaria var. formosa sensu Thiers, from Oregon.
 
 
 
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