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Toxicity, Mushroom - Amatoxin: Follow-up

Author: Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Contributor Information and Disclosures

Updated: Nov 9, 2009

Follow-up

Further Inpatient Care

  • Admission criteria: Admit all patients with amatoxin poisoning for aggressive supportive care and monitoring of hepatic function.
  • Administer multiple doses of activated charcoal every 2-4 hours if the patient is not vomiting and has a protected airway. Control nausea and vomiting with antiemetics, preferably ondansetron.
  • Administer IV NAC and silibinin until hepatic injury resolves.
  • A retrospective review of 105 patients with amatoxin poisoning from 1988-2002 in Italy showed that all patients treated within 36 hours after ingestion were cured without sequelae. Two patients died; both were admitted more than 60 hours after ingestion. Their treatment protocols included intensive fluid and supportive therapy, restitution of altered coagulation factors, multiple-dose activated charcoal, mannitol, dexamethasone, glutathione, and penicillin G.4
  • Others have described additional treatments including extracorporeal liver assist device (ELAD), charcoal hemoperfusion, and plasma exchange.

Transfer

  • Consider transfer of any patient with amatoxin poisoning to a facility with a medical toxicologist.
  • Consider transfer of any patient with progressive hepatic dysfunction to a facility that has a liver transplant service.

Deterrence/Prevention

  • No single test can be used to determine the edibility of wild mushrooms.
  • Foragers should abide by the following: "No rule is the only rule."
  • Immigrants, even if very experienced in their countries of origin, may not be able to distinguish poisonous mushrooms from edible mushrooms in the United States.

Complications

  • Liver failure is the most serious complication of amatoxin ingestion.
  • Hepatic coma and hypoglycemia can complicate liver failure.
  • Progressive hepatic failure can lead to hepatorenal syndrome.
  • A recent retrospective study concluded that the prothrombin index in combination with the serum creatinine level from day 3 to day 10 after ingestion may help predict those patients needing liver transplantation. In this study, an international normalized ratio (INR) of 2.5 or higher along with a serum creatinine level greater than 106 µmol/L was predictive of fatal outcome.5

Prognosis

  • Mortality rates of 10-60% have been reported. With good supportive care, mortality rates are now lower than in the past.
  • Liver transplant can save the life of a patient with the most severe amatoxin poisoning.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider mushroom ingestion with acute gastroenteritis or signs of hepatic injury
  • Failure to consider an amatoxin mushroom poisoning when a patient presents with symptoms early (meal may have included several different mushrooms)
  • Failure to provide aggressive symptomatic therapy in addition to IV NAC and silibinin
  • Failure to involve liver transplant team early in the course of disease
  • Relying on Meixner test to rule out or rule in exposure to amatoxin containing mushrooms
  • Failure to contact regional poison control center or medical toxicologist to assist you in the management of poisoned patient
 


More on Toxicity, Mushroom - Amatoxin

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

  1. 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]. [Full Text].

  2. Litovitz TL, Smilkstein M, Felberg L, Klein-Schwartz W, Berlin R, Morgan JL. 1996 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1997;15(5):447-500. [Medline].

  3. Enjalbert F, Rapior S, Nouguier-Soulé J, Guillon S, Amouroux N, Cabot C. Treatment of amatoxin poisoning: 20-year retrospective analysis. J Toxicol Clin Toxicol. 2002;40(6):715-57. [Medline].

  4. Giannini L, Vannacci A, Missanelli A, Mastroianni R, Mannaioni PF, Moroni F. 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].

  5. Ganzert M, Felgenhauer N, Zilker T. Indication of liver transplantation following amatoxin intoxication. J Hepatol. Feb 2005;42(2):202-9. [Medline].

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

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

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

  9. Feinfeld DA, Mofenson HC, Caraccio T, Kee M. Poisoning by amatoxin-containing mushrooms in suburban New York--report of four cases. J Toxicol Clin Toxicol. 1994;32(6):715-21. [Medline].

  10. Floersheim GL. Treatment of human amatoxin mushroom poisoning. Myths and advances in therapy. Med Toxicol. Jan-Feb 1987;2(1):1-9. [Medline].

  11. Goldfrank LR. Mushrooms: toxic and hallucinogenic. In: Goldfrank's Toxicologic Emergencies. 5th ed. Appleton & Lange; 1994:951-961.

  12. Olesen LL. Amatoxin intoxication. Scand J Urol Nephrol. 1990;24(3):231-4. [Medline].

  13. Paydas S, Kocak R, Erturk F, Erken E, Zaksu HS, Gurcay A. Poisoning due to amatoxin-containing Lepiota species. Br J Clin Pract. Nov 1990;44(11):450-3. [Medline].

  14. Pond SM, Olson KR, Woo OF, et al. Amatoxin poisoning in northern California, 1982-1983. West J Med. Aug 1986;145(2):204-9. [Medline].

  15. 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].

  16. Yamada EG, Mohle-Boetani J, Olson KR, Werner SB. Mushroom poisoning due to amatoxin. Northern California, Winter 1996-1997. West J Med. Dec 1998;169(6):380-4. [Medline].

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Further Reading

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Keywords

amatoxin toxicity, death cap, mushroom ingestion, poisonous mushroom, mushroom toxicity, mushroom poisoning, amatoxin, toxin, cyclopeptide-containing species, amatoxin poisoning, mushroom exposure,

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Contributor Information and Disclosures

Author

Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.

Pharmacy Editor

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.

Managing Editor

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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and 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.

 
 
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