eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Mushroom - Amatoxin: Treatment & Medication

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

Updated: Jul 19, 2007

Treatment

Prehospital Care

Institute supportive measures if needed, such as intravenous access and oxygen.

Emergency Department Care

Aggressively treat a patient with suspected ingestion because the mortality rate of ingested amatoxin is as high as 60%.

  • Reduction of amatoxin absorption

    • Consider gastric lavage if the patient has not already vomited. In general, lavage should be attempted within 1 hour of ingestion. Given the delayed presentation of these intoxications, efficacy of this procedure is uncertain.
    • Administer activated charcoal. Amatoxins appear to undergo enterohepatic circulation and repeat dose activated charcoal may interrupt this cycle and reduce toxicity.
  • The mainstays of treatment include aggressive intravenous fluids and electrolytes to correct and maintain adequate hydration. Serum electrolyte and glucose levels should be closely monitored.
  • Several drugs have been postulated to reduce uptake of amatoxin into hepatocytes. Animal data support the use of some of these drugs, but only anecdotal support is available for humans.

    • High-dose penicillin G along with silibinin (not approved for use in the United States) appears to be the most promising treatment.
    • Silibinin (water-soluble milk thistle extract, not available in the United States) along with high-dose penicillin G appears to be the most promising treatment.
    • Vitamin K (if coagulopathy is present)
    • N- acetylcysteine
    • Cimetidine

Consultations

  • Consult a regional poison center or toxicologist for assistance in case management.
  • Contacting a mycologist for possible mushroom identification may be helpful. Possible sources for mushroom identification include the following:
    • North American Mycological Association
    • Local botanical garden
    • Local mycology club
    • Regional poison control center
  • Consult a gastroenterologist if hepatic dysfunction is present. If hepatic failure is present, medical personnel who work with a liver transplant program should be consulted to facilitate a preoperative evaluation should spontaneous recovery not occur.
  • For fulminant hepatic failure, consult a liver transplant service.

Medication

Management of amatoxin poisoning is primarily supportive.

GI decontaminants

These agents bind toxin in the GI tract and limit systemic adsorption. Repeat doses may effectively interrupt enterohepatic circulation.


Activated charcoal (Liqui-Char)

Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water.
For maximum effect, administer within 30 min after ingesting poison.

Adult

1 g/kg (30-100 g) PO; repeat 0.5-1 g/kg q2-4h

Pediatric

1-2 g/kg (15-30 g) PO; repeat 0.5-1 g/kg q2-4h

May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix charcoal with sherbet, milk, or ice cream (decreases adsorptive properties)

Documented hypersensitivity; poisoning or overdosage of mineral acids and alkalies; unprotected airway with absent gag reflex

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before giving 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; check for presence of bowel sounds before repeat administration to minimize risk of charcoal ileus

Pharmacologic antidotes - experimental

Medications documented in case reports and literature reviews without solid clinical evidence for use.


Penicillin G (Pfizerpen)

Use based on animal studies in mice, rats, and dogs. Somewhat protective against lethal doses of amatoxin.

Adult

Up to 1 million U/kg/d IV

Pediatric

Infants (<30 lb): 600,000 U IV
Children (30-60 lb): 900,000-1.2 million U IV

Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Caution in impaired renal function


Silibinin (Milk thistle)

Thought to competitively antagonize toxin binding to liver cell membrane receptors in mushroom poisoning and other hepatotoxic exposure. Some recommend a water-soluble preparation of silymarin, which inhibits penetration of amatoxins into liver cells.

Adult

20-50 mg/kg/d

Pediatric

Not established

May decrease effectiveness of oral contraceptives

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

None reported

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
References

References

  1. 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].

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

  3. 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].

  4. 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].

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

  6. 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). 2007;45(5):539-42. [Medline].

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

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

  9. 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].

  10. 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].

  11. 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].

  12. 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].

Further Reading

Keywords

amatoxin toxicity, mushroom ingestion, poisonous mushroom, mushroom toxicity, mushroom poisoning, amatoxin, Amanita toxin, Amanita, Galerina, Lepiota, cyclopeptide-containing species, amatoxin poisoning, mushroom exposure, Amanita phalloides, A phalloides

Contributor Information and Disclosures

Author

Andrew K Chang, MD, Assistant 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, ABAT, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD, ABAT is a member of the following medical societies: American Academy of Clinical Toxicology and 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 Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School
John Halamka, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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.