Amatoxin Toxicity in Emergency Medicine Treatment & Management

  • Author: Andrew K Chang, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: May 6, 2011
 

Prehospital Care

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

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Emergency Department Care

Aggressively treat a patient with suspected amatoxin 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 of amatoxin ingestion 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.
    • The lowest mortality rate was reported in patients treated with N-acetylcysteine and silibinin (water-soluble milk thistle extract, not available in the United States) that were both administered as monotherapy.[4]
    • Poly-therapies with the lowest mortality rate included combination of high-dose penicillin G along with silibinin.[4]
    • It is interesting to note that an isolated administration of high-dose penicillin did not show improved survival.[4]
    • Vitamin K (if coagulopathy is present)
    • Cimetidine (unproven, but relatively benign treatment)
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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.
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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.

Specialty Editor Board

Jeffrey Glenn Bowman, MD, MS  Consulting Staff, Highfield MRI, Columbus, Ohio

Disclosure: Nothing to disclose.

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.

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.

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.

References

  1. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol (Phila). Dec 2010;48(10):979-1178. [Medline]. [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]. [Full Text].

  3. 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].

  4. 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].

  5. 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].

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

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

  8. 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].

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

  10. 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].

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

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

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

  14. 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].

  15. 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].

  16. 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].

  17. 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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