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Toxicity, Mushroom - Amatoxin: Treatment & Medication
Updated: Nov 9, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
Institute supportive measures if needed, such as intravenous access and oxygen.
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.3
- Poly-therapies with the lowest mortality rate included combination of high-dose penicillin G along with silibinin.3
- It is interesting to note that an isolated administration of high-dose penicillin did not show improved survival.3
- Vitamin K (if coagulopathy is present)
- Cimetidine (unproven, but relatively benign treatment)
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 - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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
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
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
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
Antidote, Mushroom Induced Liver Toxicity
N-acetylcysteine
May provide substrate for conjugation with toxic metabolite.
Adult
Loading dose: 150 mg/kg IV infused over 15 min (dilute in 200 mL D5W) (Some authors recommend administration of loading dose over 60 min in order to reduce chances for anaphylactoid reaction) follow with maintenance doses
First maintenance dose: 50 mg/kg IV infused over 4 h (dilute in 500 mL D5W), followed with second maintenance dose
Second maintenance dose: 100 mg/kg IV infused over 16 h (dilute in 1000 mL D5W).
For continuation of NAC administration, consult with poison control center or medical toxicologist
Pediatric
Administer as in adults except decrease total volume of D5W with each dose for pediatric patient
Contact poison control center and medical toxicologist for the recommendations prior administration of IV NAC to pediatric population
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
IV administration may cause anaphylactoid reaction, vasodilatation, rash, bronchospasm and angioedema. (discontinue/slower IV and administer antihistamine, epinephrine, then follow local anaphylaxis protocol if symptoms persist); IV administration may also cause acute flushing or erythema within 30-60 min after initiating infusion, which typically resolves spontaneously despite continued infusion; adjust total fluid volume for IV in patients <40 kg
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 Treatment & Medication: Toxicity, Mushroom - Amatoxin |
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References
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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].
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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].
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].
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].
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, death cap, mushroom ingestion, poisonous mushroom, mushroom toxicity, mushroom poisoning, amatoxin, toxin, cyclopeptide-containing species, amatoxin poisoning, mushroom exposure,
