The clinical manifestations of poisoning by amatoxin may be grouped into four phases.

The first phase is a period of latency, with the onset of signs and symptoms delayed until 6 to 24 hours. In some instances, patients do not present until 2-3 days after mushroom consumption [1].

The second- or gastrointestinal- phase is marked by patients developing abdominal pain, vomiting and severe diarrhea that may contain blood. The fluid loss may progress to hypovolemia, electrolyte disturbances and circulatory shock [2] [3]. The levels of liver enzymes and bilirubin are usually normal at this stage.

In the third phase, patients experience a gradual resolution of dysentery over a 24-hour period, suggesting an apparent recovery. However, elevations in alanine aminotransferase (ALT) and aspartate aminotransferase (AST) become evident at this stage, with jaundice clinically apparent in some individuals.

Two to four days after mushroom ingestion, severely poisoned patients may develop irreversible liver failure, often accompanied by acute renal failure. Multisystem organ failure, pancreatitis, disseminated intravascular coagulation, seizures, coma and death may occur within 1-3 weeks of poisoning [4] [5] [6]. Some patients may undergo full recovery with an improvement in both their symptoms and their liver profile.

• Fever

  Other symptoms : • Diarrhea, • Fever, • Headache, • Weakness, • Drowsiness, • Dizziness, sweating, • Confusion, and hallucination. 13. [slideshare.net]

• Vomiting

  The gastrointestinal phase (starts 6–40 hours after consumption) is characterised by vomiting and diarrhoea and lasts 12–24 hours. [gut.bmj.com]

  The initial symptoms of nausea, vomiting, abdominal pain and diarrhea, which are typical for the intoxication, can be interpreted as a common gastro-enteritis. The intoxication can progress to acute liver and renal failure and eventually death. [ncbi.nlm.nih.gov]

  These mushrooms cause self-limited nausea, vomiting, diarrhea and stomach pain. The onset of symptoms is rather rapid (0.5 to 3 hours). [missouripoisoncenter.org]

  It all began in January 2007, when a family of six showed up at Dominican Hospital vomiting and with diarrhea. They had recently eaten tacos made with mushrooms foraged in a state park. [theatlantic.com]

• Diarrhea

  An interval between ingestion and diarrhea CONCLUSIONS: Liver transplantation should be strongly considered in patients with an interval between ingestion and diarrhea [ncbi.nlm.nih.gov]

  It all began in January 2007, when a family of six showed up at Dominican Hospital vomiting and with diarrhea. They had recently eaten tacos made with mushrooms foraged in a state park. [theatlantic.com]

• Nausea

  The initial symptoms of nausea, vomiting, abdominal pain and diarrhea, which are typical for the intoxication, can be interpreted as a common gastro-enteritis. The intoxication can progress to acute liver and renal failure and eventually death. [ncbi.nlm.nih.gov]

  These mushrooms cause self-limited nausea, vomiting, diarrhea and stomach pain. The onset of symptoms is rather rapid (0.5 to 3 hours). [missouripoisoncenter.org]

  All persons who consumed the mushrooms developed nausea, vomiting, and diarrhea approximately 9 hours after ingestion. [cdc.gov]

  In this phase, the person experiences fatigue, stomach nausea, dizziness, headaches and feelings of cold, even freezing. [poisonousnature.biodiversityexhibition.com]

• Abdominal Pain

  The initial symptoms of nausea, vomiting, abdominal pain and diarrhea, which are typical for the intoxication, can be interpreted as a common gastro-enteritis. The intoxication can progress to acute liver and renal failure and eventually death. [ncbi.nlm.nih.gov]

  The second- or gastrointestinal- phase is marked by patients developing abdominal pain, vomiting and severe diarrhea that may contain blood. The fluid loss may progress to hypovolemia, electrolyte disturbances and circulatory shock. [symptoma.com]

  Violent vomiting, diarrhoea and abdominal pain are the first symptoms. [patient.info]

  In the second stage, which is about 24 hours long, the patient will typically experience abdominal pain, vomiting, and bloody diarrhea. The third stage is again about 24 hours. During this period, the patient appears improved and recovered. [sinaiem.org]

• Abdominal Cramps

  The toxins initially cause severe abdominal cramping, vomiting, and watery diarrhea, and then lead to liver and kidney failure. [encyclopedia.com]

  […] nausea, vomiting dyspnea, possible hypotension Coprine 0.5 to 3 hours Bronchorrhea, bronchospasm, vomiting, diarrhea, salivation, urination, lacrimation Muscarine 6 to 12 hours 12 to 24 hours 24 to 72 hours Stage 1: gastroenteritis, profuse diarrhea, abdominal [missouripoisoncenter.org]

  She returned to the ED the following day with persistent nausea, vomiting, diarrhea, and abdominal cramping. At that time, her AST was 1,712 IU/L, ALT 1,025 IU/L, total bilirubin 2.0 mg/dL, and INR 1.8 units. [cdc.gov]

  After this asymptomatic period, abdominal cramping, vomiting, and profuse watery diarrhea (rice-water or choleralike) occur. Fluid losses may be severe enough to cause profound dehydration and even circulatory collapse. [emedicine.medscape.com]

• Tachycardia

  The electrocardiogram disclosed sinus tachycardia. Aggressive treatment with fluids, activated charcoal, penicillin G and silibinin were started. The patient was sent to hemodialysis because of anuria. [ncbi.nlm.nih.gov]

  The Coprinus syndrome: rapid onset of nausea, vomiting, tachycardia, palpitations, paraesthesiae, diaphoresis and flushing. Hypotension may also occur. [patient.info]

  Initially, symptoms are gastrointestinal in nature and include colicky abdominal pain, with watery diarrhea, nausea, and vomiting, which may lead to dehydration if left untreated, and, in severe cases, hypotension, tachycardia, hypoglycemia, and acid–base [en.wikipedia.org]

• Jaundice

  Jaundice, hepatomegaly and neurological symptoms were not present, but liver enzymes were moderately increased. Alfa-amanitin was detected in sera of all patients. [ncbi.nlm.nih.gov]

  However, elevations in alanine aminotransferase (ALT) and aspartate aminotransferase (AST) become evident at this stage, with jaundice clinically apparent in some individuals. [symptoma.com]

  The chemical nature of the toxin has not been determined, but it is a source of monomethylhydrazine, which affects the central nervous system and induces hemolytic jaundice. Get unlimited access to all of Britannica’s trusted content. [britannica.com]

  Clinical evidences of liver involvement ultimately develop with the onset of jaundice. (4) Acute Liver Failure. [hindawi.com]

• Hepatomegaly

  Jaundice, hepatomegaly and neurological symptoms were not present, but liver enzymes were moderately increased. Alfa-amanitin was detected in sera of all patients. [ncbi.nlm.nih.gov]

• Blurred Vision

  Other symptoms include blurred vision, headache, loss of consciousness and confusion. In severe cases there may be features of organ failure - eg, jaundice, haemorrhage. [ 2 ] Differential diagnosis Food poisoning. [patient.info]

• Hematuria

  Microscopic hematuria may be present in the initial stages of poisoning, whilst acute renal failure may manifest as proteinuria and gross hematuria. Oliguria and anuria may be the other findings. [symptoma.com]

• Microscopic Hematuria

  Microscopic hematuria may be present in the initial stages of poisoning, whilst acute renal failure may manifest as proteinuria and gross hematuria. Oliguria and anuria may be the other findings. [symptoma.com]

• Confusion

  False elevations of cardiac markers may confuse the clinicians in differential diagnosis of myocardial infarction in ED. [ncbi.nlm.nih.gov]

  There has been a great deal of confusing, contradictory and incorrect information published about the toxicity of Amanita muscaria and A. pantherina. [erowid.org]

  Death caps are also easily confused for a variety of edible fungi--and they are spreading throughout North America, and other continents. Let's hope that silibinin, which is derived from the plant milk thistle, can make a difference. [popsci.com]

  Could I confuse the Deathcap with anything else? You shouldn’t confuse it with any of the ordinary field mushrooms (in the genus Agaricus ), where the gills are pink at first but eventually turn brown. [anbg.gov.au]

  Other symptoms : • Diarrhea, • Fever, • Headache, • Weakness, • Drowsiness, • Dizziness, sweating, • Confusion, and hallucination. 13. [slideshare.net]

• Seizure

  Multisystem organ failure, pancreatitis, disseminated intravascular coagulation, seizures, coma and death may occur within 1-3 weeks of poisoning. [symptoma.com]

  Intoxication symptoms usually appear after a latent period and may include gastrointestinal disorders followed by jaundice, seizures, and coma, culminating in death. [ncbi.nlm.nih.gov]

  Anticholinergic symptoms can occur: dizziness, lack of co-ordination, ataxia, seizures, hallucinations, muscle spasms, flushing and dilated pupils may be observed. [patient.info]

  Stage 2: resolution of GI symptoms, increased hepatic enzymes Stage 3: hepatic and renal failure, encephalopathy Cyclopeptides Amatoxin Phallotoxin Virotoxin 6 to 12 hours 24 to 36 hours Days to weeks Gastroenteritis, dizziness, headache, intractable seizures [missouripoisoncenter.org]

  • ADR :, hypersensitivity, rashes, neurotoxicity, erythema, dermatitis, angioedema, seizures. • Thioctic acid – hepatic damage • Silybinnin – hepatic toxicity • Cimetidine (have hepato protector against alpha amanitin) Dose – 4-6gm/day 21. [slideshare.net]

• Dizziness

  Other symptoms : • Diarrhea, • Fever, • Headache, • Weakness, • Drowsiness, • Dizziness, sweating, • Confusion, and hallucination. 13. [slideshare.net]

  In this phase, the person experiences fatigue, stomach nausea, dizziness, headaches and feelings of cold, even freezing. [poisonousnature.biodiversityexhibition.com]

  […] profuse diarrhea, abdominal cramping Stage 2: resolution of GI symptoms, increased hepatic enzymes Stage 3: hepatic and renal failure, encephalopathy Cyclopeptides Amatoxin Phallotoxin Virotoxin 6 to 12 hours 24 to 36 hours Days to weeks Gastroenteritis, dizziness [missouripoisoncenter.org]

  Anticholinergic symptoms can occur: dizziness, lack of co-ordination, ataxia, seizures, hallucinations, muscle spasms, flushing and dilated pupils may be observed. [patient.info]

The diagnosis of Amanita phalloides poisoning relies heavily on the accuracy of the various clinical findings and must be suspected in individuals presenting with a late onset of gastrointestinal symptoms coupled with hepatotoxic signs.

A complete liver profile may help document the hepatic injury caused by amatoxins. This includes aspartate transaminase (AST), alanine transaminase (ALT), serum bilirubin, alkaline phosphatase (ALP) and lactic acid dehydrogenase (LDH) levels. A coagulation profile measuring the prothrombin time (PT) and activated partial thromboplastin time (aPTT) is a reliable marker for mushroom intoxication and hence, should be measured routinely.

All patients with suspected ingestion of amatoxin-containing mushrooms must undergo certain baseline investigations including measurement of serum electrolyte and blood glucose levels, and a complete blood count [7]. Creatinine and blood urea nitrogen levels may be raised, especially in renal failure.

Microscopic hematuria may be present in the initial stages of poisoning, whilst acute renal failure may manifest as proteinuria and gross hematuria. Oliguria and anuria may be the other findings. Pancreatic amylase and lipase levels need to be measured as well.

Imaging studies in the form of abdominal X-rays, ultrasonography or a computed tomography (CT) scan may help to narrow the differential diagnosis. Histology of liver specimens shows centrilobular necrosis accompanied by areas of hemorrhage and necrosis.

The presence of amatoxin in the suspected mushroom samples may be detected via the Meixner test. The high number of false-positive cases with this test impairs its usage in a clinical setting. The spores of the implicated mushroom may be examined in gastric secretions, appearing smooth and turning blue on exposure to Melzer solution. Other tests used to measure the level of toxins include high-performance liquid chromatography, thin layer chromatography and radioimmunoassays [8].

• Hyperuricosuria

  The results of pyrazinamide and probenecid tests performed in patients after A. phalloides poisoning indicated that hyperuricosuria was most likely due to an increment in renal tubular urate secretion, and not due to decreased presecretory and postsecretory [ncbi.nlm.nih.gov]

• Hypouricemia

  The aim of this study was to investigate the cause of repeatedly observed episodes of hypouricemia in patients after A. phalloides poisoning. [ncbi.nlm.nih.gov]

No amatoxin was detected before treatment, after treatment, or in the HD/HP circuits. Neither HD nor HP contributed to the clearance of amatoxin. [ncbi.nlm.nih.gov]

Prognosis The prognosis in the great majority of cases of mushroom poisoning is excellent. [patient.info]

Prognosis The primary factor determining the prognosis is the quantity of mushroom that was eaten. In some cases, ingestion of a single A phalloides mushroom can be lethal. [emedicine.medscape.com]

Prognosis The mortality rate has decreased with improved and rapid treatment. However, according to some medical reports death still occurs in 20-30% of cases, with a higher mortality rate of 50% in children less than 10 years old. [encyclopedia.com]

"Early indicators of prognosis in fulminant hepatic failure". Gastroenterology. 97 (2): 439–445. [en.wikipedia.org]

Etiology Amatoxin toxicity is caused by the ingestion of mushrooms containing the toxin (especially Amanita phalloides ), such as may occur in any of the following circumstances: Amateur mushroom hunters seeking a fresh-picked meal Adults and adolescents [emedicine.medscape.com]

These criteria are based on prothrombin time (PT), age, etiology, time elapsing between appearance of jaundice and onset of encephalopathy, and bilirubin concentration. [hindawi.com]

Addresses the full range of renal problems, from epidemiology to monitoring and diagnostic procedures to pathophysiology of organ systems in relation to kidney failure. [books.google.de]

Most reports of deadly mushroom ingestion come from central and eastern Europe; Amanita poisonings are uncommon in North America (see Epidemiology). [emedicine.medscape.com]

Epidemiology Poisoning with potentially lethal mushrooms in the UK is extremely rare. Highly toxic types are not likely to be found in towns or cities. [patient.info]

A blood test that detects amatoxin would be useful to confirm exposures for epidemiological purposes. [mja.com.au]

Addresses the full range of renal problems, from epidemiology to monitoring and diagnostic procedures to pathophysiology of organ systems in relation to kidney failure. [books.google.de]

Most fatalities resulting from mushroom ingestion are associated with amatoxins within the mushrooms (see Pathophysiology). [emedicine.medscape.com]

With the exception of one fatality in a particularly high dosage suicidal intoxication, all patients survived. 4 Administration of silibrinin even up to 48 h after mushroom ingestion appears to be an effective measure to prevent severe liver damage in [ncbi.nlm.nih.gov]

The drug works by preventing the mushroom's toxins, called amatoxins, from getting into the liver. Amatoxins themselves prevent liver cells from creating a necessary enzyme. [popsci.com]

Get the skills you need now with new information on global humanitarian relief and expedition medicine, plus expanded coverage of injury prevention and environmental preservation. [books.google.de]

The major toxins are amanatins, a series of closely related heat-stable cyclic octapeptides, which inhibit RNA polymerase in liver cells Management Symptomatic-rehydration, IV glucose, instillation of 100 g of activated charcoal per os, mannitol to prevent [medical-dictionary.thefreedictionary.com]

1. Santi L, Maggioli C, Mastrorobeerto M, et al. Acute Liver Failure Caused by Amanita phalloides Poisoning. Int J Hepatol 2012;2012:487–480.
2. Becker C, Tong T, Boerner U, et al. Diagnosis and treatment of amanita phalloides-type mushroom poisoning. West J Med 1976;125:100–9.
3. NAMA. Mushroom Poisoning Syndromes. Access date 4/21/2014. Available at: http://namyco.org/toxicology/poison_syndromes.html.
4. Eren SH, Demirel Y, Urgulu S, et al. Mushroom poisoning: a retrospective analysis of 294 cases. Clinics (Sao Paulo) 2010;65:491–96.
5. Haard R, Haard K. Poisonous and Hallucinogenic Mushrooms . 2nd edition. Mayne Island and Seattle: Cloudburst press, 1977.
6. Erden A, Esmeray K, Karagöz H, et al. Acute liver failure caused by mushroom poisoning: a case report and review of the literature. Int Med Case Rep J 2013;6:85–90.
7. Colak S, Kandis H, Afacan MA, Erdogan MO, Gunes H, Kaya E, et al. Assessment of patients who presented to the emergency department with mushroom poisoning. Hum Exp Toxicol. 2015 Jul. 34 (7):725-31.
8. Parant F, Peltier L, Lardet G, et al. [Phalloidin syndrome: role of Elisa-based assay for the detection of alpha- and gamma-amanitins in urine. Preliminary results]. Acta Clin Belg 2006; 61 Suppl 1:11.