Edit concept Question Editor Create issue ticket

Amanita Phalloides Poisoning

Death Cap Fung Caus Tox Effct

Amanita phalloides poisoning is the most common form of mushroom poisoning. These mushrooms contain the poison amatoxin that affects primarily the liver and leads to disturbances in gastrointestinal and renal function, seizures, coma and death.


Presentation

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]
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]
  • Abstract Intoxication due to eating wild mushrooms presents with a variety of signs, ranging from mild diarrhea to severe organ failure.[ncbi.nlm.nih.gov]
  • 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 following findings emerged: vomiting (76%), diarrhea (62%), hepatic failure (24%), and renal failure (11%). Two patients died on the fifth day after mushroom ingestion.[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]
Vomiting
  • 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 gastrointestinal phase (starts 6–40 hours after consumption) is characterised by vomiting and diarrhoea and lasts 12–24 hours.[gut.bmj.com]
  • The following findings emerged: vomiting (76%), diarrhea (62%), hepatic failure (24%), and renal failure (11%). Two patients died on the fifth day after mushroom ingestion.[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]
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]
  • All persons who consumed the mushrooms developed nausea, vomiting, and diarrhea approximately 9 hours after ingestion.[cdc.gov]
  • Methods Case Four women, living together in a convent, were admitted because of nausea, vomiting and diarrhoea. Symptoms started approximately 10 hours after eating wild mushrooms, self-picked in the forest.[gut.bmj.com]
  • 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]
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]
  • Within 6 to 12 hours after eating the mushrooms, violent abdominal pain, vomiting, and bloody diarrhea appear, causing rapid loss of fluid from the tissues and intense thirst.[britannica.com]
  • 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]
  • 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]
  • […] 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]
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]
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]
  • 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]
  • 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]
  • .  Delayed symptom category – After 24 hours • Jaundice, hypoglycemia, MODS followed by death. 12. Other symptoms : • Diarrhea, • Fever, • Headache, • Weakness, • Drowsiness, • Dizziness, sweating, • Confusion, and hallucination. 13.[slideshare.net]
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]
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]
  • Other symptoms : • Diarrhea, • Fever, • Headache, • Weakness, • Drowsiness, • Dizziness, sweating, • Confusion, and hallucination. 13.[slideshare.net]
  • 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]
  • The ingestion of A. muscaria (fly agaric), which contains muscarine and other toxic alkaloids, is soon followed by nausea, vomiting, diarrhea, excessive salivation, perspiration, watering of the eyes, slowed and difficult breathing, dilated pupils, confusion[britannica.com]
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]
  • 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]

Workup

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].

Liver Biopsy
  • In the remaining patients, there was no normalization of transaminase values and liver biopsy specimens showed a picture of chronic active hepatitis.[ncbi.nlm.nih.gov]

Treatment

  • RESULTS: Six patients, with mean age of 46 years (range: 9-70 years), underwent one to three ECAD treatments. The mean time from mushroom ingestion until the first ECAD treatment was 76 h.[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]
  • All 16 patients who did not meet King's College Criteria and received conservative treatment survived.[ncbi.nlm.nih.gov]
  • Successful treatment of patients with fulminant liver failure and hepatic coma caused by Amanita phalloides poisoning is possible using urgent orthotopic liver transplantation when conservative medical treatment modalities are ineffective.[ncbi.nlm.nih.gov]
  • However, there is no standard treatment strategy and no antidote against the ensuing hepatic failure.[ncbi.nlm.nih.gov]

Prognosis

  • 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]

Epidemiology

  • 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]
Sex distribution
Age distribution

Pathophysiology

  • 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]

Prevention

  • This review of 14 investigations published over the last 20 years shows that the introduction of detoxification techniques, in particular the use of plasmapheresis, in combination with supportive therapy to prevent the absorption of aminitine toxins into[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • Certainly, silibinin didn’t prevent the sickest patients from dying: all patient who died — but none of the survivors — had lactate levels 10 mmol/L.[thepoisonreview.com]
  • 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]

References

Article

  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.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-21 20:02