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]

  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 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]

  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]

  This phase is characterized by nausea, vomiting, crampy abdominal pain, and severe secretory diarrhea. Both diarrhea and emesis may become grossly bloody. [hindawi.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]

  This phase is characterized by nausea, vomiting, crampy abdominal pain, and severe secretory diarrhea. Both diarrhea and emesis may become grossly bloody. [hindawi.com]

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

• 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]

• 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]

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

• 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]

• 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]

• 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]

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

  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]

  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]

  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]

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.