Mushrooms

Hussein Unwala, Dr. Ingrid Vicas

February 4, 2010

Pretest

Overview of Different Classes

Approach to clinical classification

Management of the unknown mushroom ingestion

Cases

Objectives

Ten are identifiable: ◦ Cyclopeptides◦ Gyromitrin◦ Muscarine◦ Coprine◦ ibotenic acid and muscimol◦ psilocybin◦ general GI irritants◦ Orellinine◦ allenic norleucine◦ Myotoxins

Mushroom Groups

Amanita species, including  A. verna, A. virosa,

and A. phalloides

Galerina spp, including G. autumnalis, G. marginata,and Galerina venenata

Lepiota species, including L. helveola, L. josserandi, and L. brunneoincarnata.

Group I -- Cyclopeptides

Phase 1:◦ Severe gastroenteritis, 5-24 hours post ingestion

Phase 2:◦ Quiescent phase, 12-36 hours post ingestion

Phase 3:◦ Hepatic, renal toxicity, death; 2-5 days post

ingestion◦ Endocrine malfunction - TSH, Ca, Insulin

Cyclopeptides -- Clinical

Activated charcoal 1g/kg q 2-4 hours, antiemetics Correct fluid, electrolyte abnormalities

Forced diuresis and hemodialysis techniques

Penicillin G 1g/kg/day IV, administered 5 days post ingestion

Silibinin 20-50 mg/kg/day◦ May modify cell membrane receptor sites◦ safe◦ Worked in dogs, but . . .

Extracorporeal albumin dialysis as a bridge to liver transplant

Cyclopeptides – Management

Group II - Gyromitra Gyromitrin

Monomethydrazine◦ (Inhibits pyridoxine)

Disrupts GABA

Common : GI toxicity 5-10 hours post ingestion

Rare: ◦ delirium, stupor, convulsions, coma

◦ Hepatorenal syndrome

Gyromitra – Clinical

Activated Charcoal 1g/kg

Benzo’s for seizures◦ Pyrodixine 70mg/kg

Gyromitra -- Management

SLUDGEM/DUMBELLS No central muscarinic effects Usually mild effects, develop 0.5-2hrs post Atropine rarely needed

Group III -- Muscarine

Group IV -- Coprine Disulfuram effect, inhibiting acetaldehyde

dehydrogenase for up to 48-72 hours EtOH Alcohol DehydrogenaseAcetaldehyde Acetaldehyde DehydrogenaseAcetic Acid

tachycardia, flushing, nausea, and vomiting Fomepizole theoretic benefit

Group V – Ibotenic Acid/Muscimol GABAergic in adults,

◦ Somnolence, hallucinations, dysphoria, delerium Glumatamatergic in kids

◦ Myoclonic movements, seizures Onset 0.5-2hrs Benzo prn

http://www.youtube.com/watch?v=MkCS9ePWuLU

Aka magic mushrooms Toxicity common Thought to act at 5-HT2 receptors Rapidly (within 1 hour) : ataxia,

hyperkinesis, visual hallucinations, and illusions.

Rare : renal failure, seizures, cardiopulmonary arrest

Benzo prn

Group VI-- Psylocybin

Hundreds of mushrooms fall in this group (“Little Brown Mushrooms”)

GI toxicity occurs 0.5-3 hours post ingestion; clinical course is brief (6-24hours)

Rare : hypovolemic shock, immune-mediated hemolytic anemia

Supportive care

Group VII – GI Toxins

Nephrotoxic Symptoms 24-36 hours post ingestion:

headache, chills, flank/abdo pain, polydypsia, anorexia, nausea/vomitting

Oliguric renal failure develops several days to weeks later

Treatment : hemodialysis, renal transplantation.

No evidence suggests plasmapheresis/hemoperfusion is of any benefit in preventing chronic renal failure even when initiated in the first 48 hours.

Group VIII – Orelline/Orellanine

Associated with ingestion of Amanita smithiana

Symptoms noted 30min – 12hours Often GI initially Then ARF 4-6 days later, azotemia

Suggest treat with activated charcoal, early hemodialysis

Group IX Allenic Norleucine

All reported cases in Europe

Tricholoma equestre

All 15 cases led to subsequent death

Group X: Rhabdomyolysis-Associated

The unknown mushroom

Determine whether ingestion was a deadly variety; ie Amatotoxin◦ if outside southwestern Canada, onset of GI

symptoms within 3 hours rules out amatoxin Attempt collection of mushrooms, detailed

description Dry paper bag; gastric contents? Consult a mycologist! If not available, Melzer reagent : 20mL H20, 1.5g KI, 0.5g I, 20g

chloral hydrate. Amatoxin turns dark blue upon contact

Symptoms < 3 h

Muscarine, Coprine, Ibotenic Acid, Psilocybin,

GI Irritants

No tests essential, monitor fluids and electrolyte status

Activated CharcoalIf Hallucinating/seizures, benzos prnIf Hypotension, fluid resuscitation, Dopamine 5-20 mcg/kg/min, then

NEElectrolyte Repletion

Discharge once GI/psychadelic symptoms resolve, volume depletion

corrected

Symptoms > 6 h

Cyclopeptides, Gyromitra

Activated Charcoal initially, then q 4h/continuous

Electrolyte, Glucose Repletion

Penicillin GConsultation with liver transplant specialistMethylene blue for

methemoglobinemia, Blood transfusion if

hemolysisPyridoxine/benzos if

seizuresMycologist if availableELFT’s

If suspecting Gyromitra, check methemoglobin

levels

Symptoms > 24 h

orelline

Assess Renal Function

Activated Charcoal

Electrolyte Repletion

Amanita Smithsiana can present 0.5-12 hours

Mixed Ingestions can present any time

Cases . . .