Presentation on theme: "Hussein Unwala, Dr. Ingrid Vicas February 4, 2010."— Presentation transcript:
Hussein Unwala, Dr. Ingrid Vicas February 4, 2010
Pretest Overview of Different Classes Approach to clinical classification Management of the unknown mushroom ingestion Cases
Ten are identifiable: ◦ Cyclopeptides ◦ Gyromitrin ◦ Muscarine ◦ Coprine ◦ ibotenic acid and muscimol ◦ psilocybin ◦ general GI irritants ◦ Orellinine ◦ allenic norleucine ◦ Myotoxins
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.
Phase 1: ◦ Severe gastroenteritis, 5-24 hours post ingestion Phase 2: ◦ Quiescent phase, hours post ingestion Phase 3: ◦ Hepatic, renal toxicity, death; 2-5 days post ingestion ◦ Endocrine malfunction - TSH, Ca, Insulin
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 mg/kg/day ◦ May modify cell membrane receptor sites ◦ safe ◦ Worked in dogs, but... Extracorporeal albumin dialysis as a bridge to liver transplant
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
Hundreds of mushrooms fall in this group (“Little Brown Mushrooms”) GI toxicity occurs hours post ingestion; clinical course is brief (6-24hours) Rare : hypovolemic shock, immune-mediated hemolytic anemia Supportive care
Nephrotoxic Symptoms 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.
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
All reported cases in Europe Tricholoma equestre All 15 cases led to subsequent death
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 Charcoal If Hallucinating/seizures, benzos prn If Hypotension, fluid resuscitation, Dopamine 5-20 mcg/kg/min, then NE Electrolyte 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 G Consultation with liver transplant specialist Methylene blue for methemoglobinemia, Blood transfusion if hemolysis Pyridoxine/benzos if seizures Mycologist if available ELFT’s If suspecting Gyromitra, check methemoglobin levels Symptoms > 24 h orelline Assess Renal Function Activated Charcoal Electrolyte Repletion Amanita Smithsiana can present hours Mixed Ingestions can present any time