3Case 122 male student from SAIT presents with severe abdominal pain and profuse non-bloody vomitting. States that he ate a pizza with “shrooms” his friend had put on it approximately 2 hours ago.Looks unwell120, 110/90, 10, 96% RA, 37.9Management planinitial resuscitationidentify mushroom, if possible (toxicologist or mycologist)further care if necessary
4Mushroom Poisoning 5 exposures per 100 000 population most exposures are relatively benignapprox 5% result in moderate poisoningapprox 3 deaths per year
5Mushroom PoisoningPrognosis is dependent on the specific species of mushroomif a specimen is available store at room temp in a bagcan collect vomitus as wellspecies ingested remains unknown in approx 90% of casesamanita species responsible for the majority of fatal ingestionsidentification efforts should be spent identifying this high risk species.
6Mushroom Poisoning Early Onset Late onset cyclopeptides Ibotenic and muscimolcoprineGI toxinpsilocybingyromitrinorellaninemuscarine
7Mushroom Poisoning Early onset symptoms usually develop <4 hours GI symptoms common and usually predominateinclude hallucinogenic mushroomscan last upto 24htreatment is supportivegood outcome is the general rule
8Case 216 girl brought in by EMS. Friends describe a seizure at their house about 1 hours after eating 5 mushrooms. When EMS arrived they witnessed a 30 sec tonic-clonic seizure.O/EGCS 11, drowsy and dehydratedVitals150, 12, 99% RA, 38.6, 130/90Management?
9Mushroom Poisoning Early Onset Ibotenic and coprine muscimol Early onset symptomsCNS effectspsilocybin and ibotenic acid/muscimol groupeg Psilocybe cubenesis (Gold caps)found in Florida, Lousianna and Texas.grow in cow dungstructurally related to LSD and serotoninremain active when dried or cookedEarly OnsetIbotenic andmuscimolcoprineGI toxinpsilocybinmuscarine
10Mushroom Poisoning Early Onset Ibotenic and coprine muscimol Early onset symptomsibotenic acid and muscimoleg amanita muscariastructurally related to GABA and glutamatelethargy, hallucination, seizures and agitiation usually begin within 2hrusually produce anticholinergic not cholinergic symptomsdo not use atropineEarly OnsetIbotenic andmuscimolcoprineGI toxinpsilocybinmuscarine
11Case 328 male river guide. Presents with emesis and diarrhea 3 hrs after sampling ‘edible’ mushrooms from the river bank.O/EVSS, afebrile, not jaundiced.eyes are tearing and he is salivatingno RUQ or abdominal pain.
12Mushroom Poisoning Muscarine containing Early Onset Ibotenic and eg Clitocybe dealbatacholinergic toxidromedoes not cross BBBatropine can be used for severe symptomsEarly OnsetIbotenic andmuscimolcoprineGI toxinpsilocybinmuscarine
13Case 4 Early Onset Ibotenic and coprine muscimol psilocybin GI toxin 30 male chef. Presents with 2 hours of severe nausea and vomitting. He ate mushrooms on a dare 3 hours ago and has been drinking beer since then to get the taste out of his mouth. States he has never felt this sick in his life.Vitals 38.0, 110, 12, 99%, 120/80O/Elooks ill and flushedvomits during examexam within normalEarly OnsetIbotenic andmuscimolcoprineGI toxinpsilocybinmuscarine
14Mushroom Poisoning Coprine-containing mushrooms only cause symptoms with the simultaneous ingestion of ethanola dislfiram-type reaction caused by ADH antagonism
15Case 550 woman, previously healthy. Presents with 10 hours of N/V and abdominal cramping. States that she was on a nature walk with a friend yesterday morning and they sampled some of the mushrooms along the route. Felt well until this am.Vitals , 100/60, 16, 97% RA, 37.0O/Elooks ill and dehydrated, not jaundiced.LabINR 3.4, PTT 80, ALT 3500, Cr 265
16Mushroom Poisoning Early Onset Late onset cyclopeptides Ibotenic and muscimolcoprineGI toxinpsilocybingyromitrinorellaninemuscarine
17Red Flag CasesA 32-year-old man gathered and ate wild mushrooms that he believed were similar to other mushrooms he had previously gathered and eaten. Eight hours later, he developed vomiting and profuse diarrhea; he was admitted to a hospital 19 hours after ingestion.A 30-year-old man used a guidebook to assist in the collection of wild mushrooms. Twelve hours after eating the mushrooms he had gathered, he developed vomiting and severe diarrhea. He was admitted to a hospital 17 hours after ingestion because of orthostatic hypotension and dehydration
18Mushroom Poisoning Late onset cyclopeptides gyromitrin orellanine Late onset symptomsCyclopeptide Mushrooms3 main types of toxins: amatoxins, virotoxins, phallotoxinsamanita phalloides (“Death Cap”) most well known speciescontains amatoxinsresponsible for the vast majority of deathseasily misdiagnosed as gastroenteritispatients may not associate symptoms with mushroom ingestions because of the delayed onsetLate onsetcyclopeptidesgyromitrinorellanine
19Amanita PhalloidesFound primarily in the cool coastal regions of the west coast, but it also grows in several other regions, including the mid-Atlantic coast and in the northeast.Reported ingestions in the pacific Northwest, the Gulf Coast region, and even in suburban New YorkFlourish in favorable weather conditions during the fall or the rainy season.Toxin not destroyed by cooking or drying
20Amanita Phalloides 4 stage disease process Stage 1: incubation phase (upto 12 hrs)Stage 2: GI stage (lasts 12-24h). N/V/D abd cramps, dehydration, fever and hypoglycemiaStage 3: quiescent stageStage 4: hepatocellular and renal damage with coagulopathydeath from A. phalloides poisoning usually results from hepatic and/or renal failure and may occur 4-9 days after ingestion.fatality rate among persons treated for A. phalloides poisoning is 20%-30%.median lethal dose is 0.1 mg to 0.3 mg of the toxin per kg of body weight.
21Amanita Phalloides Investigations and Management CBC, lytes, Cr, BUN, PTT, INR, LFTs, bili?HPLC for the amatoxin in serum and urineTLC of the mushroom itself
22Amanita Phalloides Investigations and Management lavage MDAC (?interrupt enterohepatic circulation)hydration and supportive carecorrection of any coagulopathyempiric vit K and FFPunproven but attempted therapies inclludenon-invasive:high-dose penicillin ( U/Kg/d)dexamethasoneNACinvasive:dialysis (must initiate within first 24hr)transplantation
23Mushroom MythsA mushroom is safe to eat if it does not turn a silver spoon black when boiled together.No deadly mushrooms grow on wood.If an animal eats it, the mushroom is safe.Boiling, drying, and salting will detoxify the mushroom.Poisonous mushrooms will turn rice-water red.Mushrooms are safe; toadstools are poisonous.A mushroom is safe to eat if the cap has been peeled.