1. Myth, History and Medicine
Mushroom Poisoning
Myth, History and Medicine
John D. Halamka MD

2. Goals How to consult a mycologist
Recognizing the symptoms of mushroom poisoning
Current treatment strategies
Recognizing selected mushroom species

3. Roman History
Claudius (AD 54) marries his niece Agrippina who serves him Amanita Phaloides, Nero ascends to the throne
Pope Clement VII excommunicates Henry VIII. Pope is fed Amanita Phaloides and dies

4. Indo-European History
First written record of mushroom use. Of Hindu Vedas ( BC), 120 mention Amanita Muscaria to visualize the gods and improve spiritual vitality

5. Mesoamerican History
Over 400 religious mushroom stones have been found in Mayan excavations.
Use of Psilocybe species by Chignahuapan Indians first described in Life Magazine in 1957 and inspired the fascination with psychedelics in the 1960’s

6. Japanese History
Japanese were first to agriculturally propagate fungi. Lentinus edodes (Shitake) was domesticated in 100 BC
Haiku - “I forgot falling off a horse with the happiness of finding Mushrooms” Anon BC

7. Chinese History
The Chinese have used Ganoderma species (polypore mushroom) for food and medicine for years

8. Russian History
The Siberians of the th Century collected Amanita Muscaria as the intoxicant of choice until Vodka was invented in the 16th Century. Siberian peasants also invented mushroom “recycling”

9. Russian History
Tsar Alexis and his wife (parents of Peter the Great) ate Amanita Phalloides and died on January 25, Peter ascended to the throne and changed the course of history.

10. European History
German Emperor Charles VI was fatally poisoned by Amanita Phalloides
Mushroom propagation was invented in the Western world by Louis XIV’s agronomists in the 17th Century

11. English History
Sir Arthur Conan Doyle wrote “the fields were spotted with monstrous fungi of a size and color never matched before- sarlet and mauve and black- it was as though the sick earth has burst into foul pustules.”

12. English History
Emily Dickinson wrote “Had nature any outcast face, could she a son condemn, had nature an Iscariot, the mushroom - it is him.”

13. The New American Attitude
The Boonville Times reports “Deputy Mason responded to reports of a woman screaming near the Branscomb Road turnoff. The distressed woman turned out to be a mushroom hunter, screaming with delight at each new find.”

14. Mushroom cuisine
Soak one dozen morels in 3/4 cup cream and a tablespoon of dry sherry. Saute a shallot, a clove of garlic and 1/2 cup chopped pecans. Mix in 4oz goat cheese, fresh nutmeg and stuff the morels. Serve over paste

15. Typical Mushroom Hunter
Eastern European expert taught by oral tradition who gathers mushrooms to eat
Harvard scientist interested in the ethnobotany of fungi
Tie-dye shirt wearer asking “Do those mushrooms grow around here...”

16. There is no such thing as a Toad Stool

17. General Morphology
Mushrooms are described by Size, color, color changes, texture, order, taste, gap, gills, stem/stipe, veil, annulus, volva, mycelium, and spore prints

19. Cap
Cap descriptions include viscid (sticky), glutinous (slimy), dry, smooth, scaly, fibrillose or warty
Cap margins may be inrolled, incurved, straight, uplifted or striate

20. Gills
Gills are described by the attachment pattern to the stalk and by spacing, thickness, depth and forking pattern

21. Stem/Stipe
Stipe features include size, color, color changes, shape, position, structure, and surface characteristics

22. Veils and Volva
A veil is residual tissue from mushroom development that is left on the stalk and varies from a few remnants to a complete annulus
A volva is a sack that is found at the base of the stalk

23. Spore Prints
Spore prints are a very powerful way to identify species of mushrooms. They are created by leaving a mushroom on top of a piece of paper for 2-6 hours

24. Consulting a Mycologist
How many people ate the mushroom?
What are their ages and genders?
What was the time from ingestion to symptoms?
Did all the individuals get sick?
Was alcohol consumed?
Were the mushrooms cooked or raw?
Were the mushrooms in good condition?

25. Habitat Questions Where were the mushrooms growing?
Were they in a yard, lawn or wild area?
Had pesticides or herbicides been applied?
If trees were nearby, what were they?
Was the mushroom growing on wood, ground or other material?
If wood, was the wood living or dead?

26. Cap Questions How big is the cap? What is the cap color?
Is it smooth, scaly, hairy or sticky?
What is the shape of the cap?
How thick is the cap?
Does the cap change color when it is cut?
What is the total height of the mushroom?

27. Stem Questions What is the thickness of the step?
Is it curved or straight?
Is there a ring or veil?
Is there any material at the base of the stem?
Is the surface smooth, scaly or hairy?
Is it hollow?
Does the color change when exposed to air?

28. Gill Questions Are there gills on the underside of the cap?
What is the color of the gills?
Are they attached to the stem?
Is there a fine powder on the gills and if so, what color?
If no gills are present, what is the color and texture of the underside of the cap?

29. Group 1 - Amatoxins
Most difficult to treat. 90% of all deaths due to mushroom poisoning
Species include Amanita Phalloides, Amanita Ocreata, Gallerina Autumnalis
Toxin is stable to cooking, pickling, salting and is not hydrolyzed by digestion
Toxins include amanitins and phallotoxin which inhibit RNA polymerase II
Toxins are resorbed by the distal tubule

30. Amatoxin Clinical Effects
Delay of 6 to 12 hours before initial symptoms is common
Sudden onset of sharp, colicky abdominal pain, nausea, vomiting, thirst, bloody stools
Latent period of web being lasting 3 to 5 days
Recurrence of abdominal pain with jaundice, renal shutdown, seizures, coma and death

31. Amatoxins - Treatment Toxin elimination via repeat dose charcoal
Supportive care with fluids, electrolytes
Penicillin G may displace amanitin from plasma binding sites 300k-1000k u/kg/d
Silymarin (from milk thistle) may compete for membrane transport
Liver Transplant

32. Amanita Phalloides

33. Amanita Ocreata

34. Group 1A - Orellanine Cortinarius species - over 1000 in the US
Causes severe renal tubular damage resulting in reduced GFR, decreased absorption of water/NA/K, proteinuria, glucosuria
Inhibits RNA and DNA synthesis in kidney cells

35. Orellanine Clinical Effects
Initial mild gastroenteritis
Long latent period of 36 hours to 17 days
Symptoms include severe thirst, abdominal or flank pain, chills and fever
Progresses to acute renal failure. Chronic failure occurs in 50% of cases
Recovery takes weeks to months

36. Orellanine Treatment Standard decontamination Hemodialysis
Renal transplant
Steroids, hemoperfusion, and forced diuresis do not improve outcome

37. Group II - Muscimol/Ibotenic Acid
Amanita Muscaria, Amanita Pantherina, Amanita Gemmata
Toxin is Ibotenic acid which is metabolized to Muscimol
Muscimol is a false neurotransmitter which acts on GABA receptors and affects brain levels of serotinin, dopamine and noradrenalin. Usually results in anticholinergic symptoms
May present with cholinergic symptoms

38. Muscimol/Ibotenic Acid Clinical Effects
Onset within 30 to 90 minutes, most marked at 2 to 3 hours
Drowsiness, confusion resembling alcohol intoxication, dizziness, ataxia, euphoria, muscle cramps and spasms, delirium, visual disturbances, hallucinations
Vomiting is rare
Deep sleep or coma terminates the episode which usually lasts from 4 to 8 hours

39. Musicmol/Ibotenic Acid Treatment
Standard decontamination measures
Support airway and hemodynamics with standard measures
With life threatening anticholinergic signs, consider physostigmine .5 to 2 mg slow IVP over 5 minutes
With life threatening cholinergic signs consider atropine

40. Amanita Muscaria

41. Amanita Pantherina

42. Group III - Monomethylhydrazine
Gyromitra and Helvella
Toxin is Gyrometrin which is hydrolyzed to MMH at 87.5 C and only affects the person cooking the mushroom
Toxin chelates pyridoxal phosphate and inhibits reactions where B6 is a cofactor

43. Monomethylhydrazine Clinical Effecs
Relatively long latent period of 6 to 12 hours followed by vomiting, watery diarrhea, abdominal pain, weakness and headache.
Severe cases notable for jaundice, tachycardia, hyperreflexia, vertigo, loss of muscle coordination, seizures and coma
Recovery in 2 to 6 days

44. Monomethylhydrazine Treatment
Standard decontamination measures
For seizures, give B6 at 25mg/kg over 15 to 30 minutes IVP.
For methemoglobin levels which are greater than 30% or patients who present with symptomatic hypoxia, give methylene blue 1% solution ml/kg IV over 5 minutes IVP

45. Group IV - Muscarine Clitocybe, Omphalotus
Toxin is muscarine which stimulates postganglion parasympathic fibers
Muscarine is very slowly hydrolyzed by acetylcholinesterase

46. Muscarine Clinical Effects
Onset within 30 to 120 minutes
Excessive perspiration, salivation, lacrimation (PSL symptoms), bradycardia, miosis, blurred vision, increased peristalsis, abdominal pain, and watery stools
Severe cases notable for hypotension, bronchorrhea and wheezing
Recovery in 6 to 24 hours

47. Muscarine Treatment Standard decontamination methods
In severely symptomatic presentations consider atropine 1mg to 2mg for adults and children
0 to 2 years .2 mg
3 to 4 years .3 mg
5 to 10 years .4mg

48. Group V - Coprine Coprinus atramentarius
Toxin is coprine, the metabolite of which inhibits aldehyde dehydrogenase
Ingestion is asymptomatic unless ethanol is consumed in the following 2 hours to 5 days

49. Coprine Clinical Effects
Onset of symptoms within 20 minutes to 2 hours after ingestion of alcohol
Symptoms include flushing of the face and neck, swelling an parathesias in the hands and feet, metallic taste, and tachycardia
Late symptoms include nausea, vomiting and sweating
Severe cases include vertigo, weakness, confusion, hypotension and arrhythmias

50. Coprine Treatment
Decontamination measures if mushroom recently ingested
Symptomatic treatment
B-blockers or sedatives for anxiety and tachycardia
Fluids for hypotension

51. Group VI - Psilocybin Psilocybe, Panaeolus, Gymnopolis
Toxins are Psilocybin and its metabolite psilocin
Effects are serotonin and norepinephrine mediated
Blue staining reaction aids identification

52. Psilocybin Clinical Effects
Onset of symptoms within 30 to 60 minutes, occassionally as late as 3 hours after ingestion of 5 to 15 mg of psyilocybin (10 to 30g fresh weight of mushrooms)
Symptoms include hallucination, impaired judgement, hyperkinesis, laughter, vertigo, ataxia, muscle weakness and drowsiness

53. Psilocybin Treatment
Decontamination not recommended as this may increase agitation
Rest and reassurance in a dark, quiet room
Consider benzodiazepines for severe anxiety

54. Group VII - GI Irritants
Chlorophyllum Molybdites, Agaricus Xanthodermis, Russula Emetica
No specific toxins identified
Most mushrooms cause more symptoms when eaten raw

55. GI Irritants Clinical Effects
Onset of symptoms within 30 minutes to 2 hours after ingestion
Symptoms include nausea, vomiting, diarrhea and abdominal pain
In severe cases electrolyte disturbances may occur

56. GI Irritants Treatment
Standard decontamination measures
Be wary of antiemetics and antidiarrheals as these may have unpredictable interactions with mushroom toxins

57. Epidemoiology
American Association of Poison Control Centers = 9208 cases/year
Group I - Cyclopeptide 61 cases/year
Group III - MMH 57 cases/year
Group VI - Hallucinogens 330 cases/year
Group VII - GI Irritants 202 cases
Minimal effect 10,% moderate 5%, major 1%, death in 3 cases

58. 5 year old Ingestion of red mushroom
Nausea and vomiting within 2 hours
Given charcoal in local Emergency Department
Now appears well

59. Russula Emetica

60. 30 year old male Chardonnay and Shaggy Manes
Nausea/Vomiting 2 hours after dinner
Tachycardia
Hydrated and back to baseline after 6 hours

61. Coprinus Atramentarius

62. 16 year old male Magic mushrooms Unsure of dose Ate one pound
Required sedation and intubation

63. Psilocybe Cubensis

64. Questions