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M&p poisoning
 

M&p poisoning

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Poisonous factors in both Mushroom & Potato,etiology,presentation,treatment ,

Poisonous factors in both Mushroom & Potato,etiology,presentation,treatment ,

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    M&p poisoning M&p poisoning Presentation Transcript

    • M&P poisoningM&P poisoningProf. Dr. Saad S Al AniSenior Pediatric ConsultantHead of Pediatric departmentKhorfakkan HospitalSharjah ,UAEsaadsalani@yahoo.com
    • 2MushroomMushroom PoisoningPoisoning06/19/13M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
    • MushroomMushroom PoisoningPoisoning• Mushrooms are a great source of nutrition• They are:- Low in calories- Fat free- High in proteinMaking them an ideal food except for thefact that some are highly toxic if ingestedM&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13 3
    • Cont.Cont.• The clinical syndromes produced bymushroom poisoning are dividedaccordingto the:- Rapidity of onset of symptoms- Predominant system involved.•The symptoms are due to the principal toxinpresent in the ingested mushroomsM&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital406/19/13
    • Cont.Cont.• The eight major toxins produced by mushroomsare categorized as:1. Cyclopeptides2. Monomethylhydrazine3. Muscarine4. Hallucinogenic indoles5. Isoxazole6. Coprine (disulfiram-like reaction)7. Orellanine8. Gastrointestinal tract–specific irritantsM&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital506/19/13
    • Cont.Cont.• The wild mushroom:-Tricholoma equestre has been associatedwith delayed rhabdomyolysis-Clitocybe amoenolens and Clitocybeacromelalgia have been reported tocauseerythromelalgia.• The toxins responsible for these effectsare unknown.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital606/19/13
    • Gastrointestinal: Delayed OnsetAmanita Poisoning•Poisonings by species of Amanita andGalerina account for 95% of the fatalitiesdue to mushroom intoxication•The mortality rate for this group is 5-10%.•Cells with high turnover rates, such as thosein the gastrointestinal mucosa, kidneys, andliver, are the most severely affected.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital706/19/13
    • • Most species produce two classes ofcyclopeptide toxins:(1)Phallotoxins, which are heptapeptidesbelieved to be responsible for the earlysymptoms of Amanita poisoning(2) Amanitotoxin, an octapeptide thatinhibits RNA polymerase and subsequentproduction of messenger RNA.Cyclopeptide toxinsM&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital806/19/13
    • PathogenesisAmanita poisoning causes:• Cellular necrosis which may occurthroughout the gastrointestinal tract,the most heavily exposed site.• Acute yellow atrophy of the liver• Necrosis of the proximal renal tubulesare found in lethal cases.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital906/19/13
    • The clinical course of poisoning• The clinical course of poisoning withAmanita or Galerina species is biphasic.• Nausea, vomiting, and severe abdominalpain ensue 6-24 hr after ingestion.• Profuse watery diarrhea follows shortlythereafter and may last for 12-24 hr.• During this time, as much as 9 L of fluidmay be lost.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1006/19/13
    • Cont.• From 24-48 hr after poisoning, jaundice,hypertransaminasemia (peaking at 72 to96 h), renal failure, and coma occur.• Death occurs 4-7 days after the ingestion.• A prothrombin time less than 10% ofcontrol is a poor prognostic factor.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1106/19/13
    • Treatment•Treatment for Amanita poisoning is bothsupportive and specific.•Fluid loss from severe diarrhea during theearly course of the illness is profound,requiring aggressive therapy for correctionof this loss.• In the late phase of the disease, managementof renal and hepatic failure is also necessary.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1206/19/13
    • Cont.• Specific therapy for Amanita poisoningis designed to remove the toxin rapidlyand to block binding at its target site.• Oral activated charcoal and lactulosecombined with fluid and electrolytereplacement are recommended as partof the initial treatment for children withAmanita poisoning.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1306/19/13
    • Cont.• Forced diuresis should be avoided,since this increases renal exposure.• Intravenous penicillin G (400,000 U/kg/24 hr) administered as a continuousinfusion• Silybin dihemisuccinate, the water-solubleisomer of the flavolignone silymarin (in anintravenous dosage of 20-50 mg/kg/24 hrM&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1406/19/13
    • Cont.• Silybin dihemisuccinate, act synergisticallyto:1.Inhibit binding of both toxins2.Interrupt enterohepatic recirculation ofamanitotoxin,3.Protect from further hepatic injury fromthe toxins. .M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1506/19/13
    • Monomethylhydrazine Intoxication• Species of Gyromitra contain mono-methylhydrazine (CH3NHNH2), whichinhibits central nervous system (CNS)enzymatic production of γ-aminobutyricacid (GABA).• Monomethylhydrazine also oxidizesironin hemoglobin, resulting in methemo-globinemia.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1606/19/13
    • Cont.•Children with Gyromitra poisoningexperience:vomiting, diarrhea, hematocheziaand abdominal pain within 6-24 hrof ingestion of the toxin.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1706/19/13
    • Cont.• Symptoms of CNS depression andseizures develop later in the clinicalcourse.•Hemolysis and methemoglobinemiaare potential life-threateningcomplications of monomethylhydrazinepoisoning.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1806/19/13
    • Treatment•Hypovolemia due to gastrointestinal fluidlosses and seizures requires supportiveintervention.•Pyridoxal phosphate, the coenzyme thatcatalyzes the production of GABA, canreverse the effects of monomethylhydrazinewhen administered in high doses.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital1906/19/13
    • Cont.• Pyridoxine hydrochloride (25 mg/kg) isadministered intravenously at afrequencydependent on clinical improvement.• Parenteral administration of methyleneblue is indicated if the methemoglobinconcentration exceeds 30%;M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital2006/19/13
    • Cont.• Severe methemoglobinemia may requiredialysis.•Blood transfusions may be required forsignificant hemolysisM&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital2106/19/13
    • Renal: Delayed OnsetOrellanine Poisoning•Species of Cortinarius contain the heat-stable toxin bipyridyl orellanine, whichcauses severe non-glomerular renal injurycharacterized by interstitial fibrosis andacute tubular necrosis.22M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital06/19/13
    • •The exact mechanism of injury is unknown.• Cortinarius poisoning is characterized by:nausea, vomiting, and diarrheaThat manifest 36-48 hr after ingestion.Orellanine Poisoning (Cont.)23M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Orellanine Poisoning (Cont.)• Although the initial symptoms may betrivial, more serious renal toxicityoccurs in several days.• Acute renal failure occurs in 30-50%of those affected, beginning withpolyuria and progressing to renalfailure24M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Treatment• Treatment for orellanine poisoning issupportive.• Early presentation, within 4-6 hr afteringestion, can be treated with activatedcharcoal and gastric lavage25M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Treatment (Cont.)• Hemodialysis may be needed inpatientssuffering from renal failure.• Most patients recover within 1 mo butchronic renal insufficiency develops inone third to one half of patients26M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Autonomic Nervous System: Rapid OnsetMuscarine Poisoning•Mushrooms of the genera Inocybe and, to alesser degree, Clitocybe contain muscarineor muscarine-related compounds.•These quaternary ammonium derivativesbind to postsynaptic receptors, producingan exaggerated cholinergic response.27M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Cont.• The onset of symptoms is rapid (30min to 2 hr after consumption) andthedisease spectrum is characterized bythe following:-Hypercholinergic responsediaphoresis- Excessive lacrimation- Salivation and vomiting- Miosis- Urinary and fecal incontinence 28M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Cont.• Respiratory distress caused by broncho-spasm and increased bronchopulmonarysecretions is the most serious complication•The symptoms subside spontaneously within6-24 hr.29M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Treatment•Atropine sulfate, the specific antidote, isadministered intravenously (0.01 mg/kg; max 2 mg).•This is repeated until the pulmonarysymptoms resolve or the patient becomesovertly tachycardic30M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Coprine Ingestion• Coprinus atramentarius and Clitocybeclavipes contain coprine.•Like disulfiram ,coprine inhibits themetabolism of acetaldehyde after ethanolingestion.• The clinical manifestations result fromaccumulation of acetaldehyde.31M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Cont.• Coprine intoxication becomes apparentafter ethanol ingestion and may occurup to 5 days after consumption of themushroom.•Hyperemia of the face and trunk, tinglingof the hands, metallic taste, tachycardia,and vomiting occur acutely.•Hypotension may result from intenseperipheral vasodilation.32M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Cont.• The syndrome typically is self-limitedand lasts only several hours.• No specific antidote is available.• If hypotension is severe, vascularreexpansion with isotonic parenteralsolutions may be required.• Small oral doses of propranolol havealso been suggested.33M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Central Nervous System: Rapid OnsetIsoxazole Intoxication•Although Amanita muscaria and Amanitapantherina may contain muscarine, thetoxins responsible for the CNS symptomsafteringestion of these mushrooms are muscimoland ibotenic acid, the heat-stable derivativesof the isoxazoles.•Muscimol, a hallucinogen, and ibotenicacid, an insecticide, have anticholinergiceffects. 34M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Cont.• From 30 min to 3 hr after ingestion, CNSsymptoms appear: obtundation, alternatinglethargy and agitation, and, occasionally,seizures.•Nausea and vomiting are uncommon.• If large amounts of muscarine are containedin the mushroom, symptoms of cholinergiccrisis also may occur.35M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Cont.• Specific therapy must be carefullyselected• If an exaggerated cholinergic response isobserved, atropine should be administered.• Because ingestions of A. muscaria oftenare associated with anticholinergic findingsthe acetylcholinesterase inhibitorphysostigmine is often used to reverse thedelirium and coma.36M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Cont.• Benzodiazepines also are used for theagitation and delirium.• Seizures can be controlled with diazepam•In most cases, however, early treatmentwith ipecac (if the patient is conscious)and close observation are all that isrequired.37M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Indole Intoxication• Mushrooms belonging to the genusPsilocybe (“magic mushrooms”) containpsilocybin and psilocin, two psychotropiccompounds.• Within 30 min after ingestion, patientsexperience euphoria and hallucinations, oftenaccompanied by tachycardia and mydriasis.38M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Cont.• Fever and seizures have also been observedin children with psilocybin poisoning.• These symptoms are short-lived, usuallylasting for 6 hr after consumption of themushroom.•Severely agitated patients may show responseto diazepam.39M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Gastrointestinal: Rapid Onset• Many mushrooms from various generaproduce local gastrointestinalmanifestations.•The causative toxins are diverse andlargely unknown.• Within 1 h of ingestion, patientsexperience acute abdominal pain,nausea, vomiting, and diarrhea.•Symptoms may last from hours to daysdepending on the species of mushroom40M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • Treatment• Treatment is mainly supportive.• Children with large fluid losses mayrequire parenteral fluid therapy.• It is imperative to differentiate ingestion ofmushrooms of this class from ingestionof Amanita and Galerina species containingcyclopeptide toxins.41M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13
    • 42PotatoPotato PoisoningPoisoning06/19/13M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
    • Potato Poisoning• Solanine is a mixture of several relatedtoxins found in greened and sproutedpotatoes.•Potatoes exposed to light and allowed tosprout produce a number of alkaloidglycosides containing the cholesterolderivative solanidine.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13 43
    • Solanine Poisoning• Two of these glycosides, α- solanine andα- chaconine, are found in highest concentrationin the peels of greened potatoes and in thesprouts.•Some solanine can be removed by boiling butnot by baking.M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital 06/19/13 44
    • Solanine Poisoning•The major effect of α-solanine andα- chaconine is inhibition of cholinesterase•Cardiotoxic and teratogenic effects havealso been reported.4506/19/13M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
    • Clinical manifestations of solanine and chaconine poisoning•Intoxication occur within 7-19 hr afteringestion.•The most common symptoms are:vomiting, abdominal pain, and diarrhea• In more severe instances of poisoningneurologic symptoms, including:drowsiness, apathy, confusion, weakness,and vision disturbances, are rarelyfollowedby coma or death.06/19/13 46M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
    • Treatment of solanine poisoning• Is largely supportive.• In the most severe cases, symptoms resolvewithin 11 days.•Atropine treatment has not been evaluated.06/19/13 47M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
    • References• Bedry R, Baudrimont I, Deffieux G, et al:Brief report: wild mushroom intoxication as a cause of rhabdomyolysis.N Engl J Med 2001; 345:798-804.•Diaz JH:Syndromic diagnosis and management of confirmed mushroom poisonings.Crit Care Med 2005; 33:427-436.•Berger KJ, Guss DA: Mycotoxins revisited: part II. J EmergMed 2005; 28:175-183•Korpan YI, Nazarenko EA, Skryshevskaya IV, et al: Potatoglycoalkaloids: true safety or false sense of security?. TrendsBiotechnol 2004; 22:147-151.•Ruprich J, Rehurkova I, Boon PE, et al: Probabilistic modelling ofexposure doses and implications for health risk characterization:glycoalkaloids from potatoes. Food Chem Toxicol 2009; 47:2899-2905.•http://www.crazyaboutmushrooms.com/mushroom_poisoning.html06/19/13 48M&P Poisoning Prof. Dr. Saad S Al Ani Khorfakkan Hospital
    • Thank You