brief review of mushroom poisoning

1. “What is edible & what is not?”
A glance at Mushroom Poisoning
Dr. Shatdal Chaudhary MD
Assistant Professor
Department of Internal Medicine
B.P. Koirala Institute of Health Sciences, Dharan
shatdalchaudhary@yahoo.com

2. • Historical aspects
• Magnitude of problem
• How are Mushroom Poisonings classified clinically?
• What is the specific management strategy for each
group?
• Identification of mushroom species & “What is edible
& what is not?”
Outline

3. Mesoamerican History :
• Over 400 religious mushroom stones have
been found in Mayan excavations.

4. Roman History :
• Claudius (AD 54) marries his niece Agrippina
who serves him Amanita Phaloides, Nero
ascends to the throne.*
*De Impertoribus Romanis An Online Encyclopedia of Roman Emperor

5. Roman History:
• Pope Clement VII
excommunicates Henry
VIII.
• Pope was fed Amanita
Phaloides and died

6. Russian History :
• The Siberians of the 14-
15th Century collected
Amanita Muscaria as the
intoxicant of choice until
Vodka was invented in
the 16th Century.
• Tsar Alexis and his wife
(parents of Peter the
Great) ate Amanita
Phalloides and died on
January 25, 1694. Peter
ascended to the throne
and changed the course
of history.

7. Chinese History :
• The Chinese have used Ganoderma
species (polypore mushroom) for food
and medicine for 5000 years

8. Magnitude of problem
• Accidental mushroom poisoning are
constantly seen all over world.
• American Association of Poison Control
Centers = 10000 cases/year
• Incidence: In USA 5 /100,000 population
per year.

9. • Even in USA 95% cases exact species were
unidentified.
• Amanita and Boletus species were
responsible for fatality
• Although over 5000 varieties of mushrooms
are present, only a 100 are toxic and only 32
have been associated with fatalities.

10. • Utility values of Nepalese mushrooms tabulated by
Adhikari et al (2000) are 110 as edible, 13 as
medicinal, 45 as toxic and 6 others.
• Out of 110 species of edible mushrooms, 40 species
are sold in local markets every season.
• Unlike European’s pastime of mushroom hunting or
lacto vegetarian's craze for “organic” food, in
developing country like Nepal, either poor man’s
delicacy or hunger often drives people to forage for
wild mushrooms.
Mushrooms in Nepal

11. • Exact magnitude of problem in Nepal is
unknown.
• In Nepal, the mortality had been found to occur
around 15-20 annually (Adhikari, 2004).
• Undocumented and unrecorded mushroom
poisonings are much more common than the
published incidents because so many cases
occur in very remote areas.
Magnitude of problem in Nepal

12. There is a proverb
“Bahun le chyau khaosna swad paos”
Means: if the Brahmines have eaten the
mushrooms, they could have known the actual taste
of mushrooms”.

13. Experience from BPKIHS
• In 2008-9 Seventy cases of Mushroom
poisoning were admitted in various wards.
– Medicine ward: 49 cases (5 expired)
– Paediatric Ward: 21 cases (3 expired)

14. • How are Mushroom Poisonings classified clinically
And What is the specific management strategy for
each group?
• Because mushroom species vary widely in the
toxins they contain and because identifying them
with certainty is difficult, a clinical rather than
taxonomic system of classification is useful.

15. • Eight groups of toxins are identifiable:
1. Cyclopeptide-containing Mushrooms
2. Monomethylhydrazine-containing Mushrooms
3.Muscarine-containing Mushrooms
4. Coprine-containing Mushrooms
5. Ibotenic Acid and Muscimol- containing Mushrooms
6. Psilocybin-containing Mushrooms
7. Gastrointestinal Toxins
8. Orelline & Orellanine- containing Mushrooms

16. Group I - Cyclopeptide-containing Mushroom
• Most difficult to treat.
• 95% of all fatality due to mushroom poisoning
• Species include Amanita phalloides, A verna, A virosa,
Gallerina Autumnalis
• Toxins include amanitins and phallotoxin which inhibit
RNA polymerase II
• Toxin is stable to cooking, pickling, salting and is not
hydrolyzed by digestion

19. Amatoxin Clinical
Effects :
• Delay of 6 to 12 hours before initial symptoms
is common
• Phase 1: Severe Gastroenteritis- profuse
watery diarrhoea, nausea, vomiting, thirst,
• Phase 2: transient improvement in symptoms
– Latent period of web being lasting 1 to 5 days
• Phase 3: Recurrence symptoms, manifested
with hepatic, renal toxicity, seizures, coma
and death

20. Amatoxins -
Treatment :
• Toxin elimination via repeat dose charcoal
• Supportive care with fluids, electrolytes
• Penicillin G may displace amanitin from plasma
binding sites 1 million Unit/kg/d
• Thioctic acid
• Silymarin compete for membrane transport
• Liver Transplant
• Forced diuresis, hemodialysis, plasmapheresis-
– Not useful

21. Group II
Monomethylhydrazine
containing Mushrooms :
• Gyromitra esculenta, G californica
• Brain like appeaance
• Gyromitrin: Chelate with pyridoxal phosphate- disrupt
GABA function
• Clinical Effects: long latent period of 6 to 12 hours
followed by vomiting, watery diarrhea, abdominal
pain, weakness and headache.
• Severe cases notable for jaundice, hyperreflexia,
vertigo, loss of muscle coordination, seizures and
coma
• Recovery in 2 to 6 days

22. Gyromitra esculenta

23. Treatment
• Standard decontamination measures
• For seizures, Pyridoxine at 25mg/kg in 15 to
30 minutes IV.
Group II
Monomethylhydrazine
containing Mushrooms :

24. Group III- Muscarine
containing:
• Clitocybe dealbata, Omphalotus olearius
• Toxin is muscarine which stimulates
postganglion parasympathic fibers
Omphalotus olearius

25. Muscarine Clinical
Effects:
• Onset within 30 to 120 minutes
• Clinical Feature: like OP Poisoning
• Recovery in 6 to 24 hours

26. Muscarine Treatment :
• Standard decontamination methods
• In symptomatic patients
– 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

27. Group IV – Coprine-containing
Mushrooms :
• Coprinus atramentarius “Inky caps”
• 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
– Disulfiram like effect

28. Coprinus atramentarius

29. Coprine Treatment :
• Decontamination
• Symptomatic treatment
– B-blockers or sedatives for anxiety and
tachycardia
• Fluids for hypotension

30. Group V -
Muscimol/Ibotenic Acid-
containing Mushrooms :
• Amanita Muscaria, Amanita Pantherina,
Amanita Gemmata
• Toxin is Ibotenic acid which is metabolized to
Muscimol
• Muscimol is a false neurotransmitter which
stimulates GABA receptors and usually results
in anticholinergic symptoms

31. Amanita gemmata

32. 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

33. 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

34. Group VI - Psilocybin
containing Mushrooms:
• Psilocybe caerulescens, Panaeolus, Gymnopolis
• “Magic mushrooms”
• Toxins are Psilocybin and its metabolite psilocin
• Effects are serotonin and norepinephrine mediated
• Effects like LSD

35. Psilocybe caerulescens

36. Psilocybin Clinical
Effects :
• Onset of symptoms within 30 to 60 minutes,
occasionally as late as 3 hours
• Symptoms include hallucination, impaired
judgement, hyperkinesis, laughter, vertigo,
ataxia, muscle weakness and drowsiness

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

38. Group VII - GI
Irritants :
• Largest group with a diverse type of mushrooms
(little brown mushrooms)
• Chlorophyllum molybdites, Agaricus Xanthodermis,
Russula Emetica
• No specific toxins identified
• Most mushrooms cause more symptoms when eaten
raw
• Onset of symptoms within 30 minutes to 2 hours
after ingestion

39. Chlorophyllum molybdites

40. GI IrritantsTreatment :
• Standard decontamination measures
• Beware of antiemetics and antidiarrheals as
these may have unpredictable interactions
with mushroom toxins

41. Group VIII- Orelline &
Orellanine-containing
Mushrooms :
• Cortinarius species - over 1000 in the US
• Causes severe renal tubular damage resulting
in reduced GFR, decreased absorption of
water/NA/K, proteinuria, glucosuria

42. Cortinarius armillatus

43. Orellanine Clinical
Effects :
• Initial mild gastroenteritis
• Long latent period of 36 hours to 21 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

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

45. • Identification of mushroom species & “What
is edible & what is not?”

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

48. Cap : Shape, Surface and Margins

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

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

51. 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 the partial
remnant of the veil found
around the base of the
stalk

52. 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

53. 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?

54. • Identification of mushroom species?
• What is edible & what is not?

55. Species Identification
• Colorful field guide is helpful.
– David Arora's Mushrooms Demystified, 2nd
edition (1986) .
– Taylor Lockwood's Treasures from the
Kingdom of Fungi
• Web Browsing
– http://www.mushroomfieldguides.com/
– http://americanmushrooms.com
– http://www.mushroomexpert.com/
– http://www.mykoweb.com/
• Online Mycologist
– Los Angeles Mycological Society (LAMS)
identification_request@lamushrooms.org

56. Species Identification
• The toxins can be detected in poisoned
patients from GI fluids, serum, urine, stool,
liver and kidney biopsies using
– High-performance liquid chromatography (HPLC)
– Thin-layer chromatography
– or Radioimmunoassay (RIA).
• Species-specific identification of the major
cooked and fresh poisonous mushrooms in
Japan was performed using a
– Real-time PCR.

57. Ralph's Rule for (relatively) Safe
Mushrooming
• If uncertain of the identity of a species, don't try it..
• Stick with mushrooms you know well and expand
your repertoire slowly
• For a new species, you should be able to find
it via the keys in at least three books.
• When trying a new mushroom always eat a very
small amount of one, and only one mushroom, and
wait 24 hours before eating more. Save some
specimens so they can be identified if trouble
develops.
• Eat only fresh & cooked mushrooms (not old or
moldy)

58. Mushroom hunting is a true sport: The fungi
do have an equal chance to win. If we are
correct in our identification, at very best we
win a tasty side-dish, or an optimally
seasoned main course. On the other hand, if
we are not correct, we win repeated trips to
the head, maybe a trip to the emergency
room, and in the extreme, a trip to the
mortuary .

59. "There are old mushroom hunters, and
there are bold mushroom hunters, but
there are no old, bold mushroom hunters"

60. The End