10 Patients - 7 were recent immigrants or visitors 8 hepatotoxicity 4 died Natural Selection ... with low P volumes
GI Toxicity - Vomiting with Severe Diarrhoea (like Cholera) The earlier the GI Sx, or the higher the lactate the worse the toxicity
Transported by OATP 1B3 and Na Taurocholate co-transporter Does not appear to cross placenta
Specific Ix: LFTs 18-24/24 post ingestion Meixner Test: conc HCl onto newspaper (contains lignin) - blue colour NB: +ve for psilocybin as well Rx Charcoal - best evidence for reduction in mortality, not specifically stated
In vitro studies using cultured human hepatocytes Systematic review + observational study - less effective if commenced &gt; 24/24 post ingestion
Less effective than Silibinin in vitro studies
Systematic review: mortality 6.8% vs 11.6% average
BCC4 Tzannes - Seemed like a good idea at the time: Mushroom Poisoning
What is Important?
Phone a friend
Often eat multiple mushrooms
GI Sx most common - usually within 2-3/24
Toxin not clear
Kids vs Adults
Number mushrooms ingested by how many
Time since ingestion
Time onset GI Sx + period of Sx
?Near Oak trees
Risk for simple gastroenteritis
Very similar to safe
High risk populations...
Delayed GI toxicity (6-24/24) with severe
fluid losses from Cholera-like diarrhoea
Hepatorenal toxicity from 18-36/24
Often minimal Sx “Honeymoon Period”
Progressive Hepatic Failure from 36-96/24
often with associated hepatorenal
syndrome and pancreatitis
Amatoxins - particularly alpha-amatoxin
H2O insoluble, heat stable - not safe post parboiling
Absorbed from GI tract, transported to Liver
Actively transported into hepatocytes
Binds to RNA polymerase Type II
Halts protein synthesis
Organs with rapid cell turnover - GI, Prox tubules
Fluids for GI Sx
Ongoing Fluids/BSL control
Screening + Specific
MDAC +/- Plasmapheresis
Start within 24/24 (if possible)
Transplant after 4/7
Loading: 5mg/kg iv over 1/24
Infusion 20mg/kg/day for 3/7
Blocks hepatocyte uptake of amatoxin
OATP 1B3 + Na Taurocholate
Can use Silymarin po if Silibinin not
approx 10g/day NB: Side Fx Diarrhoea +
1 000 000u/kg/day
Blocks amatoxin uptake
May decrease effectiveness
(Ceftazidime 4.5g q2h)
Same dosing as for paracetamol
150mg/kg load (15-60 min)
50mg/kg over 4/24
100mg/kg over 16/24 then repeat...
What doesn’t work
Fab - increased renal toxicity
- doesn’t clear the toxin effectively
Thioctic Acid - no benefit
Six Point Plan
Call a friend
Good supportive care
Silybinin +/- Penicillin
Stop the boats
1. Faulstich H, Kirchner K, Derenzini M. Strongly enhanced toxicity of the mushroom
toxin alpha-amanitin by an amatoxin-specific Fab or monoclonal antibody. Toxicon.
2. Diaz JH. Syndromic diagnosis and management of confirmed mushroom poisonings.
Crit Care Med. 2005 Feb;33(2):427-36.
3. Jander S, Bischoff J. Treatment of Amanita phalloides poisoning: I. Retrospective
evaluation of plasmapheresis in 21 patients. Ther Apher. 2000 Aug;4(4):303-7.
4. Becker CE, Tong TG, Boerner U, et al: Diagnosis and treatment of Amanita
phalloides-type mushroom poison- ing-Use of thioctic acid. West J Med 125:100-109,
5. Murray L, Daly FFS, Little M, and Cadogan M. Toxicology Handbook (2nd edition),
Elsevier Australia 2011
1. Amatoxin-containing mushroom poisoning including ingestion of Amanita phalloides
2. Management of mushroom poisoning
3. Clinical manifestations and evaluations of mushroom poisoning
4. Magdalan J, Ostrowska A, Piotrowska A, et al. Benzylpenicillin, acetylcysteine and
silibinin as antidotes in human hepatocytes intoxicated with alpha-amanitin. Exp
Toxicol Pathol 2010; 62:367.
5. Thomas J. Duffy, MD Toxic Fungi of Western North America
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