Mushroom Poisoning
Anthony Tzannes
Mushroom Poisoning
Anthony Tzannes
It seemed like a Good
Idea at the Time...
What is Important?
Phone a friend
Common presentations
Amanita phalloides
Diagnosis
Management
Presentations
Often eat multiple mushrooms
GI Sx most common - usually within 2-3/24
Toxin not clear
Kids vs Adults
“Magic...
Key Questions
Number mushrooms ingested by how many
people?
Time since ingestion
Time onset GI Sx + period of Sx
Location ...
Amanita phalloides
Very similar to safe
mushrooms
High risk populations...
Clinical Features
Delayed GI toxicity (6-24/24) with severe
fluid losses from Cholera-like diarrhoea
Hepatorenal toxicity ...
Toxinokinetics
Amatoxins - particularly alpha-amatoxin
H2O insoluble, heat stable - not safe post parboiling
Absorbed from...
Treatment
Fluids for GI Sx
Important Questions
Ongoing Fluids/BSL control
Screening + Specific
Charcoal
MDAC +/- Plasmaphe...
Silibinin
Loading: 5mg/kg iv over 1/24
Infusion 20mg/kg/day for 3/7
Blocks hepatocyte uptake of amatoxin
OATP 1B3 + Na Tau...
Penicillin
1 000 000u/kg/day
Blocks amatoxin uptake
OATP 1B3
May decrease effectiveness
of Silibinin...
(Ceftazidime 4.5g ...
NAC
Same dosing as for paracetamol
150mg/kg load (15-60 min)
50mg/kg over 4/24
100mg/kg over 16/24 then repeat...
Glutathi...
What doesn’t work
Fab - increased renal toxicity
Dialysis/Charcoal Haemoperfusion
- doesn’t clear the toxin effectively
Th...
Six Point Plan
Call a friend
Charcoal
Good supportive care
Silybinin +/- Penicillin
NAC
Stop the boats
References
1. Faulstich H, Kirchner K, Derenzini M. Strongly enhanced toxicity of the mushroom
toxin alpha-amanitin by an ...
BCC4 Tzannes - Seemed like a good idea at the time: Mushroom Poisoning
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BCC4 Tzannes - Seemed like a good idea at the time: Mushroom Poisoning

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Anthony Tzannes talks mushroom poisoning at BCC4.
For the audio and more great talks, head over to www.intensivecarenetwork.com,

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  • Kids - more likely to partially sample single mushrooms, less likely to eat a significant amount
    Magic Mushrooms - Psilocybin
  • 1 Mushroom potentially deadly
    3 mushrooms mortality ~ 80%
  • 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 > 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

    1. 1. Mushroom Poisoning Anthony Tzannes
    2. 2. Mushroom Poisoning Anthony Tzannes
    3. 3. It seemed like a Good Idea at the Time...
    4. 4. What is Important? Phone a friend Common presentations Amanita phalloides Diagnosis Management
    5. 5. Presentations Often eat multiple mushrooms GI Sx most common - usually within 2-3/24 Toxin not clear Kids vs Adults “Magic Mushrooms”
    6. 6. Key Questions Number mushrooms ingested by how many people? Time since ingestion Time onset GI Sx + period of Sx Location (Canberra/SA/Vic) ?Near Oak trees Risk for simple gastroenteritis
    7. 7. Amanita phalloides Very similar to safe mushrooms High risk populations...
    8. 8. Clinical Features 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
    9. 9. Toxinokinetics 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
    10. 10. Treatment Fluids for GI Sx Important Questions Ongoing Fluids/BSL control Screening + Specific Charcoal MDAC +/- Plasmapheresis Start within 24/24 (if possible) Transplant after 4/7 Resus R S I D E A D
    11. 11. Silibinin 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 available approx 10g/day NB: Side Fx Diarrhoea + +
    12. 12. Penicillin 1 000 000u/kg/day Blocks amatoxin uptake OATP 1B3 May decrease effectiveness of Silibinin... (Ceftazidime 4.5g q2h)
    13. 13. NAC Same dosing as for paracetamol 150mg/kg load (15-60 min) 50mg/kg over 4/24 100mg/kg over 16/24 then repeat... Glutathione magic...
    14. 14. What doesn’t work Fab - increased renal toxicity Dialysis/Charcoal Haemoperfusion - doesn’t clear the toxin effectively Thioctic Acid - no benefit
    15. 15. Six Point Plan Call a friend Charcoal Good supportive care Silybinin +/- Penicillin NAC Stop the boats
    16. 16. References 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. 1988;26(5):491-9. 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, Aug 1976 5. Murray L, Daly FFS, Little M, and Cadogan M. Toxicology Handbook (2nd edition), Elsevier Australia 2011 UptoDate: 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 http://www.mykoweb.com/TFWNA/P-17.html
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