Liver transplantation for severe Amanita phalloides mushroom poisoning

Amanitin intoxication: effects of therapies on clinical outcomes - a review of 40 years of reported cases

BACKGROUND AND AIMS

Amanita phalloides poisoning causes severe liver damage which may be potentially fatal. Several treatments are available, but their effectiveness has not been systematically evaluated. We performed a systematic review to investigate the effect of the most commonly used therapies: N-acetylcysteine (NAC), benzylpenicillin (PEN), and silibinin (SIL) on patient outcomes. In addition, other factors contributing to patient outcomes are identified.

METHODS

We searched MEDLINE and Embase for case series and case reports that described patient outcomes after poisoning with amanitin-containing Amanita mushrooms. We extracted clinical characteristics, treatment details, and outcomes. We used the liver item from the Poisoning Severity Score (PSS) to categorize intoxication severity.

RESULTS

We included 131 publications describing a total of 877 unique cases. The overall survival rate of all patients was 84%. Patients receiving only supportive care had a survival rate of 59%. The use of SIL or PEN was associated with a 90% (OR 6.40 [3.14-13.04]) and 89% (OR 5.24 [2.87-9.56]) survival rate, respectively. NAC/SIL combination therapy was associated with 85% survival rate (OR 3.85 [2.04, 7.25]). NAC/PEN/SIL treatment group had a survival rate of 76% (OR 2.11 [1.25, 3.57]). Due to the limited number of cases, the use of NAC alone could not be evaluated. Additional analyses in 'proven cases' (amanitin detected), 'probable cases' (mushroom identified by mycologist), and 'possible cases' (neither amanitin detected nor mushroom identified) showed comparable results, but the results did not reach statistical significance. Transplantation-free survivors had significantly lower peak values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total serum bilirubin (TSB), and international normalized ratio (INR) compared to liver transplantation survivors and patients with fatal outcomes. Higher peak PSS was associated with increased mortality.

CONCLUSION

Based on data available, no statistical differences could be observed for the effects of NAC, PEN or SIL in proven poisonings with amanitin-containing mushrooms. However, monotherapy with SIL or PEN and combination therapy with NAC/SIL appear to be associated with higher survival rates compared to supportive care alone. AST, ALT, TSB, and INR values are possible predictors of potentially fatal outcomes.

Acute liver failure caused by Amanita verna: a case series and review of the literature

BACKGROUND

Amanita verna is one of the most harmful wild fungi in China. Amanita verna poisoning occurs every year, and the mortality is as high as 50%. However, its clinical manifestations are complex and diverse.

CASE PRESENTATION

In March 2019, three patients took a large amount of Amanita, and one of them received liver transplantation in Zhongshan hospital, Sun Yat-sen University. All patients had vomiting and diarrhea 8-12 h after eating wild mushrooms (Amanita). The patients were initially diagnosed with Amanita poisoning. One case (case 3) was complicated and diagnosed as mushroom poisoning (fatal Amanita), toxic hepatitis, acute liver failure, toxic encephalopathy, hemorrhagic colitis, toxic myocarditis, disseminated intravascular coagulation (DIC) and pregnancy. The general clinical data of all patients were recorded, who received early treatment such as hemodialysis, artificial liver plasma exchange, hormone shock and anti-infection. One case (case 1) recovered smoothly after liver transplantation, and the indexes of liver, kidney, coagulation function and infection were improved. The other two cases died of intracerebral hemorrhage.

CONCLUSION

Liver transplantation is an effective method for the treatment of acute liver failure caused by mushroom poisoning and can improve the survival rate of patients with toxic liver failure.

Using MALDI-ToF mass spectrometry to identify mushroom species: Proof of concept analysis of Amanita genus specimens

Food poisoning caused by toxic mushrooms, such as species in the Amanita genus, occurs frequently around the world. To properly treat these patients, it is important to rapidly and accurately identify the causal species. Matrix-assisted laser desorption/ionization time-of-flight (MALDI-ToF) mass spectrometry is a rapid technique that has been used in medical laboratories for the past three decades to identify bacteria, yeasts, and filamentous fungi.Matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-Tof MS) is a rapid method used for the past three decades to identify microorganisms. In this study, we created and internally validated a MALDI-Tof MS reference database comprising 15 Amanita species frequently encountered in France, and we challenged this database with 38 Amanita specimens from four French locations, using a free online application for MALDI-ToF spectra identifications.Assessment of the database showed that mass spectra can be obtained by analyzing any portion of a carpophore and that all portions enabled identification of the carpophore at the species level. Most carpophores were correctly identified using our database, with the exception of specimens from the Vaginatae section. Decay tests also demonstrated that decayed portions (like those found in the kitchen garbage can) of Amanita phalloides mushrooms could be properly identified using MALDI-ToF MS.Our findings provide important insight for toxicology laboratories that often rely on DNA sequencing to identify meal leftovers implicated in food poisoning. In future developments, this technique could also be used to detect counterfeit mushrooms by including other genera in the reference database.

LAY SUMMARY

MALDI-ToF MS is a powerful identification tool for microorganisms. We demonstrate that the technique can be applied to Amanita specimens. This will prevent food intoxications as a rapid and definite identification can be obtained, and it can also be used for food remnants.

Human Poisoning from Poisonous Higher Fungi: Focus on Analytical Toxicology and Case Reports in Forensic Toxicology

Several families of higher fungi contain mycotoxins that cause serious or even fatal poisoning when consumed by humans. The aim of this review is to inventory, from an analytical point of view, poisoning cases linked with certain significantly toxic mycotoxins: orellanine, α- and β-amanitin, muscarine, ibotenic acid and muscimol, and gyromitrin. Clinicians are calling for the cases to be documented by toxicological analysis. This document is therefore a review of poisoning cases involving these mycotoxins reported in the literature and carries out an inventory of the analytical techniques available for their identification and quantification. It seems indeed that these poisonings are only rarely documented by toxicological analysis, due mainly to a lack of analytical methods in biological matrices. There are many reasons for this issue: the numerous varieties of mushroom involved, mycotoxins with different chemical structures, a lack of knowledge about distribution and metabolism. To sum up, we are faced with (i) obstacles to the documentation and interpretation of fatal (or non-fatal) poisoning cases and (ii) a real need for analytical methods of identifying and quantifying these mycotoxins (and their metabolites) in biological matrices.

Toxicant-Induced Hepatic Injury

The sudden failure of a previously healthy and functioning liver is a dramatic and devastating event. Acute liver failure is the common final pathway of a multitude of conditions and insults, all of which result in massive hepatic necrosis or loss of normal hepatic function. The ensuing multiorgan system failure frequently has a fatal outcome, with mortality rates in most series ranging from approximately 55% to 95% [1]. Acute liver failure (ALF, previously often referred to as fulminant hepatic failure (FHF)) knows no age boundaries, with many cases occurring in those younger than 30 years. Short of excellent intensive care unit (ICU) support and liver transplantation in selected cases, few viable treatment options are available. Over the past few decades, however, survival has been improved by anticipation, recognition, and early treatment of associated complications, as well as the application of prognostic criteria for early identification of patients requiring liver transplantation (along with improvement in the techniques and science of transplantation itself). The etiology of ALF varies from country to country and the incidence change over time. Paracetamol (acetaminophen) has now replaced viral hepatitis as the leading cause of ALF [2]. In a study from London including 310 patients with ALF in the period 1994–2004, 42% of the cases were caused by paracetamol [3], whereas this was only the cause in 2% of 267 patients in Spain from 1992 to 2000 [4]. However, less than 10% of all liver transplants are performed in patients with ALF [5, 6].

Acute liver injury and acute liver failure from mushroom poisoning in North America

BACKGROUND & AIMS

Published estimates of survival associated with mushroom (amatoxin)-induced acute liver failure (ALF) and injury (ALI) with and without liver transplant (LT) are highly variable. We aimed to determine the 21-day survival associated with amatoxin-induced ALI (A-ALI) and ALF (A-ALF) and review use of targeted therapies.

METHODS

Cohort study of all A-ALI/A-ALF patients enrolled in the US ALFSG registry between 01/1998 and 12/2014.

RESULTS

Of the 2224 subjects in the registry, 18 (0.8%) had A-ALF (n = 13) or A-ALI (n = 5). At admission, ALF patients had higher lactate levels (5.2 vs. 2.2 mm, P = 0.06) compared to ALI patients, but INR (2.8 vs. 2.2), bilirubin (87 vs. 26 μm) and MELD scores (28 vs. 24) were similar (P > 0.2 for all). Of the 13 patients with ALF, six survived without LT (46%), five survived with LT (39%) and two died without LT (15%). Of the five patients with ALI, four (80%) recovered and one (20%) survived post-LT. Comparing those who died/received LT (non-spontaneous survivors [NSS]) with spontaneous survivors (SS), N-acetylcysteine was used in nearly all patients (NSS 88% vs. SS 80%); whereas, silibinin (25% vs. 50%), penicillin (50% vs. 25%) and nasobiliary drainage (0 vs. 10%) were used less frequently (P > 0.15 for all therapies).

CONCLUSION

Patients with mushroom poisoning with ALI have favourable survival, while around half of those presenting with ALF may eventually require LT. Further study is needed to define optimal management (including the use of targeted therapies) to improve survival, particularly in the absence of LT.

Investigation of Toxic Effects of Mushroom Poisoning on the Cardiovascular System

Mushroom poisoning (MP) is a public health problem in many countries. It is well known that consumption of wild mushrooms may cause serious toxicity on renal, hepatic and brain functions. In the literature, however, studies investigating cardiotoxic effects of MP are rare. In this study, we evaluated laboratory and ECG findings of patients and sought for possible toxic effects of MP on the cardiovascular system. During a 2-year period, 175 patients with MP were included in the study. The majority of the poisonings occurred in early summertime. The most common complaint was found to be nausea and vomiting followed by mental status alterations. Methods of treatment were mainly based on gastric lavage, activated charcoal and supportive therapy. The most common ECG abnormalities in the patients with MP were sinus tachycardia, sinus arrhythmia, ST/T inversion, 1st degree AV block and QT prolongation, respectively. Cardiac markers of the patients were found to be normal. Then, patients were divided into two subgroups according to symptom onset after consumption (less than 6 hr and more than 6 hr). When the two groups were compared, prevalence of tachycardia was significantly higher in Group II. Additionally, the interval between mushroom consumption and onset of symptoms was strongly correlated with blood pressure (BP). As this interval prolonged, BP of the patients tended to increase. In conclusion, according to our results, although mechanisms need to be clarified, MP causes hypertension and ECG alterations, particularly tachycardia in patients with late-onset symptoms.

Acute Pancreatitis Caused By Mushroom Poisoning: A Report of Two Cases

Of the more than 5000 species of mushrooms known, 100 types are toxic and approximately 10% of these toxic types can cause fatal toxicity. A type of mushroom called Amanita phalloides is responsible for 95% of toxic mushroom poisonings. In this article, we report 2 cases of mushroom poisonings caused by Lactarius volemus, known as Tirmit by the local people. The patient and his wife were admitted to the emergency room with abdominal pain, nausea, and vomiting 20 hours after consuming Lactarius volemus, an edible type of mushroom. The patients reported that they had been collecting this mushroom from the mountains and eating them for several years but had never developed any clinicopathology to date. Further examination of the patients revealed a very rare case of acute pancreatitis due to mushroom intoxication. The male patient was admitted to the intensive care unit while his wife was followed in the internal medicine service, because of her relative mild clinical symptoms. Both patients recovered without sequelae and were discharged. In this article, we aimed to emphasize that gastrointestinal symptoms are often observed in mushroom intoxications and can be confused with acute pancreatitis, thus leading to misdiagnosis of patients. Early diagnosis and appropriate treatment can improve patients’ prognosis and prevent the development of complications.

A breakthrough on Amanita phalloides poisoning: an effective antidotal effect by polymyxin B

Amanita phalloides is responsible for more than 90 % of mushroom-related fatalities, and no effective antidote is available. α-Amanitin, the main toxin of A. phalloides, inhibits RNA polymerase II (RNAP II), causing hepatic and kidney failure. In silico studies included docking and molecular dynamics simulation coupled to molecular mechanics with generalized Born and surface area method energy decomposition on RNAP II. They were performed with a clinical drug that shares chemical similarities to α-amanitin, polymyxin B. The results show that polymyxin B potentially binds to RNAP II in the same interface of α-amanitin, preventing the toxin from binding to RNAP II. In vivo, the inhibition of the mRNA transcripts elicited by α-amanitin was efficiently reverted by polymyxin B in the kidneys. Moreover, polymyxin B significantly decreased the hepatic and renal α-amanitin-induced injury as seen by the histology and hepatic aminotransferases plasma data. In the survival assay, all animals exposed to α-amanitin died within 5 days, whereas 50 % survived up to 30 days when polymyxin B was administered 4, 8, and 12 h post-α-amanitin. Moreover, a single dose of polymyxin B administered concomitantly with α-amanitin was able to guarantee 100 % survival. Polymyxin B protects RNAP II from inactivation leading to an effective prevention of organ damage and increasing survival in α-amanitin-treated animals. The present use of clinically relevant concentrations of an already human-use-approved drug prompts the use of polymyxin B as an antidote for A. phalloides poisoning in humans.

Severe mushroom poisoning in one Macedonian family

BACKGROUND

Collecting and consuming wild mushrooms is a historical tradition in many European countries, including The Republic of Macedonia. This activity is predominantly performed in the period between June and October, when the weather is warm and humidity in the air and soil is at higher levels.The Amanita genus consists of 500 different species of mushrooms; among these, Amanita phaloides, Amanita virosa and Amanita verna are most commonly found in oak forests in our country. These species are highly poisonous and because they can be similar to some edible mushrooms, they have often been misidentified. Their consumption causes severe intoxication.

PURPOSE

The aim of this case series report is to demonstrate a severe poisoning with Amanita mushrooms (A. verna) that occurred in 8 patients, all from 1 Macedonian family.

RESULTS

We show the differences in the clinical appearance and status of these patients, the wide spectrum of symptoms as well as the treatment and outcome of this rare poisoning. One patient, an 8-month-old baby, was excluded from the study because the infant was immediately transferred to the pediatric clinic after admission to our clinic.

CONCLUSIONS

Despite modern therapy, poisoning due to ingestion of Amanita mushrooms is a serious clinical and health problem that may even be potentially lethal. The most efficient way for the general public to protect itself against potential poisoning is to avoid ingesting mushrooms that may not be edible.

Amanita phalloides poisoning and treatment with silibinin in the Australian Capital Territory and New South Wales

OBJECTIVES

To report the frequency and clinical outcomes of Amanita phalloides poisoning in the Australian Capital Territory and New South Wales, and the treatments used (including silibinin).

DESIGN, SETTING AND PATIENTS

Retrospective case series of patients admitted to public hospitals in Canberra and Sydney for suspected A. phalloides poisoning between 1999 and 2012 (identified from hospital records and calls to the New South Wales Poisons Information Centre).

MAIN OUTCOME MEASURES

Frequency of poisoning and the clinical outcomes.

RESULTS

Twelve patients presented with a history suggesting A. phalloides poisoning, 10 with probable poisoning and two with possible poisoning. Eight of those with probable poisoning developed significant hepatotoxicity and four died. Silibinin was administered to nine of those with probable poisoning (the other presented before 2005). Maintaining silibinin supply became a challenge during two clusters of poisoning. Eight of the patients with probable poisoning were not long-term residents of the ACT, and six were immigrants from Asia.

CONCLUSIONS

The mortality rate due to A. phalloides poisoning in this case series was high despite treatment according to current standards, including use of silibinin, and the frequency of hepatotoxicity was more than double that for the previous decade. Ongoing public health campaigns are required.

A rare case of amatoxin poisoning in the state of Texas

Ingestion of mushrooms from the genus Amanita can present detrimental consequences to the human body. The mushroom is frequently found in the coastal Pacific Northwest, Pennsylvania, New Jersey, and Ohio. Amanitin, one of the two distinct toxins isolated from the Amanita mushroom, is responsible for the majority of symptoms and signs seen with mushroom poisoning. Clinically, ingestion of these mushrooms can result in a wide range of clinical symptoms including nausea, vomiting, crampy abdominal pain, and diarrhea. There have been several case reports of patients who developed severe hepatic failure that required liver transplantation. Thus, it is important to recognize the symptoms early and treat the patients with the available agents including multidose activated charcoal, N-acetylcysteine, penicillin G, and Silybum. Through an extensive literature search, we found no published literature on amatoxin poisoning in the state of Texas. With new cases of amatoxin poisoning emerging in the state, it is important for healthcare providers and workers to have a better awareness and early recognition of the detrimental effects of Amanita species poisoning and to be educated to provide the proper care for this group of patients.

Clinical features and outcome of patients with amatoxin-containing mushroom poisoning

OBJECTIVE. We aimed to determine clinical and laboratory findings that were different between those patients who died and those who survived and to look for factors associated with the mortality in amatoxin-containing mushroom poisoning. METHODS. The mushroom poisoning patients who were admitted to our clinic between 1996 and 2009 were retrospectively evaluated. The diagnosis was based on a history of mushroom ingestion, clinical picture and the presence of serum alpha-amanitin. Patients were divided into two groups as the survival group and the fatality group. Clinical and laboratory findings were compared between the two groups. Relation between variables and clinical outcome was analyzed. RESULTS. A total of 144 amatoxin poisoning patients were included in this study. Patients who died were more likely to have demonstrated low mean arterial pressure, encephalopathy, mucosal hemorrhage, oliguria-anuria, hypoglycemia, and thrombocytopenia during the hospitalization. Low sodium values and high urea, AST, ALT, total bilirubin, LDH, prothrombin time, international normalized ratio, and activated partial thromboplastin time values were associated with increased likelihood of mortality. Nineteen patients developed acute renal failure. Fourteen patients developed acute hepatic failure. All the 14 patients who died developed acute hepatic failure. The mortality rate was 9.7%. CONCLUSIONS. The factors associated with mortality determined in this retrospective study may be helpful for clinical outcome assessment and monitoring of patients with amatoxin-containing mushroom poisoning.

Development of a DNA-based macroarray for the detection and identification of Amanita species

A DNA-based macroarray was designed to quickly and accurately identify certain Amanita mushroom specimens at the species level. The macroarray included probes for Amanita phalloides and Amanita ocreata, toxic species responsible for most mushroom poisonings, and Amanita lanei and Amanita velosa, edible species sometimes confused with toxic species, based on sequences of the highly variable internal transcribed spacer (ITS) region of rDNA. A cryptic species related to A. ocreata and one related to A. lanei, identifiable by ITS sequences, were also included. Specific multiple oligonucleotide probes were spotted onto nylon membranes and the optimal hybridization temperatures were determined. The Amanita DNA array was highly specific, sensitive (0.5 ng DNA/μL and higher were detected), and reproducible. In two case studies, the method proved useful when only small amounts of mushroom tissue remained after a suspected poisoning. An identification could be completed in 12 h.

Mushroom poisoning: retrospective analysis of 294 cases

OBJECTIVE

The objective of this study was to present special clinical and laboratory features of 294 cases of mushroom poisoning.

MATERIALS AND METHODS

In this retrospective study, 294 patients admitted to the Pediatric and Adult Emergency, Internal Medicine and ICU Departments of Cumhuriyet University Hospital were investigated.

RESULTS

Of 294 patients between the ages of 3 and 72 (28.97 +/- 19.32), 173 were female, 121 were male and 90 were under the age of 16 years. One hundred seventy-three patients (58.8%) had consumed the mushrooms in the early summer. The onset of mushroom toxicity symptoms was divided into early (within 6 h after ingestion) and delayed (6 h to 20 d). Two hundred eighty-eight patients (97.9%) and six (2.1%) patients had early and delayed toxicity symptoms, respectively. The onset of symptoms was within two hours for 101 patients (34.3%). The most common first-noticed symptoms were in the gastrointestinal system. The patients were discharged within one to ten days. Three patients suffering from poisoning caused by wild mushrooms died from fulminant hepatic failure.

CONCLUSION

Education of the public about the consumption of mushrooms and education of health personnel working in health centers regarding early treatment and transfer to hospitals with appropriate facilities are important for decreasing the mortality.

Amanita phalloides poisoning: reassessment of prognostic factors and indications for emergency liver transplantation

BACKGROUND/AIMS

Amanita phalloides poisoning is an uncommon cause of acute liver failure with an especially rapid course. The aim of this study was to re-assess transplantation criteria in patients with mushroom poisoning.

METHODS

Twenty-seven patients admitted for Amanita phalloides poisoning were studied. Previously reported transplantation criteria, including the recent Ganzert's criteria, were tested retrospectively.

RESULTS

The rate of fatal intoxication (death and/or transplantation) was 8/27 (30%). An interval between ingestion and diarrhea <8h was a very early predictor of a fatal outcome (accuracy of 78%). Later on, non-paracetamol and paracetamol King's College criteria were superior to Clichy's and Ganzert's criteria (accuracy of 100% compared to 85% and 85%, respectively). Encephalopathy and renal insufficiency were not constant in the fatal intoxication group. Prothrombin index below 10% 4 days or more after ingestion had a 100% accuracy for predicting a fatal outcome.

CONCLUSIONS

Liver transplantation should be strongly considered in patients with an interval between ingestion and diarrhea <8h. Encephalopathy should not be an absolute prerequisite for deciding transplantation. From day 4 after ingestion, prothrombin index lower than 10% ( approximately INR of 6) alone is a reliable tool for deciding emergency transplantation.

Amanita bisporigera ingestion: mistaken identity, dose-related toxicity, and improvement despite severe hepatotoxicity

Ingestion of wild mushrooms has led to unintentional poisonings caused by mistaken identity. We report 3 cases of exposure to Amanita bisporigera, demonstrating dose-related toxicity. The use of nasobiliary drainage as a novel approach to interrupting the enterohepatic circulation of amatoxins is illustrated. Pathophysiology and treatment of Amanita poisoning are reviewed.

Evolving global epidemiology, syndromic classification, general management, and prevention of unknown mushroom poisonings

OBJECTIVE

To assess the evolving global epidemiology of mushroom poisoning and to identify new and emerging mushroom poisonings and their treatments, a descriptive analysis and review of the world's salient scientific literature on mushroom poisoning was conducted.

DATA SOURCE

Data sources from observation studies conducted over the period 1959-2002 and describing 28,018 mushroom poisonings since 1951 were collected from case reports, case series, regional descriptive studies, meta-analyses, and laboratory studies of mushroom poisonings and the toxicokinetics of mycotoxins.

STUDY SELECTION

Studies included in the review were selected by a MEDLINE search, 1966-2004, an Ovid OLDMEDLINE search, 1951-1965, and a medical library search for sources published before 1951.

DATA EXTRACTION

To better guide clinicians in establishing diagnoses and implementing therapies, despite confusing ingestion histories, data were extracted to permit an expanded syndromic classification of mushroom poisoning based on presentation timing and target organ systemic toxicity.

DATA SYNTHESIS

The final 14 major syndromes of mushroom poisoning were stratified first by presentation timing and then by target organ systemic toxicity and included early (<6 hrs), late (6-24 hrs), and delayed syndromes (> or =1 day). There were eight early syndromes (four neurotoxic, two gastrointestinal, two allergic); three late syndromes (hepatotoxic, accelerated nephrotoxic, erythromelalgia); and three delayed syndromes (delayed nephrotoxic, delayed neurotoxic, rhabdomyolysis). Four new mushroom poisoning syndromes were classified including accelerated nephrotoxicity (Amanita proxima, Amanita smithiana), rhabdomyolysis (Tricholoma equestre, Russula subnigricans), erythromelalgia (Clitocybe amoenolens, Clitocybe acromelalgia), and delayed neurotoxicity (Hapalopilus rutilans). In addition, data sources were stratified by three chronological time periods with >1,000 confirmed mushroom ingestions reported and tested for any statistically significant secular trends in case fatalities from mushroom ingestions over the entire study period, 1951-2002.

CONCLUSIONS

Since the 1950s, reports of severe and fatal mushroom poisonings have increased worldwide. Clinicians must consider mushroom poisoning in the evaluation of all patients who may be intoxicated by natural substances. Since information on natural exposures is often insufficient and incorrect, a new syndromic classification of mushroom poisoning is recommended to guide clinicians in making earlier diagnoses, especially in cases where only advanced critical care, including organ transplantation, may be life saving.

Indication of liver transplantation following amatoxin intoxication

BACKGROUND/AIMS

Indication of liver transplantation in acute liver failure following amatoxin intoxication is still uncertain.

METHODS

One hundred and ninety-eight patients were studied retrospectively. The laboratory parameters alanine-aminotransferase, serum bilirubin, serum creatinine and prothrombin index were analyzed over time. Predictors of fatal outcome and survival were determined by receiver-operating-characteristic and sensitivity-specificity analysis.

RESULTS

Twenty-three patients died in the median 6.1 days (range, 2.7-13.9 days) after ingestion. Using a single parameter as predictor of fatal outcome the area under the receiver-operating-characteristic curve of prothrombin index (0.96) and serum creatinine (0.93) were both significantly greater (P<0.05) compared with serum bilirubin (0.82) and alanine-aminotransferase (0.69). Prediction of fatal outcome had an optimum, if a prothrombin index less than 25% was combined with a serum creatinine greater than 106 micromol/l from day 3 after ingestion onwards (sensitivity 100%, 95% confidence interval 87-100; specificity 98%, 95% confidence interval 94-100). The median time period between the first occurrence of this predictor in non-survivors and death was 63h (range, 3-230h).

CONCLUSIONS

A decision model of liver transplantation following amatoxin intoxication using prothrombin index in combination with serum creatinine from day 3 to 10 after ingestion enables an early and reliable assessment of outcome.

Mycotoxins revisited: Part I

Mushrooms are ubiquitous in nature. They are an important source of nutrition; however, certain varieties contain chemicals that can be highly toxic to humans. Industrially cultivated mushrooms are historically very safe, but foraging for mushrooms or accidental ingestion of mushrooms in the environment can result in serious illness and death. The emergency department is the most common site of presentation for patients suffering from acute mushroom poisoning. Although recognition can be facilitated by identification of a characteristic toxidrome, the presenting manifestations can be variable and have considerable overlap with more common and generally benign clinical syndromes. The goal of this two-part article is to review the knowledge base on this subject and provide information that will assist the clinician in the early consideration, diagnosis and treatment of mushroom poisoning. Part I, presented in this issue of the Journal, reviews the epidemiology and demographics of mushroom poisoning, the physical characteristics of the most toxic varieties, the classification of the toxic species, and an overview of the cyclopeptide-containing mushroom class. Part II, to be published in the next issue of the Journal, will be focused on the presentation of the other classes of toxic mushrooms along with an up-to-date review of the most recently identified poisonous varieties.

Cardiac morbidity and mortality related to orthotopic liver transplantation

This article briefly discusses the cardiac status of liver transplant recipients and their preoperative cardiac evaluation. It describes in detail perioperative and early and late postoperative complications as well as the cardiac problems associated with immunosuppression. The preoperative cardiovascular status of patients is important in determining how they cope with the stresses imposed by liver transplantation. Minor early cardiac events are common and may influence longer term cardiac morbidity. Immunosuppressive therapy may have short term effects but is likely to adversely affect long term cardiac risk.

Recovery from severe hepatitis caused by mushroom poisoning without liver transplantation

BACKGROUND & AIMS

Toxic mushroom poisoning leads to a variety of clinical outcomes ranging from self-limited gastrointestinal symptoms to fulminant hepatic failure requiring orthotopic liver transplantation. We reviewed the outcomes of patients with severe acute hepatitis secondary to mushroom poisoning, treated with contemporary modalities.

METHODS

We retrospectively reviewed patients admitted to our institution over a 5-year period with elevated transaminase levels (>1000 IU/L) attributed to recent mushroom ingestion. The patients' clinical course, laboratory data, and treatment regimen were recorded and analyzed.

RESULTS

Eight patients who presented with severe hepatitis after mushroom ingestion qualified for analysis. The mean peak serum levels were: aspartate transaminase 5488 IU/L, alanine transaminase 7618 IU/L, and total bilirubin 10.5 mg/dL. The mean peak prothrombin time was 31 seconds. One patient developed acute renal failure requiring hemodialysis. Three patients developed encephalopathy ranging from grade I to III. All 8 patients survived without significant morbidity or need for liver transplantation. Subgroup analysis revealed that older patients spent more days in the intensive care unit and subsequently had longer hospital stays. The older group also had a trend toward more severe laboratory abnormalities.

CONCLUSIONS

Patients with severe hepatitis from mushroom poisoning are thought to have a poor prognosis and frequently need liver transplantation for survival. We suggest that with early and aggressive multidisciplinary care, such patients have improved outcomes and may avoid liver transplantation.

Treatment of amatoxin poisoning: 20-year retrospective analysis

BACKGROUND

Amatoxin poisoning is a medical emergency characterized by a long incubation time lag, gastrointestinal and hepatotoxic phases, coma, and death. This mushroom intoxication is ascribed to 35 amatoxin-containing species belonging to three genera: Amanita, Galerina, and Lepiota. The major amatoxins, the alpha-, beta-, and gamma-amanitins, are bicyclic octapeptide derivatives that damage the liver and kidney via irreversible binding to RNA polymerase II.

METHODS

The mycology and clinical syndrome of amatoxin poisoning are reviewed. Clinical data from 2108 hospitalized amatoxin poisoning exposures as reported in the medical literature from North America and Europe over the last 20 years were compiled. Preliminary medical care, supportive measures, specific treatments used singly or in combination, and liver transplantation were characterized. Specific treatments consisted of detoxication procedures (e.g., toxin removal from bile and urine, and extracorporeal purification) and administration of drugs. Chemotherapy included benzylpenicillin or other beta-lactam antibiotics, silymarin complex, thioctic acid, antioxidant drugs, hormones and steroids administered singly, or more usually, in combination. Supportive measures alone and 10 specific treatment regimens were analyzed relative to mortality.

RESULTS

Benzylpenicillin (Penicillin G) alone and in association was the mostfrequently utilized chemotherapy but showed little efficacy. No benefit was found for the use of thioctic acid or steroids. Chi-square statistical comparison of survivors and dead vs. treated individuals supported silybin, administered either as mono-chemotherapy or in drug combination and N-acetylcysteine as mono-chemotherapy as the most effective therapeutic modes. Future clinical research should focus on confirming the efficacy of silybin, N-acetylcysteine, and detoxication procedures.

Liver transplantation in mushroom poisoning

Liver transplantation plays an important role in the treatment of patients with fulminant hepatic failure (FHF). Early determination of prognosis in cases of FHF is important to allow prompt decision-making regarding the need for liver transplantation. Mushroom poisoning is a rare cause of FHF, and as a result, prognostic criteria are not well recognized. It appears that the severity of coagulopathy and encephalopathy predicts a poor outcome, whereas the degree of bilirubin elevation may not. We present a case of FHF related to mushroom poisoning that required liver transplantation. The clinical presentation, medical management, and prognostic criteria in mushroom poisoning are discussed.

Management of Maternal Amanita phalloı̈des Poisoning during the First Trimester of Pregnancy: A Case Report and Review of the Literature

Background: Amanita phalloı̈des poisoning produces acute liver failure and often death. Maternal poisonings are rare, and medical decisions of abortion or liver transplantation in this critical situation frequently are based on laboratory data. We report here the case of a 22-year-old-woman in the 11th week of pregnancy, who ingested mushrooms.

Case Report: The patient’s clinical symptoms (e.g., vomiting and diarrhea) and blood chemistry data (persistent increases of aspartate aminotransferase and alanine aminotransferase and severe decreases in prothrombin, factor V, factor II, factor VII, and factor X) indicated poisoning of medium severity. The management consisted of intravenous hydration, and administration of silymarine and N-acetylcysteine. No fetal damage was observed, and birth and development of the infant (now 2 years of age) proceeded without incident.

Conclusion: Abortion is not necessarily indicated in maternal poisoning by A. phalloı̈des, even in the first trimester of pregnancy.

David R. Boyd lecture in trauma care and emergency medical systems: "The surgical complications of toxins."

Toxins have had major roles in our societies for thousands of years. Interactions between surgeons, both generalists and subspecialists, and those caring for poisoned patients have been extensive throughout history. The advancement of the science of toxicology, the development of regional poison control centers, the development of emergency medicine, and the development of the subspecialty of medical toxicology have led to more appropriate and creative interactions between medical toxicologists, emergency physicians, and surgeons. This article will review the diverse interfaces between the medical toxicologist and the surgeon.

Fulminant hepatic failure

Fulminant hepatic failure is a devastating illness that carries considerable mortality and affects patients with previously healthy livers. Although the etiology of FHF remains unclear in a significant number of cases, viral hepatitis and drug-induced liver injury account for the majority of identifiable causes. The clinical presentation varies widely, but is always characterized by the presence of encephalopathy. Markedly elevated transaminases are seen, but do not correlate with extent of liver injury. Prothrombin time, bilirubin, creatinine, and arterial pH are prognostic indicators of survival in FHF. FHF and its consequences must be readily recognized so that appropriate triage and treatment can be administered. All patients should be managed in an intensive care setting pending transfer to a liver transplantation center. Supportive care remains the mainstay of treatment, with liver transplantation reserved for select patients.

Toxins of Amanita phalloides

The most poisonous mushroom toxins are produced by Amanita phalloides (death cap). The occurrence and chemistry of three groups of toxins (amatoxins, phallotoxins and virotoxins) are summarized. The concentration and distribution of toxins in certain species are variable, with the young fruit body containing lower, and the well-developed fungus higher concentrations, but there is a high variability among specimens collected in the same region. Regarding phallotoxins, the volva (the ring) is the most poisonous. The most important biochemical effect of amatoxins is the inhibition of RNA polymerases (especially polymerase II). This interaction leads to a tight complex and the inhibition is of a non-competitive type. Non-mammalian polymerases show little sensitivity to amanitins. The amatoxins cause necrosis of the liver, also partly in the kidney, with the cellular changes causing the fragmentation and segregation of all nuclear components. Various groups of somatic cells of emanation resistance have been isolated, including from a mutant of Drosophila melanogaster. The phallotoxins stimulate the polymerization of G-actin and stabilize the F-actin filaments. The interaction of phallotoxins occurs via the small, 15-membered ring, on the left side of the spatial formula. The symptoms of human poisoning and the changes in toxin concentrations in different organs are summarized. Conventional therapy includes: (1) stabilization of patient's condition with the correction of hypoglycaemia and electrolytes; (2) decontamination; and (3) chemotherapy with different compounds. Finally, certain antagonists and protective compounds are reviewed, bearing in mind that today these have more of a theoretical than a practical role.

Mushroom poisoning: an indication for liver transplantation

There are numerous causes of fulminant hepatic failure including acetaminophen, viral etiologies, acute fatty liver of pregnancy, ischemic hepatitis, and acute Budd-Chiari syndrome. One of the rare causes of fulminant hepatic failure is toxic mushroom poisoning. This article describes one case in which ingestion of a toxic mushroom, Amanita phalloides, caused a patient severe liver damage ultimately requiring organ transplantation. Early identification of live dysfunction and referral to a liver transplant center for evaluation may be critical to save such a patient's life.

Liver transplantation after severe poisoning due to amatoxin-containing Lepiota--report of three cases

Four cases of severe Lepiota poisoning, including three which developed toxic fulminant hepatitis treated by orthotopic hepatic transplantation, are reported here. The toxicity of the Lepiota is discussed as well as the indications for hepatic transplantation in poisonings due to amatoxin-containing mushrooms.

Liver transplantation for severe Lepiota helveola poisoning

Orthotopic liver transplantation in patients with fulminant hepatic failure secondary to Lepiota helveola poisoning has not, to our knowledge, been reported. Our recent experience with liver transplantation in a 27-year-old woman with acute hepatic failure secondary to this poisoning is described. The indications for orthotopic liver transplantation are discussed.

Clinical symptomatology and management of mushroom poisoning

Among poisonous mushrooms, a small number may cause serious intoxication and even fatalities in man. Humans may become symptomatic after a mushroom meal for rather different reasons: (1) ingestion of mushrooms containing toxins, (2) large amounts of mushrooms may be hard to digest, (3) immunological reactions to mushroom-derived antigens, (4) ingestion of mushrooms causing ethanol intolerance, and (5) vegetative symptoms may occur whenever a patient realizes that there might be a possibility of ingestion of a toxic mushroom after a mushroom meal. Based on the classes of toxins and their clinical symptoms, seven different types of mushroom poisoning can be distinguished: (1) phalloides, (2) orellanus, (3) gyromitra, (4) muscarine, (5) pantherina, (6) psilocybin, and (7) gastrointestinal mushroom syndrome. Two other entities of adverse reactions to mushrooms are (8) coprinus and (9) paxillus syndrome. Phalloides, orellanus, gyromitra and paxillus syndrome may lead to serious poisoning, which generally requires treatment of the patient in an intensive care unit. Diagnosis of mushroom poisoning is primarily based on anamnestic data, identification of mushrooms from leftovers of the mushroom meal, spore analysis, and/or chemical analysis. Therapeutic strategies include primary detoxification by induced emesis, gastric lavage and activated charcoal, secondary detoxification, symptomatic treatment and rarely specific antidotes. Owing to progressing fulminant hepatic failure, lethality associated with phalloides syndrome is still high (5-20%). Basic treatment includes administration of silibinin and penicillin G, although controlled studies on its therapeutic efficacy are still lacking. In serious phalloides syndrome, orthotopic liver transplantation has to be considered. Fortunately, the prognosis in most other mushroom poisonings is excellent.

Fulminant hepatic failure

FHF is an uncommon but devastating condition affecting otherwise healthy persons which causes significant morbidity and mortality. The etiologic factor is most commonly viral infection, with drugs and metabolic disorders being relatively less common causes. Hopefully, newer diagnostic techniques such as PCR will increase our understanding of the causes and pathogenesis of this disorder. Medical management at the present time must focus on anticipating, preventing, and rapidly identifying and treating complications that may affect every major organ system. Encouraging research continues on the clinical application of hepatotrophic drugs and artificial liver support systems, both as potentially definitive therapies and as maintenance for patients awaiting transplantation. Consultation with physicians at a transplant center should be sought early in the course of the patient's hospitalization when OLT is being considered. Liver transplantation has dramatically changed the outlook for patients with FHF, with current survival rates in the 55% to 75% range. The continuing challenge for the transplant team is to allocate available donor organs to those patients who would not otherwise survive, but also to provide OLT in a timely fashion to ensure the best chance of post-transplantation recovery. Newer techniques such as heterotopic liver transplantation, reduced-size organ transplantation, and the utilization of living related donors may further improve the survival of these patients.

Fulminant hepatic failure after Lepiota mushroom poisoning

We present ten patients who suffered from a cyclopeptide syndrome from two different foci, one caused by Lepiota helveola (seven cases) and the other by Lepiota brunneoincarnata (three cases). Of the ten victims, five recovered completely after the intestinal stage and the other five developed a phase of visceral involvement with alterations of liver function. In two patients, hepatic function became normal after the 7th day after ingestion. Three patients developed fulminant hepatitis and two of these died of adult respiratory distress syndrome. The fulminant hepatitis patient who later improved developed active chronic hepatitis 1 year later. Finally, five patients developed mixed polyneuropathy. In this paper the indications for orthotopic liver transplant (OLTx) are discussed and the development of late complications such as active chronic hepatitis and mixed polyneuropathy are considered.

Kinetics of amatoxins in human poisoning: therapeutic implications

The kinetics of alpha and beta amanitin were studied in 45 patients intoxicated with Amanita Phalloides. The amatoxins were analyzed by high performance liquid chromatography in plasma (43 cases), urine (35 cases), gastroduodenal fluid (12 cases), feces (12 cases) and tissues (4 cases). All patients had gastrointestinal symptoms and 43 developed an acute hepatitis. Two patients underwent successful liver transplantation. Eight patients, of whom three were children, died. The detection of amatoxins in the biological fluids was time dependent. The first sample was obtained at an average of 37.9 h post ingestion in the patients with positive results and at 70.6 h in the samples without detectable amatoxins. Plasma amatoxins were detected in 11 cases at 8 to 190 ng/mL for alpha and between 23.5 to 162 ng/mL for beta. In 23 cases amatoxins were detected in urine with a mean excretion per hour of 32.18 micrograms for alpha and 80.15 micrograms for beta. In 10 patients the total amounts eliminated in the feces (time variable) ranged between 8.4 and 152 micrograms for alpha amanitin and between 4.2 and 6270 micrograms for beta amanitin. In three of four cases amatoxins were still present in the liver and the kidney after day 5. Amatoxins were usually detectable in plasma before 36 h but were present in the urine until day 4. The rapid clearance indicates that enhanced elimination of amatoxins requires early treatment. Clearance of circulating amatoxins by day 4 spares the transplanted liver.