Amatoxin poisoning: a 15-year retrospective analysis and follow-up evaluation of 105 patients

Effects of interrupting the enterohepatic circulation in amatoxin intoxications

BACKGROUND

Interruption of the enterohepatic circulation is regarded as an effective way to treat patients with amatoxin poisoning. Nonetheless, its effectiveness has not yet been systematically evaluated. Therefore, we performed a systematic review to investigate the role of enterohepatic circulation on patient outcome and clinical laboratory values. We specifically sought to evaluate the effect of activated charcoal, which absorbs drugs and toxins in the gastrointestinal tract.

METHODS

A previously established database with data extracted from case reports and series from literature, supplemented with recent publications, was used. Patient characteristics, outcome, and laboratory values were evaluated.

RESULTS

We included 133 publications describing a total of 1,119 unique cases. Survival was 75 per cent in the control group (n = 452), whereas in the group treated with single or multiple doses of activated charcoal (n = 667) survival was 83 per cent (P < 0.001, odds ratio 1.89 [95 per cent confidence interval 1.40-2.56]). Furthermore, no difference in peak values of alanine aminotransferase and aspartate aminotransferase activities were observed, whereas peak values of total serum bilirubin concentration and international normalized ratio were statistically significantly reduced in patients treated with activated charcoal.

DISCUSSION

The ability of activated charcoal to enhance the elimination of amatoxin through interruption of the enterohepatic circulation offers a potentially safe and inexpensive therapy for patients in the post-absorptive phase.

LIMITATIONS

Limitations include the potential for publication bias, the lack of universal confirmation of amatoxin concentrations, and the inability to directly measure enterohepatic circulation of amatoxin.

CONCLUSION

Treatment with activated charcoal in patients with amatoxin poisoning was associated with a greater chance of a successful outcome. Additionally, activated charcoal was associated with a reduction in markers of liver function, but not markers of liver injury.

Unexpected Amanita phalloides-Induced Hematotoxicity-Results from a Retrospective Study

INTRODUCTION

Amanita phalloides poisoning is a serious health problem with a mortality rate of 10-40%. Poisonings are characterized by severe liver and kidney toxicity. The effect of Amanita phalloides poisonings on hematological parameters has not been systematically evaluated thus far.

METHODS

Patients with suspected Amanita phalloides poisonings were retrospectively selected from the hospital database of the University Medical Center Groningen (UMCG). Medical data-including demographics; liver, kidney, and blood parameters; treatment; and outcomes-were collected. The severity of the poisoning was scored using the poison severity score.

RESULTS

Twenty-eight patients were identified who were admitted to the UMCG with suspected Amanita phalloides poisoning between 1994 and 2022. A time-dependent decrease was observed for hemoglobin and hematocrit concentrations, leukocytes, and platelets. Six out of twenty-eight patients developed acute liver failure (ALF). Patients with ALF showed a higher increase in liver enzymes, international normalized ratios, and PSS compared to patients without ALF. Conversely, hemoglobin and platelet numbers were decreased even further in these patients. Three out of six patients with ALF died and one patient received a liver transplant.

CONCLUSION

Our study shows that Amanita phalloides poisonings may be associated with hematotoxicity in patients. The quantification of hematological parameters is of relevance in intoxicated patients, especially in those with ALF.

Unraveling Hematotoxicity of α-Amanitin in Cultured Hematopoietic Cells

Amanita phalloides poisonings account for the majority of fatal mushroom poisonings. Recently, we identified hematotoxicity as a relevant aspect of Amanita poisonings. In this study, we investigated the effects of the main toxins of Amanita phalloides, α- and β-amanitin, on hematopoietic cell viability in vitro. Hematopoietic cell lines were exposed to α-amanitin or β-amanitin for up to 72 h with or without the pan-caspase inhibitor Z-VAD(OH)-FMK, antidotes N-acetylcysteine, silibinin, and benzylpenicillin, and organic anion-transporting polypeptide 1B3 (OATP1B3) inhibitors rifampicin and cyclosporin. Cell viability was established by trypan blue exclusion, annexin V staining, and a MTS assay. Caspase-3/7 activity was determined with Caspase-Glo assay, and cleaved caspase-3 was quantified by Western analysis. Cell number and colony-forming units were quantified after exposure to α-amanitin in primary CD34+ hematopoietic stem cells. In all cell lines, α-amanitin concentration-dependently decreased viability and mitochondrial activity. β-Amanitin was less toxic, but still significantly reduced viability. α-Amanitin increased caspase-3/7 activity by 2.8-fold and cleaved caspase-3 by 2.3-fold. Z-VAD(OH)-FMK significantly reduced α-amanitin-induced toxicity. In CD34+ stem cells, α-amanitin decreased the number of colonies and cells. The antidotes and OATP1B3 inhibitors did not reverse α-amanitin-induced toxicity. In conclusion, α-amanitin induces apoptosis in hematopoietic cells via a caspase-dependent mechanism.

A ten-year retrospective California Poison Control System experience with possible amatoxin mushroom calls

INTRODUCTION

Mushrooms containing amatoxin are found worldwide and represent a challenging poisoning for the clinician and consulting poison center. This study evaluates the experience of a large poison system with possible amatoxin-containing mushroom ingestion calls.

METHODS

A 10-year retrospective review of the California Poison Control System database was performed for amatoxin mushroom ingestion calls resulting in hospitalization. Cases found were abstracted and data statistically analyzed for association with a composite endpoint of death, liver transplant, and/or the need for dialysis.

RESULTS

Amatoxin-containing mushroom calls are infrequent with the vast majority (98.4 percent) coming from Northern California during the rainier first and fourth quarters (October through March) of the year. Elevated initial aminotransferase activities and international normalized ratios were predictive of the composite negative outcome. The mortality plus liver transplant and hemodialysis composite rate was 8.2 percent, consistent with current literature.

CONCLUSION

The California Poison Control System has relatively few amatoxin-containing mushroom ingestion calls that result in hospitalization but those that are reported mostly occur in Northern California. Treatment bias towards the sickest patients may explain the association of intravenous fluid use or treatment with acetylcysteine or silibinin with meeting the composite outcome. The initial presence of elevated hepatic aminotransferase activity and international normalized ratios are poor prognostic indicators and are likely reflective of late presentation, an advanced toxic phase of amatoxin poisoning, and/or delays in time to obtain poison center consultation.

Cyclopeptide mushroom poisoning: A retrospective series of 204 patients

Cyclopeptide mushroom poisoning is responsible for 90%-95% of deaths from macrofungi ingestion. The main objectives of this study are to describe cases of cyclopeptide mushroom poisoning and to determine risk factors that may influence the severity/mortality of poisoned patients. We included all cases of amatoxin toxicity reported to two French Poison Centers from 2013 through 2019. We compared the severity with the Poison Severity Score (PSS) and the outcomes of patients using simple logistic regression and multinomial logistic regression. We included 204 cases of amatoxin toxicity. More than three-quarters developed an increase in AST and/or ALT (78.1%), and over half developed a decrease in prothrombin ratio (<70%: 53%) and/or Factor V (<70%: 54%). One-third developed an acute renal injury (AKI). Twelve patients (5.9%) developed post-poisoning sequelae (persistent kidney injury more than 1 month after ingestion and liver transplant). Five patients (2.5%) received a liver transplant, and nine died (4.4%). The mean time to onset of digestive disorders was shorter in PSS2 and PSS3-4 patients (10.9 ± 3.9/11.3 ± 6.3 h) than in PSS1 patients (14 ± 6.5 h; p < 0.05). Patients who died or developed post-poisoning sequelae had more frequent cardiovascular comorbidities compared with recovered patients (60.0% versus 29.5%; p < 0.01).

Prognostic factors in acute poisoning with central nervous system xenobiotics: development of a nomogram predicting risk of intensive care unit admission

Background

Acute intoxication with central nervous system (CNS) xenobiotics is an increasing global problem. Predicting the prognosis of acute toxic exposure among patients can significantly alter the morbidity and mortality. The present study outlined the early risk predictors among patients diagnosed with acute exposure to CNS xenobiotics and endorsed bedside nomograms for identifying patients requiring intensive care unit (ICU) admission and those at risk of poor prognosis or death.

Methods

This study is a 6-year retrospective cohort study conducted among patients presented with acute exposure to CNS xenobiotics.

Results

A total of 143 patients' records were included, where (36.4%) were admitted to the ICU, and a significant proportion of which was due to exposure to alcohols, sedative hypnotics, psychotropic, and antidepressants (P = 0.021). ICU admission was associated with significantly lower blood pressure, pH, and HCO₃ levels and higher random blood glucose (RBG), serum urea, and creatinine levels (P < 0.05). The study findings indicate that the decision of ICU admission could be determined using a nomogram combining the initial HCO₃ level, blood pH, modified PSS, and GCS. HCO₃ level < 17.1 mEq/L, pH < 7.2, moderate-to-severe PSS, and GCS < 11 significantly predicted ICU admission. Moreover, high PSS and low HCO₃ levels significantly predicted poor prognosis and mortality. Hyperglycemia was another significant predictor of mortality. Combining initial GCS, RBG level, and HCO₃ is substantially helpful in predicting the need for ICU admission in acute alcohol intoxication.

Conclusion

The proposed nomograms yielded significant straightforward and reliable prognostic outcomes predictors in acute exposure to CNS xenobiotics.

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.

Silibinin: a toxicologist's herbal medicine?

Silymarin is an herbal remedy, commonly called milk thistle, or St. Mary's Thistle, and has been used for over 2000 years. It has been available as a capsule of the plant extract in Europe since 1974 to treat hepatic disorders. To date toxicologists have relied on animal studies, human case series, or retrospective reviews to decide on its use. In the U.S. the ability to use IV silibinin, its pharmacologically active purified flavonolignan, is hindered by its lack of availability as a Food and Drug Administration approved pharmaceutical preparation. This commentary reviews the in vitro studies, animal studies, and human retrospective analyses which form the basis for its clinical use. Despite the numerous publications, summarized in this issue in a systematic review, the mortality rate from Amanita mushroom ingestion remains stubbornly the same over four decades of use, and hovers around 10%. Although in the retrospective systematic review the use of silibinin, or penicillin, compared to routine care is statistically significantly superior when the primary outcome is fatality. Despite this there is no quality randomized trial to definitively demonstrate its utility. While, intravenous silibinin has a low toxicity, unanswered is whether it is useful in protecting the liver in cases of amanitin-containing mushrooms toxicity, and whether earlier administration would likely improve outcomes.

Toxicological assessment compilation of selected examples of raw materials for homeopathic and anthroposophic medicinal products - Part 2

The present successor article comprises more than 180 substances representing a continuative compilation of toxicologically evaluated starting materials prompted by the wide use and high number of homeopathic and anthroposophic medicinal products (HMP) on the market together with the broad spectrum of active substances of botanical, mineral, chemical or animal origin contained therein, and by the equally important requirement of applying adequate safety principles as with conventional human medicinal products in line with the European regulatory framework. The February 2019 issue of the Regulatory Toxicology and Pharmacology journal includes the antecedent article bearing the same title and entailing safety evaluations of more than 170 raw materials processed in HMP. This part 2 article highlights scientific evaluation following recognized methods used in toxicology with a view to drug-regulatory authority's assessment principles and practice in the context of HMP, and offers useful systematic, scientifically substantiated and simultaneously pragmatic approaches in differentiated HMP risk assessment. As a unique feature, both articles provide the most extensive publicly available systematic compilation of a considerable number of substances processed in HMP as a transparent resource for applicants, pharmaceutical manufacturers, the scientific community and healthcare authorities to actively support regulatory decision making in practice.

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.

Mushroom Poisoning

BACKGROUND

Poisonous mushrooms are eaten by mushroom hunters out of ignorance, after misidentification as edible mushrooms, or as a psychoactive drug. Mushroom poisoning commonly leads to consultation with a poison information center and to hospitalization.

METHODS

This review is based on pertinent publications about the syndromes, toxins, and diagnostic modalities that are presented here, which were retrieved by a selective search in PubMed. It is additionally based on the authors' longstanding experience in the diagnosis and treatment of mushroom intoxication, expert consultation in suspected cases, macroscopic identification of wild mushrooms, and analytic techniques.

RESULTS

A distinction is usually drawn between mushroom poisoning with a short latency of less than six hours, presenting with a gastrointestinal syndrome whose course is usually relatively harmless, and cases with a longer latency of six to 24 hours or more, whose course can be life-threatening (e.g., phalloides, gyromitra, orellanus, and rhabdomyolysis syndrome). The DRG diagnosis data for Germany over the period 2000-2018 include a total of 4412 hospitalizations and 22 deaths due to the toxic effects of mushroom consumption. 90% of the fatalities were due to the death cap mushroom (amatoxins). Gastrointestinal syndromes due to mushroom consumption can be caused not only by poisonous mushrooms, but also by the eating of microbially spoiled, raw, or inadequately cooked mushrooms, or by excessively copious or frequent mushroom consumption.

CONCLUSION

There are few analytic techniques available other than the qualitative demonstration of amatoxins. Thus, the diagnosis is generally made on the basis of the clinical manifestations and their latency, along with meticulous history-taking, assisted by a mushroom expert, about the type(s) of mushroom that were consumed and the manner of their preparation.

Intravenous rifampicin use in the management of amanita phalloides toxicity

Context: Amanita phalloides related toxicity from amatoxins can result in acute liver and multi-organ failure and is responsible for 90% of all mushroom poisoning death. However, more evidence is needed in regards to different management strategies.Case details: We present two cases of amanita mushroom ingestion who were treated with intravenous rifampicin.Discussion: Further study is needed to establish the efficacy and role of rifampicin in amatoxin related mushroom poisoning.

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.

Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 2: markers for specific intoxications

In medical intensive care units, acute intoxications contribute to a large proportion of all patients. Epidemiology and a basic overview on this topic were presented in part one. The purpose of this second part regarding toxicological biomarkers in the ICU setting focuses on specific poisons and toxins. Following the introduction of anion and osmol gap in part one, it's relevance in toxic alcohols and other biomarkers for these poisonings are presented within this publication. Furthermore, the role of markers in the blood, urine and cerebrospinal fluid for several intoxications is evaluated. Specific details are presented, amongst others, for cardiovascular drug poisoning, paracetamol (acetaminophen), ethanol, pesticides, ricin and yew tree intoxications. Detailed biomarkers and therapeutic decision tools are shown for carbon monoxide (CO) and cyanide (CN^-) poisoning. Also, biomarkers in environmental toxicological situations such as mushroom poisoning and scorpion stings are presented.

Mushroom Poisoning-A 17 Year Retrospective Study at a Level I University Emergency Department in Switzerland

The consequences of mushroom poisoning range from mild, mostly gastrointestinal, disturbances to organ failure or even death. This retrospective study describes presentations related to mushroom poisoning at an emergency department in Bern (Switzerland) from January 2001 to October 2017. Gastrointestinal disturbances were reported in 86% of the 51 cases. The National Poisons Information Centre and mycologists were involved in 69% and 61% of the cases, respectively. Identification of the mushroom type/family was possible in 43% of the cases. The most common mushroom family was Boletaceae (n = 21) and the most common mushrooms Xerocomus chrysenteron (n = 7; four being part of a cluster), Clitocybe nebularis, Lepista nuda and Lactarius semisanguifluus (n = 5 each, four being part of a cluster). Poisonous mushrooms included Amanita phalloides (n = 3, all analytically confirmed), Boletus satanas (n = 3), Amanita muscaria (n = 2) and Amanita pantherina (n = 2). There were no fatalities and 80% of the patients were discharged within 24 h. Mushroom poisoning does not appear to be a common reason for emergency consultation and most presentations were of minor severity and related to edible species (e.g., due to incorrect processing). Nevertheless, poisonous mushrooms and severe complications were also recorded. Collaboration with a poison centre and/or mycologists is of great importance, especially in high risk cases.

Prognostic value of decision criteria for emergency liver transplantation in patients with wild mushroom induced acute liver injury

BACKGROUND

The reported mortality rate of mushroom-induced acute liver failure with conventional treatment is 1.4%-16.9%. Emergency liver transplantation may be indicated and can be the only curative treatment option. This study aimed to assess the prognostic value of criteria for emergency liver transplantation in predicting 28-day mortality in patients with mushroom-induced acute liver injury.

METHODS

A retrospective cohort study was performed between January 2005 and December 2015. All adult patients aged≥18 years admitted with mushroom intoxication at our emergency department were evaluated. All patients with acute liver injury, defined as elevation of serum liver enzymes (>5 times the upper limit of normal, ULN) or moderate coagulopathy (INR > 2.0) were included. The ability of the King's College, Ganzert's, and Escudié's criteria to predict 28-day mortality was evaluated.

RESULTS

Of the 23 patients with acute liver injury following mushroom intoxication, 10 (43.5%) developed acute liver failure and subsequently died. The mean time interval from ingestion to death was 11.3 ± 6.6 days. Eight patients fulfilled Ganzert's criteria, while 10 patients fulfilled the King's College and Escudié's criteria for emergency liver transplantation. King's College and Escudié's criteria had 100% accuracy in predicting 28-day mortality; however, Escudié's criteria were able to identify fatal cases earlier.

CONCLUSIONS

Escudié's criteria demonstrated the best performance with 100% accuracy and the ability to promptly identify fatal cases of mushroom-induced acute liver failure.

Management of Amanita phalloides poisoning: A literature review and update

Amanita phalloides poisoning with a high mortality is a serious health problem in the world. The typical clinical manifestations are usually characterized by the absence of any symptoms followed by severe gastrointestinal disorders and acute liver failure. Inhibition of RNA polymeraseII (RNAP II) activity, apoptosis, and oxidative stress are considered as the major mechanism of amatoxins intoxication. The current treatment measures mainly include prevention of amatoxins absorption, elimination of absorbed amatoxins, potential antidotes therapy, and liver transplantation. Nevertheless, there are no widely accepted treatment criteria for Amanita phalloides poisoning. This paper will focus on the treatment measures based on the previous studies and provide the currently available information for clinicians.

Hong Kong Poison Information Centre: Annual Report 2013

Objective

To report and analyse the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2013.

Methods

In 2013, all poisoning cases received by HKPIC were retrieved from its database [Poison Information and Clinical Management System (PICMS)] for analysis.

Results

A total of 3,783 poisoned cases were analysed. There were 1,595 male patients (42.2%), 2,185 female patients (57.8%) and 3 sex unspecified patients (0.1%). Middle aged group (30-39 years) composed about one-fifth (20.8%) of the poisoning cases while about two-third (66.8%) of them were between 20 and 59 years old. Common causes for poisoning were suspected self-harm/suicidal attempt (43%), unintentional exposure (15.3%) and abusive substances use (14.5%). Five commonest types of poison exposed were paracetamol, benzodiazepine, zopiclone, household products and Chinese herbal medicine. Majority of the patients were managed with supportive measures, and 13.2% and 10.8% of them were treated by decontamination and antidotes respectively. Most cases had uneventful recovery; 0.9% of the poisoning resulted in death and 4.3% had major outcomes.

Conclusions

This 8th annual report provided updated epidemiological information on poisoning pattern in Hong Kong and highlighted important changes in comparing with our previous reports. (Hong Kong j. emerg.med. 2014;21:249-259)

Clinical characteristics and outcome of toxicity from Amanita mushroom poisoning

Objective

To describe and analyze the clinical characteristics and outcome of amatoxin poisoning cases.

Methods

We performed a retrospective cohort study of amatoxin poisoning cases from Ramathibodi Poison Center Toxic Exposure Surveillance System, from May 2013 to August 2015.

Results

There were 30 consultations with a total of 55 poisoning cases. Most cases were male and from the north-east region. Hepatitis, acute kidney injury, jaundice, and coagulopathy accounted for 74%, 46.3%, 44.7%, and 52.8% of the cases, respectively. Almost all of the patients were admitted to the hospital, and the median duration of hospital stay was found to be 4 days. Mortality rate was found to be 27.3%. Most patients (73%) received the treatment including multiple-dose activated charcoal (67.5%), intravenous N-acetylcysteine (87.5%), and benzylpenicillin (45%). In 60% of the cases, the treatment was initiated within 24 h after eating mushrooms. Exchange transfusion and liver transplantation were performed in one severe case. However, this patient died eventually. Because intravenous silybinin is not available in Thailand during the study period, 8 patients received oral silymarin instead. All 8 patients had hepatitis and were treated with high dosage of oral silymarin (5 patients with 4.48 g/day, 2 patients with 1.68 g/day, and 1 patient with 1.4 g/day) for a couple of days. One of these patients died as she received treatment very late; she was treated with silymarin at 1.68 g/day dosage. Thus, the fatality in oral silymarin treatment group was 12.5%. We performed the analysis between the dead and survival groups. We found that in hepatitis, initial and maximum serum aspartate transaminase, initial and maximum serum alanine transaminase, and acute kidney injury were significantly different between the two groups.

Conclusion

Amanita mushroom poisoning caused high fatalities. Serum transaminase and creatinine were the factors associated with death. Treatment with oral high dose silymarin should be investigated further as one of the principal therapies in amatoxin poisoning.

Epidemiology and clinics of mushroom poisoning in Northern Italy: A 21-year retrospective analysis

Background:

Limited information exists about epidemiology and management of mushroom poisoning. We analyzed and described epidemiology, clinical presentation, and clinical course of mushroom-poisoned patients admitted to emergency departments (EDs) of the Province of Parma, Italy.

Methods:

Data from the database of mycological service were matched with clinical information retrieved from hospitals’ database, from January 1, 1996 to December 31, 2016.

Results:

Mycologist consultation was obtained in 379/443 identified mushroom poisonings. A remarkable seasonality was found, with significant peak in autumn. Thanks to the collaboration, the implicated species could be identified in 397 cases (89.6%); 108 cases (24.4%) were due to edible mushrooms, Boletus edulis being the most represented (63 cases). Overall, 408 (92%) cases presented with gastrointestinal toxicity. Twenty cases of amatoxin poisoning were recorded (11 Amanita phalloides and 9 Lepiota brunneoincarnata). One liver transplantation was needed. We observed 13 cases of cholinergic toxicity and 2 cases of hallucinogenic toxicity. Finally, 46 cases were due to “mixed” toxicities, and a total of 69 needed hospitalization.

Conclusions:

Early identification and management of potentially life-threatening cases is challenging in the ED, so that a mycologist service on call is highly advisable, especially during periods characterized by the highest incidence of poisoning.

Should We Be Using the Poisoning Severity Score?

INTRODUCTION

Despite the existence of a number of severity-of-illness classifications for other areas of medicine, toxicology research lacks a well-accepted method for assessing the severity of poisoning. The Poisoning Severity Score (PSS) was developed in the 1990s in Europe as a scoring system for poisonings reported to a poison center in order to describe a patient's most severe symptomatology. We reviewed the literature to describe how the PSS is utilized and describe its limitations.

DISCUSSION

We searched the medical literature in all languages using PUBMED, EMBASE, and SCOPUS from inception through August 2013 using predefined search terms. Out of 204 eligible publications, 40 met our criteria for inclusion in this review. There has been a paucity of published studies from North America that used the PSS. In some cases,  the PSS was misapplied or modified from standard scoring, making a bottom line appraisal of the validity or reliability of the original version of the instrument challenging. The PSS has several subjective criteria, is time consuming to score, and is likely to be of little use with some types of poisonings, limiting its clinical utility.

CONCLUSION

The PSS was developed as a tool to document encounters with poisoned patients. However, it is used infrequently and, when applied, has been misused or modified from its original form. In its current form, it has limited clinical utility and likely cannot be broadly applied to many exposures due to their unique clinical circumstances. With better global collaboration among medical toxicologists, it is possible that a modified score could be developed for use clinically or as a research instrument.

Management of Acute Hepatotoxicity Including Medical Agents and Liver Support Systems

Drug-induced liver injury (DILI) can be predictable or idiosyncratic and has an estimated incidence of approximately 20 cases per 100,000 persons per year. DILI is a common cause of acute liver failure in the United States. No accurate tests for diagnosing DILI exist, and its diagnosis is based on exclusion of other conditions. Managing DILI includes discontinuing the suspected causative agent and in selected cases administering an antidote. Liver support systems are used for long-term support or as a bridge to transplantation and are effective for improving encephalopathy, hyperbilirubinemia, and other liver-related conditions, but whether they improve survival remains uncertain.

Ulcerating Ileocolitis in Severe Amatoxin Poisoning

Amatoxin poisoning is still associated with a great potential for complications and a high mortality. While the occurrence of acute gastroenteritis within the first 24 hours after amatoxin ingestion is well described, only very few descriptions of late gastrointestinal complications of amatoxin poisoning exist worldwide. We present the case of a 57-year-old female patient with severe amatoxin poisoning causing fulminant but reversible hepatic failure that on day 8 after mushroom ingestion developed severe abdominal pain and watery diarrhea. Ulcerating ileocolitis was identified by computed tomography identifying a thickening of the bowel wall of the entire ileum and biopsies taken from the ileum and large bowel revealing distinct ileitis and proximally accentuated colitis. The absence of discernible alternative etiologies such as infectious agents makes a causal relationship between the ulcerating ileocolitis and the amatoxin poisoning likely. Diarrhea and varying abdominal pain persisted over several weeks and clinical follow-up after six months showed a completely symptom-free patient. The case presented highlights the importance to consider the possibility of rare complications of Amanita intoxication in order to be able to respond to them early and adequately.

Severe but reversible acute kidney injury resulting from Amanita punctata poisoning

Mushroom-related poisoning can cause acute kidney injury. Here we report a case of acute kidney injury after ingestion of Amanita punctata, which is considered an edible mushroom. Gastrointestinal symptoms occurred within 24 hours from the mushroom intake and were followed by an asymptomatic period, acute kidney injury, and elevation of liver and pancreatic enzymes. Kidney function recovered with supportive care. Nephrotoxic mushroom poisoning should be considered as a cause of acute kidney injury.

Mycetism: a review of the recent literature

Approximately 100 of the known species of mushrooms are poisonous to humans. New toxic mushroom species continue to be identified. Some species initially classified as edible are later reclassified as toxic. This results in a continually expanding list of toxic mushrooms. As new toxic species are identified, some classic teachings about mycetism no longer hold true. As more toxic mushrooms are identified and more toxic syndromes are reported, older classification systems fail to effectively accommodate mycetism. This review provides an update of myscetism and classifies mushroom poisonings by the primary organ system affected, permitting expansion, as new, toxic mushroom species are discovered.

Rapid genetic detection of ingested Amanita phalloides

Mushrooms are often poorly digested by humans. Thus, their remains (tissues, spores) may persist in the gastrointestinal tract and can be detected in feces several days after mushroom consumption. In this report, we present protocols for the rapid PCR-based detection of fungal traces in a variety of complex samples. Novel primers were designed to amplify portions of ribosomal DNA from deadly poisonous European members of the genus Amanita, namely the death cap (A. phalloides), the destroying angel (A. virosa) and the fool's mushroom (A. verna), respectively. Assay sensitivity was sufficient to discover diluted DNA traces in amounts below the genomic content of a single target mushroom cell. Specificity testing was performed with DNA extracts from a variety of mushroom species. Template amplification was exclusively observed with intended targets and it was not compromised by a vast excess of non-target DNA (i.e. DNA from human and human fecal origin, respectively). A series of experiments was conducted with prepared specimens in order to follow the course of mushroom food processing and digestion. Amplification by direct PCR was successful with raw, fried and digested mixed mushrooms. To improve assay performance with fecal samples, a rapid protocol for sample pre-processing (including water-ether sedimentation and bead beating) and a modified PCR reaction mix were applied. Thereby, it was possible to detect the presence of A. phalloides DNA in spiked feces as well as in clinical samples (vomit, stool) from two independent cases of suspected mushroom poisoning.

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 4 Year Retrospective Analysis of Our Patients with Mushroom Poisoning

Objective

This study presented the demographic, clinical and laboratory data for the patients who presented to our emergency department (ED) with mushroom poisoning.

Methods

We retrospectively examined the data for adult patients with mushroom poisoning that presented to the ED of Uludag University, Faculty of Medicine between 1 January 2007 and 31 December 2010.

Results

A total of 53 patients were enrolled in the study. The mean age was 46.58±15.47. 52.8% of the patients were female, while 47.2% were male. These patients were typically admitted in the autumn. The most commonly seen symptoms were gastrointestinal such as nausea and vomiting. The time to symptom onset was <6 hours for 30.2% of the patients and >6 hours in 69.8% of the patients. While 73.5% of the patients received gastric lavage, activated charcoal and intravenous fluid therapy, 15.1% received penicillin, N-acetylcysteine and intravenous fluid therapy. For the remaining patients (11.4%) silibinin, dialysis and plasmapheresis were administered. While 35.8% of the patients were hospitalised, 64.2% were discharged from the ED. The median duration of stay in the ED was 6 hours (range: 1-27 hours); the median duration of stay among inpatients was 6 days (range: 1-36 days). Three of the hospitalised patients died, and two underwent hepatic transplantation.

Conclusions

Mushroom poisoning remains an important issue that is encountered in rural areas during the rainy autumn season in our region. The condition may be fatal, but can be prevented by early and appropriate treatment.

Enhanced poison elimination in critical care

Nephrologists and critical care physicians are commonly involved in the treatment of severely poisoned patients. Various techniques exist presently to enhance the elimination of poisons. Corporeal treatments occur inside of the body and include multiple-dose activated charcoal, resin binding, forced diuresis, and urinary pH alteration. Extracorporeal treatments include hemodialysis, hemoperfusion, peritoneal dialysis, continuous renal replacement therapy, exchange transfusion, and plasmapheresis. This review illustrates the potential indications and limitations in the application of these modalities as well as the pharmacological characteristics of poisons amenable to enhanced elimination.

Mushroom poisoning: a study on circumstances of exposure and patterns of toxicity

BACKGROUND

Picking wild mushrooms is a popular pastime in Switzerland. Correct identification of the species is difficult for laypersons. Ingestion of toxic mushrooms may result in serious toxicity, including death. The aim of the study is to analyze and describe the circumstances of exposure to mushrooms, and to define the clinical relevance of mushroom poisoning for humans in Central Europe.

MATERIALS AND METHODS

We performed a retrospective case study and analyzed all inquiries concerning human exposures to mushrooms (n = 5638, 1.2% of all inquiries) which were reported to the Swiss Toxicological Information Centre between January 1995 and December 2009.

RESULTS

The most frequent reason for contacting the poison center in cases of adult exposure was toxicity resulting from edible species. Pediatric exposure predominantly occurred from mushrooms found around the home. Severe symptoms have not only been observed after ingestion of non-amatoxin-containing toxic mushrooms, i.e. Boletus sp. and Cortinarius sp., but also after meals of edible species. The mortality of confirmed amatoxin poisonings was high (5/32) compared to other reports.

CONCLUSIONS

Inquiries regarding mushroom poisoning were a relatively infrequent reason for contacting the poison center. Nevertheless, accidental ingestion of toxic mushrooms can be responsible for severe or fatal poisonings. Although pediatric exposure to mushrooms found around the home has not led to serious toxicity in this study, prevention of exposure is warranted. Inspection of wild mushrooms by a certified mushroom expert or a mycologist seems to be a safe procedure which should be recommended.

Toxicology in the ICU: part 3: natural toxins

This is the third article of a three-part series that reviews the care of poisoned patients in the ICU. This article focuses on natural toxins, such as heavy metals and those produced by plants, mushrooms, arthropods, and snakes. The first article discussed the general approach to the patient, including laboratory testing; the second article focused on specific toxic agents, grouped into categories.

Amanitin intoxication in two beef calves in California

Two 2- and 3-month-old beef calves from 2 separate herds, locations, and times were found dead and were submitted to the veterinary diagnostic laboratory for diagnostic work-up. In both cases, no premonitory signs were seen by the owners. Histopathology revealed acute panlobular hepatic necrosis in both calves. In addition, calf A had copper and selenium deficiency, and calf B had oxalate nephrosis, and selenium and zinc deficiencies. Alpha-amanitin was detected in the urine from calf A, and in the liver and rumen contents from calf B using liquid chromatography–mass spectrometry. The cause of panlobular hepatic necrosis and death of both calves was determined to be amanitin toxicosis from ingestion of amanitin-containing mushrooms based on microscopic changes and toxicological analysis of tissues. In cases of sudden death in cows with histopathological findings of panlobular hepatic necrosis, toxicological analysis for amanitin is needed for a definitive diagnosis of poisoning by amanitin-containing mushrooms.

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.

Amatoxin poisoning treatment decision-making: pharmaco-therapeutic clinical strategy assessment using multidimensional multivariate statistic analysis

Ninety percent of fatal higher fungus poisoning is due to amatoxin-containing mushroom species. In addition to absence of antidote, no chemotherapeutic consensus was reported. The aim of the present study is to perform a retrospective multidimensional multivariate statistic analysis of 2110 amatoxin poisoning clinical cases, in order to optimize therapeutic decision-making. Our results allowed to classify drugs as a function of their influence on one major parameter: patient survival. Active principles were classified as first intention, second intention, adjuvant or controversial pharmaco-therapeutic clinical intervention. We conclude that (1) retrospective multidimensional multivariate statistic analysis of complex clinical dataset might help future therapeutic decision-making and (2) drugs such as silybin, N-acetylcystein and putatively ceftazidime are clearly associated, in amatoxin poisoning context, with higher level of patient survival.

Wild mushroom poisonings in the Middle Black Sea region in Turkey: Analyses of 6 years

Wild mushroom poisoning (MP) is an important medical emergency that may have serious clinical outcome. The aim of this study was to evaluate the demographic and clinical features of patients with wild MP. This study was designed retrospectively by examining files of the patients with wild MP who were admitted to Ondokuz Mayis University Emergency Department, between January 2002 and December 2007. Patients ≥16 years of age were included in the study. A total of 317 patients poisoned by wild mushrooms (mean age, 42.0 ± 16.3 years; 67.5% female) were studied. All poisonings were accidental, i.e. consumption of wild mushrooms collected from open fields and woodlands or purchased from local bazaars. The common symptoms and complaints on admission were nausea (86.8%) and vomiting (79.8%). The poisoning latent phase in most cases was <6 hours (86.8%). Most of the poisonings occurred in autumn (59.6%). Three patients died in the hospital due to acute liver failure and complications. The duration of hospitalization was a median 3 days (range: 1—12 days). The public should be informed about the probable hazards of wild mushroom ingestion.

Benzylpenicillin, acetylcysteine and silibinin as antidotes in human hepatocytes intoxicated with alpha-amanitin

Fatalities due to mushroom poisonings are increasing worldwide, with high mortality rate resulting from ingestion of amanitin-producing species. Intoxications caused by amanitin-containing mushrooms represent an unresolved problem in clinical toxicology since no specific and fully efficient antidote is available. The objective of this study was a comparative evaluation of benzylpenicillin (BPCN), acetylcysteine (ACC) and silibinin (SIL) as an antidotes in human hepatocytes intoxicated with alpha-amanitin (alpha-AMA). All experiments were performed on cultured human hepatocytes. Cytotoxicity evaluation of cultured cells using MTT assay and measurement of lactate dehydrogenase (LDH) activity was performed at 12, 24 and 48h of exposure to alpha-AMA and/or antidotes. The significant decline of cell viability and significant increase of LDH activity were observed in all experimental hepatocyte cultures after 12, 24 and 36h exposure to alpha-AMA at concentration 2microM. Exposure of the cells to alpha-AMA resulted also in significant reduction of cell spreading and attachment. However, addition of tested antidotes to experimental cultures significantly stimulated cell proliferation and attachment. In cell cultures exposed simultaneously to alpha-AMA and tested antidotes cytotoxic parameters (MTT and LDH) were not significantly different from control incidences. The cytoprotective effect of all antidotes was not dose-related, which reflects a high efficacy of all these substances. Administration of studied antidotes was not associated with any adverse effects in hepatocytes. The administration of ACC, BPCN or SIL to human hepatocyte cultures showed a similar strong protective effect against cell damage in alpha-AMA toxicity.