Investigation of Toxic Effects of Mushroom Poisoning on the Cardiovascular System

Mushroom Poisoning-Related Cardiac Toxicity: A Case Report and Systematic Review

We encountered a case of mushroom intoxication complicated by "toxic-like" myocarditis. Because of the lack of systematized knowledge on this subject, we performed a systematic review of the literature on cardiac toxicity in mushroom poisoning (MP). The aim of this study was to identify and describe the severity, the causal relationship, and the mushroom species involved in other reported cardiac events associated with MP. We included 39 studies in our review. We found 106 cases of cardiac events associated with MP, including 18 deaths. A wide variety of cardiac manifestations were reported, ranging from the simple elevation of cardiac enzymes (n = 61) to ventricular tachycardia (n = 14), acute heart failure (n = 18), and myocarditis (n = 7). Causal relationship between cardiac manifestations and mushroom poisoning was assessed for 42 patients, applying the algorithm validated by the French Toxicovigilance Coordination Committee. Twenty-three cases (54.8%) had a "possible" causal relationship, eight cases (19%) a "probable" relationship, and ten cases (23.8%) a "very probable" relationship. Several fungal genera were involved in reported cases, including Amanita but also rarer ones like Russula and Tricholoma. In conclusion, we showed that cases of cardiac toxicity following MP have been documented in the existing literature, and for some of them, we assessed a strong causal relationship.

Electrocardiogram Features in Non-Cardiac Diseases: From Mechanisms to Practical Aspects

Despite the noteworthy advancements and the introduction of new technologies in diagnostic tools for cardiovascular disorders, the electrocardiogram (ECG) remains a reliable, easily accessible, and affordable tool to use. In addition to its crucial role in cardiac emergencies, ECG can be considered a very useful ancillary tool for the diagnosis of many non-cardiac diseases as well. In this narrative review, we aimed to explore the potential contributions of ECG for the diagnosis of non-cardiac diseases such as stroke, migraine, pancreatitis, Kounis syndrome, hypothermia, esophageal disorders, pulmonary embolism, pulmonary diseases, electrolyte disturbances, anemia, coronavirus disease 2019, different intoxications and pregnancy.

Electrocardiogram of a patient with mushroom poisoning-induced myocarditis

A patient presented to our hospital with myocarditis caused by mushroom poisoning. The early ECG changes in this patient were very similar to the ECG of hyperacute ST-segment elevation myocardial infarction or hyperkalemia, but further tests eliminated these options. The patient was fully treated by timely hemodialysis treatment, confirming the diagnosis of mushroom poisoning-induced myocarditis. Although not specific to mushroom poisoning myocarditis, our experience shows that the observed ECG changes. Our findings have the potential to help diagnose and manage this potentially fatal disease in the future.

Successful Treatment of Near Fatal Cardiogenic Shock Following Toxic Mushroom Ingestion

Myocardial injury and hemodynamic compromise following toxic mushroom ingestion is rare. Here we present a case of cardiogenic shock after Amanita proxima ingestion, presenting with severe hemodynamic collapse necessitating mechanical circulatory support. Prompt identification, multidisciplinary clinical decision making, and timely treatment resulted in an outstanding complete clinical resolution. (Level of Difficulty: Intermediate.).

Extracorporeal membrane oxygenation combined with sequential blood purification in the treatment of myocardial damage and cardiac arrest caused by mushroom poisoning

Mushroom poisoning is a common clinical problem. Severe mushroom poisoning often causes liver and kidney failure. Although severe myocardial damage is rare, the fatality rate is extremely high. This case report describes a 56-year-old male suffered severe myocardial damage, multiple organ dysfunction, circulatory failure, recurrent malignant arrhythmia, and cardiac arrest after the ingestion of wild mushrooms. He was administered venoarterial extracorporeal membrane oxygenation (VA-ECMO) combined with hemoperfusion, plasma exchange and continuous renal replacement therapy. The heart rhythm gradually stabilized 3 hours after ECMO surgery. On the 6th day after ECMO, heart function recovered. The patient was then weaned from ECMO, and he ultimately recovered and was discharged. In patients with fatal mushroom poisoning leading to refractory arrhythmia and cardiac arrest, early implementation of VA-ECMO combined with sequential blood purification treatment can improve the prognosis and increase the survival rate.

Cardiac arrhythmias and cardiac arrest related to mushroom poisoning: A case report

BACKGROUND

Mushroom exposure is a global health issue. The manifestations of mushroom poisoning (MP) may vary. Some species have been reported as rhabdomyolytic, hallucinogenic, or gastrointestinal poisons. Critical or even fatal MPs are mostly attributable to Amanita phalloides, with the development of severe liver or renal failure. Myocardial injury and even cases mimicking ST-segment elevation myocardial infarction (STEMI) have been previously reported, while cardiac arrhythmia or cardiac arrest is not commonly seen.

CASE SUMMARY

We report a 68-year-old woman with MP who suffered from delirium, seizure, long QT syndrome on electrocardiogram (ECG), severe cardiac arrhythmias of multiple origins, and cardiac arrest. She was intubated and put on blood perfusion. Her kidney and liver functions were intact; creatine kinase-MB was mildly elevated, and then fell within normal range during her hospital stay. We sent the mushrooms she left for translation elongation factor subunit 1α, ribosomal RNA gene sequence, and internal transcribed spacer sequence analyses. There were four kinds of mushrooms identified, two of which were found to be toxic.

CONCLUSION

This is the first time that we found cardiac toxicity caused by Panaeolus subbalteatus and Conocybe lactea, which were believed to be toxic to the liver, kidney, and brain. We suggest that intensive monitoring and ECG follow-up are essential to diagnose prolonged QT interval and different forms of tachycardia in MP patients, even without the development of severe liver or renal failure. The mechanisms need to be further investigated and clarified based on animal experiments and molecular signal pathways.

[The histopathological features of the severe intoxication with amatoxin (toxin contained in Amanita phalloides mushrooms)]

Eating mushrooms known to contain amatoxin is fraught with serious complications. The analysis of the relevant literature publications revealed no article with the description of the histological picture of the internal organs in the subjects intoxicated with amatoxin. It is known, however, that such poisoning is associated with the severe irreversible injuries to all intracellular protein structures the character of which depends on time. Specifically, acute amatoxin intoxication produces the well apparent clinical picture within 6 days after intake of the poison. It is characterized by acute renal and hepatic insufficiency in the combination with the injury to the conducting system of heart and the myocrardium itself. Thereafter, the disseminated intravascular coagulation (DIC) syndrome developed accompanied by the signs of progressive tissue hypoxia that ended in death on day 9. The histological study has demonstrated necrotic foci in the liver and oedematous hepatic stroma. Kidneys underwent multiple hemorrhages, necrosis of convoluted tubules and well apparent hydropic protein dystrophy of their epithelium. The adrenal glands showed up signs of necrosis and hemorrhage. It is concluded that poisoning with mushrooms (amatoxin) should be regarded as the most probable cause of the condition requiring differential diagnostics between acute gastroenteritis and renal insufficiency.

Pharmacological activation of dimethylarginine dimethylaminohydrolase (DDAH) activity by inorganic nitrate and DDAH inhibition by NG-hydroxy-L-arginine, Nω,Nω-dimethyl-L-citrulline and Nω,Nω-dimethyl-Nδ-hydroxy-L-citrulline: results and overview

Asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) are endogenous inhibitors of nitric oxide (NO) synthase. SDMA is excreted in the urine without major metabolization. About 10% of daily produced ADMA are excreted unchanged in the urine. The major elimination route of ADMA (about 90%) involves its hydrolysis to dimethylamine (DMA) and L-citrulline by dimethylarginine dimethylaminohydrolase (DDAH) and excretion of DMA in the urine. High circulating and low excretory concentrations of ADMA are considered risk factors. Experimentally, DDAH activity can be inhibited by SH-specific agents such as inorganic and organic mercury compounds, and by S-nitrosothiols which block the SH group of a particular cysteine moiety of DDAH that is essential for its hydrolytic activity. Alternatively, DDAH activity can be inhibited by organic compounds that compete with the substrate ADMA for DDAH. Arginine analogs that contain substituents on guanidine nitrogen atom(s) (N^G) represent a class of DDAH inhibitors. In the present study, we investigated the effects of physiological and natural amino acid derivatives of L-arginine and L-citrulline as well as of nitrate and nitrite, the major circulating and excretory metabolites of NO and NO donating drugs. Here, we report for the first time that the physiological N^G-hydroxy-L-arginine, an isolable intermediate in NO synthesis, inhibits recombinant DDAH-1 activity (IC₅₀ ≈ 100 µM). Two plant L-citrulline derivatives, i.e., N^ω,N^ω-dimethyl-L-citrulline and N^ω,N^ω-dimethyl-N^δ-hydroxy-L-citrulline (connatin), were found to inhibit almost completely hepatic DDAH activity in vitro in rat homogenate at a concentration of 100 µM each. At pharmacological concentrations (i.e., 1 mM), inorganic nitrate, but not inorganic nitrite, was found to increase rat liver DDAH activity. In urine of 18 patients with Becker's muscular dystrophy, nitrate was found to correlate closely with DMA (Spearman, r = 0.73, p = 0.002). In summary, N^G-hydroxy-L-arginine, N^ω,N^ω-dimethyl-L-citrulline and N^ω,N^ω-dimethyl-N^δ-hydroxy-L-citrulline are novel inhibitors of DDAH activity. This article provides an overview of amino acid-based DDAH inhibitors and discusses potential underlying inhibition mechanisms.