New syndromes in mushroom poisoning

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.

No Evidence Was Found for the Presence of Terreolides, Terreumols or Saponaceolides H-S in the Fruiting Bodies of Tricholoma terreum (Basidiomycota, Agaricales)

Two different collections of the gilled wild fungus Tricholoma terreum, collected in Italy, were subjected to phytochemical analysis. The fungal material was confidently identified by analysis of the ITS genomic sequences. Using both HR-LC-MS and NMR techniques, no evidence was found for the presence in the fruiting bodies of terreolides, terreumols or saponaceolides H-S, in striking contrast with the isolation of these terpenoids by Chinese authors from a mushroom collected in France and identified as T. terreum. The main cytotoxic terpenoid identified and isolated from the extracts of the specimens investigated in this work was the C30 derivative saponaceolide B, which had been previously isolated from T. saponaceum and other T. terreum collections. Although saponaceolide B is a rather labile molecule, easily degradable by heat or in acidic conditions, our study indicated that none of the extraction protocols used produced saponaceolide H-S or terreolide/terreumol derivatives, thus excluding the possibility that the latter compounds could be extraction artifacts. Considered together, these findings point to the need for the unambiguous identification of mushroom species belonging to the complex genus Tricholoma, characterized by high variability in the composition of metabolites. Moreover, based on our data, T. terreum must be considered an edible mushroom.

Family matters inside the order Agaricales: systematic reorganization and classification of incertae sedis clitocyboid, pleurotoid and tricholomatoid taxa based on an updated 6-gene phylogeny

The phylogenetic position of several clitocyboid/pleurotoid/tricholomatoid genera previously considered incertae sedis is here resolved using an updated 6-gene dataset of Agaricales including newly sequenced lineages and more complete data from those already analyzed before. Results allowed to infer new phylogenetic relationships, and propose taxonomic novelties to accommodate them, including up to ten new families and a new suborder. Giacomia (for which a new species from China is here described) forms a monophyletic clade with Melanoleuca (Melanoleucaceae) nested inside suborder Pluteineae, together with the families Pluteaceae, Amanitaceae (including Leucocortinarius), Limnoperdaceae and Volvariellaceae. The recently described family Asproinocybaceae is shown to be a later synonym of Lyophyllaceae (which includes also Omphaliaster and Trichocybe) within suborder Tricholomatineae. The families Biannulariaceae, Callistosporiaceae, Clitocybaceae, Fayodiaceae, Macrocystidiaceae (which includes Pseudoclitopilus), Entolomataceae, Pseudoclitocybaceae (which includes Aspropaxillus), Omphalinaceae (Infundibulicybe and Omphalina) and the new families Paralepistaceae and Pseudoomphalinaceae belong also to Tricholomatineae. The delimitation of the suborder Pleurotineae (= Schizophyllineae) is discussed and revised, accepting five distinct families within it, viz. Pleurotaceae, Cyphellopsidaceae, Fistulinaceae, Resupinataceae and Schizophyllaceae. The recently proposed suborder Phyllotopsidineae (= Sarcomyxineae) is found to encompass the families Aphroditeolaceae, Pterulaceae, Phyllotopsidaceae, Radulomycetaceae, Sarcomyxaceae (which includes Tectella), and Stephanosporaceae, all of them unrelated to Pleurotaceae (suborder Pleurotineae) or Typhulaceae (suborder Typhulineae). The new family Xeromphalinaceae, encompassing the genera Xeromphalina and Heimiomyces, is proposed within Marasmiineae. The suborder Hygrophorineae is here reorganized into the families Hygrophoraceae, Cantharellulaceae, Cuphophyllaceae, Hygrocybaceae and Lichenomphaliaceae, to homogenize the taxonomic rank of the main clades inside all suborders of Agaricales. Finally, the genus Hygrophorocybe is shown to represent a distinct clade inside Cuphophyllaceae, and the new combination H. carolinensis is proposed. Taxonomic novelties: New suborder: Typhulineae Vizzini, Consiglio & P. Alvarado. New families: Aphroditeolaceae Vizzini, Consiglio & P. Alvarado, Melanoleucaceae Locq. ex Vizzini, Consiglio & P. Alvarado, Paralepistaceae Vizzini, Consiglio & P. Alvarado, Pseudoomphalinaceae Vizzini, Consiglio & P. Alvarado, Volvariellaceae Vizzini, Consiglio & P. Alvarado, Xeromphalinaceae Vizzini, Consiglio & P. Alvarado. New species: Giacomia sinensis J.Z. Xu. Stat. nov.: Cantharellulaceae (Lodge, Redhead, Norvell & Desjardin) Vizzini, Consiglio & P. Alvarado, Cuphophyllaceae (Z.M. He & Zhu L. Yang) Vizzini, Consiglio & P. Alvarado, Hygrocybaceae (Padamsee & Lodge) Vizzini, Consiglio & P. Alvarado, Lichenomphaliaceae (Lücking & Redhead) Vizzini, Consiglio & P. Alvarado. New combination: Hygrophorocybe carolinensis (H.E. Bigelow & Hesler) Vizzini, Consiglio & P. Alvarado. New synonyms: Sarcomyxineae Zhu L. Yang & G.S. Wang, Schizophyllineae Aime, Dentinger & Gaya, Asproinocybaceae T. Bau & G.F. Mou. Incertae sedis taxa placed at family level: Aphroditeola Redhead & Manfr. Binder, Giacomia Vizzini & Contu, Hygrophorocybe Vizzini & Contu, Leucocortinarius (J.E. Lange) Singer, Omphaliaster Lamoure, Pseudoclitopilus Vizzini & Contu, Resupinatus Nees ex Gray, Tectella Earle, Trichocybe Vizzini. New delimitations of taxa: Hygrophorineae Aime, Dentinger & Gaya, Phyllotopsidineae Zhu L. Yang & G.S. Wang, Pleurotineae Aime, Dentinger & Gaya, Pluteineae Aime, Dentinger & Gaya, Tricholomatineae Aime, Dentinger & Gaya. Resurrected taxa: Fayodiaceae Jülich, Resupinataceae Jülich. Citation: Vizzini A, Alvarado P, Consiglio G, Marchetti M, Xu J (2024). Family matters inside the order Agaricales: systematic reorganization and classification of incertae sedis clitocyboid, pleurotoid and tricholomatoid taxa based on an updated 6-gene phylogeny. Studies in Mycology 107: 67-148. doi: 10.3114/sim.2024.107.02.

Mortality Cases of Mushroom Poisoning with Russula subnigricans

Mushroom poisoning is increasing worldwide, as well as the incidence of fatal mushroom poisoning. Several new syndromes associated with mushroom poisoning have been described in the literature. Notably, 1 of the newly identified mushroom poisonings is Russula subnigricans poisoning. R subnigricans can be classified as causing a delayed-onset rhabdomyolytic syndrome as patients with this severe poisoning present with severe rhabdomyolysis, acute kidney injury, and cardiomyopathy. However, there are only a few reports on the toxicity of R subnigricans. We recently treated 6 patients with R subnigricans mushroom poisoning, of whom 2 died. The 2 patients showed severe rhabdomyolysis, metabolic acidosis, acute renal failure, electrolyte imbalance, and irreversible shock, which caused their deaths. Mushroom poisoning should be considered in the evaluation of rhabdomyolysis of unknown origin. In addition, in cases of mushroom poisoning with severe rhabdomyolysis, R subnigricans poisoning should be promptly identified.

The epidemiology of wild mushroom poisoning in Israel

Wild mushroom (macrofungi) picking has become a popular activity in Israel in recent years. Besides the estimated 135 edible species, the mycobiota of Israel includes also around 65 poisonous and potentially dangerous species. We conducted a long-term retrospective study to monitor the frequency, severity, seasonal character, species composition, and geographic distribution of mushroom exposure and poisoning in Israel. Using data collected by the Israel Poison Information Center in Rambam Health Care Campus, Haifa, during the years 2010-2021, we report that only 4% of cases of exposures due to biological agents were caused by mushrooms. Males were significantly (P < 0.004) more affected than females. Most cases involved either above 18 years of age (41%) or below the age of 6 years (39%). Most of the children under 6 years of age did not develop signs or symptoms of toxicity. During 2017-2021, 128 cases (82.5%) involved the consumption of raw mushrooms, mostly by children under 6 years of age. The most common season of mushroom exposure was rainy winters (P < 0.05). Mushrooms collected from irrigated lawns in the summer also posed a risk. Ingestion of Chlorophyllum molybdites was the leading mushroom ingestion in summer and that of Inocybe species in winter. Our study contributes to improved awareness of mushroom exposure and poisoning patterns among the Israeli population.

Russula subnigricans Poisoning Causes Severe Rhabdomyolysis That Could be Misdiagnosed as Non-ST Segment Elevation Myocardial Infarction

Mushroom poisoning and subsequently the number of patients visiting emergency rooms are increasing, as well as the proportion of fatal mushroom poisonings. Myocytic mushroom poisoning is one of the new clinical classifications. This report documents the course of a family with Russula subnigricans poisoning complicated by severe rhabdomyolysis, including a case that was misdiagnosed as myocardial infarction. A 64-y-old man visited our hospital with symptoms including substernal chest discomfort, nausea, vomiting, and myalgia, lasting for 12 h. His laboratory tests showed elevated serum high-sensitive troponin I. He was diagnosed with non-ST segment elevation myocardial infarction. After that, 2 family members who ate mushrooms together were transferred from a local emergency room with the diagnosis of rhabdomyolysis. Consequently, rhabdomyolysis due to mushroom poisoning was diagnosed. They were hospitalized in the intensive care unit. After admission, conservative management, including primary fluid resuscitation, was performed, and the patients were discharged without complications. R subnigricans poisoning was revealed after investigation and should be considered in mushroom poisoning with rhabdomyolysis. Early recognition and intensive supportive care are important for mushroom poisoning patients.

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.

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.

Toxic Potential of Traditionally Consumed Mushroom Species-A Controversial Continuum with Many Unanswered Questions

Mushroom poisonings remain a significant cause of emergency medicine. While there are well-known species, such as Amanita phalloides, causing life-threatening poisonings, there is also accumulating evidence of poisonings related to species that have been considered edible and are traditionally consumed. In particular, the Tricholoma equestre group was reported to cause myotoxicity. In addition, particular wild mushrooms that are traditionally consumed especially in Asia and Eastern Europe have been subject to suspicion due to possible mutagenicity. Hitherto, the causative agents of these effects often remain to be determined, and toxicity studies have yielded contradictory results. Due to this, there is no consensus about the safety of these species. The issue is further complicated by difficulties in species identification and other possible sources of toxicity, such as microbiological contamination during storage, leading to sometimes opposite conclusions about the edibility of a species. This review focuses on existing data about these types of mushroom poisonings, including the still sparse knowledge about the causative chemical agents. In addition, the aim is to initiate a meta-discussion about the issue and to give some suggestions about how to approach the situation from the viewpoint of the collector, the researcher, and the practicing physician.

Mushroom Toxins: Chemistry and Toxicology

Mushroom consumption is a global tradition that is still gaining popularity. However, foraging for wild mushrooms and accidental ingestion of toxic mushrooms can result in serious illness and even death. The early diagnosis and treatment of mushroom poisoning are quite difficult, as the symptoms are similar to those caused by common diseases. Chemically, mushroom poisoning is related to very powerful toxins, suggesting that the isolation and identification of toxins have great research value, especially in determining the lethal components of toxic mushrooms. In contrast, most of these toxins have remarkable physiological properties that could promote advances in chemistry, biochemistry, physiology, and pharmacology. Although more than 100 toxins have been elucidated, there are a number of lethal mushrooms that have not been fully investigated. This review provides information on the chemistry (including chemical structures, total synthesis, and biosynthesis) and the toxicology of these toxins, hoping to inspire further research in this area.

Toxicological profile of Amanita virosa - A narrative review

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Globally, mushroom poisoning leads to a considerable number of deaths annually. However, no definite antidote has been introduced yet.

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A mushroom-poisoning outbreak occurred in 2018 in Iran; this overview presents geographical distribution of Amanita virosa along with studies reporting A. virosa poisonings.

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Also, main toxins of A. virosa, their toxicity mechanisms and pharmacological management of mushroom-poisoned individuals are presented.

Mushrooms account for a part of human diet due to their exquisite taste and protein content as well as their promising health effects unveiled by scientific research. Toxic and non-toxic mushrooms frequently share considerable morphological similarities, which mislead the collectors/consumers, resulting in mycotoxicity. Numerous mushroom species are considered “poisonous” as they produce dangerous toxins. For instance, members of the genus Amanita, especially A. phalloides, A. virosa and A. verna, are responsible for severe and even life-threatening noxious consequences. Globally, mushroom poisoning is a crucial healthcare issue as it leads to a considerable number of deaths annually. However, no definite antidote has been introduced to treat this poisoning. The present article discusses the characteristics of A. virosa in terms of epidemiology, mechanisms of toxicity, poisoning features and management.

Secondary Metabolites Isolated fromTricholomaSpecies (Basidiomycota, Tricholomatacee): A Review

The large mushroom genus Tricholoma (Fr.) Staude comprises hundreds of species growing worldwide. Phytochemical studies on the contents of these mushrooms have been increasing steadily in the last decades; this review is the first complete report about the secondary metabolites isolated to date (January 2018) from the fruiting bodies, with the exclusion of most volatile constituents. The structures, presumed biogenesis, and bioactivities of identified compounds, divided in families according to their biogenesis, are critically discussed. A brief chemotaxonomic discussion of the genus Tricholoma is included in the final part of the review.

Current pain management strategies for patients with erythromelalgia: a critical review

Erythromelalgia (EM) is a rare disorder characterized by erythematous, warm, painful extremities, which is often precipitated by cold conditions. The pathophysiology of EM is incompletely understood. Recent investigations have identified sodium channelopathy as a genetic cause for this pain condition, classified as primary inherited EM. Other subtypes are idiopathic EM and secondary EM. The management of pain in EM is challenging as no single therapy has been found to be effective. There is varying response to pharmacotherapy and significant variability within this clinical population, resulting in a stepwise trial and error approach. Consequently, EM is often associated with poorer health-related quality of life with higher morbidity. There is currently no consensus or guidelines on management of pain in EM. This is a review of the literature on management of pain using pharmacologic, procedural intervention and nonpharmacologic treatment in children and adults with EM.

Myo- and cardiotoxic effects of the wild winter mushroom ( Flammulina velutipes) on mice

Rhabdomyolysis (destruction of striated muscle) is a novel form of mushroom poisoning in Europe and Asia indicated by increased circulating creatine kinase levels. Particular wild fungi have also been reported to induce elevated creatine kinase activities in mice. Flammulina velutipes (enokitake or winter mushroom) is one of the most actively cultivated mushroom species globally. As it is marketed as a medicinal mushroom and functional food, it is important to examine whether it could induce potentially harmful health effects similar to some previously studied edible fungi. The present study examined the effects of F. velutipes consumption on the plasma clinical chemistry, hematology, and organ histology of laboratory mice. Wild F. velutipes were dried, pulverized, mixed with a regular laboratory rodent diet, and fed to the animals at 0, 3, 6, or 9 g/kg body mass/day for five days ( n = 6/group). F. velutipes consumption caused increased activities of plasma creatine kinase and the MB-fraction of creatine kinase at 6-9 g/kg/d, indicating potentially deleterious effects on both skeletal and cardiac muscle. The plasma total and high-density lipoprotein cholesterol concentrations (at 9 g/kg/d) and white blood cell and lymphocyte counts (at 6-9 g/kg/d) decreased. Although the cholesterol-lowering properties of F. velutipes can be beneficial, the previously unexamined, potentially hazardous side effects of mushroom consumption (myo- and cardiotoxicity) should be thoroughly investigated before recommending this mushroom species as a health-promoting food item. Impact statement This work is important to the field of functional foods, as it provides novel information about the potential myo- and cardiotoxic properties of an edible mushroom, Flammulina velutipes. The results are useful and of importance because F. velutipes is an actively cultivated mushroom and marketed as a health-promoting food item. The findings contribute to the understanding of the complexity of the balance between the beneficial and potentially harmful effects of mushroom consumption.

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)

Cyclopeptide toxins of lethal amanitas: Compositions, distribution and phylogenetic implication

Lethal amanitas (Amanita sect. Phalloideae) are responsible for 90% of all fatal mushroom poisonings. Since 2000, more than ten new lethal Amanita species have been discovered and some of them had caused severe mushroom poisonings in China. However, the contents and distribution of cyclopeptides in these lethal mushrooms remain poorly known. In this study, the diversity of major cyclopeptide toxins in seven Amanita species from Eastern Asia and three species from Europe and North America were systematically analyzed, and a new approach to inferring phylogenetic relationships using cyclopeptide profile was evaluated for the first time. The results showed that there were diversities of the cyclopeptides among lethal Amanita species, and cyclopeptides from Amanita rimosa and Amanita fuligineoides were reported for the first time. The amounts of amatoxins in East Asian Amanita species were significantly higher than those in European and North American species. The analysis of distribution of amatoxins and phallotoxins in various Amanita species demonstrated that the content of phallotoxins was higher than that of amatoxins in Amanita phalloides and Amanita virosa. In contrast, the content of phallotoxins was significantly lower than that of amatoxins in all East Asian lethal Amanita species tested. However, the distribution of amatoxins and phallotoxins in different tissues showed the same tendency. Eight cyclopeptides and three unknown compounds were identified using cyclopeptide standards and high-resolution MS. Based on the cyclopeptide profiles, phylogenetic relationships of lethal amanitas were inferred through a dendrogram generated by UPGMA method. The results showed high similarity to the phylogeny established previously based on the multi-locus DNA sequences.

A Case of Mushroom Poisoning with Russula subnigricans: Development of Rhabdomyolysis, Acute Kidney Injury, Cardiogenic Shock, and Death

Mushroom exposures are increasing worldwide. The incidence and fatality of mushroom poisoning are reported to be increasing. Several new syndromes in mushroom poisoning have been described. Rhabdomyolytic mushroom poisoning is one of new syndromes. Russula subnigricans mushroom can cause delayed-onset rhabdomyolysis with acute kidney injury in the severely poisoned patient. There are few reports on the toxicity of R. subnigricans. This report represents the first record of R. subnigricans poisoning with rhabdomyolysis in Korea, describing a 51-year-old man who suffered from rhabdomyolysis, acute kidney injury, severe hypocalcemia, respiratory failure, ventricular tachycardia, cardiogenic shock, and death. Mushroom poisoning should be considered in the evaluation of rhabdomyolysis of unknown cause. Furthermore, R. subnigricans should be considered in the mushroom poisoning with rhabdomyolysis.

Acute hepatorenal failure in a patient following consumption of mushrooms: a case report

INTRODUCTION

One of the highly toxic mushrooms that are common in the northwest region of Iran is Amanita phalloides, which might result in renal or liver failure.

CASE PRESENTATION

This is a case report of a patient referred a few days after consumption of wild mushrooms to emergency department having gastrointestinal complaint whose experiments indicated liver and renal failure. The supportive treatment was given to the patient prescribing N-acetyl cysteine (NAC) and Livergol (silymarin) along with hemodialysis. A few days after admission to the hospital, the patient died due to severe clinical symptoms.

CONCLUSIONS

The patient was poisoned by A. phalloides complaining gastrointestinal symptoms including nausea; vomiting and watery diarrhea about six hours after consumption and then, amatoxin in the mushroom caused damage to hepatocytes and renal cells and finally led to hepatorenal failure. Deaths caused by this type of mushroom are extremely high and necessary trainings should be provided to the people by the health system not to consume wild mushrooms, especially in spring and summer.

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.

[Mass poisoning events]

BACKGROUND

Mass poisoning events are rare and different in some respects from other mass casualties, especially with regard to diagnosis and triage.

OBJECTIVES

Based on the description of important historical events and experiences of poison control centers, an overview is provided for different types of mass poisoning events as well as guidelines for specific medical management.

MATERIALS AND METHODS

The review is based on a literature search and case reports notified to the Giftinformationszentrum-Nord Poisons Center.

RESULTS

Toxicological risk assessment is based on identification of all relevant agents, evaluation of their toxic hazards (toxicity), and evaluation of the exposure (dose and pathway) for all persons exposed. This risk assessment constitutes the basis of medical diagnosis and management. In cases of suspicion of poisoning or poisonings caused by illegal drugs, risk assessment may be difficult due to the lack of important data needed for risk assessment. Mass poisonings caused by ethanol or contaminated food are well understood, with therapy being mainly symptomatic. However, in rare poisonings by other agents, a specific antidote treatment may be important. Thus, adequate antidote supplies must be available for these events.

CONCLUSION

As hardly any medical professional has personal practical knowledge of mass poisoning casualties, such events are unique experiences. Thorough preparation and intensive cooperation with poison control centers and-if applicable-public health authorities may be important for best practice event management.

Muscarinic toxicity among family members after consumption of mushrooms

Mushrooms are commercially cultivated over the world and safe for human consumption, except in those with known allergies. Among the thousands of mushroom species identified, few are considered to be edible. Mushroom hunting has emerged as an adventure and recreational activity in recent decades. Wild forms of mushrooms are often poisonous and visually mimic the edible ones, thus leading to mistaken harvesting, consumption, and toxicities. In literature, various systemic toxic syndromes associated with mushroom poisoning have been described. We report four members of a family with muscarinic manifestations after accidental consumption of poisonous mushrooms. The Clitocybe species of mushrooms they consumed resulted in their muscarinic toxicity. Patients with muscarinic mushroom toxicity have early onset of symptoms and they respond well to atropine and symptomatic supportive care.

Mycophilic or mycophobic? Legislation and guidelines on wild mushroom commerce reveal different consumption behaviour in European countries

Mycophiles forage for and pick vast quantities of a wide variety of wild mushroom species. As a result, mushroom intoxications are comparatively frequent in such countries with mycophiles. Thus, national governments are forced to release guidelines or enact legislation in order to ensure the safe commerce of wild mushrooms due to food safety concerns. It is in these guidelines and laws that one can observe whether a country is indeed mycophobic or mycophilic. Furthermore, these laws and guidelines provide valuable information on mushroom preferences and on the consumption habits of each country. As such we were interested in the questions as to whether mushroom consumption behaviour was different within Europe, and if it was possible to discover the typical or distinctive culinary preferences of Slavic or Romanic speaking people, people from special geographical regions or from different zones. This work is based on the analysis of edible mushroom lists available in specific guidelines or legislation related to the consumption and commerce of mushrooms in 27 European countries. The overall diversity of edible mushrooms authorised to be commercialised in Europe is very high. However, only 60 out of a total 268 fungal species can be cultivated. This highlights the importance of guidelines or legislation for the safe commerce of wild mushrooms. The species richness and composition of the mushrooms listed for commerce is very heterogeneous within Europe. The consumption behaviour is not only language-family-related, but is strongly influenced by geographical location and neighbouring countries. Indicator species were detected for different European regions; most of them are widespread fungi, and thus prove culture-specific preferences for these mushrooms. Our results highlight tradition and external input such as trade and cultural exchange as strong factors shaping mushroom consumption behaviour.

Molybdophyllysin, a toxic metalloendopeptidase from the tropical toadstool, Chlorophyllum molybdites

A toxic protein, dubbed molybdophyllysin, was isolated from the tropical toadstool Chlorophyllum molybdites by following its lethal effect in mice. Analysis of the protein using SDS-PAGE revealed a single 23-kDa band. Sequence analysis of molybdophyllysin tryptic fragments showed that this protein is highly homologous to metalloendopeptidases (MEPs) obtained from edible mushrooms, such as Grifola frondosa, Pleurotus ostreatus, and Armillaria mellea. These proteins include a HEXXH+D zinc-binding motif known as aspzincin. Accordingly, molybdophyllysin is a member of the deuterolysin family of zinc proteases. Molybdophyllysin retained its proteolytic activity at temperatures up to 60°C with an optimum pH of 7.0. The activity was inhibited by both 1,10-phenanthroline and N-bromosuccinimide, but molybdophyllysin exhibited strong resistance to SDS.

Clusters of sudden unexplained death associated with the mushroom, Trogia venenata, in rural Yunnan Province, China

Introduction

Since the late 1970's, time-space clusters of sudden unexplained death (SUD) in northwest Yunnan, China have alarmed the public and health authorities. From 2006–2009, we initiated enhanced surveillance for SUD to identify a cause, and we warned villagers to avoid eating unfamiliar mushrooms.

Methods

We established surveillance for SUD, defined as follows: sudden onset of serious, unexplained physical impairment followed by death in <24 hours. A mild case was onset of any illness in a member of the family or close socially related group of a SUD victim within 1 week of a SUD. We interviewed witnesses of SUD and mild case-persons to identify exposures to potentially toxic substances. We tested blood from mild cases, villagers, and for standard biochemical, enzyme, and electrolyte markers of disease.

Results

We identified 33 SUD, a 73% decline from 2002–2005, distributed among 21 villages of 11 counties. We found a previously undescribed mushroom, Trogia venenata, was eaten by 5 of 7 families with SUD clusters compared to 0 of 31 other control-families from the same villages. In T. venenata–exposed persons SUD was characterized by sudden loss of consciousness during normal activities. This mushroom grew nearby 75% of 61 villages that had time-space SUD clusters from 1975 to 2009 compared to 17% of 18 villages with only single SUD (p<0.001, Fisher's exact test).

Discussion

Epidemiologic data has implicated T. venenata as a probable cause of clusters of SUD in northwestern Yunnan Province. Warnings to villagers about eating this mushroom should continue.

[Occurrence of severe cardiac alterations in Amanita proxima poisoning: two original observations]

Amanita proxima is one species of white mushroom which can induce poisonings called in France "proximien" syndrome. The clinical feature of "proximien" syndrome is mainly characterized by early digestive troubles, mild hepatic cytolysis and late renal impairment. A cardiac insult has never been reported in such a circumstance. The authors describe herein two cases of white mushroom poisoning occurred in the Mediterranean French coast with a typical clinical feature of "proximien" syndrome plus secondary development of severe cardiac alterations. The outcome was good for the two patients thanks to symptomatic treatment. The cases reported here suggest that A. proxima have a potential severe cardiac toxicity leading to include early and precise cardiac examination in the management of patients poisoned by these mushrooms.

[Amanita proxima poisoning in a child]

Mushroom intoxication due to Amanita proxima poisoning is characterized by moderate gastrointestinal symptoms, followed by severe acute renal failure and sometimes by hepatic cytolysis. This syndrome was described in the 1990s in the southeast of France; we report here the first pediatric case, requiring dialysis but achieving complete recovery. The mother of this 11-year-old boy, who had eaten the same mushrooms but in smaller quantities, had only biological renal and hepatic involvement.

Toxicity of Non-protein Amino Acids to Humans and Domestic Animals

Non-protein amino acids are common in plants and are present in widely consumed animal feeds and human foods such as alfalfa ( Medicago sativa), which contains canavanine, and lentil ( Lens culinaris), which contains homoarginine. Some occur in wild species that are inadvertently harvested with crop species. Some nonprotein amino acids and metabolites can be toxic to humans, e.g. Lathyrus species contain a neurotoxic oxalyl-amino acid. Some potential toxins may be passed along a food chain via animal intermediates. The increased interest in herbal medicines in the Western countries will increase exposure to such compounds.

Non-drug-induced nephrotoxicity

Several drugs and other compounds can induce acute and/or chronic nephrotoxicity. The goal of this study was to review clinical features of nephrotoxicity induced by 'atypical' or 'unconventional' agents, such as environmental agents (metals, minerals, animals), food agents (mushrooms, aristolochic acid, medicinal traditional herbals, dietary supplements, melamine), drugs, and other products (ethylene glycol). Nephrotoxicity varies according to local background, dependent on different food and cultural customs, as well as to differences in local fauna and flora. The incidence of such a phenomenon is not well known. Many different pathophysiological pathways are involved, and the spectrum of renal lesions is rather wide. 'Epidemic nephrotoxicity' may occur, as recently illustrated by the melamine epidemics in Chinese infants receiving powdered milk formulas; a rapid reaction to unusual increased frequency of acute kidney injury and nephrolithiasis in young children has led to a rapid analysis from international experts, with subsequent recommendations for diagnosis and care. Nephrotoxicity should be considered when there is any unexplained renal impairment, especially in children.

Amanita smithiana mushroom ingestion: a case of delayed renal failure and literature review

INTRODUCTION

In the Pacific Northwest a new pattern of mushroom ingestion has emerged, attributed to Amanita smithiana, in which renal failure has been the predominant manifestation.

CASE REPORT

A 55-year-old male ate 3 raw wild mushrooms in a salad and had onset of severe nausea and vomiting within 6 hours. His vital signs were unremarkable. His labs were significant for a BUN of 14 mg/dL (5.0 mmol/L), and a creatinine of 1.0 mg/dL (88 umol/L), transaminases were elevated with an AST of 56 U/L (nl 9-40) and an ALT of 131 U/L (nl 14-72). Treatment was initiated with N-acetyl cysteine, penicillin, and milk thistle extract on the presumption that this was an amanitin-toxin containing mushroom. He developed acute renal failure that was not responsive to our treatment. Dialysis started on day 4 with a creatinine of 6.5 mg/dL, which peaked on day 7 at 10.2 mg/dL. We were able to obtain a positive mushroom identification by a mycologist as Amanita smithiana. The patient was discharged from the hospital for outpatient dialysis on day 10 and dialysis catheter was removed 39 days after ingestion with a creatinine of 1.4 mg/dL (123.8 umol/L).

DISCUSSION

Amanita smithiana mushroom poisoning presents within 6 hours of ingestion with GI toxicity, and develops delayed onset of renal insufficiency over the first 1 to 4 days. The early hospitalization of this case allowed a profile of the onset of liver and renal injury. Mild elevation of hepatic transaminases occurred on presentation and peaked 24 hours after the ingestion. Renal injury was detected 1 day after presentation, and progressed to require hemodialysis by 4 days postingestion. This pattern of delayed-onset renal toxic mushroom ingestion is emerging among mushroom ingestions in Western North America.

Excitatory actions of mushroom poison (acromelic acid) on unmyelinated muscular afferents in the rat

Ingestion of a poisonous mushroom, Clitocybe acromelalga, results in strong and long-lasting allodynia, burning pain, redness and swelling in the periphery of the body. Acromelic acid (ACRO), a kainate analogue isolated from the mushroom, is assumed to be involved in the poisoning. ACRO has two isomers, ACRO-A and ACRO-B. The potency of ACRO-A is a million times higher than that of ACRO-B for induction of allodynia when intrathecally administered in mice. The effect of ACRO on the primary afferents of somatic tissues remains largely unknown. The aim of the present study was to examine the effect of ACRO-A on the response behavior of unmyelinated afferents in the skeletal muscle. For this purpose single fiber recordings of C-afferents were made from rat extensor digitorum longus (EDL) muscle-common peroneal nerve preparations in vitro. Intramuscular injections of ACRO-A at three different concentrations (10(-12), 10(-10) and 10(-8)M, 5 microl over 5s) near the receptive field in the EDL muscle elicited excitation of C-afferents (12%, 50% and 44%, respectively). ACRO-A at the concentration of 10(-10)M induced the strongest excitation. The incidence of ACRO-A responsive fibers at the concentration of 10(-10) and 10(-8)M was significantly higher than that at 10(-12)M. The responses to mechanical and heat stimulations did not differ between ACRO-A sensitive and insensitive fibers. These results clearly demonstrated the powerful excitatory action of ACRO-A on mechanosensitive unmyelinated afferents in the rat skeletal muscle.

Outbreak of fatal mushroom poisoning with Amanita franchetii and Ramaria rufescens

Mushroom poisoning continues to occur worldwide. We report a cluster of sudden death in two villages of the Gan County, Jiangxi Province, People's Republic of China in September 2005. Extensive investigations on the clinical presentation, epidemiological features, food and water sources have led to the identification of mushroom poisoning. Each of the 10 patients ate wild mushrooms, identified as Amanita franchetii and Ramaria rufescens, and suffered gastrointestinal symptoms prior to sudden deaths.

Toxicological screening of lyophilized extract of some Nigerian wild mushrooms in mice

Mushrooms are macrofungi widely consumed as food. However, many mushrooms rot away in the wild because of fear of toxicity. Therefore, lyophilized aqueous extracts of 6 mushroom species collected from Zaria, Nigeria and taxonomically identified as Chlorophyllum molybdites, Panaeolus subalteatus, Macrolepiota procera, Leucopaxillus albissmus, Hygrophoropsis aurantiacus and Pholiota aurea were screened for toxicity in mice. Lyophilized aqueous extract of each of these mushrooms was administered to three groups of 3 mice intraperitoneally (i.p.) at doses of 100, 1000 and 10, 000 mg kg(-1), respectively. Another group of three mice given distilled water served as control. The mice were examined for clinical signs of toxicity over a period of 72 h and pathological examinations conducted on dead animals. The severity of clinical signs, onset of death and pathological lesions were dose dependent. Death occurred within 10 min in all the mice dosed at 10,000 mg kg(-1) with the lyophilized extracts of all the mushrooms screened, with the exception of that of H. aurantiacus, which produced death 21-23 h post administration. This result showed that all the screened mushrooms, including the popular edible M. procera were found toxic. Therefore, since all the mushrooms screened were found toxic, it is recommended that extreme caution should be exercised in their consumption. Furthermore, in view of the regional differences in the toxicity of mushrooms, there is the need to screen more wild mushrooms found in Nigeria for toxicity. This will boost mushroom mycophagy, reduce poisoning incidence and reduce wastage of edible mushrooms in the wild.