A series of cases of rhabdomyolysis after ingestion of Tricholoma equestre

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.

Myotoxic Mushroom Poisoning in Thailand: Clinical Characteristics and Outcomes

Purpose

To describe the clinical characteristics and outcomes of myotoxic mushroom poisoning in Thailand.

Patients and Methods

We performed a retrospective cohort study of cases of myotoxic mushroom poisoning from the Ramathibodi Poison Center Toxic Exposure Surveillance System during a 5-year period (2012-2016).

Results

Forty-one cases were included. Most (53.7%) were male with the average age of 49 years. In three cases, the mushrooms were identified as Russula species by an experienced mycologist. Common presenting symptoms were gastrointestinal (GI) symptoms and myalgia. The median onset of GI symptoms and symptoms suggesting rhabdomyolysis after consuming mushrooms was 2 hours (0.17-24 hours) and 24-48 hours (2-120 hours), respectively. Eight patients who ate the mushrooms together with other patients with rhabdomyolysis had GI symptoms but did not develop rhabdomyolysis. For patients with rhabdomyolysis, acute kidney injury (AKI) and hyperkalaemia occurred in 51.5% and 33.3% of cases, respectively. Median initial and maximum creatine phosphokinase (CPK) levels in patients with rhabdomyolysis were 31,145 and 47,861 U/L, respectively. Fifteen of 17 patients who were investigated for troponin levels had elevated troponin. Three patients had a low ejection fraction. Most patients (95.1%) were admitted to hospital, with a median stay of 5 days. The mortality rate was 26.8%. Treatments included intravenous fluid, urine alkalinization, haemodialysis and peritoneal dialysis. Among patients with rhabdomyolysis, AKI, hyperkalaemia during hospitalisation, maximum CPK level, maximum creatinine level and initial and maximum potassium levels were the factors found to be significantly different between patients who died and those who survived.

Conclusion

Myotoxic mushroom poisoning had a high mortality rate. Most patients had early or delayed onset of clinical symptoms after mushroom ingestion. Some patients developed severe cardiovascular effects. Early detection, close monitoring (especially serum potassium, creatinine, CPK and cardiac effect) and good supportive care were the main treatment modalities.

Quantitative analysis of the Tricholoma ustale-derived toxin, ustalic acid, in mushroom and food samples by LC-MS/MS

Tricholoma ustale, a poisonous member of the Tricholomataceae family, causes gastrointestinal symptoms such as diarrhea and vomiting. In Japan, 86 cases (affecting a total of 347 patients) of poisoning with Tricholoma ustale have been reported between 1989 and 2010. Ustalic acid is one of the primary toxic components in Tricholoma ustale. In the present study, the quantitative analysis of the ustalic acid content in mushroom and food samples was conducted by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Mushroom and food samples were extracted using methanol containing 0.5% formic acid and 50% aqueous methanol, respectively. Purification using SAX solid-phase extraction (SPE) was conducted prior to LC-MS/MS analysis, which was performed in the ESI negative mode using a C18 column. The method developed for the LC-MS/MS analysis of ustalic acid was extremely sensitive. The limits of quantitation calculated at a signal-to-noise ratio of 10 were 10ng/g (shiitake mushroom) and 0.40ng/g (miso soup). The accuracies of quantitation in the shiitake mushroom and miso soup samples ranged from 99.8%-105% and 98.8%-102%, respectively. This method was applied to leftover mushroom samples from a food poisoning case; here, ustalic acid was detected at 0.57, 3.7μg/g. This analytical method using LC-MS/MS could be useful in food poisoning cases involving mushrooms. This is the first report in which the ustalic acid content was determined using the leftovers of a food poisoning case.

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.

The Yellow Knight Fights Back: Toxicological, Epidemiological, and Survey Studies Defend Edibility of Tricholoma equestre

Rhabdomyolysis, a condition associated with the consumption of Yellow Knight mushrooms (Tricholoma equestre), was first reported in 2001. In response, some countries began to consider the mushroom as poisonous, whereas in others it is still consumed. In the present study, a nationwide survey of Polish mushroom foragers (n = 1545) was conducted to estimate the frequency of T. equestre consumption. The epidemiological database on mushroom poisonings in Poland was analyzed from the year 2008. Hematological and biochemical parameters were followed for a week in 10 volunteers consuming 300 g of molecularly identified T. equestre. More than half the foragers had consumed T. equestre at least once in their lifetime and a quarter had consumed it consecutively. The frequency of adverse events was low and no rhabdomyolysis was reported. The toxicological database indicated that mushrooms from the Tricholoma genus caused poisonings less frequently than mushrooms with well-established edibility and not a single case of rhabdomyolysis has been reported within the last decade. The volunteers consuming T. equestre revealed no hematological or biochemical alterations and no adverse effects were observed. The findings of this study support the view that T. equestre is edible if consumed in rational amounts by healthy subjects.

Is the Yellow Knight Mushroom Edible or Not? A Systematic Review and Critical Viewpoints on the Toxicity of Tricholoma equestre

There is no scientific consensus regarding the safety of the Yellow Knight mushroom Tricholoma equestre (L.) P.Kumm. Following reports of cases of intoxication involving effects such as rhabdomyolysis, and supportive observations from in vivo experimental models, T. equestre is considered as a poisonous mushroom in some countries while in others it is still widely collected from the wild and consumed every year. In this paper, we review all the available information on T. equestre including its morphological and molecular characterization, nutritional value, levels of contaminants observed in fruiting bodies, the possibility of mistake with species that are morphologically similar, and the in vivo data on safety and cases of human intoxication. Based on available data, it is suggested that T. equestre cannot be considered as a toxic species and does not appear to exhibit any greater health threat than other mushroom species currently considered as edible. More care should be taken when reporting cases of human poisoning to fully identify T. equestre as the causative agent and to exclude a number of interfering factors. Specific guidelines for reporting future cases of poisoning with T. equestre are outlined in this paper. Any future research involving T. equestre should present the results of molecular phylogenetic analyses.

[Mixed amanita phalloides poisoning with rhabdomyolysis: analysis of 4 cases]

We report the clinical characteristics, treatments and outcomes of 4 rare cases of mixed amanita fuliginea and amanita rimosa poisoning with rhabdomyolysis, and review the research progress in the intoxication mechanism and treatment. The latent time of amanita poisoning, defined as the period from the ingestion of poisonous mushroom to the onset of gastrointestinal symptoms, was about 8 days, and the severity of poisoning was associated with the amount of mushroom ingested. All the 4 patients developed multiple organ dysfunctions within 3 to 4 days after mushroom ingestion, predominantly in the liver, kidney and central nervous system accompanied with acute gastrointestinal injury and rhabdomyolysis. The treatment measures included persistent hemofiltration and intermittent hemoperfusion once daily for 5-7 days, and plasma exchange was administered in 2 cases for 1 or 2 times. High-dose vitamin C, glucose and corticosteroid were also given to the patients. After the treatments, two patients were cured and the other two died due to an excess intake of poisonous mushroom and lack of early preemptive therapies. Early emetic, gastric lavage, catharsis, fluid infusion and diuresis are critical to interrupt the enterohepatic circulation of amanita phalloides toxins and prevent the development of multiple organ dysfunction. Enhanced hemofiltration and sequential plasma therapy might effectively eliminate toxin from the blood to protect against further organ damages.

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.