Rosen & Barkin's 5-Minute Emergency Medicine Consult (465 page)

• Time of ingestion
  
• Time of symptom onset
  
• Quantity ingested
  
• Preparation: Raw or cooked
  
• Picked in the wild or store-bought
  
• Coingestants, other mushrooms
  
• Alcohol/drug use history
  
• Symptoms of family members, friends
  

• Vital signs
  
• Changes in mental status
  
• Pupillary response
  
• Cardiopulmonary exam
  
• Abdominal exam
  
• Neurologic exam
  

• Mushroom description:
  
  • Pileus (cap); margin shape
    
  • Stipe (stem)
    
  • Lamellae (gills)
    
  • Veil
    
  • Annulus (ring)
    
  • Volva
    
• Store mushroom in brown paper bag for future identification:
  
  • <3% of cases result in an exact mushroom identification.
    
  • Digital photography and electronic image transfer to poison control center or regional mycologist
    

• CBC
  
• Prothrombin time (PT), partial thromboplastin time (PTT)
  
• Electrolytes, BUN, creatinine, glucose
  
• Urinalysis
  
• LFTs, creatine phosphokinase (CPK)
  
• Imaging
  
• Spore print: Mycologist needed for specific genus/species interpretation
  

• Very broad differential
  
• Gastroenteritis
  
• Hepatitis/acetaminophen hepatotoxicity
  
• Acute renal failure (many causes)
  
• Rhabdomyolysis (many causes)
  
• Cholinergic syndrome (e.g., organophosphates)
  
• Anticholinergic syndrome
  
• Seizures (many causes)
  

TREATMENT

Bring any unconsumed mushrooms or mushroom pieces to hospital to aid in diagnosis:

• Refrigerate specimens if possible, place in brown paper bag.
  

• ABCs
  
• Establish IV 0.9% NS saline
  
• Monitor
  
• Naloxone, D
  ₅₀
  W (or Accu-Chek), and thiamine for altered mental status
  

• Decontamination:
  
  • Activated charcoal (50–100 g)
    
  • Gastric decontamination if early after ingestion and patient:
    
    • Has not yet vomited.
      
    • Has normal mental and respiratory status
      
    • Is not undergoing hallucinations
      
• Fluid rehydration and electrolyte replacement as necessary
  
• Call local poison control center at 800-222-1222 and request mycologist—digital picture may be electronically sent for identification.
  
• Obtain specimens (vomitus if needed) for identification.
  

• Amanitin/phalloidin:
  
  • Administer activated charcoal PO q2–4h.
    
  • Hypoglycemia and elevated PT:
    
    • Signs of liver failure
      
    • Administer fresh-frozen plasma and vitamin K for coagulation disorders with active bleeding.
      
  • Administer calcium in presence of hypocalcemia.
    
  • Liver transplant for severe hepatic necrosis
    
  • Consider
    N
    -acetylcysteine, high-dose penicillin G, or silibinin if available (thioctic acid controversial)
    
• Gyromitrin:
  
  • Treat seizure with benzodiazepines.
    
    • Administer pyridoxine (vitamin B
      ₆
      ) in severely symptomatic patients.
      
  • Treat liver dysfunctions as outlined for amanitin/phalloidin group.
    
  • Dialysis for renal failure
    
• Muscarine:
  
  • Administer atropine in severe cases.
    
• Coprine:
  
  • Self-limited toxicity—supportive care
    
  • Avoid syrup of ipecac (contains alcohol)
    
  • β-Blockers for cardiac dysrhythmias
    
• Ibotenic acid/muscimol:
  
  • Usually self-limited toxicity
    
  • Provide supportive care
    
  • Monitor for hypotension
    
  • Treat moderate symptoms with benzodiazepines, if severe anticholinergic symptoms; consider physostigmine.
    
• Psilocin/psilocybin:
  
  • Self-limited toxicity
    
  • Dark, quiet room and reassurance
    
  • Benzodiazepines for agitation
    
  • External cooling measures if needed in children
    
• GI Irritants:
  
  • When poisoning from above groups not suspected, administer fluids and antiemetics.
    
  • Provide supportive care
    
• Orellanine and
  A. smithiana
  :
  
  • Closely monitor BUN, creatinine, electrolytes, and urine output.
    
  • Forced diuresis with Lasix contraindicated
    
  • Diuresis with alkalinization of urine with NaHCO
    ₃
    if signs of rhabdomyolysis
    
  • Hemodialysis/renal transplantation may be needed.
    
• T. equestre
  (“man on horse”):
  
  • Fluid hydration
    
  • Check and follow CPK.
    
  • Monitor urine output.
    

• Activated charcoal slurry: 1–2 g/kg up to 100 g PO
  
• Atropine: 0.5 mg (peds: 0.02 mg/kg) IV; repeat 0.5–1 mg IV (peds: 0.04 mg/kg) q10min if secretions recur, to max. 1 mg/kg in children and 2 mg/kg in adults
  
• Dextrose: D
  ₅₀
  W 1 amp: 50 mL or 25 g (peds: D
  ₂₅
  W 2–4 mL/kg) IV
  
• Diazepam (benzodiazepine): 5–10 mg (peds: 0.2–0.5 mg/kg) IV
  
• Lorazepam (benzodiazepine): 2–6 mg (peds: 0.03–0.05 mg/kg) IV
  
• Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  
• Physostigmine: 0.5–2 mg IM or IV in adults
  
• Propranolol: 1 mg (peds: 0.01–0.1 mg/kg) IV
  
• Pyridoxine: 25 mg/kg IV over 30 min
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  

FOLLOW-UP

• All symptomatic patients:
  
  • Protracted vomiting, dehydration, liver or renal toxicity, or seizures
    
• Transfer to tertiary medical center for early signs of renal or hepatic failure.
  
• Symptomatic infants and young children found with mushrooms:
  
  • Assume ingestion.
    
• ICU admission for known ingestion of an amanitin-containing mushroom:
  
  • Early liver service consultation
    

Asymptomatic during 6–8 hr with 24 hr of close home observation and close follow-up (if reliable caregivers)

Potential liver or renal transplantation

Drug detoxification programs if chronic recreational use

• There are old mushroom pickers, and bold mushroom pickers; but there are no old, bold mushroom pickers.
  
• Symptoms with late onset (>6 hr) generally indicate more lethal toxins.
  
• Lack of proper mycologic identification
  
• Timely organ transplant referrals when indicated
  

• Beuhler MC, Sasser HC, Watson WA. The outcome of North American pediatric unintentional mushroom ingestions with various decontamination treatments: An analysis of 14 years of TESS data.
  Toxicon
  . 2009;53(4):437–443.
  
• Diaz JH. Syndromic diagnosis and management of confirmed mushroom poisonings.
  Crit Care Med
  . 2005;33(2):427–436.
  
• Goldfrank LR. Mushrooms In: Goldfrank LR, ed.
  Goldfrank’s Toxicologic Emergencies
  . 9th ed. New York, NY: McGraw-Hill, 2011:1522–1536.
  
• Matsuura M, Saikawa Y, Inui K, et al. Identification of the toxic trigger in mushroom poisoning.
  Nat Chem Biol
  . 2009;5(7):465–467.
  
• West PL, Lindgren J, Horowitz BZ.
  Amanita smithiana
  mushroom ingestion: A case of delayed renal failure and literature review.
  J Med Toxicol
  . 2009;5(1):32–38.
  

CODES

988.1 Toxic effect of mushrooms eaten as food

BASICS

• Antibody-mediated condition that results in painless, fatigable muscle weakness
  
• Ocular or generalized:
  
  • Ocular (eyelids and extraocular) muscle weakness:
    
    • Most common initial symptom (60%)
      
    • ∼80% of myasthenia gravis (MG) patients who present with ocular weakness initially will progress to general weakness within 2 yr.
      
  • Generalized:
    
    • Usually affects proximal limbs, axial muscle groups such as neck, face, bulbar muscles
      
• Acute or subacute, with relapses and remissions
  
• Associated with thymoma in 15% and thymic hyperplasia in 65%
  
• Myasthenic crisis:
  
  • Respiratory failure or inability to protect airway due to weakness
    
  • Triggers:
    
    • Infection
      
    • Surgery
      
    • Trauma
      
    • Pregnancy
      
    • Medication changes (e.g., rapid tapering of steroids)
      
  • Difficult to distinguish from cholinergic crisis resulting from excessive doses of acetylcholinesterase (AChE) inhibitors:
    
    • Cholinergic crisis may also include muscarinic effects such as sweating, lacrimation, salivation, and GI hyperactivity in addition to weakness.