Mushroom PoisoningMushroom Poisoning

Anthony TzannesAnthony Tzannes

Mushroom PoisoningMushroom Poisoning

Anthony TzannesAnthony Tzannes

It seemed like a Good Idea at the

Time...

It seemed like a Good Idea at the

Time...

What is Important?What is Important?

Phone a friend

Common presentations

Amanita phalloides

Diagnosis

Management

PresentationsPresentationsOften eat multiple mushrooms

GI Sx most common - usually within 2-3/24

Toxin not clear

Kids vs Adults

“Magic Mushrooms”

Key QuestionsKey QuestionsNumber mushrooms ingested by how many people?

Time since ingestion

Time onset GI Sx + period of Sx

Location (Canberra/SA/Vic)

?Near Oak trees

Risk for simple gastroenteritis

Amanita phalloidesAmanita phalloides

Very similar to safe mushrooms

High risk populations...

Clinical FeaturesClinical Features

Delayed GI toxicity (6-24/24) with severe fluid losses from Cholera-like diarrhoea

Hepatorenal toxicity from 18-36/24

Often minimal Sx “Honeymoon Period”

Progressive Hepatic Failure from 36-96/24 often with associated hepatorenal syndrome and pancreatitis

ToxinokineticsToxinokineticsAmatoxins - particularly alpha-amatoxin

H2O insoluble, heat stable - not safe post parboiling

Absorbed from GI tract, transported to Liver

Actively transported into hepatocytes

Binds to RNA polymerase Type II

Halts protein synthesis

Organs with rapid cell turnover - GI, Prox tubules

TreatmentTreatmentFluids for GI Sx

Important Questions

Ongoing Fluids/BSL control

Screening + Specific

Charcoal

MDAC +/- Plasmapheresis

Start within 24/24 (if possible)

Transplant after 4/7

Resus

R

S

I

D

E

A

D

SilibininSilibininLoading: 5mg/kg iv over 1/24

Infusion 20mg/kg/day for 3/7

Blocks hepatocyte uptake of amatoxin

OATP 1B3 + Na Taurocholate

Can use Silymarin po if Silibinin not available

approx 10g/day NB: Side Fx Diarrhoea ++

Penicillin Penicillin

1 000 000u/kg/day

Blocks amatoxin uptake

OATP 1B3

May decrease effectiveness

of Silibinin...

(Ceftazidime 4.5g q2h)

NACNAC

Same dosing as for paracetamol

150mg/kg load (15-60 min)

50mg/kg over 4/24

100mg/kg over 16/24 then repeat...

Glutathione magic...

What doesn’t workWhat doesn’t work

Fab - increased renal toxicity

Dialysis/Charcoal Haemoperfusion

- doesn’t clear the toxin effectively

Thioctic Acid - no benefit

Six Point PlanSix Point Plan

Call a friend

Charcoal

Good supportive care

Silybinin +/- Penicillin

NAC

Stop the boats

ReferencesReferences1. Faulstich H, Kirchner K, Derenzini M. Strongly enhanced toxicity of the

mushroom toxin alpha-amanitin by an amatoxin-specific Fab or monoclonal antibody. Toxicon. 1988;26(5):491-9.

2. Diaz JH. Syndromic diagnosis and management of confirmed mushroom poisonings. Crit Care Med. 2005 Feb;33(2):427-36.

3. Jander S, Bischoff J. Treatment of Amanita phalloides poisoning: I. Retrospective evaluation of plasmapheresis in 21 patients. Ther Apher. 2000 Aug;4(4):303-7.

4. Becker CE, Tong TG, Boerner U, et al: Diagnosis and treatment of Amanita phalloides-type mushroom poison- ing-Use of thioctic acid. West J Med 125:100-109, Aug 1976

5. Murray L, Daly FFS, Little M, and Cadogan M. Toxicology Handbook (2nd edition), Elsevier Australia 2011

UptoDate:

1. Amatoxin-containing mushroom poisoning including ingestion of Amanita phalloides

2. Management of mushroom poisoning

3. Clinical manifestations and evaluations of mushroom poisoning

4. Magdalan J, Ostrowska A, Piotrowska A, et al. Benzylpenicillin, acetylcysteine and silibinin as antidotes in human hepatocytes intoxicated with alpha-amanitin. Exp Toxicol Pathol 2010; 62:367.

5. Thomas J. Duffy, MD Toxic Fungi of Western North America http://www.mykoweb.com/TFWNA/P-17.html