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Hussein Unwala, Dr. Ingrid Vicas February 4, 2010.
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Transcript of Hussein Unwala, Dr. Ingrid Vicas February 4, 2010.
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Mushrooms
Hussein Unwala, Dr. Ingrid Vicas
February 4, 2010
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Pretest
Overview of Different Classes
Approach to clinical classification
Management of the unknown mushroom ingestion
Cases
Objectives
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Ten are identifiable: ◦ Cyclopeptides◦ Gyromitrin◦ Muscarine◦ Coprine◦ ibotenic acid and muscimol◦ psilocybin◦ general GI irritants◦ Orellinine◦ allenic norleucine◦ Myotoxins
Mushroom Groups
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Amanita species, including A. verna, A. virosa,
and A. phalloides
Galerina spp, including G. autumnalis, G. marginata,and Galerina venenata
Lepiota species, including L. helveola, L. josserandi, and L. brunneoincarnata.
Group I -- Cyclopeptides
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Phase 1:◦ Severe gastroenteritis, 5-24 hours post ingestion
Phase 2:◦ Quiescent phase, 12-36 hours post ingestion
Phase 3:◦ Hepatic, renal toxicity, death; 2-5 days post
ingestion◦ Endocrine malfunction - TSH, Ca, Insulin
Cyclopeptides -- Clinical
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Activated charcoal 1g/kg q 2-4 hours, antiemetics Correct fluid, electrolyte abnormalities
Forced diuresis and hemodialysis techniques
Penicillin G 1g/kg/day IV, administered 5 days post ingestion
Silibinin 20-50 mg/kg/day◦ May modify cell membrane receptor sites◦ safe◦ Worked in dogs, but . . .
Extracorporeal albumin dialysis as a bridge to liver transplant
Cyclopeptides – Management
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Group II - Gyromitra Gyromitrin
Monomethydrazine◦ (Inhibits pyridoxine)
Disrupts GABA
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Common : GI toxicity 5-10 hours post ingestion
Rare: ◦ delirium, stupor, convulsions, coma
◦ Hepatorenal syndrome
Gyromitra – Clinical
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Activated Charcoal 1g/kg
Benzo’s for seizures◦ Pyrodixine 70mg/kg
Gyromitra -- Management
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SLUDGEM/DUMBELLS No central muscarinic effects Usually mild effects, develop 0.5-2hrs post Atropine rarely needed
Group III -- Muscarine
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Group IV -- Coprine Disulfuram effect, inhibiting acetaldehyde
dehydrogenase for up to 48-72 hours EtOH Alcohol Dehydrogenase
Acetaldehyde Acetaldehyde Dehydrogenase
Acetic Acid
tachycardia, flushing, nausea, and vomiting Fomepizole theoretic benefit
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Group V – Ibotenic Acid/Muscimol GABAergic in adults,
◦ Somnolence, hallucinations, dysphoria, delerium Glumatamatergic in kids
◦ Myoclonic movements, seizures Onset 0.5-2hrs Benzo prn
http://www.youtube.com/watch?v=MkCS9ePWuLU
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Aka magic mushrooms Toxicity common Thought to act at 5-HT2 receptors Rapidly (within 1 hour) : ataxia,
hyperkinesis, visual hallucinations, and illusions.
Rare : renal failure, seizures, cardiopulmonary arrest
Benzo prn
Group VI-- Psylocybin
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Hundreds of mushrooms fall in this group (“Little Brown Mushrooms”)
GI toxicity occurs 0.5-3 hours post ingestion; clinical course is brief (6-24hours)
Rare : hypovolemic shock, immune-mediated hemolytic anemia
Supportive care
Group VII – GI Toxins
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Nephrotoxic Symptoms 24-36 hours post ingestion:
headache, chills, flank/abdo pain, polydypsia, anorexia, nausea/vomitting
Oliguric renal failure develops several days to weeks later
Treatment : hemodialysis, renal transplantation.
No evidence suggests plasmapheresis/hemoperfusion is of any benefit in preventing chronic renal failure even when initiated in the first 48 hours.
Group VIII – Orelline/Orellanine
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Associated with ingestion of Amanita smithiana
Symptoms noted 30min – 12hours Often GI initially Then ARF 4-6 days later, azotemia
Suggest treat with activated charcoal, early hemodialysis
Group IX Allenic Norleucine
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All reported cases in Europe
Tricholoma equestre
All 15 cases led to subsequent death
Group X: Rhabdomyolysis-Associated
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The unknown mushroom
Determine whether ingestion was a deadly variety; ie Amatotoxin◦ if outside southwestern Canada, onset of GI
symptoms within 3 hours rules out amatoxin Attempt collection of mushrooms, detailed
description Dry paper bag; gastric contents? Consult a mycologist! If not available, Melzer reagent : 20mL H20, 1.5g KI, 0.5g I, 20g
chloral hydrate. Amatoxin turns dark blue upon contact
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Symptoms < 3 h
Muscarine, Coprine, Ibotenic Acid, Psilocybin,
GI Irritants
No tests essential, monitor fluids and electrolyte status
Activated CharcoalIf Hallucinating/seizures, benzos prnIf Hypotension, fluid resuscitation, Dopamine 5-20 mcg/kg/min, then
NEElectrolyte Repletion
Discharge once GI/psychadelic symptoms
resolve, volume depletion corrected
Symptoms > 6 h
Cyclopeptides, Gyromitra
Activated Charcoal initially, then q 4h/continuous
Electrolyte, Glucose Repletion
Penicillin GConsultation with liver transplant specialistMethylene blue for
methemoglobinemia, Blood transfusion if
hemolysisPyridoxine/benzos if
seizuresMycologist if availableELFT’s
If suspecting Gyromitra, check methemoglobin
levels
Symptoms > 24 h
orelline
Assess Renal Function
Activated Charcoal
Electrolyte Repletion
Amanita Smithsiana can present 0.5-12 hours
Mixed Ingestions can present any time
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Cases . . .