Selected Topics: ToxicologyAmatoxin Poisoning: Case Reports and Review of Current Therapies
Introduction
Mushroom ingestion is frequently reported to poison control centers, and patients may present or be referred to Emergency Departments (EDs) for evaluation. The American Association of Poison Control Centers documented 5902 mushroom exposures in 2009, with 3 resultant deaths, 2 directly related to Amanita ingestion (1). Although the majority of mushroom ingestions are benign, some result in significant toxicity and death. Of greatest concern are the hepatotoxic amatoxin-containing mushrooms, which may be fatal after even small ingestions. Amatoxin poisoning may be difficult to diagnose due to delayed onset of symptoms. In addition, numerous therapy options are unique and controversial.
We present two cases of amatoxin mushroom toxicity; treatment options, novel mushroom identification modalities, and geographic dietary practices placing individuals at potential increased risk for Amanita poisonings are discussed. Further, we present evidence of a mushroom variety responsible for toxicity never previously implicated in the northeastern United States.
Section snippets
Case Reports
A 72-year-old Russian-speaking woman and her 45-year-old son, both residing in suburban Boston, Massachusetts and both with past medical histories of hypertension, presented to a community hospital with complaints of vomiting, diarrhea, and moderate abdominal pain after ingesting wild mushrooms. The female patient reportedly picked the mushrooms, which were growing along the sidewalk near her home. Both patients had picked and ingested similar-appearing mushrooms in their native Ukraine in the
Amatoxin Poisoning Management
Amatoxin poisoning may be difficult to diagnose due to the delayed onset of symptoms. Also, therapy options are confusing and controversial. There are several amatoxins contained in Amanita mushrooms, however, alpha-amanitin is the primary hepatic toxicant. Alpha-amanitin is taken into hepatocytes via organic anion-transporting polypeptides (OATP), including OATP1B1, OATP1B3, and OATP2B1, which are located on the hepatocyte cell surface. Alpha-amanitin may also be transported into the cell via
Conclusion
We report the successful treatment of 2 amatoxin-poisoned patients (poison determined to be Amanita ocreata by the Poison Control Center consultant mycologist) with NAC, high-dose penicillin, cimetidine, and silibinin. The mushrooms were identified via photograph analysis, providing real-time information to the busy emergency physician. Finally, this is the first time this particular Amanita species has been identified in the northeastern United States.
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