Selected Topics: Toxicology
Amatoxin Poisoning: Case Reports and Review of Current Therapies

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Abstract

Background

Diagnosis and management of Amanita mushroom poisoning is a challenging problem for physicians across the United States. With 5902 mushroom exposures and two resultant deaths directly linked to Amanita ingestion in 2009, it is difficult for physicians to determine which patients are at risk for lethal toxicity. Identification of amatoxin poisoning can prove to be difficult due to delay in onset of symptoms and difficulty with identification of mushrooms. Consequently, it is difficult for the Emergency Physician to determine proper disposition. Further, treatment options are controversial.

Objectives

To review current data to help health care providers effectively identify and treat potentially deadly Amanita mushroom ingestions.

Case Reports

We present two cases of Amanita mushroom ingestion in the northeastern United States treated with N-acetylcysteine, high-dose penicillin, cimetidine, and silibinin, a semi-purified fraction of milk thistle-derived silymarin, as part of their treatment regimen. The mushroom species was identified by a consultant as Amanita Ocreata.

Conclusions

We present the successful treatment of 2 patients who ingested what we believe to be an Amanita species never before identified in the northeastern United States.

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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