Mushroom poisoning in India: Diagnosis and management
M3 India Newsdesk Oct 09, 2018
Mushroom poisoning has a high rate of morbidity and mortality in India. These guidelines should help manage reported cases better.
In the recent years because of increased awareness and patients seeking health care early, the incidence of mushroom poisoning is now being documented accurately. Many cases have been reported in the tribal areas of South India, Eastern Ghats, Northern India, and North Eastern parts of the country as mushrooms are a part of their diet.
Diagnosis of mushroom poisoning
Evaluation of a patient for mushroom poisoning is done by considering the key elements such as a proper history, identification of the mushroom species, symptoms, and signs. The gastrointestinal tract, liver and kidneys are affected after six hours of ingestion of the toxic mushrooms.
- A complete haemogram, renal, and liver function tests, PT/INR creatinine kinase, and serum lactate at presentation are the standard baseline laboratory investigations that are performed to assess different clinical syndromes
- These are again followed by serial measurement of CMP, lactate, and PT/INR every 6 to 8 hours
- Identification of the toxic mushrooms and their toxins is done mainly by a medical toxicologist and professional mycologist
- ELISA is a rapid and specific diagnostic test for the detection of amatoxin in serum and urine but it is still not available for the clinical use
Gastrointestinal symptoms
Acute gastroenteritis: Chlorophyllum molybdites species or ‘backyard mushrooms’ are the most common causes of acute gastroenteritis. Symptoms like nausea, vomiting, diarrhoea, and abdominal cramps occur within one to three minutes of ingestion of these mushrooms.
- Cholera-like diarrhoea, vomiting, abdominal pain, and subsequent dehydration may begin six hours after mushroom ingestion
- A second phase starts after 24 to 36 hours, in which there is laboratory evidence of hepatoxicity but clinical improvement
- After 48 hours, the third phase may start in which there is an onset of fulminant hepatitis that further progresses to hepatic coma, haemorrhage and renal failure within 4 to 7 days and ultimately lead to death
Delayed effects: The Amanita species can be distinguished from the Gyromitra mushroom due to its ‘brain-like appearance’. Delayed gastroenteritis, headache, seizures, hepatitis, haemolysis, and methemoglobinemia are the clinical features associated with gyromitrin toxicity.
Delayed renal failure: Mushroom species such as Cortinarius orellanus, Mycenapura, and Omphalatusorarius containing toxins such as orellanine, cortinarin A and B can lead to interstitial nephritis and tubule interstitial fibrosis. Supportive care for acute kidney injury is given for the treatment of Cortinarius ingestion and haemodialysis can be an option in some of the patients.
Delayed rhabdomyolysis: This is another clinical syndrome associated with the Tricholoma equestre species in which myalgia and progressive weakness occurs after 24 to72 hours of its intake. Hyperkalaemia with raised creatinine phosphokinase is found on laboratory investigations.
Neurotoxicity and associated symptoms
Muscimol & ibotenic acid toxins: Ingestion of mushrooms containing psilocybin and psilocin cause hallucinogenic effects. The toxins muscimol and ibotenic acid are produced by the Amanita species that triggers this syndrome.
- Ibotenic acid causes excitation of glutamic acid receptors, while muscimol leads to CNS depression. Somnolence, dizziness, hallucination, dysphoria, bizarre behaviour and seizures are the associated symptoms.
- Obtundation, lethargy, agitation and hallucinations, as well as seizures, are usually seen in the patients with ibotenic and muscimol intoxication. To control seizures, selection of specific therapy is done on the basis of the symptoms using atropine, physostigmine, and diazepam.
Muscarine toxin: Intake of Inocybe and Clitocybe species containing muscarine toxin leads to cholinergic poisoning. Symptoms such as bradycardia, diaphoresis, salivation, lacrimation, bronchospasm, bronchorrhoea and incontinence appear commonly after 30 minutes post ingestion. Muscarine binds to postsynaptic receptors and causes a cholinergic response within 30 minutes to 2 hours of intake. When this is exaggerated, it leads to muscarine poisoning. Symptoms may take 6 to 24 hours to subside.
Indole toxin: Within 30 minutes of ingestion, patients develop euphoria, hallucinations, tachycardia and seizures like symptoms. Diazepam can be given in cases of seizure. Death is also seen in exceptionally rare cases.
Management of cases
- Patients presenting within one hour of the toxic mushroom ingestion are benefitted mostly by gastrointestinal decontamination with activated charcoal
- Least benefits are seen with gastric emptying by gastric lavage or ipecac syrup is given, and there is also an increased risk of aspiration in these cases
- An enhanced reduction in circulation of amatoxins after the ingestion of the toxins is seen with the use of multiple activated charcoals, the proposed dosage being 50 g (0.5 g/kg) given four hourly for four days
Significant amounts of mushroom toxins cannot be removed by haemodialysis or haemoperfusion so, they are not recommended for the removal of toxins. They can only be of use as long as the patient has signs of acute renal failure that requires haemodialysis when there is hyperkalaemia, metabolic acidosis, uremic signs, and encephalopathy.
Biliary drainage
In a rising number of cases, biliary drainage using interventional radiology (simple/serial gallbladder aspiration, percutaneous cholecystostomy), general surgery (open cholecystostomy), or GI (nasobiliary drainage with suction placed by ERCP) has proven effective. Amatoxin laden bile, when removed from the gallbladder eliminates chances of enterohepatic exposure to the poison, and thus ensures absolute protection to the uninvolved hepatocytes.
Therapies in use
- Benzodiazepines are used to treat agitation, delirium, and hallucination. Treatment with the short-acting benzodiazepines i.e. midazolam or lorazepam is done in cases of seizures caused by mushrooms containing muscimol, ibotenic acid, and gyromitrin.
- Phenytoin sodium is given in case the patient doesn’t respond to the above treatment as per epilepsy management protocols.
- Amatoxin uptake inhibitors such as silibinin or intravenous penicillin G guarantee higher patient survival. They cause diversion of amatoxin back into the general circulation for renal clearance. It is, however, essential to maintain good renal function and a brisk urine output to ensure the amatoxin uptake inhibitor's efficacy.
- Silibinin 5 mg/kg bolus followed by 20 mg/kg/day is the recommended dosage to be given for 6 days or till the patient recovers.
- An infusion of intravenous Penicillin G at a dose of 300,000 to 1,000,000 units/kg/day for the same period can be used in case silibilin is not available
- Anticonvulsant therapy using pyridoxine (70 mg/kg to 5 g) per day is given in cases of gyromitrin toxicity with seizures.
- In gyromitrin poisoning, intravenous methylene blue is given in detected cases of methemoglobinaemia.
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