Mushroom Poisoning

Myth, History and Medicine

John D. Halamka MD
 Goals

How to consult a mycologist

Recognizing the symptoms of mushroom
poisoning
Current treatment strategies
Recognizing selected mushroom species
 Roman History
Claudius (AD 54)
marries his niece
Agrippina who serves
him Amanita Phaloides,
Nero ascends to the
throne
Pope Clement VII
excommunicates Henry
VIII. Pope is fed
Amanita Phaloides and
dies
 Indo-European
History
First written record
of mushroom use. Of
1028 Hindu Vedas
(1500-1200 BC), 120
mention Amanita
Muscaria to visualize
the gods and improve
spiritual vitality
Mesoamerican History
Over 400 religious
mushroom stones
have been found in
Mayan excavations.
Use of Psilocybe
species by
Chignahuapan Indians
first described in Life
Magazine in 1957 and
inspired the
fascination with
psychedelics in the
1960s
 Japanese History
Japanese were first to
agriculturally propagate
fungi. Lentinus edodes
(Shitake) was
domesticated in 100 BC
Haiku - I forgot falling off
a horse with the
happiness of finding
Mushrooms Anon 2000
BC
 Chinese History
The Chinese have
used Ganoderma
species (polypore
mushroom) for food
and medicine for 5000
years
 Russian History
The Siberians of the 14-
15th Century collected
Amanita Muscaria as the
intoxicant of choice until
Vodka was invented in
the 16th Century.
Siberian peasants also
invented mushroom
recycling
 Russian History
Tsar Alexis and
his wife (parents of
Peter the Great) ate
Amanita Phalloides
and died on
January 25, 1694.
Peter ascended to
the throne and
changed the course
of history.
 European History
German Emperor
Charles VI was fatally
poisoned by Amanita
Phalloides
Mushroom propagation
was invented in the
Western world by Louis
XIVs agronomists in the
17th Century
 English History
Sir Arthur Conan Doyle
wrote the fields were
spotted with monstrous
fungi of a size and color
never matched before-
sarlet and mauve and
black- it was as though
the sick earth has burst
into foul pustules.
 English History
Emily Dickinson
wrote Had nature any
outcast face, could she
a son condemn, had
nature an Iscariot, the
mushroom - it is him.
 The New American
Attitude
The Boonville Times
reports Deputy Mason
responded to reports of
a woman screaming
near the Branscomb
Road turnoff. The
distressed woman
turned out to be a
mushroom hunter,
screaming with delight
at each new find.
 Mushroom cuisine
Soak one dozen
morels in 3/4 cup
cream and a
tablespoon of dry
sherry. Saute a
shallot, a clove of
garlic and 1/2 cup
chopped pecans.
Mix in 4oz goat
cheese, fresh nutmeg
and stuff the morels.
Serve over paste
 Typical Mushroom
Hunter
Eastern European expert taught by oral
tradition who gathers mushrooms to eat
Harvard scientist interested in the
ethnobotany of fungi
Tie-dye shirt wearer asking Do those
mushrooms grow around here...
There is no such thing
as a Toad Stool
 General Morphology

Mushrooms are described by Size, color,

color changes, texture, order, taste, gap,
gills, stem/stipe, veil, annulus, volva,
mycelium, and spore prints
 Cap Cap
descriptions
include viscid
(sticky),
glutinous
(slimy), dry,
smooth, scaly,
fibrillose or
warty
Cap margins
may be inrolled,
incurved,
straight, uplifted
 Gills

Gills are described

by the attachment
pattern to the stalk
and by spacing,
thickness, depth and
forking pattern
 Stem/Stipe
Stipe features
include size,
color, color
changes, shape,
position,
structure, and
surface
characteristics
 Veils and Volva
A veil is residual
tissue from
mushroom
development that is
left on the stalk and
varies from a few
remnants to a
complete annulus
A volva is a sack
that is found at the
base of the stalk
 Spore Prints
Spore prints are a
very powerful way to
identify species of
mushrooms. They
are created by
leaving a mushroom
on top of a piece of
paper for 2-6 hours
 Consulting a
Mycologist
How many people ate the mushroom?
What are their ages and genders?
What was the time from ingestion to
symptoms?
Did all the individuals get sick?
Was alcohol consumed?
Were the mushrooms cooked or raw?
Were the mushrooms in good condition?
 Habitat Questions
Where were the mushrooms growing?
Were they in a yard, lawn or wild area?
Had pesticides or herbicides been
applied?
If trees were nearby, what were they?
Was the mushroom growing on wood,
ground or other material?
If wood, was the wood living or dead?
 Cap Questions
How big is the cap?
What is the cap color?
Is it smooth, scaly, hairy or sticky?
What is the shape of the cap?
How thick is the cap?
Does the cap change color when it is
cut?
What is the total height of the
mushroom?
 Stem Questions
What is the thickness of the step?
Is it curved or straight?
Is there a ring or veil?
Is there any material at the base of the
stem?
Is the surface smooth, scaly or hairy?
Is it hollow?
Does the color change when exposed to
air?
 Gill Questions
Are there gills on the underside of the
cap?
What is the color of the gills?
Are they attached to the stem?
Is there a fine powder on the gills and if
so, what color?
If no gills are present, what is the color
and texture of the underside of the cap?
 Group 1 - Amatoxins
Most difficult to treat. 90% of all deaths
due to mushroom poisoning
Species include Amanita Phalloides,
Amanita Ocreata, Gallerina Autumnalis
Toxin is stable to cooking, pickling,
salting and is not hydrolyzed by digestion
Toxins include amanitins and phallotoxin
which inhibit RNA polymerase II
Toxins are resorbed by the distal tubule
 Amatoxin Clinical
Delay of 6 toEffects
12 hours before initial
symptoms is common
Sudden onset of sharp, colicky
abdominal pain, nausea, vomiting, thirst,
bloody stools
Latent period of web being lasting 3 to 5
days
Recurrence of abdominal pain with
jaundice, renal shutdown, seizures,
coma and death
 Amatoxins -
Treatment
Toxin elimination via repeat dose
charcoal
Supportive care with fluids, electrolytes
Penicillin G may displace amanitin from
plasma binding sites 300k-1000k u/kg/d
Silymarin (from milk thistle) may
compete for membrane transport
Liver Transplant
Amanita Phalloides
Amanita Ocreata
 Group 1A - Orellanine
Cortinarius species - over
1000 in the US
Causes severe renal
tubular damage resulting
in reduced GFR,
decreased absorption of
water/NA/K, proteinuria,
glucosuria
Inhibits RNA and DNA
synthesis in kidney cells
 Orellanine Clinical
Effects
Initial mild gastroenteritis
Long latent period of 36 hours to 17 days
Symptoms include severe thirst,
abdominal or flank pain, chills and fever
Progresses to acute renal failure.
Chronic failure occurs in 50% of cases
Recovery takes weeks to months
Orellanine Treatment

Standard decontamination
Hemodialysis
Renal transplant
Steroids, hemoperfusion, and forced
diuresis do not improve outcome
 Group II -
Muscimol/Ibotenic
Amanita Muscaria,
Acid Amanita Pantherina,
Amanita Gemmata
Toxin is Ibotenic acid which is
metabolized to Muscimol
Muscimol is a false neurotransmitter
which acts on GABA receptors and
affects brain levels of serotinin,
dopamine and noradrenalin. Usually
results in anticholinergic symptoms
May present with cholinergic symptoms
 Muscimol/Ibotenic
Acid
Onset within 30 to 90 minutes, most
Clinical
marked Effects
at 2 to 3 hours
Drowsiness, confusion resembling
alcohol intoxication, dizziness, ataxia,
euphoria, muscle cramps and spasms,
delirium, visual disturbances,
hallucinations
Vomiting is rare
Deep sleep or coma terminates the
episode which usually lasts from 4 to 8
hours
 Musicmol/Ibotenic
Acid
StandardTreatment
decontamination measures
Support airway and hemodynamics with
standard measures
With life threatening anticholinergic
signs, consider physostigmine .5 to 2 mg
slow IVP over 5 minutes
With life threatening cholinergic signs
consider atropine
Amanita Muscaria
Amanita Pantherina
 Group III -
Monomethylhydrazine
Gyromitra and Helvella
Toxin is Gyrometrin
which is hydrolyzed to
MMH at 87.5 C and only
affects the person
cooking the mushroom
Toxin chelates pyridoxal
phosphate and inhibits
reactions where B6 is a
cofactor
Monomethylhydrazine
Clinical Effecs
Relatively long latent period of 6 to 12
hours followed by vomiting, watery
diarrhea, abdominal pain, weakness and
headache.
Severe cases notable for jaundice,
tachycardia, hyperreflexia, vertigo, loss
of muscle coordination, seizures and
coma
Recovery in 2 to 6 days
Monomethylhydrazine
Treatment
Standard decontamination measures
For seizures, give B6 at 25mg/kg over 15
to 30 minutes IVP.
For methemoglobin levels which are
greater than 30% or patients who
present with symptomatic hypoxia, give
methylene blue 1% solution .1-.2 ml/kg
IV over 5 minutes IVP
 Group IV - Muscarine
Clitocybe, Omphalotus
Toxin is muscarine
which stimulates
postganglion
parasympathic fibers
Muscarine is very
slowly hydrolyzed by
acetylcholinesterase
 Muscarine
Clinical Effects
Onset within 30 to 120 minutes
Excessive perspiration, salivation,
lacrimation (PSL symptoms),
bradycardia, miosis, blurred vision,
increased peristalsis, abdominal pain,
and watery stools
Severe cases notable for hypotension,
bronchorrhea and wheezing
Recovery in 6 to 24 hours
 Muscarine
Treatment
Standard decontamination methods
In severely symptomatic presentations
consider atropine 1mg to 2mg for adults
and children
0 to 2 years .2 mg
3 to 4 years .3 mg
5 to 10 years .4mg
 Group V - Coprine
Coprinus
atramentarius
Toxin is coprine, the
metabolite of which
inhibits aldehyde
dehydrogenase
Ingestion is
asymptomatic unless
ethanol is consumed in
the following 2 hours to
5 days
 Coprine
Clinical Effects
Onset of symptoms within 20 minutes to
2 hours after ingestion of alcohol
Symptoms include flushing of the face
and neck, swelling an parathesias in the
hands and feet, metallic taste, and
tachycardia
Late symptoms include nausea, vomiting
and sweating
Severe cases include vertigo, weakness,
confusion, hypotension and arrhythmias
 Coprine
Treatment
Decontamination measures if mushroom
recently ingested
Symptomatic treatment
B-blockers or sedatives for anxiety and
tachycardia
Fluids for hypotension
 Group VI - Psilocybin
Psilocybe, Panaeolus,
Gymnopolis
Toxins are Psilocybin
and its metabolite
psilocin
Effects are serotonin and
norepinephrine mediated
Blue staining reaction
aids identification
 Psilocybin
Clinical Effects
Onset of symptoms within 30 to 60
minutes, occassionally as late as 3 hours
after ingestion of 5 to 15 mg of
psyilocybin (10 to 30g fresh weight of
mushrooms)
Symptoms include hallucination,
impaired judgement, hyperkinesis,
laughter, vertigo, ataxia, muscle
weakness and drowsiness
 Psilocybin
Treatment
Decontamination not recommended as
this may increase agitation
Rest and reassurance in a dark, quiet
room
Consider benzodiazepines for severe
anxiety
 Group VII - GI Irritants
Chlorophyllum
Molybdites, Agaricus
Xanthodermis, Russula
Emetica
No specific toxins
identified
Most mushrooms
cause more symptoms
when eaten raw
 GI Irritants
Clinical Effects
Onset of symptoms within 30 minutes to
2 hours after ingestion
Symptoms include nausea, vomiting,
diarrhea and abdominal pain
In severe cases electrolyte disturbances
may occur
 GI Irritants
Treatment
Standard decontamination measures
Be wary of antiemetics and
antidiarrheals as these may have
unpredictable interactions with
mushroom toxins
 Epidemoiology
American Association of Poison Control
Centers = 9208 cases/year
Group I - Cyclopeptide 61 cases/year
Group III - MMH 57 cases/year
Group VI - Hallucinogens 330 cases/year
Group VII - GI Irritants 202 cases
Minimal effect 10,% moderate 5%,
major 1%, death in 3 cases
 5 year old

Ingestion of red mushroom

Nausea and vomiting within 2 hours
Given charcoal in local Emergency
Department
Now appears well
Russula Emetica
 30 year old male

Chardonnay and Shaggy Manes

Nausea/Vomiting 2 hours after dinner
Tachycardia
Hydrated and back to baseline after 6
hours
 Coprinus
Atramentarius
 16 year old male

Magic mushrooms
Unsure of dose
Ate one pound
Required sedation and intubation
Psilocybe Cubensis
 Questions

jhalamka@hms.harvard.edu
http://geekdoctor.blogspot.com