Hussein Unwala, Dr. Ingrid Vicas February 4, 2010.
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Transcript of Hussein Unwala, Dr. Ingrid Vicas February 4, 2010.
Mushrooms
Hussein Unwala, Dr. Ingrid Vicas
February 4, 2010
Pretest
Overview of Different Classes
Approach to clinical classification
Management of the unknown mushroom ingestion
Cases
Objectives
Ten are identifiable: ◦ Cyclopeptides◦ Gyromitrin◦ Muscarine◦ Coprine◦ ibotenic acid and muscimol◦ psilocybin◦ general GI irritants◦ Orellinine◦ allenic norleucine◦ Myotoxins
Mushroom Groups
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
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
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
Group II - Gyromitra Gyromitrin
Monomethydrazine◦ (Inhibits pyridoxine)
Disrupts GABA
Common : GI toxicity 5-10 hours post ingestion
Rare: ◦ delirium, stupor, convulsions, coma
◦ Hepatorenal syndrome
Gyromitra – Clinical
Activated Charcoal 1g/kg
Benzo’s for seizures◦ Pyrodixine 70mg/kg
Gyromitra -- Management
SLUDGEM/DUMBELLS No central muscarinic effects Usually mild effects, develop 0.5-2hrs post Atropine rarely needed
Group III -- Muscarine
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
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
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
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
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
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
All reported cases in Europe
Tricholoma equestre
All 15 cases led to subsequent death
Group X: Rhabdomyolysis-Associated
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
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
Cases . . .