Amatoxin-containing mushroom poisoning including ingestion of Amanita phalloides
- Tamas R Peredy, MD, FACEP, FACMT
Tamas R Peredy, MD, FACEP, FACMT
- Medical Director
- Florida Poison Information Center (FPIC) - Tampa
- Section Editors
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics
- Harvard Medical School
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Amatoxins are found in a variety of poisonous mushrooms (eg, Amanita phalloides, Amanita virosa, and Galerina autumnalis) and are responsible for more than 90 percent of fatalities caused by mushroom poisoning worldwide. Ingestion of one or more amatoxin-containing mushrooms is a life-threatening emergency. Treatment should be initiated expeditiously when a presumptive identification is made or clinical manifestations of amatoxin poisoning develop. Orthotopic liver transplantation has greatly reduced the mortality due to this poisoning. (See 'Evaluation' below and 'Management' below.)
The epidemiology, pathophysiology, clinical manifestations, and management of amatoxin-containing mushroom poisoning will be reviewed here. Clinical manifestations, evaluation, and management of poisoning caused by other types of mushroom toxins are presented separately. (See "Clinical manifestations and evaluation of mushroom poisoning" and "Management of mushroom poisoning" and "Amanita smithiana mushroom poisoning".)
There are over 10,000 species of mushrooms worldwide. Of these, only 50 to 100 are potentially toxic. In the United States, approximately 6000 toxic mushroom exposures occur annually. Most of these patients experience no toxic effects or only mild or moderate symptoms. Over half of toxic mushroom ingestions occur in children less than six years of age and are usually limited to a partial or single bite of nontoxic or minimally toxic mushrooms (picture 1 and picture 2). Even in the uncommon cases of amatoxin-containing mushroom exposures (picture 3 and picture 4), children do well because of the limited amount of toxins available in the small amount of mushroom typically ingested. In the United States, no pediatric fatalities due to ingestion of a single mushroom have occurred in over 25 years of National Poison Data System surveillance.
When serious toxicity or mortality due to mushroom ingestion does occur, it typically results from consumption of misidentified mushrooms by foraging adults and others who shared the meal. A common scenario involves amateur mushroom hunters or recent immigrants who mistake a toxic mushroom for an edible variety with similar morphologic features (eg, Amanita species (picture 3 and picture 4 and figure 1) mistaken for Agaricus species). (See "Clinical manifestations and evaluation of mushroom poisoning", section on 'Epidemiology'.)
About 35 mushroom species in three genera (Amanita, Galerina, and Lepiota) contain amatoxin . Amatoxin-containing mushroom species (eg, Amanita phalloides (picture 3 and figure 1), A. virosa, A. bisporigera (picture 4), Galerina autumnalis) cause approximately 50 deaths annually in Europe and Asia compared with two deaths annually in the United States [2-5]. This difference in frequency of lethal exposures probably reflects the relative popularity of mushroom foraging in Europe and Asia rather than significant variance in intrinsic toxicity or prevalence of harmful mushroom species among the regions.
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- MUSHROOM APPEARANCE
- PATHOPHYSIOLOGY AND TOXICOKINETICS
- Clinical manifestations
- Ancillary studies
- Amatoxin detection
- Mushroom identification
- Supportive care
- Gastrointestinal decontamination
- Elimination enhancement
- Amatoxin uptake inhibitors
- - Silibinin dihemisuccinate
- - Silymarin
- - Penicillin G
- - Other agents
- Antioxidant therapy
- - N-acetylcysteine
- - Other agents
- Liver transplantation
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS