Clinical manifestations and evaluation of mushroom poisoning
- Timothy J Wiegand, MD, DABAM, FACMT, FAACT
Timothy J Wiegand, MD, DABAM, FACMT, FAACT
- Director of Medical Toxicology and Toxicology Consult Service
- Associate Clinical Professor of Emergency Medicine
- URMC and Strong Memorial Hospital
- Section Editors
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics and Emergency Medicine
- 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 — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Mushroom poisoning occurs frequently, but serious toxicity is uncommon. There are 12 groups of identified mushroom toxins with 14 described clinical syndromes (table 1). Defining which clinical syndrome predominates, initiating general supportive care, and administering any specific treatments for that syndrome are the key steps in the recognition and management of mushroom poisoning [1,2].
The clinical manifestations of mushroom poisoning syndromes and the diagnostic evaluation of patients with mushroom poisoning are reviewed here. The general management of mushroom poisoning, and the diagnosis and treatment of poisoning caused by potentially lethal amatoxin-containing mushrooms (eg, Amanita phalloides) or by Amanita smithiana are discussed in detail separately. (See "Management of mushroom poisoning", section on 'General management' and "Amatoxin-containing mushroom poisoning (eg, Amanita phalloides): Clinical manifestations, diagnosis, and treatment" and "Amanita smithiana mushroom poisoning".)
There are over 10,000 species of mushrooms worldwide, but of these, only 50 to 100 are potentially toxic [1,3,4]. In the United States, approximately 6000 mushroom exposures occur annually . Most of these patients experience no toxic effects or only mild or moderate symptoms. Over half of mushroom ingestions occur in children less than six years of age. In most cases, pediatric exposures are 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 typically do well due to the limited amount of toxins available in the small amount of mushroom usually ingested. In the United States, no pediatric fatalities due to ingestion of a single mushroom have been reported in over 25 years of National Poison Data System surveillance [1,5].
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 [1,2,6]. A common scenario involves amateur mushroom hunters or recent immigrants who mistake a toxic mushroom for an edible variety with similar morphologic features (eg, Gyromitra esculenta mistaken for Morchella esculenta (picture 5); Amanita species (picture 3 and picture 4) mistaken for Agaricus species) [1,7].
In up to 95 percent of cases, the species of mushroom ingested is not identified . Thus, one must rely upon the presenting signs and symptoms to aid in the clinical diagnosis and to guide treatment recommendations. (See 'Mushroom poisoning syndromes' below and 'Evaluation' below and "Management of mushroom poisoning", section on 'General management'.)
- Goldfrank LR. Mushrooms. In: Goldfrank's Toxicologic Emergencies, 9th ed, Nelson LS, Lewin NA, Howland MA, et al. (Eds), McGraw-Hill, New York 2011. p.1522.
- Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2008 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila) 2009; 47:911.
- Berger KJ, Guss DA. Mycotoxins revisited: Part I. J Emerg Med 2005; 28:53.
- Brent J, Palmer RB. Mushrooms. In: Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, 4th ed, Shannon MW, Borron SW, Burns MJ (Eds), Saunders Elsevier, Philadelphia, PA 2007. p.455.
- Beuhler MC, Sasser HC, Watson WA. The outcome of North American pediatric unintentional mushroom ingestions with various decontamination treatments: an analysis of 14 years of TESS data. Toxicon 2009; 53:437.
- Yamada EG, Mohle-Boetani J, Olson KR, Werner SB. Mushroom poisoning due to amatoxin. Northern California, Winter 1996-1997. West J Med 1998; 169:380.
- Cole FM. Amanita phalloides in Victoria. Med J Aust 1993; 158:849.
- Lehmann PF, Khazan U. Mushroom poisoning by Chlorophyllum molybdites in the Midwest United States. Cases and a review of the syndrome. Mycopathologia 1992; 118:3.
- Stenklyft PH, Augenstein WL. Chlorophyllum molybdites--severe mushroom poisoning in a child. J Toxicol Clin Toxicol 1990; 28:159.
- Passie T, Seifert J, Schneider U, Emrich HM. The pharmacology of psilocybin. Addict Biol 2002; 7:357.
- Michelot D, Melendez-Howell LM. Amanita muscaria: chemistry, biology, toxicology, and ethnomycology. Mycol Res 2003; 107:131.
- Tupalska-Wilczyńska K, Ignatowicz R, Poziemski A, et al. [Amanita pantherina and Amanita muscaria poisonings--pathogenesis, symptoms and treatment]. Pol Merkur Lekarski 1997; 3:30.
- Satora L, Pach D, Butryn B, et al. Fly agaric (Amanita muscaria) poisoning, case report and review. Toxicon 2005; 45:941.
- Benjamin DR. Mushroom poisoning in infants and children: the Amanita pantherina/muscaria group. J Toxicol Clin Toxicol 1992; 30:13.
- Handbook of Mushroom Poisoning: Diagnosis and Treatment, Rumack, BH, Spoerke, DG (Eds), CRC Press, Boca Raton 1994.
- Pauli JL, Foot CL. Fatal muscarinic syndrome after eating wild mushrooms. Med J Aust 2005; 182:294.
- Michelot D. Poisoning by Coprinus atramentarius. Nat Toxins 1992; 1:73.
- Haberl B, Pfab R, Berndt S, et al. Case series: Alcohol intolerance with Coprine-like syndrome after consumption of the mushroom Lepiota aspera (Pers.:Fr.) Quél., 1886 (Freckled Dapperling). Clin Toxicol (Phila) 2011; 49:113.
- West PL, Lindgren J, Horowitz BZ. Amanita smithiana mushroom ingestion: a case of delayed renal failure and literature review. J Med Toxicol 2009; 5:32.
- Saviuc P, Danel V. New syndromes in mushroom poisoning. Toxicol Rev 2006; 25:199.
- Kirchmair M, Carrilho P, Pfab R, et al. Amanita poisonings resulting in acute, reversible renal failure: new cases, new toxic Amanita mushrooms. Nephrol Dial Transplant 2012; 27:1380.
- Marquardt, K. Mushrooms; Mushrooms, Amatoxin-Type. In: Poisoning and Drug Overdose, 5th, Olson, K (Eds), McGraw-Hill, New York 2007. p.276.
- Maeta K, Ochi T, Tokimoto K, et al. Rapid species identification of cooked poisonous mushrooms by using real-time PCR. Appl Environ Microbiol 2008; 74:3306.
- French LK, Hendrickson RG, Horowitz BZ. Amanita phalloides poisoning. Clin Toxicol (Phila) 2011; 49:128.
- Michelot D, Toth B. Poisoning by Gyromitra esculenta--a review. J Appl Toxicol 1991; 11:235.
- Leathem AM, Dorran TJ. Poisoning due to raw Gyromitra esculenta (false morels) west of the Rockies. CJEM 2007; 9:127.
- Frank H, Zilker T, Kirchmair M, et al. Acute renal failure by ingestion of Cortinarius species confounded with psychoactive mushrooms: a case series and literature survey. Clin Nephrol 2009; 71:557.
- Mount P, Harris G, Sinclair R, et al. Acute renal failure following ingestion of wild mushrooms. Intern Med J 2002; 32:187.
- Rohrmoser M, Kirchmair M, Feifel E, et al. Orellanine poisoning: rapid detection of the fungal toxin in renal biopsy material. J Toxicol Clin Toxicol 1997; 35:63.
- Danel VC, Saviuc PF, Garon D. Main features of Cortinarius spp. poisoning: a literature review. Toxicon 2001; 39:1053.
- Bedry R, Baudrimont I, Deffieux G, et al. Wild-mushroom intoxication as a cause of rhabdomyolysis. N Engl J Med 2001; 345:798.
- Chodorowski Z, Waldman W, Sein Anand J. Acute poisoning with Tricholoma equestre. Przegl Lek 2002; 59:386.
- Anand JS, Chwaluk P, Sut M. Acute poisoning with Tricholoma equestre. Przegl Lek 2009; 66:339.
- Minami T, Matsumura S, Nishizawa M, et al. Acute and late effects on induction of allodynia by acromelic acid, a mushroom poison related structurally to kainic acid. Br J Pharmacol 2004; 142:679.
- Nakajima N, Ueda M, Higashi N, Katayama Y. Erythromelalgia associated with Clitocybe acromelalga intoxication. Clin Toxicol (Phila) 2013; 51:451.
- Gejyo F, Homma N, Higuchi N, et al. A novel type of encephalopathy associated with mushroom Sugihiratake ingestion in patients with chronic kidney diseases. Kidney Int 2005; 68:188.
- Kraft J, Bauer S, Keilhoff G, et al. Biological effects of the dihydroorotate dehydrogenase inhibitor polyporic acid, a toxic constituent of the mushroom Hapalopilus rutilans, in rats and humans. Arch Toxicol 1998; 72:711.
- Villa AF, Saviuc P, Langrand J, et al. Tender Nesting Polypore (Hapalopilus rutilans) poisoning: report of two cases. Clin Toxicol (Phila) 2013; 51:798.
- Olesen LL. [Poisoning with the brown roll-rim mushroom, Paxillus involutus]. Ugeskr Laeger 1991; 153:445.
- Winkelmann M, Borchard F, Stangel W, Grabensee B. [Fatal immunohaemolytic anaemia after eating the mushroom Paxillus involutus (author's transl)]. Dtsch Med Wochenschr 1982; 107:1190.
- Winkelmann M, Stangel W, Schedel I, Grabensee B. Severe hemolysis caused by antibodies against the mushroom Paxillus involutus and its therapy by plasma exchange. Klin Wochenschr 1986; 64:935.
- Strand RD, Neuhauser EB, Sornberger CF. Lycoperdonosis. N Engl J Med 1967; 277:89.
- Centers for Disease Control and Prevention (CDC). Respiratory illness associated with inhalation of mushroom spores--Wisconsin, 1994. MMWR Morb Mortal Wkly Rep 1994; 43:525.
- Stephany MP, Chung S, Handler MZ, et al. Shiitake Mushroom Dermatitis: A Review. Am J Clin Dermatol 2016; 17:485.
- Boels D, Landreau A, Bruneau C, et al. Shiitake dermatitis recorded by French Poison Control Centers - new case series with clinical observations. Clin Toxicol (Phila) 2014; 52:625.
- Baier, J. Mushrooms and Toadstools: An Illustrated Guide, JG Press, North Dighton, MA 1995. p.1.
- Fischbein CB, Mueller GM, Leacock PR, et al. Digital imaging: a promising tool for mushroom identification. Acad Emerg Med 2003; 10:808.
- Butera R, Locatelli C, Coccini T, Manzo L. Diagnostic accuracy of urinary amanitin in suspected mushroom poisoning: a pilot study. J Toxicol Clin Toxicol 2004; 42:901.
- Parant F, Peltier L, Lardet G, et al. [Phalloidin syndrome: role of Elisa-based assay for the detection of alpha- and gamma-amanitins in urine. Preliminary results]. Acta Clin Belg 2006; 61 Suppl 1:11.
- Spiteller P, Spiteller M, Steglich W. Occurrence of the fungal toxin orellanine as a diglucoside and investigation of its biosynthesis. Angew Chem Int Ed Engl 2003; 42:2864.
- Sarwar M, McDonald J. A rapid extraction and GC/MS methodology for the identification of psilocin in mushroom/chocolate concoctions. Microgram Journal 2003; 1:177. http://www.justice.gov/dea/programs/forensicsci/microgram/journal071203/mj071203_pg4.html.
- Epis S, Matinato C, Gentili G, et al. Molecular detection of poisonous mushrooms in different matrices. Mycologia 2010; 102:747.
- Enjalbert F, Rapior S, Nouguier-Soulé J, et al. Treatment of amatoxin poisoning: 20-year retrospective analysis. J Toxicol Clin Toxicol 2002; 40:715.
- Simmons DM. The Meixner test for amatoxins in mushrooms. Clin Toxicol 1980; 16:401.
- Beuhler M, Lee DC, Gerkin R. The Meixner test in the detection of alpha-amanitin and false-positive reactions caused by psilocin and 5-substituted tryptamines. Ann Emerg Med 2004; 44:114.
- MUSHROOM POISONING SYNDROMES
- Acute symptom onset (<6 hours after ingestion)
- - Acute gastroenteritis
- - Hallucinations
- - CNS excitation and depression
- - Cholinergic poisoning
- - Disulfuram-like reaction
- Delayed symptom onset (>6 hours after ingestion)
- - Acute gastroenteritis and delayed renal failure
- - Delayed gastroenteritis and liver toxicity
- - Delayed gastroenteritis, seizures, and liver toxicity
- - Delayed renal failure
- - Delayed rhabdomyolysis
- Rare manifestations
- - Erythromelalgia
- - Delayed encephalopathy
- - Immune-mediated hemolytic anemia
- - Allergic bronchioalveolitis
- - Shiitake dermatitis
- Physical examination
- Ancillary studies
- - Interpretation of results
- Mushroom identification
- DIFFERENTIAL DIAGNOSIS
- ADDITIONAL RESOURCES