Co-ingestion of amatoxins and isoxazoles-containing mushrooms and successful treatment: A case report

Abstract

Mushroom poisonings occur when ingestion of wild mushrooms containing toxins takes place, placing the consumers at life-threatening risk. In the present case report, an unusual multiple poisoning with isoxazoles- and amatoxins-containing mushrooms in a context of altered mental state and poorly controlled hypertension is presented. A 68-year-old female was presented to São João hospital (Portugal) with complaints of extreme dizziness, hallucinations, vertigo and imbalance, 3 h after consuming a stew of wild mushrooms. The first observations revealed altered mental state and elevated blood pressure. The examination of cooked mushroom fragments allowed a preliminary identification of Amanita pantherina. Gas chromatography-mass spectrometry (GC-MS) showed the presence of muscimol in urine. Moreover, through high-performance liquid chromatography-ultraviolet detection (HPLC-UV) analysis of the gastric juice, the presence of α-amanitin was found, showing that amatoxins-containing mushrooms were also included in the stew. After 4 days of supportive treatment, activated charcoal, silybin and N-acetylcysteine, the patient recovered being discharged 10 days post-ingestion with no organ complications. The prompt and appropriate therapy protocol for life-threatening amatoxins toxicity probably saved the patient's life as oral absorption was decreased and also supportive care was immediately started.

Mushroom Poisoning Imitating Stroke. Report of a Case and a Brief Review of the Literature

“…Mushroom poisoning usually results from the consumption of mushrooms collected from the environment, less frequently, the consumption of poisonous mushrooms for suicide (6). Our patients also applied to the ED with symptoms that developed after having an evening meal prepared with a mushroom canister taken from the market.…”

“…Musimol and ibotenic acid are members of the toxin family known as isoxazoles. Amanita muscarina and amanita pantherina are the most common mushrooms containing isoxazole (6). Especially, Amanita muscaria has a bright red color, which makes it attractive and dangerous for children.…”

Amanita phalloides poisoning: Mechanisms of toxicity and treatment

“…After careful consideration of the risks to the intoxicated patient, gastrointestinal (GI) decontamination should be considered based upon the time elapsed from ingestion to time of presentation at the hospital. Several methods of GI decontamination that can be used alone or in combination include gastric lavage, whole bowel irrigation, administration of activated charcoal, and endoscopic or surgical removal of the ingested poison (Albertson et al, 2011;Garcia et al, 2015b). Whole bowel irrigation has a very limited impact in the treatment of human poisoning, and therefore should not be used routinely in the management of the poisoned patient (Albertson et al, 2011;Santi et al, 2012;Seymour and Henry, 2001).…”

“…Activated charcoal efficacy decreases with increased time elapsed after ingestion, while the greatest benefit can be observed within 1 h after ingestion of the poison (Albertson et al, 2011). The efficacy of activated charcoal was not yet proven in controlled clinical settings towards amatoxins ingestion, but activated charcoal (20-40 g every 3-4 h) has been administered routinely because it may also interrupt the enterohepatic circulation of amatoxins and potentially reduce their toxicity (Garcia et al, 2015b). The center of anti-poisoning information (CIAV) in Portugal and TOXBASE recommend a dose of 50 g every 4 h (CIAV, 2014;TOXBASE, 2008).…”

“…If vomiting is troublesome, the dose can be reduced to 12.5 g charcoal hourly or 25 g every 2 h (TOXBASE, 2008). As most patients reach the hospital emergency hours after ingesting the mushrooms, these clinical measures have limited efficacy, although they are undertaken to assure the best clinical treatment available in a life risk situation, even before confirmation of amatoxin poisoning (Garcia et al, 2015b).…”