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Mushrooms

Mushrooms. Hussein Unwala , Dr. Ingrid Vicas February 4, 2010. Objectives . Pretest Overview of Different Classes Approach to clinical classification Management of the unknown mushroom ingestion Cases. Mushroom Groups. Ten are identifiable: Cyclopeptides Gyromitrin Muscarine

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Mushrooms

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  1. Mushrooms Hussein Unwala, Dr. Ingrid Vicas February 4, 2010

  2. Objectives • Pretest • Overview of Different Classes • Approach to clinical classification • Management of the unknown mushroom ingestion • Cases

  3. Mushroom Groups • Ten are identifiable: • Cyclopeptides • Gyromitrin • Muscarine • Coprine • ibotenic acid and muscimol • psilocybin • general GI irritants • Orellinine • allenicnorleucine • Myotoxins

  4. Group I -- Cyclopeptides • Amanita species, including  A. verna, A. virosa, and A. phalloides • Galerinaspp, including G. autumnalis, G. marginata,andGalerinavenenata • Lepiota species, including L. helveola, L. josserandi, and L. brunneoincarnata.

  5. Cyclopeptides -- Clinical • 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

  6. Cyclopeptides – Management • 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

  7. Group II - Gyromitra • Gyromitrin • Monomethydrazine • (Inhibits pyridoxine) Disrupts GABA

  8. Gyromitra – Clinical • Common : GI toxicity 5-10 hours post ingestion • Rare: • delirium, stupor, convulsions, coma • Hepatorenal syndrome

  9. Gyromitra -- Management • Activated Charcoal 1g/kg • Benzo’s for seizures • Pyrodixine 70mg/kg

  10. Group III -- Muscarine • SLUDGEM/DUMBELLS • No central muscarinic effects • Usually mild effects, develop 0.5-2hrs post • Atropine rarely needed

  11. 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

  12. Group V – Ibotenic Acid/Muscimol • GABAergic in adults, • Somnolence, hallucinations, dysphoria, delerium • Glumatamatergic in kids • Myoclonic movements, seizures • Onset 0.5-2hrs • Benzoprn • http://www.youtube.com/watch?v=MkCS9ePWuLU

  13. Group VI-- Psylocybin • 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 • Benzoprn

  14. Group VII – GI Toxins • 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

  15. Group VIII – Orelline/Orellanine • 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.

  16. Group IX AllenicNorleucine • 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

  17. Group X: Rhabdomyolysis-Associated • All reported cases in Europe • Tricholomaequestre • All 15 cases led to subsequent death

  18. The unknown mushroom • Determine whether ingestion was a deadly variety; ieAmatotoxin • 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

  19. Amanita Smithsianacan present 0.5-12 hours Mixed Ingestions can present any time

  20. Cases . . .

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