Myth, History and Medicine
Mushroom Poisoning Myth, History and Medicine John D. Halamka MD Goals How to consult a mycologist
Recognizing the symptoms of mushroompoisoning Current treatment strategies Recognizing selected mushroom species Roman History Claudius (AD 54) marries his nieceAgrippina who serveshim Amanita Phaloides,Nero ascends to thethrone Pope Clement VIIexcommunicates HenryVIII. Pope is fedAmanita Phaloides anddies Indo-European History
First written recordof mushroom use.Of Hindu Vedas( BC), 120mention AmanitaMuscaria to visualizethe gods and improvespiritual vitality Mesoamerican History Over 400 religiousmushroom stoneshave been found inMayan excavations. Use of Psilocybespecies byChignahuapan Indiansfirst described in LifeMagazine in 1957 andinspired thefascination withpsychedelics in the1960s Japanese History Japanese were first toagriculturally propagatefungi.Lentinus edodes(Shitake) wasdomesticated in 100 BC Haiku - I forgot falling offa horse with thehappiness of findingMushroomsAnon BC Chinese History The Chinese haveused Ganodermaspecies (polyporemushroom) for foodand medicine for years Russian History The Siberians of the th Century collectedAmanita Muscaria as theintoxicant of choice untilVodka was invented inthe 16th Century. Siberian peasants alsoinvented mushroomrecycling Russian History Tsar Alexis andhis wife (parents ofPeter the Great) ateAmanita Phalloidesand died onJanuary 25, Peter ascended tothe throne andchanged the courseof history. European History German EmperorCharles VI was fatallypoisoned by AmanitaPhalloides Mushroom propagationwas invented in theWestern world by LouisXIVs agronomists in the17th Century English History Sir Arthur Conan Doylewrote the fields werespotted with monstrousfungi of a size and colornever matched before- sarlet and mauve andblack- it was as thoughthe sick earth has burstinto foul pustules. English History Emily Dickinsonwrote Had nature anyoutcast face, could shea son condemn, hadnature an Iscariot, themushroom - it is him. The New American Attitude
The Boonville Timesreports Deputy Masonresponded to reports ofa woman screamingnear the BranscombRoad turnoff. Thedistressed womanturned out to be amushroom hunter,screaming with delightat each new find. Mushroom cuisine Soak one dozenmorels in 3/4 cupcream and atablespoon ofdrysherry.Saute ashallot, a clove ofgarlic and 1/2 cupchopped pecans. Mix in 4oz goatcheese, fresh nutmegand stuff the morels.Serve over paste Typical Mushroom Hunter
Eastern European expert taught by oraltradition who gathers mushrooms to eat Harvard scientist interested in theethnobotany of fungi Tie-dye shirt wearer asking Do thosemushrooms grow around here... There is no such thing as a Toad Stool General Morphology Mushrooms are described by Size, color,color changes, texture, order, taste, gap,gills, stem/stipe, veil, annulus, volva,mycelium, and spore prints Cap Capdescriptionsinclude viscid(sticky),glutinous(slimy), dry,smooth, scaly,fibrillose orwarty Cap marginsmay be inrolled,incurved,straight, upliftedor striate Gills Gills are describedby the attachmentpattern to the stalkand by spacing,thickness, depth andforking pattern Stem/Stipe Stipe featuresinclude size,color, colorchanges, shape,position,structure, andsurfacecharacteristics Veils and Volva A veil is residualtissue frommushroomdevelopment that isleft on the stalk andvaries from a fewremnants to acomplete annulus A volva is a sackthat is found at thebase of the stalk Spore Prints Spore prints are avery powerful way toidentify species ofmushrooms.Theyare created byleaving a mushroomon top of a piece ofpaper for 2-6 hours Consulting a Mycologist
How many people ate the mushroom? What are their ages and genders? What was the time from ingestion tosymptoms? Did all the individuals get sick? Was alcohol consumed? Were the mushrooms cooked or raw? Were the mushrooms in good condition? Habitat Questions Where were the mushrooms growing?
Were they in a yard, lawn or wild area? Had pesticides or herbicides beenapplied? If trees were nearby, what were they? Was the mushroom growing on wood,ground or other material? If wood, was the wood living or dead? Cap Questions How big is the cap? What is the cap color?
Is it smooth, scaly, hairy or sticky? What is the shape of the cap? How thick is the cap? Does the cap change color when it iscut? What is the total height of themushroom? Stem Questions What is the thickness of the step?
Is it curved or straight? Is there a ring or veil? Is there any material at the base of thestem? Is the surface smooth, scaly or hairy? Is it hollow? Does the color change when exposed toair? Gill Questions Are there gills on the underside of the cap?
What is the color of the gills? Are they attached to the stem? Is there a fine powder on the gills and ifso, what color? If no gills are present, what is the colorand texture of the underside of the cap? Group 1 - Amatoxins Most difficult to treat. 90% of all deathsdue to mushroom poisoning Species include Amanita Phalloides,Amanita Ocreata, Gallerina Autumnalis Toxin is stable to cooking, pickling,salting and is not hydrolyzed by digestion Toxins include amanitins and phallotoxinwhich inhibit RNA polymerase II Toxins are resorbed by the distal tubule Amatoxin Clinical Effects
Delay of 6 to 12 hours before initialsymptoms is common Sudden onset of sharp, colickyabdominal pain, nausea, vomiting, thirst,bloody stools Latent period of web being lasting 3 to 5days Recurrence of abdominal pain withjaundice, renal shutdown, seizures,coma and death Amatoxins - Treatment Toxin elimination via repeat dose charcoal
Supportive care with fluids, electrolytes Penicillin G may displace amanitin fromplasma binding sites 300k-1000k u/kg/d Silymarin (from milk thistle) maycompete for membrane transport Liver Transplant Amanita Phalloides Amanita Ocreata Group 1A - Orellanine Cortinarius species - over 1000 in the US
Causes severe renaltubular damage resultingin reduced GFR,decreased absorption ofwater/NA/K, proteinuria,glucosuria Inhibits RNA and DNAsynthesis in kidney cells Orellanine Clinical Effects
Initial mild gastroenteritis Long latent period of 36 hours to 17 days Symptoms include severe thirst,abdominal or flank pain, chills and fever Progresses to acute renal failure.Chronic failure occurs in 50% of cases Recovery takes weeks to months Orellanine Treatment Standard decontamination Hemodialysis
Renal transplant Steroids, hemoperfusion, and forceddiuresis do not improve outcome Group II - Muscimol/Ibotenic Acid
Amanita Muscaria, Amanita Pantherina,Amanita Gemmata Toxin is Ibotenic acid which ismetabolized to Muscimol Muscimol is a false neurotransmitterwhich acts on GABA receptors andaffects brain levels of serotinin,dopamine and noradrenalin. Usuallyresults in anticholinergic symptoms May present with cholinergic symptoms Muscimol/Ibotenic Acid Clinical Effects
Onset within 30 to 90 minutes, mostmarked at 2 to 3 hours Drowsiness, confusion resemblingalcohol intoxication, dizziness, ataxia,euphoria, muscle cramps and spasms,delirium, visual disturbances,hallucinations Vomiting is rare Deep sleep or coma terminates theepisode which usually lasts from 4 to 8hours Musicmol/Ibotenic Acid Treatment
Standard decontamination measures Support airway and hemodynamics withstandard measures With life threatening anticholinergicsigns, consider physostigmine .5 to 2 mgslow IVP over 5 minutes With life threatening cholinergic signsconsider atropine Amanita Muscaria Amanita Pantherina Group III - Monomethylhydrazine
Gyromitra and Helvella Toxin is Gyrometrinwhich is hydrolyzed toMMH at 87.5 C and onlyaffects the personcooking the mushroom Toxin chelates pyridoxalphosphate and inhibitsreactions where B6 is acofactor Monomethylhydrazine Clinical Effecs
Relatively long latent period of 6 to 12hours followed by vomiting, waterydiarrhea, abdominal pain, weakness andheadache. Severe cases notable for jaundice,tachycardia, hyperreflexia, vertigo, lossof muscle coordination, seizures andcoma Recovery in 2 to 6 days Monomethylhydrazine Treatment
Standard decontamination measures For seizures, give B6 at 25mg/kg over 15to 30 minutes IVP. For methemoglobin levels which aregreater than 30% or patients whopresent with symptomatic hypoxia, givemethylene blue 1% solution ml/kgIV over 5 minutes IVP Group IV - Muscarine Clitocybe, Omphalotus
Toxin is muscarinewhich stimulatespostganglionparasympathic fibers Muscarine is veryslowly hydrolyzed byacetylcholinesterase Muscarine Clinical Effects
Onset within 30 to 120 minutes Excessive perspiration, salivation,lacrimation (PSL symptoms),bradycardia, miosis, blurred vision,increased peristalsis, abdominal pain,and watery stools Severe cases notable for hypotension,bronchorrhea and wheezing Recovery in 6 to 24 hours Muscarine Treatment Standard decontamination methods
In severely symptomatic presentationsconsider atropine 1mg to 2mg for adultsand children 0 to 2 years.2 mg 3 to 4 years.3 mg 5 to 10 years .4mg Group V - Coprine Coprinus atramentarius
Toxin is coprine, themetabolite of whichinhibits aldehydedehydrogenase Ingestion isasymptomatic unlessethanol is consumed inthe following 2 hours to5 days Coprine Clinical Effects
Onset of symptoms within 20 minutes to2 hours after ingestion of alcohol Symptoms include flushing of the faceand neck, swelling an parathesias in thehands and feet, metallic taste, andtachycardia Late symptoms include nausea, vomitingand sweating Severe cases include vertigo, weakness,confusion, hypotension and arrhythmias Coprine Treatment Decontamination measures if mushroomrecently ingested Symptomatic treatment B-blockers or sedatives for anxiety andtachycardia Fluids for hypotension Group VI - Psilocybin Psilocybe, Panaeolus, Gymnopolis
Toxins are Psilocybinand its metabolitepsilocin Effects are serotonin andnorepinephrine mediated Blue staining reactionaids identification Psilocybin Clinical Effects
Onset of symptoms within 30 to 60minutes, occassionally as late as 3 hoursafter ingestion of 5 to 15 mg ofpsyilocybin (10 to 30g fresh weight ofmushrooms) Symptoms include hallucination,impaired judgement, hyperkinesis,laughter, vertigo, ataxia, muscleweakness and drowsiness PsilocybinTreatment Decontamination not recommended asthis may increase agitation Rest and reassurance in a dark, quietroom Consider benzodiazepines for severeanxiety Group VII - GI Irritants
ChlorophyllumMolybdites,AgaricusXanthodermis, RussulaEmetica No specific toxinsidentified Most mushroomscause more symptomswhen eaten raw GI Irritants Clinical Effects
Onset of symptoms within 30 minutes to2 hours after ingestion Symptoms include nausea, vomiting,diarrhea and abdominal pain In severe cases electrolyte disturbancesmay occur GI Irritants Treatment
Standard decontamination measures Be wary of antiemetics andantidiarrheals as these may haveunpredictable interactions withmushroom toxins Epidemoiology American Association of Poison ControlCenters = 9208 cases/year Group I - Cyclopeptide 61 cases/year Group III - MMH57 cases/year Group VI - Hallucinogens 330 cases/year Group VII - GI Irritants 202 cases Minimal effect 10,%moderate 5%,major 1%, death in 3 cases 5 year old Ingestion of red mushroom
Nausea and vomiting within 2 hours Given charcoal in local EmergencyDepartment Now appears well Russula Emetica 30 year old male Chardonnay and Shaggy Manes
Nausea/Vomiting 2 hours after dinner Tachycardia Hydrated and back to baseline after 6hours Coprinus Atramentarius 16 year old male Magic mushrooms Unsure of dose Ate one pound
Required sedation and intubation Psilocybe Cubensis Questions