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Amatoxins

Maladywise

Epidemiology

  • 35 mushroom species across three genera (Amanita, Galerina, Lepiota)

  • Contain Amatoxin

  • About 50 deaths per year in Europe and Asia

  • Serious toxicity occurs by foraging and eating the misidentified mushrooms

  • Boiling and cooking DOES NOT remove the Amatoxin

  • Kids rarely affected due to limited toxins in small amount of mushroom they might ingest

Amatoxin-Containing Mushrooms

  • Amanita

    • Commonly involved

    • Names include Death cap, death cup, destroying angel, and fool’s mushroom

    • Have no offensive taste or odor

    • Typically grow as a single mushroom in moist forests

  • Lepiota and Galerina less common

Pathophysiology

  • Contains fun sounding substances like amatoxins, virotoxins and the ominous sounding phallotoxin

  • Amatoxins are heat stable

  • Absorbed in gut, transported to liver and uptake into hepatocytes

  • Once in a cell, stopped protein synthesis and cause call death

Symptoms

  • Delayed symptoms more than 6 to 12 hours after consumption = potentially serious ingestion

  • Three phases

    • Phase 1: Dyssentry (6 to 24 hours post-ingestion)

      • Abdominal pain

      • Vomitting

      • Severe diarrhoea with blood and mucous

      • Haematuria

      • Shock

    • Phase 2: Apparent Recovery (24 to 36 hours post-ingestion)

      • Gradually resolution of dyssentry

      • However liver enzyme elevations peak at 60 to 72 hours post-ingestion

    • Phase 3: Fulminant hepatic and multisystem organic failure (48 to 96 hours post-ingestion)

      • Massive liver cell death

      • Liver blood vessel flow is disrupted

      • Nephrotoxin effects on kidney

      • Pancreatitis

Diagnosis

  • Unwell with a history of eating random forest mushrooms

  • Urine Amatoxin levels

Management

  • Supportive care

    • Liver toxicity

      • Treat low blood glucose

      • Treat high ammonia with lactulose

      • Vitamin K and fresh frozen plasma for blood clotting

  • Gut decontamination

    • Activated charcoal (AC)

    • No benefit to gastric emptying or lavage

  • Elimination enhancement

    • Multidose Activated Charcoal (MDAC) every 4 hours

  • Amatoxin uptake inhibitors

    • Silibinin dihemisuccinate

  • Antioxidant Therapy

    • NAC recommended

    • Cimetidine: 300 mg IV every 8 hours until clinical improvement

    • Vitamin C: 3 g IV daily until clinical improvement

  • Liver Transplant

Mortality rates

  • Previously up to 50% in older cases

  • Currently 10% with modern medicine

Resources