Ann Hepatol. 2019 May - Jun;18(3):514-516. doi: 10.1016/j.aohep.2018.11.009. Epub

2019 Apr 15.

Acute liver injury, acute liver failure and acute on chronic liver failure: A

clinical spectrum of poisoning due to Gyromitra esculenta.

Arłukowicz-Grabowska M(1), Wójcicki M(2), Raszeja-Wyszomirska J(2),

Szydłowska-Jakimiuk M(2), Piotuch B(3), Milkiewicz P(4).

Author information:

(1)Liver and Internal Medicine Unit, Department of General, Transplant and Liver

Surgery, Medical University of Warsaw, Poland. Electronic address:


(2)Liver and Internal Medicine Unit, Department of General, Transplant and Liver

Surgery, Medical University of Warsaw, Poland.

(3)Department of Surgery, Ministry of the Interior and Administration Hospital,

Szczecin, Poland.

(4)Liver and Internal Medicine Unit, Department of General, Transplant and Liver

Surgery, Medical University of Warsaw, Poland; Translation Medicine Group,

Pomeranian Medical University, Szczecin, Poland.

Gyromitra esculenta, also known as "false morel" is one of the most poisonous

mushrooms. This species is found all over the world, growing in coniferous forest

in early spring time. Common manifestation of poisoning includes gastrointestinal

symptoms which include varied degrees of liver impairment. We describe three

cases: acute liver injury, acute liver failure and acute-on-chronic liver failure

due to G. esculenta poisoning. At admission patients presented with

encephalopathy and features of liver failure. Two of them recovered completely

following supportive management while the remaining patient who also had

preexisting liver disease developed multiorgan failure and subsequently died.

Although a rare occurrence, G. esculenta poisoning should be considered in the

differential diagnosis of acute liver failure.

DOI: 10.1016/j.aohep.2018.11.009

PMID: 31014949

Food Chem Toxicol. 2019 Jun;128:267-279. doi: 10.1016/j.fct.2019.04.016. Epub
2019 Apr 14.
Poisoning associated with the use of mushrooms: A review of the global pattern
and main characteristics.
Govorushko S(1), Rezaee R(2), Dumanov J(3), Tsatsakis A(4).
Author information: 
(1)Pacific Geographical Institute, 7 Radio St., Vladivostok, 690041, Russia; Far 
Eastern Federal University, 8 Sukhanova St, Vladivostok, 690950, Russia.
Electronic address: sgovor@tigdvo.ru.
(2)Clinical Research Unit, Faculty of Medicine, Mashhad University of Medical
Sciences, Mashhad, Iran; Neurogenic Inflammation Research Center, Mashhad
University of Medical Sciences, Mashhad, Iran; Aristotle University of
Thessaloniki, Department of Chemical Engineering, Environmental Engineering
Laboratory, University Campus, Thessaloniki, 54124, Greece; HERACLES Research
Center on the Exposome and Health, Center for Interdisciplinary Research and
Innovation, Balkan Center, Bldg. B, 10th km Thessaloniki-Thermi Road, 57001,
(3)Mycological Institute USA EU, SubClinical Research Group, Sparta, NJ, 07871,
United States.
(4)Laboratory of Toxicology, University of Crete, Voutes, Heraklion, Crete,
71003, Greece.
Worldwide, special attention has been paid to wild mushrooms-induced poisoning.
This review article provides a report on the global pattern and characteristics
of mushroom poisoning and identifies the magnitude of mortality induced by
mushroom poisoning. In this work, reasons underlying mushrooms-induced poisoning,
and contamination of edible mushrooms by heavy metals and radionuclides, are
provided. Moreover, a perspective of factors affecting the clinical signs of such
toxicities (e.g. consumed species, the amount of eaten mushroom, season,
geographical location, method of preparation, and individual response to toxins) 
as well as mushroom toxins and approaches suggested to protect humans against
mushroom poisoning, are presented.
Copyright © 2019. Published by Elsevier Ltd.
DOI: 10.1016/j.fct.2019.04.016 
PMID: 30995515 

J Agric Food Chem. 2019 May 8;67(18):5053-5071. doi: 10.1021/acs.jafc.9b00414.
Epub 2019 Apr 25.
Mushroom Toxins: Chemistry and Toxicology.
Yin X(1), Yang AA(2), Gao JM(1).
Author information: 
(1)Shaanxi Key Laboratory of Natural Products & Chemistry Biology, College of
Chemistry & Pharmacy , Northwest A & F University , Yangling 712100 , People's
Republic of China.
(2)Department of Pathology , The 969th Hospital of PLA , Hohhot , Inner Mongolia 
010000 , People's Republic of China.
Mushroom consumption is a global tradition that is still gaining popularity.
However, foraging for wild mushrooms and accidental ingestion of toxic mushrooms 
can result in serious illness and even death. The early diagnosis and treatment
of mushroom poisoning are quite difficult, as the symptoms are similar to those
caused by common diseases. Chemically, mushroom poisoning is related to very
powerful toxins, suggesting that the isolation and identification of toxins have 
great research value, especially in determining the lethal components of toxic
mushrooms. In contrast, most of these toxins have remarkable physiological
properties that could promote advances in chemistry, biochemistry, physiology,
and pharmacology. Although more than 100 toxins have been elucidated, there are a
number of lethal mushrooms that have not been fully investigated. This review
provides information on the chemistry (including chemical structures, total
synthesis, and biosynthesis) and the toxicology of these toxins, hoping to
inspire further research in this area.
DOI: 10.1021/acs.jafc.9b00414 
PMID: 30986058 

Isr Med Assoc J. 2019 Mar;21(3):175-182.
Poisoning in Israel: Annual Report of the Israel Poison Information Center, 2017.
Bentur Y(1), Lurie Y(1), Cahana A(1), Bloom-Krasik A(1), Kovler N(1), Neuman
G(1), Gurevych B(1), Sofer P(1), Klein-Schwartz W(2).
Author information: 
(1)Israel Poison Information Center, Rambam Health Care Campus, affiliated with
Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa,
(2)Maryland Poison Center, Department of Pharmacy Practice and Science,
University of Maryland School of Pharmacy, Baltimore, MD, USA.
BACKGROUND: The Israel Poison Information Center (IPIC), Rambam Health Care
Campus, provides 24-hour telephone consultations on clinical toxicology and drug 
and reproductive toxicology. It participates in research, teaching and regulatory
activities, and provides laboratory services. In 2014, nurse specialists in
poison information joined the IPIC.
OBJECTIVES: To report the epidemiology of poison exposures in Israel.
METHODS: We present computerized queries and a descriptive analysis of the
medical records database of the IPIC for 2017.
RESULTS: A total of 39,928 poison exposure cases were recorded, reflecting
increases of 226.3% and 26.7% compared with 1995 and 2012, respectively. Children
< 6 years of age were involved in 47.0% of cases; 80.4% of calls were made by the
public and 17.8% by physicians; 74.2% of exposures were unintentional and 7.3%
intentional. Pharmaceuticals were involved in 51.4% of cases, chemicals in 36.9%,
bites and stings in 2.2%, and plants and mushrooms in 1.5%. Substances most
frequently involved were analgesics, cleaning products, and antimicrobials.
Clinical severity was moderate/major in 3.3%, mainly due to insecticides, drugs
of abuse, and corrosives. Three fatalities were recorded (due to colchicine,
organophosphates, and volatile substance inhalant abuse).
CONCLUSIONS: Poison exposures and poisonings have markedly increased in Israel,
contributing substantially to morbidity. The IPIC prevented unnecessary referrals
to emergency departments. Its database is a valuable national resource for
collecting and monitoring poisoning exposure cases. It can be used as a real-time
surveillance system for the benefit of public health. It is recommended that
reporting to the IPIC become mandatory, and its activities adequately supported
by national resources.
PMID: 30905103  [Indexed for MEDLINE]

Arch Toxicol. 2019 May;93(5):1449-1463. doi: 10.1007/s00204-019-02426-5. Epub
2019 Mar 19.
An effective antidotal combination of polymyxin B and methylprednisolone for
α-amanitin intoxication.
Garcia J(1), Costa VM(2), Bovolini A(3), Duarte JA(3), Rodrigues DF(2), de
Lourdes Bastos M(2), Carvalho F(4).
Author information: 
(1)Laboratory of Toxicology, Department of Biological Sciences, Faculty of
Pharmacy, UCIBIO, REQUIMTE, University of Porto, Rua José Viterbo Ferreira no
228, 4050-313, Porto, Portugal. jugarcia_18@hotmail.com.
(2)Laboratory of Toxicology, Department of Biological Sciences, Faculty of
Pharmacy, UCIBIO, REQUIMTE, University of Porto, Rua José Viterbo Ferreira no
228, 4050-313, Porto, Portugal.
(3)Faculty of Sport, CIAFEL, University of Porto, Porto, Portugal.
(4)Laboratory of Toxicology, Department of Biological Sciences, Faculty of
Pharmacy, UCIBIO, REQUIMTE, University of Porto, Rua José Viterbo Ferreira no
228, 4050-313, Porto, Portugal. felixdc@ff.up.pt.
Amanita phalloides is one of the most toxic mushrooms worldwide, and it is
involved in the majority of human fatal cases of mushroom poisoning. α-Amanitin, 
the most deleterious toxin of A. phalloides to humans, inhibits RNA polymerase II
(RNAPII), causing hepatic and renal failure. Previously, we have shown that
polymyxin B (polB) reverts α-amanitin inhibition of RNAPII, although it was not
able to guarantee the full survival of α-amanitin-intoxicated mice or prevent
α-amanitin pro-inflammatory effects. α-Amanitin is also a substrate of the
organic-anion-transporting polypeptide 1B3 (OATP1B3) and Na(+)-taurocholate
cotransporter polypeptide (NTCP) transporters. Therefore, in the present work, we
used a combination of polB [(2.5 mg/kg intraperitoneal (i.p.)] with the
anti-inflammatory and NTCP inhibitor drug, methylprednisolone (MP) (10 mg/kg
i.p.), as an attempt to fully revert α-amanitin-induced toxicity (0.33 mg/kg
i.p.) in CD-1 mice. Results showed that the administration of the polB + MP
combination, 4 h after α-amanitin, led to the full survival of the intoxicated
animals, with a significant attenuation of α-amanitin-induced renal and hepatic
necrosis. Also, the combination polB + MP led to a decrease of aminotransferase
plasma levels, of the renal myeloperoxidase activity and of renal inflammatory
cell infiltrate promoted by α-amanitin, although not preventing any of the
hepatic pro-inflammatory effect of the toxin. The obtained results indicate that 
this combination may represent an important and valuable therapeutic approach to 
be used against α-amanitin intoxication.
DOI: 10.1007/s00204-019-02426-5 
PMID: 30891624 

Toxicol Rep. 2019 Jan 9;6:143-150. doi: 10.1016/j.toxrep.2019.01.002. eCollection
Toxicological profile of Amanita virosa - A narrative review.
Tavassoli M(1), Afshari A(1), Arsene AL(2), Mégarbane B(3), Dumanov J(4), Bastos 
Paoliello MM(5)(6), Tsatsakis A(7), Carvalho F(8), Hashemzaei M(9), Karimi
G(10)(11), Rezaee R(12).
Author information: 
(1)Department of Nutrition, Faculty of Medicine, Mashhad University of Medical
Sciences, Mashhad, Iran.
(2)Department of General and Pharmaceutical Microbiology, Faculty of Pharmacy,
"Carol Davila" University of Medicine and Pharmacy, 6 Traian Vuia Street, 020956,
Bucharest, Romania.
(3)Department of Medical and Toxicological Critical Care, Paris-Diderot
University, INSERM UMRS-1144, Paris, France.
(4)Mycological Institute USA EU, SubClinical Research Group, Sparta, NJ 07871,
United States.
(5)Graduate Program in Public Health, Center of Health Sciences, State University
of Londrina - UEL, Londrina, Paraná, Brazil.
(6)Department of Molecular Pharmacology, Albert Einstein College of Medicine,
Bronx, NY, 10461, USA.
(7)Center of Toxicology Science & Research, Medical School, University of Crete, 
Heraklion, Crete, Greece.
(8)UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences,
Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira 228,
4050-313, Porto, Portugal.
(9)Department of Pharmacodynamics and Toxicology, School of Pharmacy, Zabol
University of Medical Sciences, Zabol, Iran.
(10)Department of Pharmacodynamics and Toxicology, Faculty of Pharmacy, Mashhad
University of Medical Sciences, Mashhad, Iran.
(11)Pharmaceutical Research Center, Institute of Pharmaceutical Technology,
Mashhad University of Medical Sciences, Mashhad, Iran.
(12)Clinical Research Unit, Faculty of Medicine, Mashhad University of Medical
Sciences, Mashhad, Iran.
Mushrooms account for a part of human diet due to their exquisite taste and
protein content as well as their promising health effects unveiled by scientific 
research. Toxic and non-toxic mushrooms frequently share considerable
morphological similarities, which mislead the collectors/consumers, resulting in 
mycotoxicity. Numerous mushroom species are considered "poisonous" as they
produce dangerous toxins. For instance, members of the genus Amanita, especially 
A. phalloides, A. virosa and A. verna, are responsible for severe and even
life-threatening noxious consequences. Globally, mushroom poisoning is a crucial 
healthcare issue as it leads to a considerable number of deaths annually.
However, no definite antidote has been introduced to treat this poisoning. The
present article discusses the characteristics of A. virosa in terms of
epidemiology, mechanisms of toxicity, poisoning features and management.
DOI: 10.1016/j.toxrep.2019.01.002 
PMCID: PMC6348736
PMID: 30705830 


Int J Environ Res Public Health. 2018 Dec 14;15(12). pii: E2855. doi:
Mushroom Poisoning-A 17 Year Retrospective Study at a Level I University
Emergency Department in Switzerland.
Keller SA(1), Klukowska-Rötzler J(2), Schenk-Jaeger KM(3), Kupferschmidt H(4),
Exadaktylos AK(5), Lehmann B(6), Liakoni E(7)(8).
Author information: 
(1)Department of Emergency Medicine, Inselspital, University Hospital Bern,
University of Bern, 3010 Bern, Switzerland. sarah.keller@students.unibe.ch.
(2)Department of Emergency Medicine, Inselspital, University Hospital Bern,
University of Bern, 3010 Bern, Switzerland. jolanta.klukowska-roetzler@insel.ch.
(3)National Poisons Information Centre, Tox Info Suisse, Associated Institute of 
the University of Zurich, 8032 Zurich, Switzerland. katharina.schenk@toxinfo.ch.
(4)National Poisons Information Centre, Tox Info Suisse, Associated Institute of 
the University of Zurich, 8032 Zurich, Switzerland.
(5)Department of Emergency Medicine, Inselspital, University Hospital Bern,
University of Bern, 3010 Bern, Switzerland. aristomenis.exadaktylos@insel.ch.
(6)Department of Emergency Medicine, Inselspital, University Hospital Bern,
University of Bern, 3010 Bern, Switzerland. beat.lehmann@insel.ch.
(7)Clinical Pharmacology and Toxicology, Department of General Internal Medicine,
Inselspital, Bern University Hospital, University of Bern, 3010 Bern,
Switzerland. evangelia.liakoni@insel.ch.
(8)Institute of Pharmacology, University of Bern, 3010 Bern, Switzerland.
The consequences of mushroom poisoning range from mild, mostly gastrointestinal, 
disturbances to organ failure or even death. This retrospective study describes
presentations related to mushroom poisoning at an emergency department in Bern
(Switzerland) from January 2001 to October 2017. Gastrointestinal disturbances
were reported in 86% of the 51 cases. The National Poisons Information Centre and
mycologists were involved in 69% and 61% of the cases, respectively.
Identification of the mushroom type/family was possible in 43% of the cases. The 
most common mushroom family was Boletaceae (n = 21) and the most common mushrooms
Xerocomus chrysenteron (n = 7; four being part of a cluster), Clitocybe
nebularis, Lepista nuda and Lactarius semisanguifluus (n = 5 each, four being
part of a cluster). Poisonous mushrooms included Amanita phalloides (n = 3, all
analytically confirmed), Boletus satanas (n = 3), Amanita muscaria (n = 2) and
Amanita pantherina (n = 2). There were no fatalities and 80% of the patients were
discharged within 24 h. Mushroom poisoning does not appear to be a common reason 
for emergency consultation and most presentations were of minor severity and
related to edible species (e.g., due to incorrect processing). Nevertheless,
poisonous mushrooms and severe complications were also recorded. Collaboration
with a poison centre and/or mycologists is of great importance, especially in
high risk cases.
DOI: 10.3390/ijerph15122855 
PMID: 30558129  [Indexed for MEDLINE]

Toxicon. 2019 Jan;157:53-65. doi: 10.1016/j.toxicon.2018.11.007. Epub 2018 Nov
Mushroom poisoning: A proposed new clinical classification.
White J(1), Weinstein SA(2), De Haro L(3), Bédry R(4), Schaper A(5), Rumack
BH(6), Zilker T(7).
Author information: 
(1)Toxinology Dept., Women's & Children's Hospital, North Adelaide, Australia.
Electronic address: julian.white@adelaide.edu.au.
(2)Toxinology Dept., Women's & Children's Hospital, North Adelaide, Australia.
(3)Marseille Poison Centre, Hopital Sainte Marguerite, Marseille, France.
(4)Hospital Secure Unit, Pellegrin University Hospital, Bordeaux, France.
(5)GIZ-Nord Poisons Centre, University Medical Center Göettingen, Göttingen,
(6)Department of Emergency Medicine and Pediatrics, University of Colorado School
of Medicine, Aurora, CO, USA.
(7)Dept. for Clinical Toxicology at II, Med. Klinik, TU, München, Munich,
Comment in
    Toxicon. 2019 Mar 1;159:63-64.
Mushroom poisoning is a significant and increasing form of toxin-induced-disease.
Existing classifications of mushroom poisoning do not include more recently
described new syndromes of mushroom poisoning and this can impede the diagnostic 
process. We reviewed the literature on mushroom poisoning, concentrating on the
period since the current major classification published in 1994, to identify all 
new syndromes of poisoning and organise them into a new integrated
classification, supported by a new diagnostic algorithm. New syndromes were
eligible for inclusion if there was sufficient detail about both causation and
clinical descriptions. Criteria included: identity of mushrooms, clinical
profile, epidemiology, and the distinctive features of poisoning in comparison
with previously documented syndromes. We propose 6 major groups based on key
clinical features relevant in distinguishing between poisoning syndromes. Some
clinical features, notably gastrointestinal symptoms, are common to many mushroom
poisoning syndromes. Group 1 - Cytotoxic mushroom poisoning. Syndromes with
specific major internal organ pathology: (Subgroup 1.1; Primary hepatotoxicity); 
1A, primary hepatotoxicity (amatoxins); (Subgroup 1.2; Primary nephrotoxicity);
1B, early primary nephrotoxicity (amino hexadienoic acid; AHDA); 1C, delayed
primary nephrotoxicity (orellanines). Group 2 - Neurotoxic mushroom poisoning.
Syndromes with primary neurotoxicity: 2A, hallucinogenic mushrooms (psilocybins
and related toxins); 2B, autonomic-toxicity mushrooms (muscarines); 2C,
CNS-toxicity mushrooms (ibotenic acid/muscimol); 2D, morel neurologic syndrome
(Morchella spp.). Group 3 - Myotoxic mushroom poisoning. Syndromes with
rhabdomyolysis as the primary feature: 3A, rapid onset (Russula spp.); 3B,
delayed onset (Tricholoma spp.). Group 4 - Metabolic, endocrine and related
toxicity mushroom poisoning. Syndromes with a variety of clinical presentations
affecting metabolic and/or endocrine processes: 4A, GABA-blocking mushroom
poisoning (gyromitrins); 4B, disulfiram-like (coprines); 4C, polyporic mushroom
poisoning (polyporic acid); 4D, trichothecene mushroom poisoning (Podostroma
spp.); 4E, hypoglycaemic mushroom poisoning (Trogia venenata); 4F,
hyperprocalcitoninemia mushroom poisoning (Boletus satanas); 4G, pancytopenic
mushroom poisoning (Ganoderma neojaponicum). Group 5 - Gastrointestinal irritant 
mushroom poisoning. This group includes a wide variety of mushrooms that cause
gastrointestinal effects without causing other clinically significant effects.
Group 6 - Miscellaneous adverse reactions to mushrooms. Syndromes which do not
fit within the previous 5 groups: 6A, Shiitake mushroom dermatitis; 6B,
erythromelagic mushrooms (Clitocybe acromelagia); 6C, Paxillus syndrome (Paxillus
involutus); 6D, encephalopathy syndrome (Pleurocybella porrigens).
Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.
DOI: 10.1016/j.toxicon.2018.11.007 
PMID: 30439442  [Indexed for MEDLINE]

Toxins (Basel). 2018 Nov 13;10(11). pii: E468. doi: 10.3390/toxins10110468.
The Yellow Knight Fights Back: Toxicological, Epidemiological, and Survey Studies
Defend Edibility of Tricholoma equestre.
Klimaszyk P(1), Rzymski P(2).
Author information: 
(1)Institute of Environmental Biology, Adam Mickiewicz University, 61-614 Poznan,
Poland. pklim@amu.edu.pl.
(2)Department of Environmental Medicine, Poznan University of Medical Sciences,
60-806 Poznan, Poland. rzymskipiotr@ump.edu.pl.
Rhabdomyolysis, a condition associated with the consumption of Yellow Knight
mushrooms (Tricholoma equestre), was first reported in 2001. In response, some
countries began to consider the mushroom as poisonous, whereas in others it is
still consumed. In the present study, a nationwide survey of Polish mushroom
foragers (n = 1545) was conducted to estimate the frequency of T. equestre
consumption. The epidemiological database on mushroom poisonings in Poland was
analyzed from the year 2008. Hematological and biochemical parameters were
followed for a week in 10 volunteers consuming 300 g of molecularly identified T.
equestre. More than half the foragers had consumed T. equestre at least once in
their lifetime and a quarter had consumed it consecutively. The frequency of
adverse events was low and no rhabdomyolysis was reported. The toxicological
database indicated that mushrooms from the Tricholoma genus caused poisonings
less frequently than mushrooms with well-established edibility and not a single
case of rhabdomyolysis has been reported within the last decade. The volunteers
consuming T. equestre revealed no hematological or biochemical alterations and no
adverse effects were observed. The findings of this study support the view that
T. equestre is edible if consumed in rational amounts by healthy subjects.
DOI: 10.3390/toxins10110468 
PMCID: PMC6267205
PMID: 30428584 

Clin Toxicol (Phila). 2019 Feb;57(2):99-103. doi: 10.1080/15563650.2018.1497169. 
Epub 2018 Aug 3.
Toxicity of muscimol and ibotenic acid containing mushrooms reported to a
regional poison control center from 2002-2016.
Moss MJ(1)(2), Hendrickson RG(1)(2).
Author information: 
(1)a Department of Emergency Medicine , Oregon Health and Science University ,
Portland , OR , USA.
(2)b Oregon Poison Center , Portland , OR , USA.
BACKGROUND: Amanita muscaria (AM) and A. pantherina (AP) contain ibotenic acid
and muscimol and may cause both excitatory and sedating symptoms.
Gastrointestinal (GI) symptoms are not classically described but have been
reported. There are relatively few reported cases of poisoning with these
mushrooms in North America.
METHODS: This is a retrospective review of ingestions of ibotenic acid and
muscimol containing mushrooms reported to a United States regional poison center 
from 2002-2016. Cases were included if identification was made by a mycologist or
if AM was clearly described.
RESULTS: Thirty-four cases met inclusion criteria. There were 23 cases of AM, 10 
AP, and 1 A. aprica. Reason for ingestion included foraging (12), recreational
(6), accidental (12), therapeutic (1), self-harm (1), and unknown (2). Of the
accidental pediatric ingestions 4 (25%) were symptomatic. None of the children
with a symptomatic ingestion of AM required admission. A 3-year-old male who
ingested AP had vomiting, agitation, and lethargy and received benzodiazepines.
He was intubated and had a 3-day ICU stay. There were 25 symptomatic patients.
All but one patient developed symptoms within 6 h. Six patients had symptoms for 
less than 6 h while 15 had symptoms lasting less than 24 h. Ingestions of AP were
more symptomatic than AM with regard to the presence of any GI symptoms (80% vs. 
35%), central nervous system (CNS) depression (70% vs. 35%), and CNS excitation
(70% vs. 35%) respectively. Five patients were intubated. No patients experienced
hypotension, seizures, acute kidney injury, or hepatotoxicity. No deaths were
DISCUSSION: Ingestion of ibotenic acid/muscimol containing mushrooms often
produces a syndrome with GI upset, CNS excitation, and CNS depression either
alone or in combination. Ingestion of AP was associated with a higher rate of
symptoms compared to AM.
DOI: 10.1080/15563650.2018.1497169 
PMID: 30073844 

Mycologia. 2018 Jul-Aug;110(4):637-641. doi: 10.1080/00275514.2018.1479561. Epub 
2018 Jul 31.
Mushroom poisoning epidemiology in the United States.
Brandenburg WE(1)(2), Ward KJ(3).
Author information: 
(1)a Family Medicine Residency of Idaho , RTT Caldwell, 777 N. Raymond Street,
Boise , Idaho 83704-9251.
(2)b West Valley Medical Center , 1717 Arlington Avenue, Caldwell , Idaho 83605.
(3)c Pediatric Intensive Care Unit, Saint Luke's Hospital , 190 E Bannock Street,
Boise , Idaho 83712.
Erratum in
    Mycologia. 2018 Dec 12;:1.
Ingestion of wild and potentially toxic mushrooms is common in the United States 
and many other parts of the world. US poison centers have been logging cases of
mushroom exposure in The National Poison Data System (NPDS) annual publications
for over 30 years. This study compiles and analyzes US mushroom exposures as
reported by the NPDS from 1999 to 2016. Over the last 18 years, 133 700 cases
(7428/year) of mushroom exposure, mostly by ingestion, have been reported. Cases 
are most frequently unintentional (83%, P < 0.001); cause no or only minor harm
(86%, P < 0.001); and in children <6 years old (62%, P < 0.001). Approximately
704 (39/year) exposures have resulted in major harm. Fifty-two (2.9/year)
fatalities have been reported, mostly from cyclopeptide (68-89%)-producing
mushrooms ingested by older adults unintentionally. The vast majority of reported
ingestions resulted in no or minor harm, although some groups of mushroom toxins 
or irritants, such as cyclopepides, ibotenic acid, and monomethylhydrazine, have 
been deadly. Misidentification of edible mushroom species appears to be the most 
common cause and may be preventable through education.
DOI: 10.1080/00275514.2018.1479561 
PMID: 30062915  [Indexed for MEDLINE]

Int J Occup Environ Med. 2018 Jul;9(3):152-156. doi: 10.15171/ijoem.2018.1380.
Outbreak of Mushroom Poisoning in Iran: April-May, 2018.
Soltaninejad K(1).
Author information: 
(1)Department of Forensic Toxicology, Legal Medicine Research Center, Legal
Medicine Organization, Tehran, Iran. kamsoltaninejad@gmail.com.
From April 28 to May 28, 2018, more than 1200 patients with impression of
mushroom poisoning were referred to hospital emergency departments in 13 west and
northwestern provinces, Iran; 112 (8.9%) patients were hospitalized and 19 were
expired (ie, a fatality rate of 1.5%). The outbreak began in Kermanshah province 
with increasing number of patients presenting with severe abdominal pain, nausea,
vomiting, and diarrhea soon after consumption of wild mushrooms. Lepiota
brunneioncarnata, Hypholoma fascicalare, and Coprinopsis atramentaria have been
involved in this outbreak. To prevent similar outbreaks, raising public awareness
about risky behaviors of collecting and consuming wild self-picked mushrooms is
of paramount importance. Herein, we present our experience with this outbreak.
DOI: 10.15171/ijoem.2018.1380 
PMID: 29995021  [Indexed for MEDLINE]

Medicine (Baltimore). 2018 Jul;97(27):e11288. doi: 10.1097/MD.0000000000011288.
Challenges in the early diagnosis of patients with acute liver failure induced by
amatoxin poisoning: Two case reports.
Li Y(1), Mu M, Yuan L, Zeng B, Lin S.
Author information: 
(1)Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical
College, Guizhou, China.
RATIONALE: Acute liver failure (ALF) induced by amatoxin-containing mushrooms
accounts for more than 90% of deaths in patients suffering from mushroom
poisoning. However, due to the fact that most hospitals cannot identify the
species of mushrooms involved, or detect amatoxins, the early diagnosis of
amatoxin intoxication remains a significant challenge in clinical practice.
PATIENT CONCERNS: Two patients were had ingested wild mushrooms 15 hours before
admission. Six hours prior to admission they experienced nausea, vomiting,
weakness, abdominal pain and diarrhea. The species of mushrooms they had consumed
could not be identified.
DIAGNOSES: According to their delayed gastroenteritis, the two patients were
clinically diagnosed with amatoxin poisoning. One week after the patients were
discharged, the species of the mushrooms was identified as Amanita fuliginea and 
the diagnosis was confirmed.
INTERVENTIONS: The two patients were treated with silibinin, penicillin G and
plasma exchange.
OUTCOMES: Although the two patients progressed to ALF they fully recovered and
were discharged on day 10 after admission.
LESSONS: Our case reports suggested that patients with unidentified wild mushroom
intoxication with delayed gastroenteritis could be clinically diagnosed with
amatoxin poisoning; in such cases, liver coagulation function should be
frequently evaluated. Early diagnosis and treatment are crucial for survival in
patients with ALF induced by amatoxin poisoning.
DOI: 10.1097/MD.0000000000011288 
PMCID: PMC6076086
PMID: 29979397  [Indexed for MEDLINE]

Nan Fang Yi Ke Da Xue Xue Bao. 2018 May 20;38(5):635-638.
[Mixed amanita phalloides poisoning with rhabdomyolysis: analysis of 4 cases].
[Article in Chinese]
Lu Z(1), Chen YB, Huang B, Peng S, Wang QW, Liu DL, Wang H.
Author information: 
(1)Intensive Care Unit, Zhujiang Hospital, Southern Medical University, Guangzhou
510282, China.E-mail: 821353922@qq.com.
We report the clinical characteristics, treatments and outcomes of 4 rare cases
of mixed amanita fuliginea and amanita rimosa poisoning with rhabdomyolysis, and 
review the research progress in the intoxication mechanism and treatment. The
latent time of amanita poisoning, defined as the period from the ingestion of
poisonous mushroom to the onset of gastrointestinal symptoms, was about 8 days,
and the severity of poisoning was associated with the amount of mushroom
ingested. All the 4 patients developed multiple organ dysfunctions within 3 to 4 
days after mushroom ingestion, predominantly in the liver, kidney and central
nervous system accompanied with acute gastrointestinal injury and rhabdomyolysis.
The treatment measures included persistent hemofiltration and intermittent
hemoperfusion once daily for 5-7 days, and plasma exchange was administered in 2 
cases for 1 or 2 times. High-dose vitamin C, glucose and corticosteroid were also
given to the patients. After the treatments, two patients were cured and the
other two died due to an excess intake of poisonous mushroom and lack of early
preemptive therapies. Early emetic, gastric lavage, catharsis, fluid infusion and
diuresis are critical to interrupt the enterohepatic circulation of amanita
phalloides toxins and prevent the development of multiple organ dysfunction.
Enhanced hemofiltration and sequential plasma therapy might effectively eliminate
toxin from the blood to protect against further organ damages.
PMID: 29891465  [Indexed for MEDLINE]

Int J Environ Res Public Health. 2018 May 4;15(5). pii: E919. doi:
Arsenic and Other Elemental Concentrations in Mushrooms from Bangladesh: Health
Rashid MH(1)(2)(3), Rahman MM(4)(5), Correll R(6), Naidu R(7)(8).
Author information: 
(1)Global Centre for Environmental Remediation (GCER), The University of
Newcastle, University Drive, Callaghan, NSW 2308, Australia.
(2)Cooperative Research Centre for Contamination Assessment and Remediation of
the Environment (CRC-CARE), Callaghan, NSW 2308, Australia.
(3)Soil Science Division, Bangladesh Agricultural Research Institution (BARI),
Joydebpur, Gazipur 1701, Bangladesh. mdharunur.rashid@uon.edu.au.
(4)Global Centre for Environmental Remediation (GCER), The University of
Newcastle, University Drive, Callaghan, NSW 2308, Australia.
(5)Cooperative Research Centre for Contamination Assessment and Remediation of
the Environment (CRC-CARE), Callaghan, NSW 2308, Australia.
(6)Rho Environmetrics, Highgate, SA 5063, Australia.
(7)Global Centre for Environmental Remediation (GCER), The University of
Newcastle, University Drive, Callaghan, NSW 2308, Australia.
(8)Cooperative Research Centre for Contamination Assessment and Remediation of
the Environment (CRC-CARE), Callaghan, NSW 2308, Australia.
Mushroom cultivation has been increasing rapidly in Bangladesh. Arsenic (As)
toxicity is widespread in the world and Bangladesh faces the greatest havoc due
to this calamity. Rice is the staple food in Bangladesh and among all the crops
grown, it is considered to be the main cause of As poisoning to its population
after drinking water. Consequently, rice straw, an important growing medium of
mushrooms in Bangladesh, is known to have high As content. The objective of this 
study was, therefore, to determine the concentrations of As in mushrooms
cultivated in Bangladesh and to assess the health risk as well. It also
considered other elements, including Cd, Cr, Co, Cu, Pb, Mn, Hg, Ni, and Zn
concentrations in mushrooms from Bangladesh. The mean concentrations (mg/kg) of
As, Cd, Cr, Co, Cu, Pb, Mn, Hg, Ni, and Zn in mushrooms were 0.51, 0.38, 0.28,
0.01, 13.7, 0.31, 11.7, 0.12, 0.28, and 53.5, respectively. Based on the dietary 
intake of mushrooms, the weekly intakes of As, Cd, Cr, Co, Cu, Pb, Mn, Hg, Ni,
and Zn from mushrooms for adults were 0.0042, 0.0030, 0.0024, 0.0001, 0.1125,
0.0019, 0.1116, 0.0011, 0.0023, and 0.4734 mg, respectively. Due to the low
concentrations of As and other trace elements observed in mushrooms from
Bangladesh, as well as relatively lower consumption of this food in
people&rsquo;s diet, it can be inferred that consumption of the species of
mushrooms analysed will cause no toxicological risk.
DOI: 10.3390/ijerph15050919 
PMCID: PMC5981958
PMID: 29734714  [Indexed for MEDLINE]

Dermatol Online J. 2017 Sep 15;23(9). pii: 13030/qt3kb698nh.
Simultaneous flagellate erythema in a husband and wife secondary to shiitake
mushroom ingestion.
Nagarajan T(1), Lalor L, Housholder A.
Author information: 
(1)University of Cincinnati College of Medicine, Cincinnati, Ohio.
Flagellate erythema secondary to shiitake mushroom (Lentinus edodes) ingestion is
a condition that was first documented in 1977 by Nakamura and has been reported
in Japan, Europe, and the United States. Herein, we present two cases of
flagellate erythema after a couple ate a meal containing shiitake mushrooms at a 
chain restaurant. We hypothesize that this condition may not be as rare or as
dependent on volume of exposure as previously suggested, considering that two
genetically unrelated individuals simultaneously developed the eruption after
minimal exposure.
PMID: 29469719  [Indexed for MEDLINE]

Transplant Proc. 2018 Jan - Feb;50(1):192-197. doi:10.1016/j.transproceed.2017.11.032.
Acute Liver Failure due to Amanita phalloides Poisoning: Therapeutic Approach and
Kieslichova E(1), Frankova S(2), Protus M(3), Merta D(3), Uchytilova E(3), Fronek
J(4), Sperl J(2).
Author information: 
(1)Department of Anesthesiology and Intensive Care, Transplantcenter, Institute
for Clinical and Experimental Medicine, Prague, Czech Republic. Electronic
address: eva.kieslichova@ikem.cz.
(2)Department of Hepatogastroenterology, Transplantcenter, Institute for Clinical
and Experimental Medicine, Prague, Czech Republic.
(3)Department of Anesthesiology and Intensive Care, Transplantcenter, Institute
for Clinical and Experimental Medicine, Prague, Czech Republic.
(4)Department of Transplant Surgery, Transplantcenter, Institute for Clinical and
Experimental Medicine, Prague, Czech Republic.
INTRODUCTION: Amanita phalloides poisoning is a potentially fatal cause of acute 
liver failure. The aim of this study was to analyze the impact of initial
patients' characteristics and different treatment modalities on the outcome of
patients with liver failure caused by Amanita poisoning.
MATERIAL AND METHODS: We retrospectively evaluated 23 patients admitted to our
center between July 2007 and August 2016.
RESULTS: Mean time interval between Amanita phalloides ingestion and the onset of
gastrointestinal symptoms was 12.48 ± 9.88 hours and the interval between
ingestion and hospital admission 26.26 ± 15.14 hours. The treatment was intiated 
by oral decontamination using activated charcoal followed by intravenous
rehydration and high doses of intravenous N-acetylcysteine and silibinin.
Fourteen patients (61%) underwent extracorporeal elimination method. Ten patients
had plasmapheresis, 1 patient had hemoperfusion, and 5 patients had fractionated 
plasma separation and adsorption. Seven patients who met King's College Criteria 
were listed for urgent liver transplantation; one of them died before
transplantation. Six patients underwent liver transplantation; the mean waiting
time was 6.5 ± 12.0 days (range, 1-31 days). One patient died 2 months afterward.
All 16 patients who did not meet King's College Criteria and received
conservative treatment survived.
CONCLUSION: Our results documented a good prognostic value of standard King's
College Criteria for indication of urgent liver transplantation in acute liver
failure caused by Amanita phalloides poisoning. Fractionated plasma separation
and adsorption may contribute to low mortality on the waiting list. Intensive
care and extracorporeal elimination methods seem to be crucial points of the
conservative treatment.
Copyright © 2017 Elsevier Inc. All rights reserved.
DOI: 10.1016/j.transproceed.2017.11.032 
PMID: 29407307  [Indexed for MEDLINE]

Wilderness Environ Med. 2018 Mar;29(1):111-118. doi: 10.1016/j.wem.2017.10.002.
Epub 2018 Jan 8.
Amatoxin-Containing Mushroom Poisonings: Species, Toxidromes, Treatments, and
Diaz JH(1).
Author information: 
(1)Department of Environmental and Occupational Health Sciences, School of Public
Health, Louisiana State University Health Sciences Center, New Orleans, LA.
Electronic address: jdiaz@lsuhsc.edu.
Amatoxins are produced primarily by 3 species of mushrooms: Amanita, Lepiota, and
Galerina. Because amatoxin poisonings are increasing, the objective of this
review was to identify all amatoxin-containing mushroom species, present a
toxidromic approach to earlier diagnoses, and compare the efficacies and outcomes
of therapies. To meet these objectives, Internet search engines were queried with
keywords to select peer-reviewed scientific articles on amatoxin-containing
mushroom poisoning and management. Descriptive epidemiological analyses have
documented that most mushroom poisonings are caused by unknown mushrooms, and
most fatal mushroom poisonings are caused by amatoxin-containing mushrooms.
Amanita species cause more fatal mushroom poisonings than other
amatoxin-containing species, such as Galerina and Lepiota. Amanita phalloides is 
responsible for most fatalities, followed by Amanita virosa and Amanita verna.
The most frequently reported fatal Lepiota ingestions are due to Lepiota
brunneoincarnata, and the most frequently reported fatal Galerina species
ingestions are due to Galerina marginata. With the exception of liver
transplantation, the current treatment strategies for amatoxin poisoning are all 
supportive and have not been subjected to rigorous efficacy testing in randomized
controlled trials. All patients with symptoms of late-appearing gastrointestinal 
toxicity with or without false recovery or quiescent periods preceding acute
liver insufficiency should be referred to centers providing liver
transplantation. Patients with amatoxin-induced acute liver insufficiency that
does not progress to liver failure will have a more favorable survival profile
with supportive care than patients with amatoxin-induced acute liver failure,
about half of whom will require liver transplantation.
Copyright © 2017 Wilderness Medical Society. Published by Elsevier Inc. All
rights reserved.
DOI: 10.1016/j.wem.2017.10.002 
PMID: 29325729  [Indexed for MEDLINE]

Basic Clin Pharmacol Toxicol. 2018 Jun;122(6):633-642. doi: 10.1111/bcpt.12954.
Epub 2018 Jan 24.
A Comparison of the Effectiveness of Silibinin and Resveratrol in Preventing
Alpha-Amanitin-Induced Hepatotoxicity.
Sahin A(1), Arici MA(2), Yilmaz Y(3)(4), Kalkan S(5), Durmus N(2), Ergur BU(6),
Yakut Aksu I(7), Atabey N(4)(8), Tuncok Y(5).
Author information: 
(1)Department of Emergency Medicine, Karadeniz Technical University School of
Medicine, Trabzon, Turkey.
(2)Department of Medical Pharmacology, Dokuz Eylul University School of Medicine,
Izmir, Turkey.
(3)Department of Medical Biology and Genetics, Dokuz Eylul University Institute
of Health Sciences, Izmir, Turkey.
(4)Dokuz Eylul University Izmir Biomedicine and Genome Institute (iBG-izmir),
Izmir, Turkey.
(5)Division of Clinical Toxicology, Department of Medical Pharmacology, Dokuz
Eylul University School of Medicine, Izmir, Turkey.
(6)Department of Histology and Embriology, Dokuz Eylul University School of
Medicine, Izmir, Turkey.
(7)Department of Physiology, Dokuz Eylul University School of Medicine, Izmir,
(8)Department of Medical Biology and Genetics, Dokuz Eylul University School of
Medicine, Izmir, Turkey.
Amanita phalloides species mushrooms containing alpha-amanitin (α-AMA) are
responsible for the majority of fatal mushroom intoxications and can lead to
severe poisonings resulting in hepatotoxicity and acute hepatic failure. Existing
antidotes, such as silibinin, are not sufficiently effective in the prevention
and/or resolution of α-AMA-induced hepatotoxicity. We investigated the effects of
resveratrol on α-AMA-induced hepatotoxicity and compared with silibinin, a known 
antidote using in vivo and in vitro toxicity models. In the in vivo protocol,
resveratrol (30 mg/kg) was given simultaneously with α-AMA (α-AMA + SR) or 12
(α-AMA + 12R) or 24 (α-AMA + 24R) hr after α-AMA administration. Silibinin (5
mg/kg) (α-AMA + Sil) and normal saline (α-AMA + NS) were given simultaneously
with α-AMA. We found that liver transaminase levels in α-AMA + SR and α-AMA + 12R
groups and histomorphologic injury score in the α-AMA + SR, α-AMA + 12R, α-AMA + 
24R and α-AMA + Sil groups were significantly lower than that of the α-AMA + NS
group. Resveratrol decreased mononuclear cell infiltration, necrosis and active
caspase-3 immunopositivity in the liver. In the in vitro protocol, the effects of
resveratrol and silibinin were evaluated in a reduction in cell viability induced
by α-AMA in THLE-2 and THLE-3 hepatocytes. Neither resveratrol nor silibinin was 
found to be effective in increasing cell viability decreased by α-AMA + NS. As a 
conclusion, resveratrol was found to be effective in α-AMA-induced hepatotoxicity
with its anti-inflammatory properties in in vivo conditions. It is a promising
compound with the potential for use in the treatment of hepatotoxicity associated
with Amanita phalloides type mushroom poisonings.
© 2017 Nordic Association for the Publication of BCPT (former Nordic
Pharmacological Society).
DOI: 10.1111/bcpt.12954 
PMID: 29285878  [Indexed for MEDLINE]

Int J Gen Med. 2017 Nov 3;10:395-400. doi: 10.2147/IJGM.S141111. eCollection
Clinical characteristics and outcome of toxicity from Amanita mushroom poisoning.
Trakulsrichai S(1)(2), Sriapha C(2), Tongpoo A(2), Udomsubpayakul U(3),
Wongvisavakorn S(2), Srisuma S(2)(4), Wananukul W(2)(4).
Author information: 
(1)Department of Emergency Medicine.
(2)Ramthibodi Poison Center.
(3)Section for Clinical Epidemiology and Biostatistics, Research Center.
(4)Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, Bangkok, Thailand.
Objective: To describe and analyze the clinical characteristics and outcome of
amatoxin poisoning cases.
Methods: We performed a retrospective cohort study of amatoxin poisoning cases
from Ramathibodi Poison Center Toxic Exposure Surveillance System, from May 2013 
to August 2015.
Results: There were 30 consultations with a total of 55 poisoning cases. Most
cases were male and from the north-east region. Hepatitis, acute kidney injury,
jaundice, and coagulopathy accounted for 74%, 46.3%, 44.7%, and 52.8% of the
cases, respectively. Almost all of the patients were admitted to the hospital,
and the median duration of hospital stay was found to be 4 days. Mortality rate
was found to be 27.3%. Most patients (73%) received the treatment including
multiple-dose activated charcoal (67.5%), intravenous N-acetylcysteine (87.5%),
and benzylpenicillin (45%). In 60% of the cases, the treatment was initiated
within 24 h after eating mushrooms. Exchange transfusion and liver
transplantation were performed in one severe case. However, this patient died
eventually. Because intravenous silybinin is not available in Thailand during the
study period, 8 patients received oral silymarin instead. All 8 patients had
hepatitis and were treated with high dosage of oral silymarin (5 patients with
4.48 g/day, 2 patients with 1.68 g/day, and 1 patient with 1.4 g/day) for a
couple of days. One of these patients died as she received treatment very late;
she was treated with silymarin at 1.68 g/day dosage. Thus, the fatality in oral
silymarin treatment group was 12.5%. We performed the analysis between the dead
and survival groups. We found that in hepatitis, initial and maximum serum
aspartate transaminase, initial and maximum serum alanine transaminase, and acute
kidney injury were significantly different between the two groups.
Conclusion: Amanita mushroom poisoning caused high fatalities. Serum transaminase
and creatinine were the factors associated with death. Treatment with oral high
dose silymarin should be investigated further as one of the principal therapies
in amatoxin poisoning.
DOI: 10.2147/IJGM.S141111 
PMCID: PMC5679676
PMID: 29138589 

Clin Toxicol (Phila). 2018 May;56(5):365-369. doi: 10.1080/15563650.2017.1388386.
Epub 2017 Oct 20.
Investigation and analysis of Galerina sulciceps poisoning in a canteen.
Xiang H(1), Zhou Y(1), Zhou C(2), Lei S(1), Yu H(1), Wang Y(1), Zhu S(1).
Author information: 
(1)a Guizhou Center of Disease Control and Prevention , Guiyang , China.
(2)b Qiannan Center of Disease Control and Prevention , Duyun , China.
INTRODUCTION: Guizhou Province in China has an abundant resource of wild
mushrooms, including numerous poisonous species which contain various toxins. The
mortality rate from wild mushroom poisoning has been high in this area in recent 
years. Galerina sulciceps is a dangerously toxic mushroom which can be fatal if
METHODS: we report on an epidemiological investigation of G. sulciceps poisoning 
which occurred in Duyun City of Guizhou Province. The characteristics of this
species, its toxicity, observed clinical features, laboratory data, treatment
modality, and prognosis were investigated in order to provide a reference point
for the prevention and treatment of this kind of mushroom poisoning.
RESULTS: Thirteen employees showed toxic symptoms after ingesting wild mushrooms 
the previous day in a company canteen. Clinical manifestation varied from
gastroenteritis to hepatic and renal dysfunction. Most of the 13 patients
presented with nausea, vomiting, abdominal pain, diarrhea, and elevated levels of
biochemical indices of hepatic and renal function, during which transaminase
concentration peaked within 48-72 h. At 48 hours post-ingestion, all patients had
hemodialysis, in addition to supportive care for hepatic and renal injury with
oral Silibinin and Shenshuaining. All acute renal injury had resolved by day 10, 
and liver transaminases had trended toward normal in all patients and they were
discharged. At follow-up in 30 days, both liver and renal function had completely
recovered in all.
CONCLUSION: This poisoning occurs as a result of unintentional consumption of G. 
sulciceps, which is relatively rare in mushroom poisonings. All patients
recovered fully after timely diagnosis and treatment. To prevent wild mushroom
poisoning, the best preventive measure is to educate the public not to gather and
eat any unidentified wild mushrooms.
DOI: 10.1080/15563650.2017.1388386 
PMID: 29052443 

10.13075/ijomeh.1896.01063. Epub 2017 Aug 22.
Poisoning deaths in Poland: Types and frequencies reported in Łódź, Kraków,
Sosnowiec, Gdańsk, Wrocław and Poznań during 2009-2013.
Krakowiak A(1), Piekarska-Wijatkowska A(2), Kobza-Sindlewska K(3), Rogaczewska
A(4), Politański P(5), Hydzik P(6), Szkolnicka B(7), Kłopotowski T(8), Picheta
S(9), Porębska B(10), Antończyk A(11), Waldman W(12), Sein Anand J(13),
Matuszkiewicz E(14), Łukasik-Głębocka M(15).
Author information: 
(1)Nofer Institute of Occupational Medicine, Łódź, Poland (Department of
Toxicology, Toxicology Unit). annakrak@imp.lodz.pl.
(2)Nofer Institute of Occupational Medicine, Łódź, Poland (Department of
Toxicology, Poison Information Centre). piekarska@imp.lodz.pl.
(3)Nofer Institute of Occupational Medicine, Łódź, Poland (Department of
Toxicology, Poison Information Centre). kasind@imp.lodz.pl.
(4)Nofer Institute of Occupational Medicine, Łódź, Poland (Department of
Toxicology, Poison Information Centre). annarog@imp.lodz.pl.
(5)Nofer Institute of Occupational Medicine, Łódź, Poland (Department of
Radiological Protection). piopolit@imp.lodz.pl.
(6)Jagiellonian University Medical College, Kraków, Poland (Department of
Clinical Toxicology). piodzik@poczta.onet.pl.
(7)Jagiellonian University Medical College, Kraków, Poland (Poison Information
Centre). szkolbe@cm-uj.krakow.pl.
(8)Institute of Occupational Medicine and Environmental Health, Sosnowiec, Poland
(Regional Poisons Control Centre). t.klopotowski@gmail.com.
(9)Institute of Occupational Medicine and Environmental Health, Sosnowiec, Poland
(Regional Poisons Control Centre). yaris22@wp.pl.
(10)T. Marciniak Lower Silesian Specialized Hospital - Emergency Medicine Centre,
Wrocław, Poland. bmporebs@mp.pl.
(11)T. Marciniak Lower Silesian Specialized Hospital - Emergency Medicine Centre,
Wrocław, Poland. ooz.ww@interia.pl.
(12)Pomeranian Center of Toxicology, Gdańsk, Poland. w.waldman@pctox.pl.
(13)Pomeranian Center of Toxicology, Gdańsk, Poland. j.anand@pctox.pl.
(14)University of Medical Sciences, Poznań, Poland (Department of Emergency
Medicine). eryk.m@wp.pl.
(15)University of Medical Sciences, Poznań, Poland (Department of Emergency
Medicine). magda.glebocka@op.pl.
OBJECTIVES: The aim of this study has been to assess the characteristics of acute
poisoning deaths in Poland over a period of time 2009-2013.
MATERIAL AND METHODS: The analysis was based on the data obtained from the
patient records stored in toxicology departments in 6 cities - Łódź, Kraków,
Sosnowiec, Gdańsk, Wrocław and Poznań. Toxicological analyses were routinely
performed in blood and/or urine. Major toxic substances were classified to one of
the following categories: pharmaceuticals, alcohol group poisonings (ethanol and 
other alcohols), gases, solvents, drugs of abuse, pesticides, metals, mushrooms, 
others. Cases were analyzed according to the following criteria: year, age and
gender of analyzed patients, toxic substance category and type of poisoning. The 
recorded fatal poisonings were classified according to the International
Classification of Diseases.
RESULTS: The record of 261 deaths were retrospectively reviewed. There were 187
males (71.64%) and 74 females (28.36%) and the male to female ratio was 2.52.
Alcohol group poisonings were more frequently responsible for deaths in men
compared to all poisonings, 91.1% vs. 71.6%, respectively (p < 0.05), and
pharmaceutical agents were more frequently responsible for deaths in women, 47.4%
vs. 28.4%, (p < 0.05). Methanol was the most common agent in the alcohol group
poisonings, accounting for 43.75% (N = 49), followed by ethylene glycol, 39.29%
(N = 44), and ethanol, 16.96% (N = 19).
CONCLUSIONS: Epidemiological profile data from investigation of poisoning deaths 
in Poland may be very useful for the development of preventive programs. Int J
Occup Med Environ Health 2017;30(6):897-908.
This work is available in Open Access model and licensed under a CC BY-NC 3.0 PL 
DOI: 10.13075/ijomeh.1896.01063 
PMID: 28832029  [Indexed for MEDLINE]

Hum Exp Toxicol. 2018 Jul;37(7):697-703. doi: 10.1177/0960327117730882. Epub 2017
Sep 14.
Epidemiology and clinics of mushroom poisoning in Northern Italy: A 21-year
retrospective analysis.
Cervellin G(1), Comelli I(1), Rastelli G(2), Sanchis-Gomar F(3), Negri F(4), De
Luca C(4), Lippi G(5).
Author information: 
(1)1 Emergency Department, University Hospital of Parma, Parma, Italy.
(2)2 Emergency Department, Hospital of Fidenza, Fidenza, Parma, Italy.
(3)3 Leon H. Charney Division of Cardiology, New York University School of
Medicine, New York, NY, USA.
(4)4 Mycological Consultation Service, Local Health Agency of Parma, Parma,
(5)5 Section of Clinical Biochemistry, University of Verona, Verona, Italy.
BACKGROUND: Limited information exists about epidemiology and management of
mushroom poisoning. We analyzed and described epidemiology, clinical
presentation, and clinical course of mushroom-poisoned patients admitted to
emergency departments (EDs) of the Province of Parma, Italy.
METHODS: Data from the database of mycological service were matched with clinical
information retrieved from hospitals' database, from January 1, 1996 to December 
31, 2016.
RESULTS: Mycologist consultation was obtained in 379/443 identified mushroom
poisonings. A remarkable seasonality was found, with significant peak in autumn. 
Thanks to the collaboration, the implicated species could be identified in 397
cases (89.6%); 108 cases (24.4%) were due to edible mushrooms, Boletus edulis
being the most represented (63 cases). Overall, 408 (92%) cases presented with
gastrointestinal toxicity. Twenty cases of amatoxin poisoning were recorded (11
Amanita phalloides and 9 Lepiota brunneoincarnata). One liver transplantation was
needed. We observed 13 cases of cholinergic toxicity and 2 cases of
hallucinogenic toxicity. Finally, 46 cases were due to "mixed" toxicities, and a 
total of 69 needed hospitalization.
CONCLUSIONS: Early identification and management of potentially life-threatening 
cases is challenging in the ED, so that a mycologist service on call is highly
advisable, especially during periods characterized by the highest incidence of
DOI: 10.1177/0960327117730882 
PMID: 28905663  [Indexed for MEDLINE]

Sud Med Ekspert. 2017;60(3):23-26. doi: 10.17116/sudmed201760323-26.
[The peculiar features of the morphological manifestations of the damage to the
liver associated with the death cap mushroom poisoning].
[Article in Russian; Abstract available in Russian from the publisher]
Ivleva EA(1), Bogomolov DV(2), Putintsev VA(2), Bogomolova IN(2).
Author information: 
(1)Belgorod Regional Bureau of Forensic Medical Expertise, Belgorod, Russia,
(2)Federal state budgetary institution 'Russian Federal Centre of Forensic
Medical Expertise', Ministry of Health of the Russia, Moscow, Russia, 125284.
This article is focused on the peculiar features of the morphological
manifestations of massive hepatic necrosis associated with the death cap mushroom
(Amanita phalloides) poisoning in comparison with similar cases of intoxication. 
It has been shown that the poisoning is associated with cell proliferation in the
peri-portal regions of the liver and induction of the mechanisms of apoptosis
responsible for the death of hepatocytes.
Publisher: Рассмотрены морфологические особенности массивного некроза печени при 
отравлении ядами бледной поганки (Amanita phalloides) в сравнении с другими его
причинами. Показано наличие пролиферации в перипортальных зонах печени и участие 
механизмов апоптоза при гибели гептоцитов. Уточнен темп умирания при данном
DOI: 10.17116/sudmed201760323-26 
PMID: 28656949  [Indexed for MEDLINE]

MMWR Morb Mortal Wkly Rep. 2017 Jun 2;66(21):549-553. doi:
Amanita phalloides Mushroom Poisonings - Northern California, December 2016.
Vo KT, Montgomery ME, Mitchell ST, Scheerlinck PH, Colby DK, Meier KH, Kim-Katz
S, Anderson IB, Offerman SR, Olson KR, Smollin CG.
Amanita phalloides, colloquially known as the "death cap," belongs to the
Phalloideae section of the Amanita family of mushrooms and is responsible for
most deaths following ingestion of foraged mushrooms worldwide (1). On November
28, 2016, members of the Bay Area Mycological Society notified personnel at the
California Poison Control System (CPCS) of an unusually large A. phalloides bloom
in the greater San Francisco Bay Area, coincident with the abundant rainfall and 
recent warm weather. Five days later, CPCS received notification of the first
human A. phalloides poisoning of the season. Over the following 2 weeks, CPCS was
notified of an additional 13 cases of hepatotoxicity resulting from A. phalloides
ingestion. In the past few years before this outbreak, CPCS received reports of
only a few mushroom poisoning cases per year. A summary of 14 reported cases is
presented here. Data extracted from patient medical charts revealed a pattern of 
delayed gastrointestinal manifestations of intoxication leading to dehydration
and hepatotoxicity. Three patients received liver transplants and all but one
recovered completely. The morbidity and potential lethality associated with A.
phalloides ingestion are serious public health concerns and warrant medical
provider education and dissemination of information cautioning against consuming 
foraged wild mushrooms.
DOI: 10.15585/mmwr.mm6621a1 
PMCID: PMC5657817
PMID: 28570504  [Indexed for MEDLINE]

Emerg (Tehran). 2017;5(1):e23. Epub 2017 Jan 10.
Mushroom Poisoning in the Northeast of Iran; a Retrospective 6-Year Epidemiologic
Dadpour B(1), Tajoddini S(2), Rajabi M(3), Afshari R(4).
Author information: 
(1)Addiction Research Center, Faculty of Medicine, Mashhad University of Medical 
Sciences, Mashhad, Iran.
(2)Neuroscience Research Center, Institute of Neuropharmacology, Kerman
University of Medical Sciences, Kerman, Iran.
(3)Medical Toxicology Research Centre, School of Medicine, Mashhad University of 
Medical Sciences, Mashhad, Iran.
(4)Environmental Health Services, BC Centre for Disease Control, Vancouver,
INTRODUCTION: Toxic mushrooms are distributed across the globe with over 5000
species. Among them, 100 species are responsible for most of the cases of
mushroom poisoning. This study aimed to evaluate the epidemiologic pattern of
mushroom poisoning among patients referred to the main toxicology center of
Mashhad province located in North-east of Iran.
METHOD: This cross-sectional study was conducted on patients with final diagnosis
of mushroom poisoning referred to the toxicology center of Mashhad, Iran, from
February 2005 to 2011. Patients' demographic characteristics, clinical
presentations, laboratory findings, outcomes, and therapeutic measures were
collected using a predesigned checklist and searching patient's profile.
RESULTS: 32 cases with the mean age of 24.6 ± 16.7 years were presented to the
toxicology center following mushroom poisoning (59% female). Mushroom poisoning
accounted for 0.1% of all admitted cases. The mean time elapsed from consumption 
to referral to poisoning department was 61.9 ± 49.4 hours. 19 (59%) cases were
discharged with complete recovery, 7 (22%) expired, and 6 (19%) cases left
hospital against medical advice. Mushroom poisoning mortality accounted for 1.5% 
of deceased cases in the studied center. There was significant relationship
between mortality rate and higher values of INR (p = 0.035), PT (p = 0.011) and
PTT (p = 0.003). Likewise, there was significant relationship between the need
for mechanical ventilation and higher values of INR (p = 0.035), PT (p = 0.006)
and PTT (p = 0.014). The relationships between the need for ICU admission,
mechanical ventilation, and mortality rate with the rise of hepatic transaminases
and serum bilirubin were not significant.
CONCLUSION: Based on the findings, the prevalence of mushroom poisoning among
patients referred to Mashhad toxicology center was very low (0.1%), but with a
high mortality rate of 22%. Nausea and vomiting were the most common early
symptoms of intoxication and higher values of coagulation profile were correlated
with poor outcome.
PMCID: PMC5325892
PMID: 28286830 

Clin Gastroenterol Hepatol. 2017 May;15(5):776-779. doi:10.1016/j.cgh.2016.11.039. Epub 2017 Feb 9.
Features of Patients With Severe Hepatitis Due to Mushroom Poisoning and Factors 
Associated With Outcome.
Bonacini M(1), Shetler K(2), Yu I(3), Osorio RC(4), Osorio RW(5).
Author information: 
(1)Department of Gastroenterology and Hepatology, California Pacific Medical
Center, San Francisco, California. Electronic address: bonacim08@gmail.com.
(2)Palo Alto Medical Foundation, Mountain View, California.
(3)National Kidney and Transplant Institute, Manila, Philippines.
(4)Washington University, St Louis, Missouri.
(5)Department of Transplantation, California Pacific Medical Center, San
Francisco, California.
BACKGROUND & AIMS: Acute liver failure after ingestion of toxic mushrooms is a
significant medical problem. Most exposures to toxic mushrooms produce no
symptoms or only mild gastroenteritis, but some lead to severe hepatic necrosis
and fulminant hepatic failure requiring liver transplantation. We aimed to assess
mortality from mushroom poisoning and identify variables associated with survival
and liver transplantation.
METHODS: We collected information from 27 patients (13 male; median age, 47
years) admitted to the emergency department within 24 hours of ingesting wild
mushrooms. They developed severe liver injury (serum levels of transaminases
greater than 400 IU/L) and were treated with activated charcoal and
N-acetylcysteine at a tertiary medical center in San Francisco, California from
January 1997 through December 2014. Viral hepatitis, autoimmune liver disease,
acetaminophen, salicylate toxicity, and chronic liver diseases were ruled out for
all patients. We analyzed patient demographics, time since ingestion, presenting 
symptoms, laboratory values, and therapies administered. A good outcome was
defined as survival without need for liver transplant. A poor outcome was defined
as death or liver transplant. Positive predictive values were calculated, and the
χ2 test was used to analyze dichotomous variables.
RESULTS: Liver injury was attributed to ingestion of Amanita phalloides in 24
patients and Amanita ocreata in 3 patients. Twenty-four of the patients ingested 
mushrooms with meals and 3 patients for hallucinogenic purpose. At 24-48 hours
after ingestion, all patients had serum levels of alanine aminotransferase
ranging from 554 to 4546 IU/L (median, 2185 IU/L). Acute renal impairment
developed in 5 patients. Twenty-three patients survived without liver
transplantation, and 4 patients had poor outcomes (1 woman underwent liver
transplantation on day 20 after mushroom ingestion, and 3 women died of hepatic
failure). Of the 23 patients with peak levels of total bilirubin of 2 mg/dL or
more during hospitalization, only 4 had a poor outcome. Peak serum level of
aspartate aminotransferase less than 4000 IU/L, peak international normalized
ratio less than 2, and a value of serum factor V greater than 30% identified
patients with good outcomes with 100% positive predictive value; if these peak
values were used as a cutoff, 10 of 27 patients (37%), 7 of 27 patients (26%),
and 6 of 12 patients (50%), respectively, could have avoided transfer to a
transplant center.
CONCLUSIONS: In an analysis of 27 patients with hepatocellular damage due to
mushroom (Amanita) poisoning and peak levels of total bilirubin greater than 2
mg/dL, the probability of liver transplantation or death is 17%, fulfilling Hy's 
law. Patients with peak levels of aspartate aminotransferase less than 4000 IU/L 
can be monitored in a local hospital, whereas patients with higher levels should 
be transferred to liver transplant centers. Women and older patients were more
likely to have a poor outcome than men and younger patients.
Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.
DOI: 10.1016/j.cgh.2016.11.039 
PMID: 28189696  [Indexed for MEDLINE]

Int J Dermatol. 2017 Jun;56(6):610-616. doi: 10.1111/ijd.13433. Epub 2017 Jan 4.
Clinical features of shiitake dermatitis: a systematic review.
Nguyen AH(1), Gonzaga MI(2), Lim VM(1), Adler MJ(3), Mitkov MV(4), Cappel MA(4).
Author information: 
(1)Creighton University School of Medicine, Omaha, NE, USA.
(2)Department of Biology, Frank R. Seaver College of Science and Engineering,
Loyola Marymount University, Los Angeles, CA, USA.
(3)Portland Dermatology Clinic, Portland, OR, USA.
(4)Department of Dermatology, Mayo Clinic Florida, Jacksonville, FL, USA.
Shiitake dermatitis is a rare cutaneous reaction to lentinan, a polysaccharide
component in the cell walls of shiitake mushrooms (Lentinula edodes). Herein, we 
systematically review the case report and case series English-language literature
on shiitake dermatitis, which refers to a total of 50 patients (38 males, 12
females; mean age: 44.58 years). The majority of cases occurred after the
consumption of raw mushrooms, whereas 22% of cases were caused by the eating of
lightly or undercooked mushrooms. The most common clinical presentations,
localized symptoms, and systemic findings include linear flagellated dermatitis
(98%), pruritus (78%), and fever, diarrhea, and mucosal ulcers, respectively. The
diagnosis of this entity continues to be based on clinical findings as laboratory
abnormalities, and the findings of skin biopsies and patch/prick tests are
nonspecific and inconsistent. The condition is self-limiting, resolving in
approximately 12.5 d without treatment. Based on the included case reports, it
appears that medical treatment may slightly shorten the course of disease (to
9-11 d, varying by therapy) but should be considered on an individual patient
basis. However, the treatment of symptoms, reassurance, and the avoidance of
re-exposure are sufficient treatment recommendations for this condition.
© 2017 The International Society of Dermatology.
DOI: 10.1111/ijd.13433 
PMID: 28054338  [Indexed for MEDLINE]

Med Klin Intensivmed Notfmed. 2017 Sep;112(6):531-534. doi:10.1007/s00063-016-0238-9. Epub 2016 Dec 20.
[Mother and son between omnipotence and coma].
[Article in German]
Heyckendorf J(1)(2)(3), Brede S(4), Guo X(5), Haberl B(6), Sayk F(4)(7).
Author information: 
(1)Klinische Infektiologie, Medizinische Klinik, Forschungszentrum Borstel,
Klinische Tuberkulose Unit (ClinTB), Deutsches Zentrum für Infektionsforschung
(DZIF), Parkallee 35, 23845, Borstel, Deutschland. jheyckendorf@fz-borstel.de.
(2)Deutsches Zentrum für Infektionsforschung (DZIF), Standort Borstel,
Forschungszentrum Borstel, Borstel, Deutschland. jheyckendorf@fz-borstel.de.
(3)Medizinische Kliniken I-III, Internistische Intensivmedizin, UKSH Campus
Lübeck, Lübeck, Deutschland. jheyckendorf@fz-borstel.de.
(4)Medizinische Kliniken I-III, Internistische Intensivmedizin, UKSH Campus
Lübeck, Lübeck, Deutschland.
(5)Klinik für Urologie, UKSH Campus Lübeck, Lübeck, Deutschland.
(6)Abteilung für klinische Toxikologie und Giftnotruf München, Klinikum rechts
der Isar, Technische Universität München, München, Deutschland.
(7)Sektion Intensivmedizin, Sana Kliniken Lübeck GmbH, Lübeck, Deutschland.
An academic and his mother, both with Chinese roots, present to the emergency
department due to acute confusion. After short latency nausea, complex-focal
seizures and finally coma with preserved protective reflexes occur. The
cardiorespiratory stable patients are observed in an intensive care unit. The
extended emergency diagnostic work-up revealed no cause for the underlying
symptoms. Following medical request, the apartment of the patient is inspected by
the police, where a meal with self-picked mushrooms is found. Special laboratory 
exams lead to the diagnosis of pantherina syndrome.
DOI: 10.1007/s00063-016-0238-9 
PMID: 27999891  [Indexed for MEDLINE]

Intern Emerg Med. 2018 Jan;13(1):59-67. doi: 10.1007/s11739-016-1585-5. Epub 2016
Dec 17.
Mushroom poisoning: a retrospective study concerning 11-years of admissions in a 
Swiss Emergency Department.
Schmutz M(1), Carron PN(1), Yersin B(1), Trueb L(2).
Author information: 
(1)Emergency Department, Lausanne University Hospital CHUV, Rue du Bugnon 46,
1011, Lausanne, Switzerland.
(2)Emergency Department, Lausanne University Hospital CHUV, Rue du Bugnon 46,
1011, Lausanne, Switzerland. lionel.trueb@chuv.ch.
Wild mushroom intoxication is an unusual cause of toxic ingestion in Europe. A
great diversity of clinical symptoms may arise depending on the variety of wild
mushrooms ingested. These initial symptoms are often non-specific, with frequent 
gastrointestinal symptoms, and have no direct correlation with the outcome.
Therefore, management of mushroom poisoning and risk evaluation are a challenge
for emergency clinicians. We retrospectively reviewed all cases of mushroom
poisoning identified in the ED database spanning 11 years. Demographic and
clinical data, time from consumption to symptoms, type of mushrooms, the number
of patients presenting at the same time, treatment(s) provided, length of stay,
discharge diagnosis, in-hospital mortality, and serious complications were
evaluated. We identify 87 cases of mushroom poisoning. The most common symptoms
are nausea and vomiting (71 cases, 82%), followed by diarrhea (68%), syncope
(10%), abdominal pain (8%), and hallucinations (7%). Sixty-four patients (74%)
exhibited early symptoms (appearance <6 h after ingestion) and 23 (26%) late
symptoms (appearance >6 h after ingestion). Eleven patients (13%) required
hospitalization over 24 h. Patients with late symptoms tended to have longer
in-hospital lengths of stay. Only one patient had Amanita phalloides
intoxication, with a favorable outcome. Thirty-eight patients (44%) were involved
in cluster presentations. Mushroom poisoning is an unusual but potentially severe
form of intoxication. Patients presenting with late-appearing symptoms (>6 h) are
associated with a higher risk of A. phalloides intoxication, and therefore
require specific investigation and management.
DOI: 10.1007/s11739-016-1585-5 
PMID: 27988828  [Indexed for MEDLINE]

PLoS One. 2016 Sep 20;11(9):e0162314. doi: 10.1371/journal.pone.0162314.
eCollection 2016.
Introducing Mushroom Fruiting Patterns from the Swiss National Poisons
Information Centre.
Schenk-Jäger KM(1), Egli S(2), Hanimann D(2), Senn-Irlet B(2), Kupferschmidt
H(1), Büntgen U(2)(3)(4).
Author information: 
(1)National Poisons Information Centre, Tox Info Suisse, Associated Institute of 
the University of Zurich, Zurich, Switzerland.
(2)Swiss Federal Research Institute WSL, Birmensdorf, Switzerland.
(3)Oeschger Centre for Climate Change Research, Bern, Switzerland.
(4)Global Change Research Centre AS CR, Brno, Czech Republic.
Changes in the ecology of macrofungi are poorly understood, not only because much
of their life cycle is hidden belowground, but also because experiments often
miss real-world complexity and most fruitbody inventories are limited in space
and time. The National Poisons Information Centre 'Tox Info Suisse' provides
countrywide 24hours/7days medical advice in case of poisonings since 1966. Here, 
we introduce a total of 12,126 mushroom-related phone calls that were received by
Tox Info Suisse between 1966 and 2014. This indirect source of mycological
information is dominated by the families of Boletaceae (11%), Agaricaceae (10%)
and Amanitaceae (8%), which account for ~30% of all cases. Mushroom fruiting
patterns revealed by the Poisons Centre inventory statistically resemble changes 
in fungal phenology, productivity and diversity as reflected by the Swiss
National Data Centre 'SwissFungi'. Although the newly developed Tox Info Suisse
dataset provides an innovative basis for timely environmental research, caution
is advised when interpreting some of the observed long-term changes and autumnal 
extremes. Uncertainty of the new record relates to possible data incompleteness, 
imprecise species description and/or identification, as well as the inclusion of 
cultivated and non-indigenous mushrooms. Nevertheless, we hope that the Tox Info 
Suisse inventory will stimulate and enable a variety of ecological-oriented
follow-up studies.
DOI: 10.1371/journal.pone.0162314 
PMCID: PMC5029870
PMID: 27648562  [Indexed for MEDLINE]

Toxicon. 2016 Sep 15;120:78-88. doi: 10.1016/j.toxicon.2016.07.018. Epub 2016 Jul
Cyclopeptide toxins of lethal amanitas: Compositions, distribution and
phylogenetic implication.
Tang S(1), Zhou Q(1), He Z(1), Luo T(1), Zhang P(1), Cai Q(2), Yang Z(2), Chen
J(3), Chen Z(4).
Author information: 
(1)College of Life Science, Hunan Normal University, Changsha 410081, China.
(2)Key Laboratory for Plant Diversity and Biogeography of East Asia, Kunming
Institute of Botany, Chinese Academy of Sciences, Kunming, Yunnan 650201, China.
(3)State Key Laboratory of Toxicology and Medical Countermeasures, and Laboratory
of Toxicant Analysis, Institute of Pharmacology and Toxicology, Academy of
Military Medical Sciences, Beijing 100850, China.
(4)College of Life Science, Hunan Normal University, Changsha 410081, China.
Electronic address: chenzuohong@263.net.
Lethal amanitas (Amanita sect. Phalloideae) are responsible for 90% of all fatal 
mushroom poisonings. Since 2000, more than ten new lethal Amanita species have
been discovered and some of them had caused severe mushroom poisonings in China. 
However, the contents and distribution of cyclopeptides in these lethal mushrooms
remain poorly known. In this study, the diversity of major cyclopeptide toxins in
seven Amanita species from Eastern Asia and three species from Europe and North
America were systematically analyzed, and a new approach to inferring
phylogenetic relationships using cyclopeptide profile was evaluated for the first
time. The results showed that there were diversities of the cyclopeptides among
lethal Amanita species, and cyclopeptides from Amanita rimosa and Amanita
fuligineoides were reported for the first time. The amounts of amatoxins in East 
Asian Amanita species were significantly higher than those in European and North 
American species. The analysis of distribution of amatoxins and phallotoxins in
various Amanita species demonstrated that the content of phallotoxins was higher 
than that of amatoxins in Amanita phalloides and Amanita virosa. In contrast, the
content of phallotoxins was significantly lower than that of amatoxins in all
East Asian lethal Amanita species tested. However, the distribution of amatoxins 
and phallotoxins in different tissues showed the same tendency. Eight
cyclopeptides and three unknown compounds were identified using cyclopeptide
standards and high-resolution MS. Based on the cyclopeptide profiles,
phylogenetic relationships of lethal amanitas were inferred through a dendrogram 
generated by UPGMA method. The results showed high similarity to the phylogeny
established previously based on the multi-locus DNA sequences.
Copyright © 2016 Elsevier Ltd. All rights reserved.
DOI: 10.1016/j.toxicon.2016.07.018 
PMID: 27476461  [Indexed for MEDLINE]

Ann Transplant. 2016 Jul 8;21:428-32.
Effectiveness of Fractionated Plasma Separation and Absorption as a Treatment for
Amanita Phalloides Poisoning.
Stankiewicz R(1), Lewandowski Z(2), Kotulski M(1), Patkowski W(1), Krawczyk M(1).
Author information: 
(1)Department of General, Transplant, and Liver Surgery, Medical University of
Warsaw, Warsaw, Poland.
(2)Department of Epidemiology, Medical University of Warsaw, Warsaw, Poland.
BACKGROUND Fractionated plasma separation and absorption (FPSA) is an
extracorporeal liver support method that detoxifies accumulated toxins. There are
limited data of its use in the treatment of Amanita phalloides intoxication. The 
objective of this study was to investigate whether FPSA before liver
transplantation improves patients' short-term post liver transplantation survival
in Amanita phalloides poisoning. MATERIAL AND METHODS The study population
consisted of ten patients who had liver transplantation (LT) due to acute liver
failure (ALF) caused by Amanita phalloides poisoning. Six patients were treated
with FPSA before liver transplantation. All the patients who were started on FPSA
were also placed on the liver transplantation list according to emergent liver
transplantation criteria. RESULTS Patients treated with FPSA were in a more
severe clinical condition presenting in higher mean MELD, total bilirubin, INR
and ammonia along with more frequent hypoglycemia and hepatic encephalopathy
grade 3/4. FPSA group had longer mean waiting time on the recipient list (3.5 vs.
1.25 days) but inferior thirty-day survival rate (16.5% vs. 100%). CONCLUSIONS
When conservative medical modalities are ineffective, the only treatment for
Amanita phalloides poisoning is a liver transplant. Although FPSA treated
patients had inferior post-LT survival, FPSA was found to prolong the pre
surgical waiting time for critically ill patients, consequently giving a chance
of life-saving procedure.
PMID: 27389675  [Indexed for MEDLINE]

Dtsch Med Wochenschr. 2016 Jul;141(13):940-2. doi: 10.1055/s-0042-103987. Epub
2016 Jun 30.
[Acute liver failure after ingestion of death cap mushrooms].
[Article in German]
Zuliani AM, Kabar I, Mitchell T, Heinzow HS.
Amatoxins, which are mainly found in Amanita phalloides, Amanita virosa, and
Galerina autumnalis, are responsible for the majority of fatal intoxication with 
green death cap. The intoxication is associated with acute liver failure, which
explains the poor prognosis. Acute liver injury is generally preceeded by a
gastrointestinal phase with nausea, vomiting and diarrhea. In the course,
pre-renal kidney failure due to the associated fluid deficit and fulminant liver 
failure may occur. General guidelines for the treatment of amatoxin poisoning are
yet not available. We report on three patients who suffered from amatoxin
mushroom poisoning after ingestion of green death cap mushrooms. Based on the
pathophysiology of amatoxin poisoning, we discuss a potential therapeutic
© Georg Thieme Verlag KG Stuttgart · New York.
DOI: 10.1055/s-0042-103987 
PMID: 27359312  [Indexed for MEDLINE]

Clin Toxicol (Phila). 2016 Aug;54(7):597-600. doi: 10.1080/15563650.2016.1188205.
Epub 2016 May 24.
Nicotinic acid treatment for Paralepistopsis acromelalga intoxication: assessment
using magnetic resonance imaging.
Nakajima N(1), Ueda M(2).
Author information: 
(1)a Department of Neurology , Kitamurayama Hospital , Yamagata , Japan ;
(2)b Department of Neurology and Stroke Medicine , Tokyo Metropolitan Tama
Medical Center , Tokyo , Japan.
CONTEXT: Paralepistopsis acromelalga, formerly known as Clitocybe acromelalga, is
a rare poisonous mushroom. The mycotoxins in this mushroom cause symptoms
resembling those of erythromelalgia; however, its pathogenesis remains unclear.
In this report, a patient who received nicotinic acid treatment for P.
acromelalga poisoning and radiological evaluation for erythromelalgia has been
presented. Case detail: A 59-year-old woman was hospitalized for redness,
swelling, and burning pain in her extremities that rendered difficulty in
walking, and a diagnosis of P. acromelalga poisoning was made by detailed
interview and mushroom identification. She was treated with intravenous nicotinic
acid for 17 days followed by oral nicotinic acid amide for 2 months. She
exhibited rapid symptomatic improvement and walked independently after 11 days of
initial treatment. Initial MRI of her feet revealed toe-dominated subcutaneous
thickening. After nicotinic acid treatment, those radiological findings improved 
DISCUSSION: The subcutaneous thickening evident on MRI indicated P. acromelalga
poisoning-induced erythromelalgia involved subcutaneous inflammatory edema. The
typical duration of edema without treatment is more than a month. The improvement
on MRI after nicotinic acid treatment indicated that the adequate vasodilation
induced by nicotinic acid contributed to resolution of the symptoms. Nicotinic
acid was associated with the improvement of the edematous changes caused by the
P. acromelalga intoxication.
DOI: 10.1080/15563650.2016.1188205 
PMID: 27219910  [Indexed for MEDLINE]

Sud Med Ekspert. 2016 Jan-Feb;59(1):22-28. doi: 10.17116/sudmed201659122-28.
[Forensic medical diagnostics of intoxication with certain poisonous mushrooms in
the case of the lethal outcome in a hospital].
[Article in Russian; Abstract available in Russian from the publisher]
Zaraf'iants GN(1).
Author information: 
(1)Saint-Petersburg State Medical University, Saint-Petersburg, Russia,199034;
Institute of Toxicology, Russian Federal Medico-Biological Agency, Bureau of
Forensic Medical Expertise, Saint-Petersburg, Russia, 192019.
The present study was undertaken with a view to improving forensic medical
diagnostics of intoxication with poisonous mushrooms in the cases of patients'
death in a hospital. A total of 15 protocols of forensic medical examination of
the corpses of the people who had died from acute poisoning were available for
the analysis. The deathly toxins were amanitin and muscarine contained in various
combinations in the death cap (Amanita phalloides) and the early false morels
(Gyromitra esculenta and G. gigas). The main poisoning season in the former case 
was May and in the latter case August and September (93.4%). The mortality rate
in the case of group intoxication (such cases accounted for 40% of the total)
amounted to 28.6%. 40% of the deceased subjects consumed mushrooms together with 
alcohol. The poisoning caused the development of either phalloidin- or
gyromitrin-intoxication syndromes (after consumption of Amanita phalloides and
Gyromitra esculenta respectively). It is emphasized that the forensic medical
experts must substantiate the diagnosis of poisoning with mushroom toxins based
on the results of the chemical-toxicological and/or forensic chemical
investigations. The relevant materials taken from the victim or the corpse should
be dispatched for analysis not only within the first day but also on days 2-4
after intoxication. The mycological and genetic analysis must include the
detection and identification of mushroom microparticles and spores in the smears 
from the oral cavity, vomiting matter, wash water, gastric and intestinal
contents. In addition, the macro- and microscopic morphological signs, clinical
data (major syndromes, results of laboratory studies, methods of treatment)
should be taken into consideration as well as the time (season) of mushroom
gathering, simultaneous poisoning in a group of people, and other pertinent
Publisher: В целях совершенствования судебно-медицинской диагностики отравлений
ядовитыми грибами при смерти в стационаре провели анализ 15 актов
судебно-медицинского исследования трупов людей, умерших от острого отравления
токсинами бледной поганки - Amanita phalloides ("death cap"), строчков -
Gyromitra esculenta, или G. gigas ("snow falce morel"), и сочетания токсинов:
аманитина и мускарина. Сезон отравления август-сентябрь (93,4%), в 1 случае -
май. Смертность при отравлении группы людей (40% случаев) составила 28,6%. Грибы 
вместе с алкоголем употребляли 40% потерпевших. У больных наблюдали фаллоидный
(отравление Amanita phalloides) или гиромитровый (отравление Gyromitra esculenta)
синдром. Сделан вывод, что судебно-медицинский эксперт должен обосновать диагноз 
отравления токсинами грибов результатами химико-токсикологического и/или
судебно-химического исследования (направлять материал от потерпевшего или от
трупа не только в 1-е сутки, но и на 2-4-е сутки после отравления),
микологического и генетического анализа (выявление и идентификация микрочастиц
грибов и их спор в тампонах из содержимого ротовой полости, в рвотных массах,
промывных водах, содержимом желудка и кишечника), морфологическими признаками
(макро- и микроскопические), клиническими данными (основные синдромы, результаты 
лабораторных исследований, методы лечения) с учетом сезона (сбор грибов),
одновременного отравления группы людей.
DOI: 10.17116/sudmed201659122-28 
PMID: 27030094  [Indexed for MEDLINE]

Parasitol Res. 2016 Jun;115(6):2485-8. doi: 10.1007/s00436-016-5015-4. Epub 2016 
Mar 18.
Fresh fruit, vegetables, and mushrooms as transmission vehicles for Echinococcus 
multilocularis in Europe: inferences and concerns from sample analysis data from 
Robertson LJ(1), Troell K(2), Woolsey ID(3), Kapel CM(3).
Author information: 
(1)Parasitology, Department of Food Safety and Infection Biology, Norwegian
University of Life Sciences, PO Box 8146 Dep., 0033, Oslo, Norway.
(2)Section of Bioinformatics and Molecular Biology, Department of Microbiology,
National Veterinary Institute, SE-751 89, Uppsala, Sweden.
(3)Section of Organismal Biology, Department of Plant and Environmental Sciences,
Faculty of Science, University of Copenhagen, Thorvaldsensvej 40, DK1870,
Frederiksberg C, Denmark.
Fresh fruit, vegetables, mushrooms, and other fresh produce are recognised as
important vehicles of infection for several foodborne parasites, particularly
those with a faecal-oral transmission route and robust environmental transmission
stages. Nevertheless, analysis of such foods for parasite transmission stages,
even during outbreaks, tends to show only low contamination. Echinococcus
multilocularis is considered one of the most important foodborne parasites, but
there are few studies in which fresh produce or like foods collected in their
natural habitat is analysed for contamination with E. multilocularis eggs. In
this article, we question a recent study from Poland reporting over 23 % of fresh
berries, vegetables, and mushroom being highly contaminated with E.
multilocularis eggs. In particular, it appears unlikely that 20 % of raspberries,
which are elevated from ground level, should be exposed to faecal contamination. 
Additionally, the similar egg contamination of vegetation in forest and
plantation environments is surprising considering the preference of the
parasite's most competent intermediate hosts for the latter environment.
Furthermore, a lack of specific temporal information is concerning due to the
varying infection pressure (and therefore environmental contamination) occurring 
in definitive hosts over the course of the year. Several important aspects of the
study seem to us to have been neglected, and we are concerned that the published 
data might, if not questioned, lead to incorrect interpretation, and unnecessary 
losses in the agricultural sector.
DOI: 10.1007/s00436-016-5015-4 
PMCID: PMC4863902
PMID: 26987642  [Indexed for MEDLINE]

Hong Kong Med J. 2016 Apr;22(2):124-30. doi: 10.12809/hkmj154706. Epub 2016 Mar
Mushroom poisoning in Hong Kong: a ten-year review.
Chan CK(1), Lam HC(1), Chiu SW(2), Tse ML(1), Lau FL(1).
Author information: 
(1)Hong Kong Poison Information Centre, United Christian Hospital, Kwun Tong,
Hong Kong.
(2)School of Life Sciences, The Chinese University of Hong Kong, Shatin, Hong
INTRODUCTION: Mushroom poisoning is a cause of major mortality and morbidity all 
over the world. Although Hong Kong people consume a lot of mushrooms, there are
only a few clinical studies and reviews of local mushroom poisoning. This study
aimed to review the clinical characteristics, source, and outcome of mushroom
poisoning incidences in Hong Kong.
METHODS: This descriptive case series review was conducted by the Hong Kong
Poison Information Centre and involved all cases of mushroom poisoning reported
to the Centre from 1 July 2005 to 30 June 2015.
RESULTS: Overall, 67 cases of mushroom poisoning were reported. Of these, 60
(90%) cases presented with gastrointestinal symptoms of vomiting, diarrhoea, and 
abdominal pain. Gastrointestinal symptoms were early onset (<6 hours
post-ingestion) and not severe in 53 patients and all recovered after symptomatic
treatment and a short duration of hospital care. Gastrointestinal symptoms,
however, were of late onset (≥6 hours post-ingestion) in seven patients; these
were life-threatening cases of amatoxin poisoning. In all cases, the poisonous
mushroom had been picked from the wild. Three cases were imported from other
countries, and four collected and consumed the amatoxin-containing mushrooms in
Hong Kong. Of the seven cases of amatoxin poisoning, six were critically ill, of 
whom one died and two required liver transplantation. There was one confirmed
case of hallucinogenic mushroom poisoning caused by Tylopilus nigerrimus after
consumption of a commercial mushroom product. A number of poisoning incidences
involved the consumption of wild-harvested dried porcini purchased in the market.
CONCLUSION: Most cases of mushroom poisoning in Hong Kong presented with
gastrointestinal symptoms and followed a benign course. Life-threatening cases of
amatoxin poisoning are occasionally seen. Doctors should consider this diagnosis 
in patients who present with gastrointestinal symptoms that begin 6 hours or more
after mushroom consumption.
DOI: 10.12809/hkmj154706 
PMID: 26980450  [Indexed for MEDLINE]

Basic Clin Pharmacol Toxicol. 2016 Sep;119(3):317-21. doi: 10.1111/bcpt.12569.
Epub 2016 Mar 8.
Investigation of Toxic Effects of Mushroom Poisoning on the Cardiovascular
Erenler AK(1), Doğan T(2), Koçak C(3), Ece Y(1).
Author information: 
(1)Department of Emergency Medicine, Çorum Education and Research Hospital, Hitit
University, Çorum, Turkey.
(2)Department of Cardiology, Çorum Education and Research Hospital, Hitit
University, Çorum, Turkey.
(3)Department of Statistics, Çorum Education and Research Hospital, Hitit
University, Çorum, Turkey.
Mushroom poisoning (MP) is a public health problem in many countries. It is well 
known that consumption of wild mushrooms may cause serious toxicity on renal,
hepatic and brain functions. In the literature, however, studies investigating
cardiotoxic effects of MP are rare. In this study, we evaluated laboratory and
ECG findings of patients and sought for possible toxic effects of MP on the
cardiovascular system. During a 2-year period, 175 patients with MP were included
in the study. The majority of the poisonings occurred in early summertime. The
most common complaint was found to be nausea and vomiting followed by mental
status alterations. Methods of treatment were mainly based on gastric lavage,
activated charcoal and supportive therapy. The most common ECG abnormalities in
the patients with MP were sinus tachycardia, sinus arrhythmia, ST/T inversion,
1st degree AV block and QT prolongation, respectively. Cardiac markers of the
patients were found to be normal. Then, patients were divided into two subgroups 
according to symptom onset after consumption (less than 6 hr and more than 6 hr).
When the two groups were compared, prevalence of tachycardia was significantly
higher in Group II. Additionally, the interval between mushroom consumption and
onset of symptoms was strongly correlated with blood pressure (BP). As this
interval prolonged, BP of the patients tended to increase. In conclusion,
according to our results, although mechanisms need to be clarified, MP causes
hypertension and ECG alterations, particularly tachycardia in patients with
late-onset symptoms.
© 2016 Nordic Association for the Publication of BCPT (former Nordic
Pharmacological Society).
DOI: 10.1111/bcpt.12569 
PMID: 26879235  [Indexed for MEDLINE]

J Investig Med High Impact Case Rep. 2016 Jan 21;4(1):2324709615627474. doi:
10.1177/2324709615627474. eCollection 2016 Jan-Mar.
Acute Pancreatitis Caused By Mushroom Poisoning: A Report of Two Cases.
Karahan S(1), Erden A(2), Cetinkaya A(3), Avci D(3), Ortakoyluoglu AI(3), Karagoz
H(4), Bulut K(3), Basak M(3).
Author information: 
(1)Akdeniz University School of Medicine, Antalya, Turkey.
(2)Hacettepe University School of Medicine, Ankara, Turkey.
(3)Kayseri Training and Research Hospital, Kayseri, Turkey.
(4)Acibadem Hospital, Kayseri, Turkey.
Of the more than 5000 species of mushrooms known, 100 types are toxic and
approximately 10% of these toxic types can cause fatal toxicity. A type of
mushroom called Amanita phalloides is responsible for 95% of toxic mushroom
poisonings. In this article, we report 2 cases of mushroom poisonings caused by
Lactarius volemus, known as Tirmit by the local people. The patient and his wife 
were admitted to the emergency room with abdominal pain, nausea, and vomiting 20 
hours after consuming Lactarius volemus, an edible type of mushroom. The patients
reported that they had been collecting this mushroom from the mountains and
eating them for several years but had never developed any clinicopathology to
date. Further examination of the patients revealed a very rare case of acute
pancreatitis due to mushroom intoxication. The male patient was admitted to the
intensive care unit while his wife was followed in the internal medicine service,
because of her relative mild clinical symptoms. Both patients recovered without
sequelae and were discharged. In this article, we aimed to emphasize that
gastrointestinal symptoms are often observed in mushroom intoxications and can be
confused with acute pancreatitis, thus leading to misdiagnosis of patients. Early
diagnosis and appropriate treatment can improve patients' prognosis and prevent
the development of complications.
DOI: 10.1177/2324709615627474 
PMCID: PMC4724762
PMID: 26835473