Pediatric Case of the Week 24: The "Morel" of the story...

It has been a very wet spring.  A very long, wet spring.  This is great if you are a duck, or a mushroom;  but not so great if you are a 14 year old boy with dreams of playing baseball, riding your bike, or swimming in a lake.  

Your next patient is a 14 year old boy who awoke early this morning retching and vomiting.  He also developed diarrhea and severe abdominal cramping. 

The story becomes more complex.  Yesterday, he was at his uncle Nick's for his cousin's high school graduation party  He reports feeling fine until this morning when he began vomiting. He denies hematemesis, melena, or hematochezia.  He reports intermittent sweats.  No prior surgeries and his review of systems is otherwise negative.

His mother is suspicious that he may have "gotten into the beer."  He emphatically denies ingesting any alcohol. His father notes that he ate "about 6 plates of beer batter deep fried morel mushrooms...can that make you drunk?"  Apparently, Uncle Nick had a bumper crop of morels this year (one of the few positives of on otherwise dismal rain filled spring.)  

Your patient's vitals are notable for mild tachycardia. He is otherwise afebrile.  BP and Sats are normal.

His exam is unremarkable except for occasional retching and dry heaving.  

You order IV placement, 1 liter NS bolus, and zofran 4 mg IV.  

As the IV is being placed, his father turns a few shades of green and begins to retch.  He runs out to the bathroom conveniently located just across the hall. 

Could this be an 'epidemic'?  

How would you evaluate further? 

What would you worry about in a case of mushroom poisoning?

Can you pick out the 3 "non-morels" in the picture above?

Do you know the other name for an amateur mycologist?

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PCW24 Weekend Update

Mushroom Toxicity has been reported to occur in 3 phases:

Early symptom category – within the first 6 hours of ingestion and include gastrointestinal (GI), allergic, and neurologic syndromes

Late symptom category – between 6 and 24 hours after ingestion and may include hepatotoxic, nephrotoxic, and erythromelalgic syndromes

Delayed symptom category – more than 24 hours after ingestion and include mostly nephrotoxic syndromes

There are many types of mushroom toxins (just as there are many types of mushrooms):

Cyclopeptides - Amatoxin

Gyromitrins (monomethylhydrazine)

Orellanine

Muscarine

Psilocybin

Muscimol and ibotenic acid

Coprine

Nephrotoxins (norleucine)

Myotoxins

Immunoactive toxins

Hemolytic toxins

GI irritants

GI poisons are the most frequently encountered mushroom toxins. 

Amatoxins, gyromitrins, and orellanine are the toxins which are most likely to be FATAL.

The amatoxins, and to a lesser extent the gyromitrins, are hepatotoxic. Gyromitrins are also epileptogenic. Orellanine and norleucine are nephrotoxic. Muscarine, psilocybin, muscimol, and ibotenic acid are CNS poisons. Coprine causes a disulfiramlike reaction when combined with alcohol. (Not cool if you love to drink beer with your mushrooms.)

Our case is that of a mistaken morel.  Most likely this would be

   A. The "False Morel" or "Beefsteak" (Gyromitra Esculenta) 

   B. The "Caps" or "Early Morel" (Verpa Bohemica)

Apparently the Michiganders are big on morel mushrooms or at least picking the wrong mushroom. Here is a link to Michigan Morels which discusses the morel mimics: http://www.michiganmorels.com/morels2.shtml

Also a great link to the POISON REVIEW which discussed the Michigan mushroom toxicity cluster that occurred in 2011: http://www.thepoisonreview.com/2011/05/29/false-morel-poisoning-in-michigan/

In Short the management of mushroom poisoning depends on that which has been ingested. Most likely GI contamination is not indicated because too much time will have passed between ingestion and symptoms.  Kids are more susceptible to the dehydration that can follow vomiting. (so give fluids.)  As a general rule you would want to give supportive therapy and admit to watch for Liver and Renal toxicity.  

Here are a few specific considerations (Courtesy of Medscape): 

Hemolysis, which may occur with gyromitrin toxicity, is usually mild, necessitates the administration of large amounts of IV fluids only to prevent renal complications; blood transfusions are rarely required. Hemolysis due to Paxillus species may be more severe and may result in acute renal failure.

Rhabdomyolysis has been reported with several species. Direct damage to myocytes with resultant onset on rhabdomyolysis occurs after ingestion of the so-called “man-on-horseback” mushroom, Tricholoma equestre (also known as Tricholoma flavovirens). Patients may present with muscle pain and have been reported with elevated creatinine phosphokinase levels, in the 10,000 U/L to 100,000 U/L range. Other mushrooms implicated in less severe forms of rhabdomyolysis are Russula subnigricans (blackening Russula), Boletus edulis (king boletus), Leccinium versipelle (brown birch boletus), and Albatrellus ovinus (sheep polypore). Many of these are identified in field guides as edible. Treatment is with aggressive IV fluid resuscitation and consideration for IV sodium bicarbonate to alkalinize the urine. In rare cases, dialysis may be needed if renal failure occurs.

Agitation, commonly observed with hallucinogenic mushrooms, is treated with benzodiazepines; phenothiazines are best avoided in this setting. Other causes of agitation (eg, hypoxia, hypovolemia, and shock) should also be sought and corrected.

Anticholinergic poisoning may be treated with benzodiazepines; in rare cases, physostigmine may be required. Severe muscarinic symptoms may be treated with the infusion of small doses of atropine. In muscarine poisoning, the entire episode usually subsides in 6-8 hours; some symptoms may take up 24 hours to fully resolve. Atropine should be considered only when excessive bronchial secretions compromise breathing and cause shortness of breath. Monitoring with pulse oximetry is indicated. Clinicians should be prepared to support the airway and perform orotracheal suctioning if necessary.

Disulfiram Reaction- Patients may benefit from fomepizole (4-methylpyrazole), which blocks alcohol dehydrogenase and, hence, the formation of the toxic aldehyde.

Fulminant hepatic failure is a common complication observed with amatoxin and gyromitrin poisoning, and it should be treated aggressively because it commonly follows a fatal course. Orthotopic liver transplantation (OLT) may be indicated 

Renal failure commonly observed with norleucine and orellanine poisoning, may have to be treated with hemodialysis. Acute renal failure (ARF) with mild reversible liver injury may also follow the ingestion of Amanita smithiana and Amanita proxima. Conventional indications for dialysis include uremic encephalopathy, fluid overload (with pulmonary edema), severe hyperkalemia, and acidosis. Patients with unremitting renal failure are candidates for renal transplantation, but since most cases resolve slowly over time, several months of hemodialysis should occur before this is considered.

Endotracheal intubation is recommended in all patients at risk of aspiration, and mechanical ventilation should be initiated in all patients with hypoxia, hypercarbia, acidemia, and shock. Aggressive rehydration in the intensive care unit (ICU) may be necessary in patients with choleralike gastroenteritis, and infusions of large amounts of electrolytes with dextrose solutions may be necessary to maintain vital functions.

Blood transfusions may be required in patients with hemorrhagic diarrhea, blood loss, and severe hemolytic anemia. Blood pressure support with dopamine and norepinephrine may be required when crystalloids and colloid infusions fail. Hypoglycemia is treated with infusions of 10% dextrose.

Cerebral edema is also treated in a conventional manner, which is aimed at reducing intracerebral pressure and preventing herniation. Hyperventilation, fluid restriction, osmotic diuresis, hypertonic saline, positioning the head of the bed at 30° from the horizontal plane, barbiturate coma, and anticonvulsants may be necessary.

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What is another name for an amateur mycologist?  "DEAD" (Courtesy of ED Boyer, UMass Toxicology).