Toxicology Committee Annual Reports
NAMA Toxicology Committee Report for 2006
Recent Mushroom Poisonings in North America
By Michael W. Beug, Ph.D., Chair NAMA Toxicology Committee
This year was distinguished by a record number of reported poisonings by "Death Cap" and "Destroying Angel" mushrooms including Amanita phalloides, Amanita ocreata, Amanita bisporigera and/or Amanita virosa and possibly Amanita verna. Of the total of 132 people reported poisoned by mushrooms 71 or 58% were poisoned by one of the deadly Amanitas in 16 separate incidents. There was a report of one death in Canada that occurred in 2003. For the United States 11 reports of deadly Amanita ingestion involved 44 or 45 people poisoned and 4 deaths (with 6 of these people poisoned Jan 1, 2007 resulting in 1 death and 1 death that may have been in 2005 and not 2006). The major tragedies in the reports came from Mexico where there were reports of 16 people with 8 (or 9) deaths that occurred in 2005 in at least 4 incidents and 10 people with 10 deaths in 2006 in one incident. Counting only the cases that actually occurred in 2006, we still have 48 people poisoned in one year by deadly Amanita species that contain amanitoxins. Over the previous 30 years, we had only received reports of a total of 126 people poisoned by these mushrooms or an average of about 4 people poisoned per year.
There were 9 cases that involved whole families or extended families – five large cases in Mexico, 1 large case involving Mexican immigrants in California, one large case involving Hmong immigrants in Minnesota, a huge case involving others of Asian ancestry in New Jersey and one large case involving unidentified individuals in California. In most of these cases, the meal contained at least three different mushroom species and it is difficult to point to what species the collector thought that he/she had collected. In two cases, each involving one person, the individual put his story on the web. In one case the person thought he had picked Inky Caps and wondered why on cooking they did not give off black juice -–but ate the mushrooms anyway. He did not look in a book until the next day when he complained of feeling ill and friends warned him that he should not have eaten an all-white mushroom. He had eaten three and survived after a few weeks of pain and with his own liver that should largely recover. In the other story on the web, the man ate the mushrooms because he thought they looked like something he had eaten before but he did not look in Arora to try to do an ID until after he began to feel sick. He wound up with 5 months of pain, a new liver and over $800,000 in medical bills – and though he has no insurance he is thrilled to be alive.
The most striking feature of these poisonings is the difference in outcome between Mexico and the rest of North America. While there is no antidote to poisoning by "Death Caps" and "Destroying Angels," with prompt medical care the survival rate is 90% or greater, but with little or no medical care the survival rate is 50% or less. Poisoning by these mushrooms occurs in two phases. The first phase is incorrectly assumed by some to be due to phallotoxins (the specific cause is unknown). This phase is characterized by nausea and diarrhea starting 6-24 (typically 12) hours after ingestion of the mushroom. This is usually followed by a period of apparent recovery. In the past some hospitals would unfortunately discharge the patient at this point. However, by day 2 there is typically evidence of liver damage due to amanitins so asking for and getting blood tests for liver function is critical (in the now rare instances where the hospital physicians have not already recognized that). Treatment involves repeated doses of activated charcoal to remove any traces of mushroom that may remain in the system, iv fluid replacement, massive doses of Penicillin G (for patients who are not allergic to it), and treatment with iv and/or oral N-acetylcysteine, a drug used to treat Tylenol overdoses. Both the Penicillin G and the N-acetylcysteine probably help the liver manage the damaging effects of the amanitins. In several of the U.S. cases, patients also received oral Silymarin capsules (milk thistle extract) and in one case experimental injectable Silymarin (Legalon®) was donated and flown in from Europe. Silymarin is used as a liver tonic in European folk medicine and has been used in Europe to treat cirrhosis of the liver. Legalon® is used in 13 European countries where it is considered to be the only effective therapy for combating amatoxin poisoning. The effects were dramatic when it was used this January in California. On four patients with LFTs in excess of 10,000 (up to 18,000) and prothrombin times and thromboplastin times (clotting factors) so high that one would expect on average 84% mortality (my conclusions from the data) all four patients showed dramatic improvement in liver function after injection of Legalon® (Todd Mitchell MD, personal communication). All soon recovered liver function, though the most elderly 83 year-old patient succumbed to kidney failure. There is no way that there will ever be a clinical trial to prove that Silymarin helps in these cases but there is also no evidence to suggest that it should not be used. Indeed, this one dramatic case leads me to conclude that we should do everything we can to support making injectable Silymarin available for experimental use in these relatively rare poisonings. Silymarin has been experimentally tested in dogs and it is highly effective in treating dogs poisoned by deadly Amanita species.
In one other poisoning involving deadly amanatins, a Canadian woman survived a 2005 ingestion of Lepiota josserandii. There are few details of her treatment other than the fact that she was hospitalized for several days and received dialysis.
The other poisonings reported in this past year are typical of an average year. Chlorophyllum molybdites did not retain its usual first place as a mushroom-poisoning agent. Morels poisoned the usual number of people who have eaten them before and then became sensitive from eating them one too many times. Amanita muscaria and Amanita pantherina poisoned the usual number of people and dogs and the usual number of people mistook Amanita muscaria buttons for puffballs. One couple wondered why the inside of the puffball had “fins” (the developing gills of the Amanita) and one woman should have wondered why there was a yellow band of tissue near the outermost layer of the puffball (the developing cap surface of the Amanita). One person started itching and then suffered paranoia and confusion just from carrying three specimens of Amanita muscaria in his hands. In three separate incidents, young men had purchased Amanita muscaria over the Internet as a medicinal – in one case to relieve back pain.
A very interesting case involved a Washington man who carried a large Sparassis crispa for two miles in his bare arms. He broke out in hives all over his body and suffered for 4 days – and never even took a nibble of the mushroom. Another interesting case of hives and an edible mushroom involved a Colorado man who sautéed and ate Chanterelles that he had previously frozen raw and uncleaned. He was covered head to toe in a red rash the morning after his meal.
The only animals reported poisoned were dogs. Of 19 dogs poisoned, 4 are known to have died and one additional dog was in liver failure at the last report received. One dog death was due to an unidentified Amanita species and the other deaths were due to unknown mushrooms. In two cases members of the Toxicology committee received inquiries as to how owners could keep their dogs from eating mushrooms. I have always said that the only choices were to keep their dogs inside or to totally pave their yard so no mushroom could grow. Marilyn Shaw has a better solution. She suggests muzzling mushroom-eating dogs when they are outside. My favorite dog case involved a Golden Retriever in Vermont – every time the owner let the dog out and certain mushrooms were present, the dog would smell the mushrooms and gobble them down in a flash – followed every time by profuse salivation, lethargy, staggering and apparent hallucinations.