Review Articles Mushroom poisoning Paulo de Oliveira Abstract The diversity of toxicity syndromes caused by mushroom inges- for the implementation of detailed enquiries that standardise the tion entails, on one hand, a many-sided and flexible approach information. A model form to serve as starting point for the design to diagnosis that can benefit from any information obtained of such enquiries is included. from the patients or company, and on the other hand, a need to Key words: mushroom poisoning, intoxication, mushrooms, identify, in collaboration with mycologists, the causative species. enquiry. The known syndromes are systematised and a proposal is made Introduction extend to a considerable number of species. In fact, Cases of mushroom poisoning (mycetism) are a re- Mycology registers several dozen European species current event, albeit with low incidence in Portugal. of significant gastronomic interest,2,3 most of which This fact, and the seasonality of incidents, contribute entail a risk of confusion, even for experienced pi- to the Emergency Services’ relatively low awareness ckers. Moreover, it was seen that a large proportion of the variety of situations that can occur, and the of the cases analyzed in Évora were due to lack of respective treatments. Hence, when they are called due attention, or excessive confidence on the part of upon to deal with such cases, they may not always these pickers.1 give a sufficiently precise diagnosis. This review aims to facilitate the process of diag- The Portuguese population is essentially myco- nosing mushroom poisoning, through the proposal phobic, and the picking and consumption of wild of two tools: a classification of the known syndromes, mushrooms is generally restricted to rural areas, and and a model questionnaire to be applied when diag- to a small number of species. This fact can limit cases nosing the victim of the presumed poisoning. Lists of poisoning to a typology that is easily recognizable of relevant species for Portugal are contained in the locally. For example, at the Hospital do Espírito appendix, arranged by syndrome and by common Santo, in Évora,1 the majority of cases are associated name. with the consumption of Amanita ponderosa Malç. & Heim, known in the Alentejo district as “silarca”, Mycetism syndromes as it can be confused with the lethal species Amanita The systematization of syndromes given in this sec- verna (Bull.)Lam. tion is intended to facilitate a quick diagnosis, and to Nevertheless, there are always cases with different identify those that are generally more severe, with a etiology, as has become even more evident in recent period of onset of more than five hours after ingestion. years, owing to the presence of markedly mycophiles As some syndromes can be covered from more than immigrants from the Slavic countries and speakers of one symptomatology perspective, the reference to the Romanian language, whose consumption habits some of them is repeated where relevant, to establish their discrimination. Table I summarizes this systematic treatment. The most likely species that cause mushroom poisoning in Portugal are indicated, where possible, using the scientific binomial by which they are best Department of Biology known as the most functional option. The appendix Évora University is referred to, for searching on some corresponding Received for publication on 17th September 2007 common names and the scientific binomials curren- Accepted for publication on 24th April 2009 tly accepted, in cases where there has been a recent 232 Medicina Interna REVISTA DA SOCIEDADE PORTUGUESA DE MEDICINA INTERNA REVIEW artICLES Medicina Interna review of the taxonomic nomen- TABLE I clature. Except where specifically refe- Latency Pathology Main signs Syndrome renced, this section was compiled Short Gastrointestinal Abdominal pain, without Resinoid based on two highly regarded gui- (up to 5 hours) hepatic failure 3,4 des. Generic information can Indigestion, or diarrhea without Digestive also be consulted in the INTOX complications Databank5 of the WHO Inter- Nausea and hemolysis Hemolytic national Program on Chemical Safety (ICPS). Cardiovascular Bradycardia, vasodilation Muscarine Tachycardia, mucosa dryness, Pantherine I — Start of symptoms up to neurological disorders 5 hours after the last Hypotension, intravascular Paxillus* ingestion coagulation Gastrointestinal syndrome Facial rubor, palpitations Coprine Violent abdominal pains, nau- sea, vomiting and diarrhea, wi- Neurological Hallucinations Psilocybin thout hepatic failure: resinoid Euphoria, hallucinations Pantherine syndrome, most likely caused or aphrodisiac effect, by Omphalotus olearius (due to cardiovascular disorders confusion with Cantharellus ci- Gastrointestinal Acute gastroenteritis, vomiting, Phalloidin* barius), generally associated with Long diarrhea, hepatic failure after olive-trees (oleasters), but the (more than 5 apparent remission list of species is much longer: in hours) Gastroenteritis, nausea, Gyromitrin* forest systems, Entoloma sinuatum possible hepatitis and other entoloma, species of the Boletus satanas group, of the Aga- Renal Late renal failure Orellanine* ricus xanthodermus group, and (in Myopathic Fatigue progressing to late- Rhabdomyolysis* alpine zones) Tricholoma pardi- onset rhabdomyolysis, with num; also found in meadows and high creatine kinase clearings, a species of the genus Neurological Paresthesia with intense pain Acromelalgia/ Chlorophyllum (easily confused in the extremities erythromelalgia with Chlorophyllum rhacodes). Treat with antispasmodics. Treat with antispasmodics. Analyze hepatic function markers (transaminases Nausea and vomiting associated with hemolysis: and lactate dehydrogenase) to exclude phalloidin hemolytic syndrome, caused by ingestion of raw or syndrome. poorly cooked specimens, either of Amanita rubescens Indigestion (which can be severe) generally pro- (or other amanitas) or species of the genera Morchella voked by excessive consumption, associated with or Helvella. trehalose or chitin sensitivity, osmotic pressure due to mannitol, or to allergy to antibiotic substances of the Cardiovascular syndrome fungus: digestive syndrome, often caused by species Bradycardia, vasodilation, hypotension, diaphoresis that are harmless to other individuals. and excessive salivation (also miosis, intestinal pro- Symptomatic treatment. blems, nausea and vomiting): muscarine syndrome, Diarrhea, generally benign, due to laxative subs- due to toxins of the autonomic nervous system tances: digestive syndrome, associated with Ramaria present in Inocybe patouillardii and the like, in white formosa and related and species of Suillus from which mushrooms of the Clitocybe dealbata group, or in the outer skin has not been removed. Mycena pura, M. rosea and related. PUBLICAÇÃO TRIMESTRAL 233 VOL.16 | Nº 4 | OUT/DEZ 2009 artIGOS DE REVISÃO Medicina Interna Atropine or belladonna tincture. Can be fatal penicillin); confirm with hepatic function markers (Inocybe). (transaminases and lactate dehydrogenase), super- Tachycardia, vasoconstriction, hyperactivity, vise for several days, until liver recovery is confir- mucosa dryness (also neurological disorders due to med. Renal function should also be monitored. An stimulant, hallucinogenic or aphrodisiac substances intermediate phase of apparent remission occurs 24 present in the fungus): pantherine syndrome, caused hours after ingestion, followed by hepatic failure by Amanita pantherina, A. muscaria or A. junquillea (sometimes with hepatomegaly and abdominal pain) (in decreasing order of toxicity). with high mortality rates (depending on the quantity Treat with sedatives and barbiturates. Can be fatal ingested). (A. pantherina). First symptoms 5 to 48 hours after ingestion, with Hypotension, intravascular coagulation, jaun- gastroenteritis, debilitation, nausea and vomiting dice, kidney failure, resulting from immunological (also profuse diarrhea and fever): gyromitrin syn- hypersensitivity acquired by repeated consumption drome, due to the ingestion of Gyromitra esculenta of Paxillus involutus: Paxillus syndrome. and related, as well as Cudonia circinans, Spathularia Treat by renal compensation (can be fatal). flavida or poisonous species of Helvella. Facial rubor, palpitations and considerable dis- Treat symptomatically, paying attention to a later comfort: Coprine syndrome, due to alcohol intoleran- phase with potentially fatal hepatitis (where hemoly- ce when ingesting Coprinus atramentarius, C. micaceus sis, kidney failure, neurological problems, delirium, or others. The intolerance lasts for several days and cramps and generalized convulsions also occur). is similar to the effects of the drug Antabuse. Renal syndrome Neurological syndrome First symptoms can occur several days after ingestion Hallucinogenic (identical to that provoked by LSD): (for this reason it is not easy to make the association psilocybin syndrome, due to the psilocin or psilocybin with mushroom ingestion), with kidney failure that present in Psilocybe semilanceata and related (these may become permanent in non-fatal cases: Orella- mushrooms are illegally commercialized or cultivated nine syndrome, caused by Cortinarius orellanus and at home, and they are generally consumed by indivi- related. duals who are aware of their effects). Treat symptomatically, generally in association Euphoria, hallucinations or aphrodisiac effects, with hemodialysis. with cardiovascular alterations: see above, pantherine Phalloidin syndrome, see above, can also