TOXCON5101_proof ■ 17 June 2015 ■ 1/5 Toxicon xxx (2015) 1e5 55 Contents lists available at ScienceDirect 56 57 Toxicon 58 59 60 journal homepage: www.elsevier.com/locate/toxicon 61 62 63 Clinical report 64 65 1 Co-ingestion of amatoxins and isoxazoles-containing mushrooms and 66 2 67 3 Q4 successful treatment: A case report 68 4 69 a, * a b c 5 Q3 Juliana Garcia , Vera M. Costa , Ana Elisa Costa ,Sergio Andrade , 70 6 Ana Cristina Carneiro c, Filipe Conceiçao~ c, Jose Artur Paiva b, Paula Guedes de Pinho a, 71 7 * Paula Baptista d, Maria de Lourdes Bastos a,Felix Carvalho a, 72 8 73 9 a UCIBIO-REQUIMTE/Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Rua Jose Viterbo Ferreira nº 228, 74 10 4050-313 Porto, Portugal b ~ ~ 75 11 Internal Medicine Service, Sao Joao Hospital Center, 4200-319 Porto, Portugal c Intermediate Care Unit of Emergency Service, Sao~ Joao~ Hospital Center, 4200-319 Porto, Portugal 76 12 d CIMO/School of Agriculture, Polytechnic Institute of Bragança, Campus de Santa Apolonia, Apartado 1172, 5301-854 Bragança, Portugal 77 13 78 14 79 15 article info abstract 80 16 81 17 Article history: Mushrooms poisoning occurs when ingestion of wild mushrooms containing toxins takes place, placing 82 18 Received 10 March 2015 the consumers at life-threatening risk. In the present case report, an unusual multiple poisoning with 83 19 Received in revised form isoxazoles- and amatoxins-containing mushrooms in a context of altered mental state and poorly 84 29 May 2015 20 controlled hypertension is presented. A 68-year-old female was presented to Sao~ Joao~ hospital (Portugal) Accepted 8 June 2015 85 21 with complaints of extreme dizziness, hallucinations, vertigo and imbalance, 3 h after consuming a stew Available online xxx 86 fi 22 of wild mushrooms. The rst observations revealed altered mental state and elevated blood pressure. The 87 examination of cooked mushroom fragments allowed a preliminary identification of Amanita pantherina. 23 Keywords: 88 Gas chromatographyemass spectrometry (GCeMS) showed the presence of muscimol in urine. More- 24 Wild mushrooms 89 25 Amanita pantherina over, through high-performance liquid chromatography-ultraviolet detection (HPLC-UV) analysis of the gastric juice, the presence of a-amanitin was found, indicating that amatoxins-containing mushrooms 90 26 Amanita phalloides Isoxazoles were also included in the stew. After 4 days of supportive treatment, activated charcoal, silybin and N- 91 27 Amatoxins acetylcysteine, the patient recovered being discharged 10 days post-ingestion with no organ complica- 92 28 Intoxication tions. The prompt and appropriate therapy protocol for life-threatening amatoxins toxicity probably 93 29 saved the patient's life as oral absorption was decreased and also supportive care was immediately 94 30 started. 95 31 © 2015 Published by Elsevier Ltd. 96 32 97 33 98 34 99 35 100 36 101 37 1. Introduction trauma; alcohol; infection; psychoses; stroke; hypertensive, 102 38 metabolic, hepatic, or uremic encephalopathies), consumption of 103 39 An altered mental state is a very common occurrence in the psycho-active substances; and others (Schwartz et al., 1992). 104 40 emergency room and the diagnosis/treatment is highly challenging Among these, possible accidental or intentional exposure to 105 41 (Xiao et al., 2012). In fact, two or more etiologies may coexist, psycho-active substances present in some wild mushrooms species 106 42 including pathological disorders, (e.g. hypoglycemia; cranial should not be neglected (Tsujikawa et al., 2006). In fact, con- 107 43 sumption of wild mushrooms has increased substantially in the last 108 44 decades (Thimmel and Kluthe, 1998). Mushrooms are appreciated 109 45 worldwide as a delicacy, due to their exquisite palatability and 110 46 Abbreviations: CNS, central nervous system; DAD, diode-array; EC, electro- texture. Moreover, their chemical, nutritional, and functional 111 e 47 chemical coulometric detection; DNA, deoxyribonucleic acid; GC MS, gas chro- properties make them exceptional in the human diet (Cheung, e 112 48 matography mass spectrometry; HPLC, high performance liquid chromatography; fi RNA, ribonucleic acid; RNAP II, RNA polymerase II; TIC, total ion chromatogram; UV, 2010). Despite these bene ts, the ingestion of wild mushrooms- 113 49 ultraviolet. containing toxins frequently occurs, which can put the consumers 114 50 * Corresponding authors. at life-threatening risk. Mushroom poisoning is usually accidental, 115 51 E-mail addresses: [email protected] (J. Garcia), [email protected] rarely suicidal, and frequently occurs as a result of misidentification 116 (F. Carvalho). 52 117 53 http://dx.doi.org/10.1016/j.toxicon.2015.06.012 118 54 0041-0101/© 2015 Published by Elsevier Ltd. 119 Please cite this article in press as: Garcia, J., et al., Co-ingestion of amatoxins and isoxazoles-containing mushrooms and successful treatment: A case report, Toxicon (2015), http://dx.doi.org/10.1016/j.toxicon.2015.06.012 TOXCON5101_proof ■ 17 June 2015 ■ 2/5 2 J. Garcia et al. / Toxicon xxx (2015) 1e5 1 of a toxic mushroom as an edible species (Barbato, 1993; Cochran, Physical exam demonstrated dry skin and dry mucous membranes. 66 2 1987). The severity of mushroom poisoning depends on the spe- Additionally, she had clear breath and heart sounds, no abdominal 67 3 cies of mushroom, the amount of mushroom consumed, the tenderness, and no gross focal neurologic deficits. A brain 68 4 prompt therapy and the health status of the individual (Broussard computed tomography was immediately performed revealing no 69 5 et al., 2001; Durukan et al., 2007). The main toxins associated to abnormalities. Additionally, electrocardiogram, funduscopy and 70 6 mushroom poisoning are: cyclopeptides, orellanine, gyromitrin, urinary sediment were analyzed demonstrating no evidence of 71 7 isoxazoles, muscarine, psilocybin and gastrointestinal specific irri- lesions. Her serial hematological parameters, coagulation profile, 72 8 tants (Koppel, 1993). Of the mentioned toxins, the most dangerous liver and renal function tests were normal. 73 9 and potentially fatal poisonings are caused by cyclopeptides As a standard procedure for intoxications with wild mushrooms 74 10 (mainly amatoxins) (Karlson-Stiber and Persson, 2003), while and until species identification by the laboratory, the general 75 11 orellanine, isoxazoles, muscarine, psilocybin, and gyromitrin can detoxification treatment with oral-activated charcoal was imme- 76 12 cause a serious illness but are rarely fatal (Koppel, 1993). Amatoxins diately instituted on admission, and it was followed by the specific 77 13 are natural toxic bicyclic octapeptides present in mushroom species treatment for A. phalloides poisoning, through the administration of 78 14 from three different genera: Amanita, Galerina, and Lepiota (Vetter, silybin and N-acetylcysteine. N-acetylcysteine and silybin were 79 15 1998). The species Amanita phalloides is involved in the majority of administered in a loading dose of 10.5 g (150 mg/kg) and 350 mg 80 16 human fatal cases of mushroom poisoning (Karlson-Stiber and (5 mg/kg), respectively, followed by perfusion. The perfusion of 81 17 Persson, 2003). Its main toxin is a-amanitin, which causes hepatic silybin was maintained at a dosage of 58 mg/h (20 mg/kg/d) and N- 82 18 and kidney damage, often fatal (Faulstich, 1979; Klein et al., 1989; acetylcysteine at 875 mg/h (12.5 mg/kg/h) for the following 4 h. 83 19 Santi et al., 2012). The mechanisms of toxicity of a-amanitin are Labetalol perfusion was also administered for blood pressure con- 84 20 complex, but its most known mechanism is the inhibition of RNA trol. The patient was then transferred to intermediate care unit to 85 21 polymerase II (RNAP II) (Vetter, 1998). continue with the treatment with continuous surveillance. A total 86 22 Muscimol and ibotenic acid belong to the family of toxins of 300 mg/kg of N-acetylcysteine was administered in the first 21 h 87 23 known as isoxazoles. Amanita pantherina and Amanita muscaria are after admission. The perfusion of activated charcoal and silybin 88 24 the most commonly known isoxazoles-containing mushrooms were kept until the fourth day (at the fourth day, normal coagula- 89 25 (Diaz, 2005). Data on the incidence of intoxication by isoxazoles- tion profile and liver function tests were observed). Serum ami- 90 26 containing mushrooms are scarce. The severity of the symptoms notransferases and coagulation profile were normal during all the 91 27 is mild, thus intoxicated people often do not seek medical attention. time that the patient remained admitted, although an elevation of 92 28 In Portugal, very few cases of isoxazoles-containing mushrooms total bilirubin (twofold the normal value) was observed at day 2 93 29 intoxications have been reported (Morgado et al., 2006). The (conjugated bilirubin was normal at that time). Two days after, total 94 30 American Association of Poison Control Centers annual report of bilirubin level started to decline, and it normalized within one 95 31 2012 presented 36 cases of isoxazoles-containing mushroom in- week. After labetalol perfusion, the blood pressure control was 96 32 toxications in the United States of America, with no related deaths achieved by administration of sublingual captopril until the fourth 97 33 (Mowry et al., 2013). Ibotenic acid is an agonist of glutamic acid day. 98 34 receptors; its decarboxylated derivative, muscimol, is an agonist at The patient kept some of the stew's leftovers, which were then 99 35 gamma-aminobutyric acid (GABA) receptors. The central effects of provided for analysis. The identification of the mushrooms was 100 36 these toxins are generally attributed to the previously mentioned firstly performed by 2 experts based on the macroscopic features of 101 37 pharmacological properties (Krogsgaard-Larsen et al., 1980; the fruiting body (Courtecuisse, 1999; Courtecuisse and Duhem, 102 38 Michelot and Melendez-Howell, 2003; Snodgrass, 1978) and 2005).