Influence of Neutrophil/Lymphocyte Ratio on Prognosis in Mushroom Poisoning

Acta Medica Mediterranea, 2014, 30: 849

INFLUENCE OF NEUTROPHIL/LYMPHOCYTE RATIO ON PROGNOSIS IN MUSHROOM POISONING

RAMAZAN KOYLU1, ZERRIN DEFNE DUNDAR2, OZNUR KOYLU3, YAHYA KEMAL GUNAYDIN1, NAZIRE BELGIN AKILLI1, HUSEYIN MUTLU1, MUSTAFA ONDER GONEN1, MEHMET YORTANLI1, BASAR CANDER2 - 1Konya Training and Research Hospital, Emergency Department, Konya - 2Necmettin Erbakan University Meram Faculty of Medicine, Emergency Medicine Department, Konya - 3Konya Training and Research Hospital, Biochemistry Department, Konya, Turkey

ABSTRACT

Objective: Mushroom poisoning is a severe poisoning which is commonly seen, particularly, in spring and autumn and may be fatal. This study aimed to study the influence of the neutrophil/lymphocyte ratio on prognosis in patients hospitalized in the toxicology unit with a diagnosis of mushroom poisoning. Methods: A total of 236 patients, admitted to the emergency room and hospitalized due to mushroom poisoning between July 2008 and March 2013, were retropsectively analysed. Patients were analysed in terms of age, gender, medical history, type of mushroom ingested, onset time of symptoms, complaints upon admission, and whether they received extracorporeal therapy and laboratory tests. Results: The mean age of patients hospitalized with mushrom poisoning was 41.88±17.81 years. Of the patients, 95 (40.3%) were male and 141 (59.7%) were female. In their medical history, 15 (64%) patients had diabetes mellitus, 8 (3.4%) had hypertension and 7 (3.0%) had coronary artery disease. 100 (42.4%) patients had eaten cultivated mushrooms, and 104 (44.1%) had eaten wild mushrooms. The mushroom type could not be determined in 32 (3.6%) patients. Symptoms appeared within the first 6 hours in 99 (84.3%) patients and after 6 hours in 37 (15.7%). Patients were usually admitted with nausea, vomiting, abdominal pain and diarrhea. 24 (10.2%) patients required hemoperfusion during their follow-up and treatment. Duration of hospital stay was 2.28±2.20 days in patients with normal liver functions, and 2 (0.8%) patients died. Neutrophil/lymphocyte ratio was 15.14±15.76 in patients with impaired liver functions, and this was statistically significant compared to patients with normal liver function tests (5.48±7.69) (p= 0.001). Conclusions: These results indicated that patients whose neutrophil/lymphocyte ratio is high upon admission should be monitored carefully both for prognosis and hemoperfusion requirement considering longer duration of hospital stay and more aggressive treatment options.

Key words: mushroom poisoning, neutrophil/lymphocyte ratio.

Received February 18, 2014; Accepted March 24, 2014

Introduction In that case, airway, respiratory and circulato- ry support is important. Hepatic and renal insuffi- Mushroom poisoning is frequently seen; how- ciency, hemolytic anemia, methemoglobinemia, ever, severe poisoning is rare. Poisonings with toxic seizures and rhabdomyolysis may develop, and they wild mushrooms are usually seen in spring and consist the mainstay of treatment. autumn, as they usually grow in these seasons. Aggressive fluid replacement therapy is fre- Various findings including nausea, vomiting, quently needed in patients with severe nausea and abdominal pain, diarrhea, increased secretions, vomiting. The application of supportive therapy and watery eyes, bradycardia, and bronchospasm may special therapies toward the predominant clinical be seen as clinical findings of mushroom poison- condition when needed are important steps in diag- ings. However, potentially fatal mushroom poison- nosis and treatment of mushroom poisoning(1,2). ings like delayed hepatic toxicity are usually seen Although more than 10,000 mushroom types due to poisonings with mushroooms which contain are available worldwide, only 50-100 are potential- amatoxin (amanita phalloides). Hepatic toxicity ly toxic(1,3,4). Mushroom types which contain ama- typically appears 24-36 hours after ingestion. toxin (amanita phalloides and amanita muscarina) 850 Ramazan Koylu, Zerrin Defne Dundarb et Al are the most common cause of mushroom poison- in mushroom poisoning. Liver function tests are ing in Turkey(5). Poisoning signs are seen within usually within normal ranges; however, liver three hours, even if these type of mushrooms are enzyme elevations usually begin 24-36 hours after consumed after cooking, as A. muscarina does not ingestion of potentially fatal mushrooms like lose its effect, even under high temperature. amanita phalloides(3). The A. phlloides types of mushrooms do not Hyperammonemia, along with thrombocy- show a severe effect if they are consumed after topenia, coagulopathy, hyperbilirubinemia or cooking. Severe poisoning findings are only seen encephalopathy, indicates progressive toxicity and when the mushrooms are eaten raw. The effects is seen together with gastrointestinal hemorrhage. begin 6-24 hours after ingestion. Acidosis, hypoglycemia and renal insufficiency, a The type of mushroom cannot be determined component of hepatorenal syndrome, are poor prog- in 95% of cases(2). Therefore, treatment recommen- notic indicators. Acute renal insufficiency may have dations, according to guidelines, should be fol- resulted from hypovolemic shock due to vomiting lowed, and treatment should begin immediately and diarrhea or may directly develop due to nor- after clinical diagnosis is made based on signs and leucine toxin (amanita smithiana)(6). Renal insuffi- symptoms. Clinical symptoms like nausea, vomit- cieny developing days or weeks after mushroom ing, abdominal cramps and diarrhea begin within 1- ingestion is charcteristic for orellanine toxin (corti- 3 hours after ingestion(4). Duration between inges- narius type of mushrooms)(7). tion and onset of symptoms should be carefullyin- In a study by Nilsson et al., orellanine toxin in vestigated. Differential diagnosis of acute onset the cortinarius type of mushrooms was shown to gastroenteritis and late onset gastroenteritis due to lead to renal insufficiency a couple of days after poisoning with potentially fatal mushroom types ingestion through accumulating in renal tubular can only be done this way, so it is important to epithelium(8). In this study, an attempt was made to learn the onset time of symptoms after ingestion. find the mechanism of renal injury, and oxidative Findings that appear six hours after ingestion protein injury was immunhistochemically shown to may indicate poisonings with potentially fatal cause this. Ingestion of gyromitrin-containing mushroom types. If the patient is asymptomatic mushrooms (gyromitra esculenta) may lead to after ingestion of a potentially toxic mushroom, methemoglobinemia. Creatine kinase elevation seen he/she may be monitored without any tests. 1-3 days after mushroom ingestion supports rhab- However serum electrolytes, calcium, phos- domyolysis induced by tricholoma equestre or rus- phate, blood urea nitrogen and serum creatinine, sula type (russula emetica) mushrooms(9). urine analysis, serum creatin kinase, liver function Colinergic findings may arise following mus- tests (aspartate aminotransferase [AST], alanine carin ingestion, which is the toxin found in most aminotransferase [ALT], total protein, albumin, mushroom types worldwide(1,4). Determination of total and direct bilirubin), prothrombin time (PT), mushroom type is not possible at the beginning of partial thromboplastin time (PTT), platelet count treatment. In fact, full identification of the mush- and whole blood count should be tested afteringes- rooms causing the toxicity is never possible(2). tion of a potentally fatal mushroom even if the However, identification of the specific mush- patient is asymptomatic. room type would be beneficial for treatment and In symptomatic patients, serum glucose, blood prognosis. Although mechanism of action is differ- gas analysis, serum lactate, blood amonnium, and ent due to toxins, oxidative injury occurs in almost serum lactate dehydrogenase (LDH) should be test- all of the severe intoxications and a general inflam- ed in fulminant hepatic insufficiency, blood glu- matory response develops(10). This acute inflamma- cose, blood gas analysis, and cerebral computed tory response reflects in laboratory findings as ele- tomography in the case of mental status alterations, vated neutrophil and monocyte count and decreased and methemoglobin level should be tested in the lymphocyte levels(8). case of syanosis irresponsive to oxygen therapy. Recent studies show that the neutrophil/lym- Blood gas analysis, pulse oxymeter, and chest phocyte ratio may also be used as an inflammatory radiography should be tested in the presence of marker. In recent years, studies have been available hypoxia or respiratory distress. Electrolyte imbalance indicating that the neutrophil/lymphcyte ratio is a is usually seen with gastrointestinal symptoms (vom- sensitive inflammatory and prognostic marker in iting, diarrhea, abdominal pain) and commonly seen various clinical conditions like cancer, renal failure, Influence of neutrophil/lymphocyte ratio on prognosis in mushroom poisoning... 851 sepsis, coronary diseases, stroke, and acute appen- Differences of hematologic parameters dicitis(11-15). Inflammatory markers like leucocyte, between these dual groups were compared. neutrophil, lymphocyte, and neutrophil/lymphocyte Statistical analysis was done using SPSS 16.0 ratio may also be used as prognostic factors for (SPSS inc, Chicago, Illinois) software. Quantitative determining the severity of poisoning due to similar variables were presented as mean ± standard devia- inflammatory mechanisms in pathophysiology of tion and categorcal variables were presented as case mushroom poisoning. number (percent). All data were subjected to nor- In this retrospective study, the aim was to mality analysis. Differences between groups were investigate the prognostic value of whole blood compared using student’s t-test for quantitative count parameters and neutrophil/lymphocyte ratios, variables of normal distribution and Mann-Whitney tested upon admission tothe emergency room and U test for quantitative variables without normal dis- toxicology unit, in mushroom poisoning cases. tribution. Categorical variables were compared between groups using chi-square test and Fischer Materials and methods exact test. The association of parameters was- analysed using Pearson’s correlation test. This study was conducted retrospectively in Receiver-operating characteristics (ROC) the emergency room and toxicology unit of a curves were plotted in order to determine the pre- research and training hospital. Patients who were dictive value of parameters in the need for hemop- admitted to the emergency room between July 2008 erfusion and impairment in liver function tests. and February 2013 and hospitalized in the toxicolo- Youden index (sensitivity+specifity-1) was used for gy unit due to mushroom poisoning were enrolled each parameter and cut-off values were determined. in the study. The diagnosis of mushroom poisoning Sensitivity, specifity, positive predictive value was given based on the history of mushroom inges- (PPV), negative predictive value (NPV), and accu- tion, presence of common clinical findings of racy rate values were calculated for each parameter mushroom poisoning, history of mushroom intake according to determined cut-off values. in other family members, and presence of similar symptoms. The onset time of symptoms was care- Results fully questioned. Patients who had cancer, hematologic diseases, heart failure, renal disease, coexist- A total of 236 patients were included in the ing trauma, pregnant and who were considered to study. Mean age of the patients hospitalized with have sepsis, stroke or acute appendicitis were mushroom poisoning was 41.9±17.8 years, of excluded from the study. whom 95 (40.3%) were male and 141 (59.7%) were Documents of the patients who met incluson female. 15 (6.4%) patients had diabetes, 8 (3.4%) criteria were analysed. Demographic data, type of patients had hypertension and 7 (3.0%) had coro- the ingested mushroom (wild or cultivated), com- nary artery disease. 100 (42.4%) patients had eaten plaints upon admission, onset time of symptoms cultivated mushrooms, and 104 (44.1%) patients after ingestion, physical examination findings, leu- had eaten wild mushrooms. Mushroom type could cocyte, neutrophil, lymphocyte, platelet, AST, ALT not be determined in 32 (13.6%) patients. values upon admission, duration of hospital stay, Symptoms began within the first 6 hours in whether hemoperfusion was applied or not, and 199 (84.3%) patients and after 6 hours in 37 outcome data were recorded. (15.7%) patients. Patients were usually admitted Accuracy of these data, which were collected with nausea, vomiting, abdominal pain and diar- by three different researchers, was verified by rhea. Hemoperfusion was needed in 24 (10.2%) another independent researcher. Neutrophil/lym- patients. Mean duration of hospital stay was phocyte and platelet/lymphocyte ratios were calcu- 8.36±3.96 days in patients whose liver function lated using laboratory records and neutrophil, lym- tests were impaired and 2.28±2.20 days in patients phocyte and platelet counts. with normal liver function tests. The number of Patients were allocated to two groups: those patients who died was 2 (0.8%). Neutrophil/lym- who received hemoperfusion and those who didn’t. phocyte ratio was 15.14±15.76 in patients with They were also divided into two groups as those impaired liver function tests and statistically signif- with impaired liver functions tests and those with icant compared to the patients with normal liver normal liver function tests. function tests (5.48±7.69) (p= 0.001). 852 Ramazan Koylu, Zerrin Defne Dundarb et Al

The comparison of variables of normal and Patients who Patients who did received not receive impaired liver function tests is shown in Table 1. p value hemoperfusion hemoperfusion Impaired liver Normal liver func- (n=24) (n=212) function tests p value tion tests (n=225) (n=11) Age 41.9±16.9 41.9±17.9 0.888 Age 50.1±18.2 41.5±17.7 0.104 Gender Gender male 14 (58.3) 81 (38.2) 0.057

male 9 (81.8) 86 (38.2) 0.004 female 10 (41.7) 131 (61.8) Mushroom type (by history) female 2 (18.2) 139 (61.8) Mushroom type (by history) cultivated mushrooms 7 (29.2) 93 (43.9) 0.038 cultivated mushrooms 5 (45.5) 95 (42.2) 0.808 wild mushrooms 17 (70.8) 87 (41.0) wild mushrooms 6 (54.5) 98 (43.5) unknown 0 (0.0) 32 (15.1) unknown 0 (0.0) 32 (14.2) Symptom time Symptom time

first 6 hours first 6 hours 17 (70.8) 20 (9.4) 0.001 5 (45.5) 194 (86.2) < 0.001

after 6 hours 6 (54.5) 31 (13.8) after 6 hours 7 (29.2) 192 (90.6) Admitting symptoms Admitting symptoms

nausea 11 (100.0) 183 (81.3) nausea 24 (100.0) 170 (80.2) 0.019 0.071 vomiting 11 (100.0) 173 (87.8) vomiting 22 (91.7) 162 (76.4) abdominal pain 5 (45.5) 29 (14.7) abdominal pain 7 (29.2) 27 (12.7) diarrhea 4 (36.4) 20 (10.2) diarrhea 5 (20.8) 19 (8.9) Hemoperfusion 11 (100.0) 13 (5.8) < 0.001 Duration of hopital 7.75±3.94 1.98±1.61 < 0.001 Duration of hopital stay(day) 8.36±3.96 2.28±2.20 < 0.001 stay(day) WBC 12.4±8.8 10.2±6.2 0.119 WBC 14.4±13.3 10.2±6.0 0.644 Neutrophil 10.2±8.6 7.1±3.6 0.014 Neutrophil 12.4±12.8 7.2±3.5 0.169 Lymphocyte 1.55±0.91 2.12±1.44 0.015 Lymphocyte 1.1±0.6 2.1±1.4 0.002 Platelet 244.7±71.9 246.9±71.5 0.916 Platelet 249±101 246±69 0.692 AST 403.4±777.4 26.4±45.6 <0.001 AST 895±971 24±12 < 0.001 ALT 521.2±782.1 22.6±26.9 <0.001 Neutrophil/lymphocyte ALT 1068±888 25±35 < 0.001 9.91±11.72 5.48±7.89 0.002 ratio Neutrophil/ 15.14±15.76 5.48±7.69 0.001 lymphocyte ratio Platelet/lymphocyte ratio 225.0±168.8 156.8±120.5 0.023 Platelet/lymphocyte ratio 307.2±209.5 156.8±118.4 0.003 Table 2: Comparison of variables between patient groups Table 1: The comparison of variables of normal and who received hemoperfusion or not is given. impaired liver function tests.

Neutrophil/lymphocyte ratio was 9.91±111.72 with high morbidity and mortality. Although culti- in patients who received hemoperfusion and the dif- vated mushrooms are generally accepted as nonpoi- ference was statistically significant compared to the sonous, symptoms of poisoning may arise if they patients who did not receive hemoperfusion are contaminated by catching toxic particles or by (5.48±7.89) (p= 0.002). Comparison of variables mcroorganisms due to growing conditions or isola- between patient groups who received hemoperfu- tion conditions. Hospitalization was required due to sion or not is given in Table 2. clinical findings in 100 patients following ingestion of cultivated mushrooms, and liver function tests Discussion were out of normal ranges in 5 of these patients, and 7 patients required hemoperfusion. Mushroom poisoning is among the severe poi- Supportive therapy, applied in addition to spe- sionings common in rainy seasons, spring and cific therapy toward the ingested mushroom type, autumn, and may be fatal. Approximately half of particularly hydration and organ-preserving thera- herbal poisonings are mushroom poisonings(2). py, is of vital importance inthe management of Some mushroom types, particularly amanita patients who are admitted to the emergency room type, is very toxic and their poisoning is related with mushroom poisoning. Influence of neutrophil/lymphocyte ratio on prognosis in mushroom poisoning... 853

Decisions about hospitalization or follow-up hemoperfusion and had impaired liver function in the intensive care unit and the prediction of tests. In addition, platelet/lymphocyte ratio was patients who could have a poor prognosis are of found statistically significantly higher in patients importance. Another important problem seen during with impaired liver function tests compared to the clinical management of mushroom poisoning cases patients with normal liver function tests. However, is that mushroom type and toxic metabolites cannot our study indicates that lymphocyte alone has the be detected in emergency laboratories in 95% of same prognostic power. All three parameters should cases(2). Advanced mycology laboratories are avail- be re-evaluated in larger patient groups. able in only a few centers worldwide. It is not always easy to predict prognosis, to Limitations decide to hospitalize the patient, or to follow up in This study was performed retrospectively. The an outpatient setting. These decisions should be number of patients who required hemoperfusion made based on objective data, so reliable laboratory and whose liver function tests were impaired was results reflecting objective data are needed. For quite small compared to the total patient number. example, complete blood count may be used for The small number of cases hindered sub-group this purpose. analysis. In addition, detection of mushroom types Complete blood count should be tested in poi- was done based on anemnesis, and the absence of soning cases as in most cases admitted to emer- modern mycology laboratories to do mushroom gency room. Besides, this test is both economic and analysis hindered making an objective differential provides results in avery short amount of time. diagnosis between mushroom types. Therefore, In our study, while leucocyte count is elevated prognostic value of neutrophil/lymphocyte ratios in with neutrophil predominacy, lymphocyte count is poisoning cases should be supported by prospective reduced. The main underlying process in mushroom studies conducted with a larger number of patients. poisoningis oxidative stress, as it is in many diseases(16). Free radicals, resulting from increased Conclusion oxidative stress, consist the main mechanism of injury(8). Fungal nephrotoxins like orellanine con- These results showed that care should be currently leads oxidative stress to increase and givenboth for prognosis and hemoperfusion impairs defense mechanisms through causing injury requirement in patients whose neutrophil/lympho- at the cellular level(17). cyte ratio is high upon admission, considering Some cellular changes, which can be detected longer duration of hospital stay and more aggres- in laboratory analysis, will arise when these mecha- sive treatment options. nisms, which play a role in pathogenesis, cannot be Lymphocyte and netrophil/lymphocyte ratios controlled and antioxidant capacity is inadequate(18). measured within the first 24 hours of admission In general, leucocyte count increases as a response seem to be easy and usable parameters in monitor- to oxidative stress. When distribution of elevated ing mushroom poisoning cases. leucocyte count is analysed, neutrophilia, lymphocytopenia and monocytosis are seen in an acute period of oxidative stress as in sepis trauma(15). In our study, both neutrophil/lymphocte count and platelet/lymphocyte ratios were significantly high in patients whose liver funtion tests were impaired. While neutrophil/lymphocyte ratio was significant in patients who needed hemoperfusion, References platelet/lymhocyte ratio was not statistically significant although it was found higher. It is reported in 1) Goldfrank LR. Mushrooms. In: goldfrank’s toxicologic many studies that neutrophil/lymphocyte ratio is a emergencies, 9th, Nelson LS, Lewin NA, Howland MA et al. (Eds), Mcgraw-Hill, New York 2011. 1522. strong indicator of inflammation and prognosis in 2) Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2008 (19) many diseases . Annual report of the american association of poison In our study, neutrophil/lymphocyte ratio was control centers’ national poison data system (npds): detected to be a strong prognostic indicator in the 26th annual report. Clin Toxicol (Phila) 2009; 47: 911. prediction of mortality in patients who both needed 3) Berger JK, Guss DA. Mycotoxins revisited: Part I. J Emerg Med 2005; 28: 53. 854 Ramazan Koylu, Zerrin Defne Dundarb et Al

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