Mushroom Poisoning in Thailand: Incidence and Intoxication To

Tawatsin A. et al. Medical Research Archives, vol. 6, issue 9, September 2018 Page 1 of 12

RESEARCH ARTICLE

Mushroom Poisoning in Thailand: Incidence and Intoxication to Human Health Apiwat Tawatsin1*, Sittiporn Parnmen1, Usavadee Thavara1, Padet Siriyasatien2, Pornpimol Kongtip3

Authors’ affiliations: 1 National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi 11000 Thailand 2 Faculty of Medicine, Chulalongkorn University, Bangkok 10330 Thailand 3 Department of Occupational Health and Safety, Faculty of Public Health, Mahidol University, Bangkok 10400 Thailand

* Corresponding author: Apiwat Tawatsin, E-mail: [email protected]

ABSTRACT Mushroom poisoning is one of the public health issues related to food-borne diseases in Thailand and worldwide. This paper revealed the incidence of mushroom poisoning in Thailand between 2008 and 2017 and discussed relevant information involved. About 1,200 to 2,000 reported cases were reported each year with morbidity rates from 1.86 to 3.34 per 100,000 population and mortality rates from 0.12 to 1.12%. Overall, 15,680 patients of mushroom poisoning were reported in Thailand during the 10-year period from 2008 to 2017 with an average of 1,568 patients annually. The cases were reported mainly from northeast and north Thailand. Actually, the incidence of mushroom poisoning increased during rainy season between May and September. The highest risk was found among patients aged between 55 and 64 years and over 65 years followed by the group of 45- 54 years. The poison risk to women was always greater than to men with ratios varying between 1.13:1 and 1.70:1 and the incidence was found mainly among farmers and general workers. Four groups of toxins have been found in Thailand including protoplasmic poisons, neurotoxins, gastrointestinal irritants and disulfiram-like toxins. The protoplasmic poisons are a major cause of death in most cases and are found among some mushrooms, such as Amanita exitialis, A. fuliginea, A. fuligineoides and A. gleocystidiosa. Gastrointestinal irritants are the most common toxins found in all regions of Thailand and found among some mushrooms, such as Chlorophyllum molybdites, Russula sp., Cantharocybe virosa, Entoloma sp., Lactarius sp.and Tricholoma sp. Commonly, consumption of poisonous mushrooms is usually a result from misidentification of some poisonous ones, closely similar to those of the commonly edible mushrooms. Therefore, educating the public to recognize poisonous mushrooms to avoid to harvesting them for consumption or sale is urgently needed.

Keywords: Mushroom, Poisoning, Toxin, Consumption, Health, Thailand

INTRODUCTION tion of mushrooms included DNA extraction, PCR amplification, DNA sequencing, fungal Mushrooms are commonly found throughout identification using BLAST and BOLD-IDS, the world and are an important source of sequence alignments and phylogenetic ana- food for humans. About 140,000 species of lyses while the liquid chromatography mass 1 mushrooms have already been identified. spectrometry (LC-MS) method was used to Among these, approximately 2,000 species detect toxins in the mushrooms.15 All data are recognized as edible mushrooms while were statistically calculated and presented as about 700 species are considered as medicin- proper figures. al ones.1 Thailand is located in a tropical area in Southeast Asia with a high degree of bio- diversity; and as a result, many species of RESULTS AND DISCUSSION mushroom can be found in forest The annual incidence of mushroom poison- areas. Almost 2,000 species of edible and ing in Thailand from 2008 to 2017 is shown inedible mushrooms are distributed around 2 in Figure 1. As can be seen, about 1,200 to the country. Mushrooms have been com- 2,000 cases were reported each year with a monly consumed by Thais. However, mu- morbidity rate between 1.86 and 3.34 per shroom poisoning is also one of the major 100,000 population during that period. The public health issues related to food-borne lowest incidence of mushroom poisoning was diseases in Thailand. Mushroom poisoning found in 2016 with 1,220 reported cases resulting in death is reported by the Ministry while the highest in 2012 reported 2,148 cas- of Public Health yearly and remains a signif- es. Overall, 15,680 mushroom poisoning icant cause of poisoning-related mortality in 3 patients were reported in Thailand during the the country. This study intended to investi- 10-year period between 2008 and 2017 with gate the epidemiology of mushroom poison- an average of 1,568 patients/year. This inci- ing in Thailand during the past decade. In- dence is dramatically high as compared with formation about poisonous mushrooms and other countries, such as Japan (192 pa- their toxins found in Thailand were revealed tients/year),16 Switzerland (79 pa- and discussed.Some attempts to minimize the tients/year),17 Hong Kong (67 patients/year)18 incidence were also investigated and solu- and Korea (21 patients/year).19 Therefore, tions suggested. minimizing the incidence of mushroom poisoning in Thailand is urgent needed as much MATERIALS AND METHODS as possible using various strategies. Howev- er, the number of people reporting mushroom The data on the incidence of mushroom poi- poisoning in Thailand yearly should be high- soning in Thailand between 2008 and 2017 er than those reported in the Figure 1 because was obtained using online published annual people presenting only mild symptoms after reports of the Bureau of Epidemiology, De- ingesting the mushrooms do not want to visit partment of Disease Control, Ministry of hospitals, especially those living in remote 4-13 Public Health, Thailand. The information areas with poor access to health services. about mushroom species identification using Normally, the number of reported mushroom molecular techniques and laboratory detec- poisoning cases increases during the rainy tion of toxins in mushroom samples was ob- season between May and September. In fact, tained from the Toxicology Center, National this is the best period for mushroom growing Institute of Health (Thai NIH) and the pub- in Thailand, especially for those residing in lished annual reports of the National Institute forests. Thais collect many mushrooms from of Health, Department of Medical Sciences, the forests nearby their homes for consump- 14 Ministry of Public Health, Thailand. The tion in their families as well as for local sale. molecular techniques for species identifica-

Some commonly edible mushrooms, such as Therefore, many Thais are active in harvest- Termitomyces fuliginosus, Termitomyces ing edible mushrooms in the forests during globulus and Astraeus hygrometricus have rainy season yearly to supplement their in- relatively high prices in the market, approx- come. imately 600-1,000 THB/kg (USD 20-35/kg).

2 400 5,0 2 200 2 000 Reported cases 4,0 1 800 Morbidity rates 1 600 1 400 3,0

1 200 Reported Reported cases 1 000 2,0 800 600

1,0 Mortbidity rates (per 100,000population) 400 200 0 0,0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Figure 1. Reported cases and morbidity rates of mushroom poisoning in Thailand, from 2008 - 2017.

The number of reported deaths because of methods, such as boiling, grilling or stir- poisonous mushrooms and mortality rates frying cannot affect the toxicity of some mu- (%) between 2008 and 2017 are presented in shrooms because the toxins are heat stable. Figure 2. The lowest incidence (2 deaths) As for the individual response, the elderly was found in 2009 with 0.12% mortality and children are at higher risk for the serious whereas the highest (24 deaths) was found in effects from mushroom poisoning than 2012 with a 1.12% mortality rate. Overall, 79 healthy young adults.20 In this study, the patients died by mushroom poisoning in highest risk was usually found among the Thailand from 2008 to 2017 with an average patients aged between 55 and 64 years and of about 8 deaths annually. Most cases were over 65 years, followed by the group 45-54 caused by consuming poisonous mushrooms years. As can be seen, most cases of mu- from the genus Amanita. Actually, the severi- shroom poisoning in Thailand commonly ty of mushroom poisoning depends mainly occurred among adults with ages at least 45 on the species poisonous mushrooms in- years old. Additionally, the poison risk to gested, the amount of toxins received, the women was always greater than men from cooking process and individual response to 2008 to 2017, with ratios varying between the toxins. Many toxins produced by poison- 1.13:1 (in 2011) and 1.70:1 (in 2017) and ous mushrooms can affect the organs, vary- was found mainly among farmers and gener- ing from mild to severe symptoms. Cooking al workers.

25 1,4

20 Reported deaths 1,2 Mortality rates 1,0 15

0,8 Mortbidity Mortbidity rates (%)

Reported Reported deaths 10 0,6

0,4 5 0,2

0 0,0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Figure 2. Reported deaths and mortality rates of mushroom poisoning in Thailand, from 2008 - 2017.

Mushroom poisoning can be classified in without presenting any symptoms could last four groups by the physiological effects: pro- about 6-24 hours after mushroom ingestion. toplasmic poisons, neurotoxins, gastrointes- Later, the gastrointestinal phase occurs tinal irritants and disulfiram-like toxins.21 among patient with symptoms such as nau- These poisoning categories have been found sea, vomiting, profuse watery diarrhea and in various regions of Thailand (Figure 3). abdominal pain, typically lasting 1-2 days Firstly, the protoplasmic poisons are toxins then followed by brief clinical remission.24 that destroy cells of some organs, such as the Multiple organ failure is the final stage when liver and kidney; as a result the organs fail at the start damaged liver and kidney cells, and possible death. The toxins found in this leading to systemic failure in both organs group include amatoxins, gyromitrins and within 2-7 days after mushroom consumption orellanine that produce hepatotoxicity.22-23 and death could occur in severe case within Among these, amatoxins are the most toxic 4-16 days.24,26 However, rapid diagnosis and and cause over 95% of mushroom-related appropriate treatment could substantially fatalities in the US.22 The ten known amatox- alter mortality by amatoxin poisoning as fa- ins, include alpha-, beta- and gamma- talities may be reduced from 50-60% to less amanitins, etc., and alpha-amanitin is the than 5% with good supportive care.20 Mengs primary toxin damaging liver and kidney et al27 pointed out the reasonable use of sili- cells.24 A single mushroom may contain binin as Legalon® SIL in almost 1,500 ama- about 5-7 mg of amatoxin and could cause nita poisoning cases. Among these, the mor- death when ingested; even the small amount tality rate among patients treated with intra- of 0.1 mg amatoxin/kg body weight could venous silibinin (Legalon® SIL) is less than cause human death.25 The four stages of clin- 10% as compared with more than 20% when ical symptoms comprise latency phase, ga- using penicillin alone or a combination of strointestinal phase, clinical remission and silibinin and penicillin.27 On the other hand, multiple organ failure.24 The latency phase, treatment with oral high dose silymarin could

Copyright 2018 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra Tawatsin A. et al. Medical Research Archives, vol. 6, issue 9, September 2018 Page 5 of 12 be one of the principal treatments in amatox- mushrooms in Thailand containing protop- in poisoning when silibinin is unavailable as lasmic poisons include Amanita exitialis, A. it could provide about a 87% survival rate in fuliginea, A. fuligineoides, A. gleocystidiosa severe cases.28 In addition, liver transplanta- (Figure 4, no.1-4) and A. virosa and are tion could be lifesaving for those severe cas- found in the north, northeast and central re- es with acute liver failure.29 Some poisonous gions of Thailand (Figure 3).

Figure 3. Distribution of mushroom toxins found in various regions of Thailand

Secondly, the neurotoxins cause neurological tremor and bladder contraction. These symp- symptoms including three: muscarine, ibo- toms usually occur 15 minutes to 5 hours tenic acid/muscimol and psilocybin poison- after ingestion of the poisonous mushroom.24 ing.22 The muscarine toxin causes various Symptoms caused by ibotenic acid/muscimol symptoms, such as hypersalivation, perspira- poisoning include drowsiness, delirium, dys- tion, lacrimation, blurred vision, bronchos- phoria and vertigo that may last for a few pasm, vomiting, diarrhea, abdominal pain, hours, whereas those of psilocybin poisoning

Copyright 2018 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra Tawatsin A. et al. Medical Research Archives, vol. 6, issue 9, September 2018 Page 6 of 12 involve hallucinations that may decrease rotoxins.24 Amanita muscaria, A. pantherina, within 2 hours.22 Fatalities by mushrooms Clitocybe sp., Inocybe sp. (Figure 4, no. 6-7), containing neurotoxins are rarely found Entoloma sp. (Figure 4, no. 10) are poison- among adults but may among children when ous mushrooms containing neurotoxins and large amounts of the mushrooms are in- are found in north, northeast and south re- gested.22 Supportive treatment with fluid and gions of Thailand (Figure 3). electrolytes may be necessary for those neu-

Figure 4. Species of poisonous mushrooms containing various toxins: Protoplasmic poisons (1. Amanita exitialis, 2. Amanita fuliginea, 3. Amanita fuligineoides, 4. Amanita gleocystidiosa), Neurotoxins (6-7. Inocybe sp., 10. Entoloma sp.), Gastrointestinal irritants (11. Chlorophyllum molybdites, 12-13. Russula sp., 14. Cantharocybe virosa), Disulfiram-like toxins (15. Coprinus sp.) and nonpoisonous mushrooms (5. Amanita princeps, 8-9. Termitomyces sp.) found in Thail- and

Thirdly, gastrointestinal irritants are toxins after ingesting the suspected mushroom. Fa- that cause abdominal pain, nausea, vomiting talities caused by these toxins are rare; how- and profuse diarrhea.24 Symptoms usually ever, the severity could occur among very occurred between 30 minutes and 4 hours old or young patients due to extensive dehy-

Copyright 2018 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra Tawatsin A. et al. Medical Research Archives, vol. 6, issue 9, September 2018 Page 7 of 12 dration and electrolyte imbalances.22 There- Hygrocybe, Alboleptonia, Geastrum, Lacta- fore, fluid and electrolyte replacement are the rius, Pisolithus, Psilocybe, Scleroderma, and actual treatment.24 Some poisonous mu- Mycena. However, only 15 species could be shrooms in Thailand containing gastrointes- identified and these included Amanita cf. tinal irritants include Chlorophyllum molyb- bisporigera, Boletus cf. rubiicolor, Chloro- dites, Russula sp., Cantharocybe virosa (Fig- phyllum molybdites, Clitocybe cf. odora, ure 4, no. 11-14), Entoloma sp., Lactarius sp. Clitocybe cf. atrobrunnea, Entoloma cf. and Tricholoma sp. Notably, mushrooms rhombispora var. rhombispora, Entoloma cf. having gastrointestinal irritants are found in occultipigmentatum, Entoloma cf. pallidaa- all regions of Thailand (Figure 3). Similarly, vum, Entoloma cf. strictius, Entoloma talis- C. molybdites is commonly found on lawns porum, Gaestrum saccatum, Inocybe cf. in the US and it is also recognized as the rep- agardhii, Pisolithus tinctorius, Psilocybe resentative GI toxic mushroom of the coun- cubensis and Scleroderma verrucosum.31 try.24 From 1 October 2014 to 30 September 2015, Lastly, disulfiram-like toxins are normally a total of 225 samples of mushrooms were nontoxic among humans but will cause ill- sent to the Toxicology Center, National Insti- ness when consumed with alcohol within 72 tute of Health, Thailand (Thai NIH) for la- hours after ingesting the poisonous mu- boratory identification of mushroom species shroom. Corprinopsis atramentaria, Corpri- and toxin.14 These samples were collected nopsis sp. and Coprinus sp. (Figure 4, no.15) from patients admitted in hospitals with a are poisonous mushrooms containing disulfi- diagnosis of food poisoning after mushroom ram-like toxins found in Thailand. Actually, ingestion. Three groups of toxins were identi- the mushrooms produce coprine, a toxin in- fied as gastrointestinal irritants (75%), pro- hibiting the breakdown of alcohol beverages toplasmic poisons (α-amanitin 9.9%, β- consumed within 72 hours after ingesting the amanitin 3.4%) and alkaloid muscarine mushroom.22 The illness includes headache, (11.7%). The toxins of gastrointestinal irri- flushing, diaphoresis, nausea, vomiting, ta- tants were identified from the poisonous mu- chycardia, hypotension, palpitations, dizzi- shrooms in the genus Chlorophyllum, Ento- ness and dyspnea and symptoms may last for loma, Lactarius, Russula and Tricholoma. a few hours.22,30 Actual treatment is suppor- The cyclopeptides were from Amanita while tive using fluid and electrolyte replacement24; the alkaloid muscarines were from Clitocybe however, patients with severe symptoms may and Inocybe. benefit by receiving fomepizole.22 Surpri- singly, poisonous mushrooms having disulfi- The correct diagnosis of mushroom poison- ram-like toxins are found only in the north- ing should be based on clinical features, la- east region of Thailand at present (Figure 3). boratory investigations and mushroom identification. The clinical features of patients are In a study conducted in Thailand in 2012, a always observed by physicians and laborato- total of 113 samples received from mu- ry investigations are also conducted in hos- shroom poisoning cases were collected be- pital whereas the suspected mushrooms must tween 2008 and 2012 and examined for spe- be sent to the Toxicology Center, the refer- cies and their toxins.31 Among these, only 58 ence laboratory in Thailand to identify the samples could be identified whereas the 55 mushroom species. Identifying mushrooms samples remained unclassified. Of the 58 when the sample is inappropriate is difficult. known mushrooms, 35 samples were re- The right identification requires an appropri- vealed to be poisonous, belonging to various ate sample of the suspected mushroom. The genera, such as Amanita, Entoloma, Clito- whole mushroom should be preserved as cybe, Agaricus, Lepiota, Russula, Boletus, much as possible for the original characteris-

Copyright 2018 KEI Journals. All Rights Reserved http://journals.ke-i.org/index.php/mra Tawatsin A. et al. Medical Research Archives, vol. 6, issue 9, September 2018 Page 8 of 12 tics of the stem, bulb and cap. In addition, the es.34 However, we are going to expand this mushrooms should be individually kept in a technique to identify other genera of poison- dry paper bag, not cloth or plastic. Transport- ous mushrooms found in Thailand as well. ing the mushrooms with these practices could minimize destruction of their natural charac- To explore as many poisonous mushrooms in teristics.22 However, mushroom samples Thailand as possible, attempts have been usually sent to the Toxicology Center for the made by staff of the Toxicology Center and laboratory to identify the mushroom species the Regional Medical Science Centers, De- and toxins were frequently inappropriate be- partment of Medical Sciences (DMSc) to cause they were sent from a remote areas survey fresh mushrooms found in forests taking many days to transport. The mu- throughout Thailand, especially those in the shroom samples were then usually decayed areas with reported cases of mushroom poi- and unable to be identified by morphological soning. The collected mushrooms have been characteristics. Also, some mushrooms were identified properly by their morphological already cooked. Therefore, attempts have characteristics and molecular techniques to been made by staff of the Toxicology Center, identify species. According to the genus and Thai NIH to develop methods for detecting species identified and the relevant literature poisonous mushroom species using DNA review, the collected mushrooms were also barcoding, a technique that can be used to investigated for the potential toxins that they identify species of organisms quickly and may contain. The information obtained from precisely using standard DNA fragments these investigations will be established as a compared with reference databases.15 The database of poisonous mushrooms in Thail- internal transcribed spacer (ITS) region of and. This will be valuable for local people to nuclear ribosomal DNA was then selected to know more about the poisonous mushrooms be used for this purpose. Widely used to in particular areas that they must avoid har- study genetic variability and the divergence vesting for consumption or sale, especially of closely related species of various mu- those species that closely semble edible mushrooms,32 it is also recognized as the univer- shrooms. In Figure 4, for instance, poisonous sal barcode region for fungal identification.33 mushrooms containing protoplasmic poisons: As a result, Parnmen et al15 in 2016 suc- A. exitialis (no. 1), A. fuliginea (no. 2), A. ceeded in molecular identification of poison- fuligineoides (no. 3) and A. gleocystidiosa ous mushrooms using nuclear ITS sequence (no. 4) are closely similar to the edible mu- data in 26 mushroom samples eaten in nine shroom A. princeps (no. 5), while those con- fatal cases from 2008 to 2014. Three species taining neurotoxins: Inocybe sp. (no. 6-7) of mushrooms: Amanita exitialis, Amanita also closely resemble the edible mushroom, fuliginea and Amanita sp. 1 were identified Termitomyces sp. (no. 8-9). In addition, a and newly recorded as the causes of death in detailed comparison of similar mushrooms of those fatal cases. Interestingly, this was also the genus Amanita was also conducted by the first time to reveal the presence of A. ex- staff of the Toxicology Center to discrimi- itialis in Thailand.15 Presently, we can use nate the differences between (a) Amanita the molecular technique to precisely identify princeps, an edible mushroom commonly many species of the poisonous mushrooms, consumed by Thais and (b) Amanita exitialis, especially those in the genus Amanita which a poisonous mushroom containing fatal tox- is the most important one that always cause ins (α-amanitin, β-amanitin and phallacidin) fatal cases in Thailand. Additionally, the (Figure 5). Obviously, it provides three sig- technique was also applied to identify some nificant points of differences that can help wild mushrooms in the genus Tylopilus and people to easily distinguish poisonous mu- Parvixerocomus that caused two fatal cas- shrooms when they harvesting them.

(a) (b) Figure 5. Comparison of similar mushrooms of the genus Amanita, (a) Amanita princeps, an edible mushroom commonly consumed by Thais (b) Amanita exitialis, the poisonous mushroom containing fatal toxins (α-amanitin, β-amanitin and phallacidin)

In Thailand, misconceptions abound from found in Thailand (Figure 6). This book pro- folk knowledge about mushroom consump- vides important information relevant to poi- tions, such as boiling or stir-frying mu- sonous mushrooms, such as the toxins found shrooms make them safe for human con- in particular mushrooms, discriminating be- sumption, a silver spoon will turn blackish in tween poisonous mushrooms from edible contact with poisonous mushrooms, mu- ones, misconceptions on testing poisonous shrooms that have been partially bitten by mushrooms, suggestions for safe consump- insects are safe for humans, vinegar or salt tion of mushrooms, first aid treatment after can detoxify toxins in poisonous mushrooms, ingesting poisonous mushroom and proper poisonous mushrooms tarnish garlic or rice treatment and appropriate collection and grains, the soup will turn blackish when boil- transportation methods of suspected poisoning poisonous mushrooms with onions and ous mushrooms for laboratory identification. poisonous mushrooms are always colorful Additionally, the DMSc has also attempted to while the edible ones are usually white or develop a mobile application to distinguish pale. This local knowledge false needs to be between poisonous and edible mushrooms. corrected by government agencies for the This alternative advanced device could help right understanding by the public. Recently people to easily differentiate poisonous mu- in 2018, the DMSc published a handbook of shrooms in the field for safer harvesting mu- poisonous mushrooms (in Thai) for people to shrooms. easily learn about poisonous mushrooms

Figure 6. A handbook of poisonous mushrooms (in Thai) for public awareness published by the De- partment of Medical Sciences (DMSc) for Thais to easily learn about poisonous mushrooms found in Thailand

In conclusion, mushroom poisoning remains their kind assistance in laboratory identifica- an important health issue in Thailand. Annual tion of mushroom species and the relevant incidence has been relative high with some toxins. reported of deaths during the past decade. Therefore, educating the public to recognize REFERENCES poisonous mushrooms and avoid harvesting them for consumption or sale is urgently [1] Lull C, Wichers HJ, Savelkoul HFJ. needed. Public awareness plays an important Antiinflamatory and immunomodulating role to prevent and minimize the incidence of properties of fungal metabolites. Mediat In- mushroom poisoning. flamm. 2005;2005(2):63-80. [2] Chandrasrikul A, Suwanarit P, Sang- CONFLICT OF INTEREST wanit U, et al. Checklist of mushrooms (Ba- None of the authors has any conflict of inter- sidiomycetes) in Thailand. Bangkok, Thail- est to disclose. and: Office of Natural Resources and Envi- ronmental Policy and Planning; 2011. ACKNOWLEDGEMENTS [3] Saoraya J, Inboriboon PC. Acute poi- The authors would like to thank staff of the soning surveillance in Thailand: the current Toxicology Center, National Institute of state of affairs and a vision for the future. Health, Department of Medical Sciences for ISRN Emergency Medicine. 2013; Article ID

812836, 9 pages. http://dx.doi.org/10.1155/ [12] Bureau of Epidemiology, Department 2013/812836 of Disease Control, Ministry of Public Health. Annual Epidemiological Surveillance [4] Bureau of Epidemiology, Department Report 2016. http://www.boe.moph.go.th/ of Disease Control, Ministry of Public Annual/ AESR2016/index.html. Health. Annual Epidemiological Surveillance Report 2008. http://www.boe.moph.go.th/ [13] Bureau of Epidemiology, Department Annual/ AESR2008/index.html. of Disease Control, Ministry of Public Health. Annual Epidemiological Surveillance [5] Bureau of Epidemiology, Department Report 2017. http://www.boe.moph.go.th/ of Disease Control, Ministry of Public Annual/ AESR2017/index.html. Health. Annual Epidemiological Surveillance Report 2009. http://www.boe.moph.go.th/ [14] National Institute of Health, Thailand. Annual/ AESR2009/index.html. Annual Report 2015, National Institute of Health, Department of Medical Sciences, [6] Bureau of Epidemiology, Department page 106-108. ISBN: 978-616-11-2800-5. of Disease Control, Ministry of Public Health. Annual Epidemiological Surveillance [15] Parnmen S, Sikaphan S, Leudang S, Report 2010. http://www.boe.moph.go.th/ Boonpratuang T, Rangsiruji A, Naksuwankul Annual/ AESR2010/index.html. K. Molecular identification of poisonous mushroom using nuclear ITS region and pep- [7] Bureau of Epidemiology, Department tide toxins: a retrospective study on fatal cas- of Disease Control, Ministry of Public es in Thailand. J Toxicol Sci. 2016;41(1):65- Health. Annual Epidemiological Surveillance 76. Report 2011. http://www.boe.moph.go.th/ Annual/ AESR2011/index.html. [16] Yamamura Y. Recent trends of mushroom poisoning in Japan. Chudoku [8] Bureau of Epidemiology, Department Kenkyu. 2013; 26(1):39-43. of Disease Control, Ministry of Public Health. Annual Epidemiological Surveillance [17] Schmutz M, Carron PN, Yersin B, Report 2012. http://www.boe.moph.go.th/ Trueb L. Mushroom poisoning: a retrospec- Annual/ AESR2012/index.html. tive study concerning 11-years of admissions in a Swiss emergency department. Intern [9] Bureau of Epidemiology, Department Emerg Med. 2016;17. of Disease Control, Ministry of Public Health. Annual Epidemiological Surveillance [18] Chan CK, Lam HC, Chiu SW, Tse Report 2013. http://www.boe.moph.go.th/ ML, Lau FL. Mushroom poisoning in Hong Annual/ AESR2013/index.html. Kong: a ten-year review. Hong Kong Med J. 2016;22(2):124-130. [10] Bureau of Epidemiology, Department of Disease Control, Ministry of Public [19] Kim SY, Baek YH, Han SY, et al. Health. Annual Epidemiological Surveillance Mushroom poisoning by Macrolepiota neo- Report 2014. http://www.boe.moph.go.th/ mastoidea. Korean J Gastroenterol. Annual/ AESR2014/index.html. 2018;71(2):94-97. [11] Bureau of Epidemiology, Department [20] Saviuc PF, Danel VC, Moreau PA, et of Disease Control, Ministry of Public al. Erythromelalgia and mushroom poison- Health. Annual Epidemiological Surveillance ing. J Toxicol Clin Toxicol. 2001;39(4):403- Report 2015. http://www.boe.moph.go.th/ 407. Annual/ AESR2015/index.html.

[21] Tyler Jr. VE. Poisonous mushrooms. [29] Broussard CN, Aggarwal A, Lacey Progress in Chemistry Toxicology SR, et al. Mushroom poisoning--from diarr- 1963;1:339-384. hea to liver transplantation. Am J Gastroente- rol. 2001;96(11):3195-3198. [22] Horowitz BZ, Hendrickson RG. Mu- shroom toxicity 2015. https://emedicine. [30] Haberl B, Pfab R, Berndt S, et al. medscape.com/article/167398-overview. Ac- Case series: alcohol intolerance with Co- cessed May 28, 2018. prine-like syndrome after consumption of the mushroom Lepiota aspera (Pers.:Fr.) Quel., [23] Karlson-Stiber C, Persson H. Cyto- 1886 (Freckled Dapperling). Clin Toxicol. toxic fungi – an overview. Toxicon. 2003;42 2011;49(2):113–114. (4):339–349. [31] Boonpratuang T, Choeyklin R, Prom- [24] Graeme KA. Mycetism: a review of kium-on P, Teeyapan P. The identification of the recent literature. J Med Toxicol. poisonous mushrooms in Thailand during 2014;10:173–189. 2008-2012. Thai Mushroom. July-December [25] Roberts DM, Hall MJ, Falkland MM, 2012;6-13. et al. Amanita phalloides poisoning and [32] Zhang LF, Yang JB, Yang ZL. Mole- treatment with silibinin in the Australian cular phylogeny of eastern Asian species of Capital Territory and New South Wales. Med Amanita (Agaricales, Basidiomycota): tax- J Aust. 2013; 198(1):43–47. onomic and biogeographic implications. [26] Mas A. Mushrooms, amatoxins and Fungal Divers. 2004;17:219-238. the liver. Journal of Hepatology. [33] Schoch CL, Seifert KA, Huhndorf S, 2005;42(2):166-169. et al. Nuclear ribosomal internal transcribed [27] Mengs U, Pohl RT, Mitchell T. Lega- spacer (ITS) region as universal DNA bar- lon® SIL: the antidote of choice in patients code marker for fungi. Proc Natl Acad Sci with acute hepatotoxicity from amatox- USA. 2012;109:6241-6246. in poisoning. Curr Pharm Biotechnol. [34] Parnmen S, Sikaphan S, Leudang S, 2012;13(10):1964-1970. et al. Molecular identification of wild bolete [28] Trakulsrichai S, Sripha C, Tongphoo mushrooms resulting in fatal outcome via the fungal large-subunit ribosomal RNA gene. A, et al. Clinical characteristics and outcome th of toxicity from Amanita mushroom poison- Proceeding of the 26 Annual Medical ing. Int J Gen Med. 2017;10:395-400. Sciences Conference, Bangkok, 28-30 March 2018, p78.