# I scream you scream we all scream for mushrooms!



## samiam (Aug 12, 2014)

54 y/o male presents to the er with server abdominal pain, neasuea, vomiting, haematochezia. Slightly hypertensive at 140/90 other vitals wnl. A/o x3 Slight dehydration noted. Not taking any medication, no history of alcohol use. Approximately 10 hours before symptoms presented patient consumed some mushrooms on his annual mushroom hunting trip with a few buddies. Whats next?


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## chaz90 (Aug 12, 2014)

Any chance his buddies took a picture of the mushroom or brought any home with them?


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## samiam (Aug 12, 2014)

Unfortunately no.


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## chaz90 (Aug 12, 2014)

Pre-hospitally, supportive therapy and consider the possibility of liver and/or kidney damage later. Establish IV access, and think about the possibility of using atropine later if the patient begins to present with more symptoms consistent with a cholinergic toxidrome. If the patient gets drastically worse, benzodiazepines could come into play as well.


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## DesertMedic66 (Aug 12, 2014)

chaz90 said:


> Pre-hospitally, supportive therapy and consider the possibility of liver and/or kidney damage later. Establish IV access, and think about the possibility of using atropine later if the patient begins to present with more symptoms consistent with a cholinergic toxidrome. If the patient gets drastically worse, benzodiazepines could come into play as well.



Pretty much this. Supportive care. IV, fluids, draw bloods for the hospital including grey top (drug panel), Zofran for the N/V, possibly pain meds (haven't looked up how they interact with shrooms) id have to call for an order for it because it's not in my protocols.

Edit: if they had any left the best thing to do is to test some out and have a trippy ride to the hospital as well.... Kidding


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## Ewok Jerky (Aug 12, 2014)

I agree with chaz.  working on a ddx for s&gs...any medical Hx?  Previous surgeries?  No medication including over-the-counter?  Any GI symptoms over the last few days/weeks/months?  What is his normal diet?  Did anyone else eat these mushrooms too?  Hematochezia...any details like estimated blood loss?  Was his stool hard/soft/watery?


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## Ewok Jerky (Aug 12, 2014)

just noticed that this guy presented to the ED.  Can I get a CBC, BMP, LFTs, rectal exam, stool guiac, and CT abdomen please?


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## samiam (Aug 12, 2014)

No one else ate the mushrooms. For a pre-hospital approach supportive care would be sufficient. No OTC Meds, This is the first time it has presented. You may get a (Liver Panel) AST (600U/L) ALT (300U/L) Normal is around 35-40 I think. A PTT (Clotting Time) 26 seconds (Normal is 25-35) and a LDH 400U/L  and a platelet count of 384,000. 

These are the only lab values I have. There are no visible hemorrhoids and rectal exam was unremarkable. Guiac was not done as visible blood was noted. No CT Abdomen However there was activated charcol as well as NS administered and gastric lavage.


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## samiam (Aug 12, 2014)

I will give you a little twist. In the next 6 hours his symptoms completely resolved and patient was discharged home. Approximately 24 hours later patient was readmitted with similar bust much worse presentation and lab values.


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## Ewok Jerky (Aug 12, 2014)

And it is frank red blood, as in lower GI?  That is rectal CA until proven otherwise... As in imaging.

Add abd pain and vomiting with abnormal liver labs now in interested.  Amylase and lipase, bilirubin, lipid panel, RUQ ultrasound would all be helpful, as would a KUB, AFU, and CT.  Enough here to have me interested but not enough to pin down a differential I would be proud of.

When did he poop last?  What was he doing when his symptoms returned?  What is his abdominal pain like? What does his vomit look like?

OK: diverticulitis, small bowel obstruction, colon CA, acute pancreatitis, some sort of hepatitis, some sort of biliary obstruction.


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## samiam (Aug 12, 2014)

Hepatitis antigens were negative. Patient was not doing anything remarkable when symptoms returned. Upon this second admission, Labs were
AST was 3049 U/L ALT 3288 U/L LDH 4459 U/L total bilirubin 12.4 mg/dL PTT 111 seconds INR 11.05 (normal in someone on coumadin is 2) and Platelets 11000. Some time later the patient lost consciousness. His temp was 38.2°C, pulse 112 , rr 32   Bp 89/57 patient was jaundice like no other


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## Meursault (Aug 12, 2014)

samiam said:


> N (Liver Panel) AST (600U/L) ALT (300U/L) Normal is around 35-40 I think.



Does he have a POLST? Is he religious? Anyone he wants to call? 
(A. phalloides?)


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## Akulahawk (Aug 13, 2014)

samiam said:


> Labs were AST was 3049 U/L ALT 3288 U/L LDH 4459 U/L total bilirubin 12.4 mg/dL PTT 111 seconds INR 11.05 (normal in someone on coumadin is 2) and Platelets 11000. Some time later the patient lost consciousness. His temp was 38.2°C, pulse 112 , rr 32   Bp 89/57 patient was jaundice like no other


Sounds like A. phalloides to me too... and this guy could very well end up having a very bad day if his liver doesn't recover.


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## samiam (Aug 13, 2014)

You guys are on point! The diagnosis is alpha aminitin poisoning from ingesting a death cap mushroom. The poison is a RNA polymerase II inhibitor that really does a number on the liver. One of the key diagnostic factors that the ER missed is a refractory period where symptoms completely resolve for 15 hours or so and then come back with a furor. In this case the ER made the common mistake of discharging this patient.


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## Ewok Jerky (Aug 13, 2014)

samiam said:


> You guys are on point! The diagnosis is alpha aminitin poisoning from ingesting a death cap mushroom. The poison is a RNA polymerase II inhibitor that really does a number on the liver. One of the key diagnostic factors that the ER missed is a refractory period where symptoms completely resolve for 15 hours or so and then come back with a furor. In this case the ER made the common mistake of discharging this patient.


Could they have done anything different in those 15 besides look for another liver? What was the outcome?


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## chaz90 (Aug 13, 2014)

Probably a bit late for gastric lavage right? Yeah, I'm definitely curious what would even slow this down after it's been ingested.


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## samiam (Aug 13, 2014)

This case was a little interesting and different in that there were some liver abnormalities in the beginning
Normally there are just Gi symptoms and associated pathologies like dehydration and after about 6 hours after onset 
symptoms present. It is very easily missed as symptoms completely go away and if no one asks about mushroom ingestion or
if the patient does not offer it then it is unlikely to be brought up as it could have been up to 24 hours before symptom onset
and the patient could have had some bad gas station sushi more recently. With supportive care the
mortality rate drops from 50% to 10%. Treatment includes fluids, lots of fluids, FFP, Penicillin G, NAC. Silibinin (antihepatotoxic), Prepare for 
Possible liver transplant. 

In the case of this patient the treatment was too little to late and the patient arrested and died approimately
72 hours after ingestion. The treatment was starting to work with slightly better lab values but by this time the 
damage was done.

BTW Gastric Lavage and activated charcoal are part of the treatment plan but to me it seems after such a long incubation period it would not matter. They do it anyways.


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