From activated charcoal to selective plasma exchange: A retrospective analysis of mushroom poisoning cases treated in the intensive care unit

Abstract

Introduction: This study aims to evaluate presenting symptoms, clinical and laboratory findings, and treatment modalities of adult patients presenting with mushroom poisoning treated in the intensive care unit (ICU) with special consideration of extracorporeal liver support systems. Materials and methods: Records of patients with mushroom poisoning treated in the ICU between January 2007 and December 2014 were analyzed retrospectively. Results: Sixteen adult patients were treated in the ICU for mushroom poisoning during the designated study period. Presentation to the hospital was most common during October of each year. Average time from ingestion of mushrooms to first symptoms was 17.81 hours, and to ICU admission was 2.38 days. The most common symptoms were nausea, vomiting and diarrhea. The most common laboratory finding was elevation of liver transaminases. In cases with elevated liver transaminases, penicillin G, silibinin and N-acetyl cysteine were used. Extracorporeal support systems were used in 9 cases. Two cases underwent emergency liver transplantation. Conclusion: Liver transplantation is the most definitive and effective treatment in indicated cases of mushroom poisoning. Extracorporeal support systems should be considered in the early period both as a treatmet modality on their own or to save time until the definitive treatment is possible. The question of which extracorporeal detoxification technique to use is difficult to answer and controlled clinical trials which compare their efficacy are needed.

Keywords

• mushroom poisoning
• selective plasma exchange
• activated charcoal
• intensive care unit

References

1. Eren SH, Demirel Y, Ugurlu S, Korkmaz I, Aktas C, Guven FM. Mushroom poisoning: retrospective analysis of 294 cases. Clinics (Sao Paulo) 2010; 65: 491-496. doi: 10.1590/S1807-59322010000500006
2. Gonmori K, Yoshioka N. The examination of mushroom poisonings at Akita University. Leg Med (Tokyo) 2003; 5: S83-86. doi: 10.1016/s1344-6223(02)00127
3. Gurbuz Ş, Oguzturk H, Turgut K, Turtay MG, Guven T. Mushrooms: The velvety poison. Acta Medica Mediterranea 2015; 31: 947-951.
4. Durukan P, Yildiz M, Cevik Y, Ikizceli I, Kavalci C, Celebi S. Poisoning from wild mushrooms in Eastern Anatolia region: analyses of 5 years. Hum Exp Toxicol 2007; 26: 579-582. doi: 10.1177/0960327106079545
5. Diaz JH. Evolving global epidemiology, syndromic classification, general management, and prevention of unknown mushroom poisonings. Crit Care Med 2005; 33: 419-426. doi: 10.1097/01.ccm.0000153530.32162.b7
6. Santi L, Maggioli C, Mastroroberto M, Tufoni M, Napoli L, Caraceni P. Acute Liver Failure Caused by Amanita phalloides Poisoning. Int J Hepatol 2012; 2012: 487480. doi: 10.1155/2012/487480
7. Özcan N, İkincioğulları D. Ulusal Zehir Danışma Merkezi 2008 Yılı Çalışma Raporu Özeti. Türk Hij Den Biyol Derg 2009; 66: S3
8. Chaudhary S, Chaurasia RK, Patel S, Agrawal KK, Aswani R, Jaiswal N. Clinical profile and outcome of patients presenting with mushroom poisoning in a tertiary care center of eastern Nepal. JNMA J Nepal Med Assoc 2013; 52: 543-548.

9. Ying Li, Maoyuan Mu, Ling Yuan, Baimei Zeng, Shide Lin. Challenges in the early diagnosis of patients with acute liver failure induced by amatoxin poisoning Medicine (Baltimore). 2018 Jul; 97(27): e11288 doi: 10.1097/MD.0000000000011288.
10. Verma N, Bhalla A, Kumar S, Dhiman RK, Chawla YK. Wild mushroom poisoning in north India: case series with review of literature. J Clin Exp Hepatol 2014; 4: 361-365. doi: 10.1016/j.jceh.2014.09.004
11. Ward J, Kapadia K, Brush E, Salhanick SD. Amatoxin poisoning: case reports and review of current therapies. J Emerg Med 2013; 44: 116-121. doi:10.1016/j.jemermed.2012.02.020
12. Roberts DM, Hall MJ, Falkland MM, Strasser SI, Buckley NA. Amanita phalloides poisoning and treatment with silibinin in the Australian Capital Territory and New South Wales. Med J Aust 2013; 198: 43-47. doi: 10.5694/mja12.11180.
13. Allen B, Desai B, Lisenbee N. Amatoxin: A review. International Scholarly Research Notices 2012; 2012: 1-4. doi:10.4172/2165-7548.1000110
14. Tong TC, Hernandez M, Richardson WH 3rd, Betten DP, Favata M, Riffenburgh RH, Clark RF, Tanen DA. Comparative treatment of alpha-amanitin poisoning with N-acetylcysteine, benzylpenicillin, cimetidine, thioctic acid, and silybin in a murine model. Ann Emerg Med 2007; 50: 282-288. doi: 10.1016/j.annemergmed.2006.12.015
15. Magdalan J, Ostrowska A, Piotrowska A, Gomulkiewicz A, Szelag A, Dziedgiel P. Comparative antidotal efficacy of benzylpenicillin, ceftazidime and rifamycin in cultured human hepatocytes intoxicated with alpha-amanitin. Arch Toxicol 2009; 83: 1091-1096. doi: 10.1007/s00204-009-0466-3
16. Pillukat MH, Schomacher T, Baier P, Gabriels G, Pavenstadt H, Schmidt HH. Early initiation of MARS(R) dialysis in Amanita phalloides-induced acute liver injury prevents liver transplantation. Ann Hepatol 2016; 15:775-87. doi: 10.5604/16652681.1212613
17. Enjalbert F, Rapior S, Nouguier-Soule J, Guillon S, Amouroux N, Cabot C. Treatment of amatoxin poisoning: 20-year retrospective analysis. J Toxicol Clin Toxicol 2002; 40: 715-757. doi: 10.1081/clt-120014646
18. Bergis D, Friedrich-Rust M, Zeuzem S, Betz C, Sarrazin C, Bojunga J. Treatment of Amanita phalloides intoxication by fractionated plasma separation and adsorption (Prometheus®). J Gastrointestin Liver Dis 2012; 21: 171-176.
19. Jander S, Bischoff J. Treatment of Amanita phalloides poisoning: I. Retrospective evaluation of plasmapheresis in 21 patients. Ther Apher 2000; 4: 303-307. doi: 10.1046/j.1526-0968.2000.004004303
20. Nenov VD, Marinov P, Sabeva J, Nenov DS. Current applications of plasmapheresis in clinical toxicology. Nephrol Dial Transplant 2003; 18 Suppl 5: v56-58. doi: 10.1093/ndt/gfg1049
21. Jander S, Bischoff J, Woodcock BG. Plasmapheresis in the treatment of Amanita phalloides poisoning: II. A review and recommendations. Ther Apher 2000; 4: 308-312. doi: 10.1046/j.1526-0968.2000.004004308
22. Gok F, Topal A, Hacibeyoglu G, et al A. Fulminant Liver Failure Due to Amanita Phalloides Toxicity Treated with Emergent Liver Transplantation. Eur J Gen Med 2015; 12: 244-248. doi: 10.15197/sabad.1.12.51
23. Nakae H, Igarashi T, Tajimi K. Selective plasma exchange with dialysis in patients with acute liver failure. Ther Apher Dial 2012; 16: 467-471. doi: 10.1111/j.1744-9987.2012.01112
24. Nakae H, Eguchi Y, Saotome T, et al. Multicenter study of plasma diafiltration in patients with acute liver failure. Ther Apher Dial 2010; 14: 444-450. doi: 10.1111/j.1744-9987.2010.00864
25. Kantola T, Koivusalo AM, Hockerstedt K, Isoniemi H. Early molecular adsorbents recirculating system treatment of Amanita mushroom poisoning. Ther Apher Dial 2009; 13: 399-403. doi: 10.1111/j.1744-9987.2009.00758
26. Faybik P, Hetz H, Baker A, et al. Extracorporeal albumin dialysis in patients with Amanita phalloides poisoning. Liver Int 2003; 23 Suppl 3: 28-33. doi: 10.1034/j.1478-3231.23.s.3.8
27. Constantine JK, Holly T, Alexander AL, et al. Acut liver injury and acute liver failure from mushroom poisoning in North America. Liver Int. 2016; 36: 1043–1050 doi: 10.1111/liv.13080