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Toxicity, Mushroom - Hallucinogens
Article Last Updated: Jul 9, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 9  
Author: C Crawford Mechem, MD, MS, FACEP, Associate Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department
C Crawford Mechem is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Coauthor(s):
Diane F Giorgi, MD, FACEP, Director of Research, Department of Emergency Medicine, New York University; Attending Physician, Department of Emergency Medicine, Brooklyn Hospital Center
Editors: Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio; John T VanDeVoort, PharmD, ABAT, Director of Pharmacy, Sacred Heart Hospital; Michael Hodgman, MD, Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
mushroom toxicity, hallucinogenic mushroom, hallucinogen toxicity, hallucinogen poisoning, hallucinogen exposure, mushroom poisoning, fungal hallucinogens, Amanita gemmata, Amanita muscaria, fly agaric, Amanita pantherina, the panther, Amanita phalloides, Amanita verna, Amanita virosa, hallucinogenic fungi, psilocybin-containing mushrooms, Psilocybe caerulipes, Psilocybe cubensis, Gymnopilus spectabilis, Panaeolus species, Panaeolus foenisecii, Psathyrella foenisecii, ibotenic acid, muscimol
Background
Hallucinogenic fungi have been used in divinatory or religious contexts for at least 3000 years. However, not until the 1950s were the involved species of fungi identified and the chemical nature of active substances determined.
In general, 2 groups of mushrooms with significant psychoactive effects exist.
- Mushrooms containing ibotenic acid and muscimol (isoxazoles), including Amanita gemmata, Amanita muscaria (fly agaric), and Amanita pantherina (the panther), comprise the first group. These are not to be confused with deadly Amanita phalloides, Amanita verna, and Amanita virosa. For centuries, A muscaria has been consumed in central Asia as a hallucinogen. Some Siberian tribes report that 3 fresh A muscaria mushrooms can be lethal, while others claim that eating as many as 21 of these mushrooms is safe.
- Psilocybin-containing mushrooms, including Psilocybe caerulipes, Psilocybe cubensis, Gymnopilus spectabilis, Panaeolus species (eg, Panaeolus foenisecii), and Psathyrella foenisecii, comprise the second group of mushrooms with psychoactive effects.
Mushrooms containing ibotenic acid and muscimol and those containing psilocybin are New World fungal hallucinogens. Reports of toxicity associated with this group of mushrooms have increased because of their growing popularity as hallucinogens.
Pathophysiology
Ibotenic acid is an agonist at central glutamic acid receptors; its decarboxylated derivative is an agonist at gamma-amino butyric acid receptors. Central effects of these hallucinogenic mushrooms are thought to be caused by these actions. Although muscarinic acid originally was isolated from A muscaria, the clinical syndrome does not suggest marked significance; in fact, anticholinergic findings may be observed.
The psilocybin group contains the indoles psilocybin and psilocin. Psilocin and its phosphate ester, psilocybin, are similar in structure to lysergic acid diethylamide (LSD). They are structural analogues of serotonin (5-hydroxytryptamine); thus, hallucinogenic effects probably are mediated through effects on serotonergic receptors.
Frequency
United States
Estimating frequency of hallucinogenic mushroom use is difficult. Psilocybin-containing mushrooms are popular recreational drugs of abuse.
Mortality/Morbidity
Mortality from hallucinogenic mushrooms is very rare.
Age
While little data exist on the age of users of hallucinogenic mushrooms, college students are known to abuse psilocybin mushrooms.
History
Hallucinogenic mushrooms usually are ingested for their psychoactive properties.
- Mushrooms containing ibotenic acid and muscimol
- Symptoms begin 30 minutes to 1 hour postingestion; however, symptom onset rarely may be delayed as long as 3 hours.
- Hallucinations may be accompanied by dysarthria, ataxia, and muscle cramps and may persist for as long as 8 hours. However, a recent case report describes an otherwise healthy 48-year-old man who accidentally ingested A muscaria mushrooms. He experienced a 5-day paranoid psychosis accompanied by visual and auditory hallucinations. By the sixth day, he had returned to baseline, with no long-term adverse effects reported.
- Central nervous system (CNS) effects range from agitation to coma.
- Heavy intoxication may cause vomiting, diarrhea, and seizures.
- Fatal A pantherina poisonings have been reported in the Pacific Northwest.
- Psilocybin-containing mushrooms
- Alterations in perception begin within 30 minutes and subside after 6 hours.
- Widely varying CNS manifestations, including euphoria, visual and religious hallucinations, and feeling closer to nature have been reported. Visual hallucinations may include perceived motion of stationary objects or surfaces.
- Patients presenting in the ED may experience more unpleasant effects such as fear, agitation, confusion, delirium, psychosis, and schizophrenialike syndromes.
- Symptoms may include nausea and sympathomimetic activity such as mydriasis and tachycardia.
- Symptoms in children include hyperpyrexia and seizures.
Physical
Predominant findings in these intoxications are neurologic.
Fever, tachycardia, and hypotension may occur because of agitation.
- Neurologic findings
- Ataxia
- Incoordination
- Confusion
- Delirium
- Psychosis
Abdominal Trauma, Blunt
Toxicity, Anticholinergic
Toxicity, Hallucinogen
Toxicity, Sympathomimetic
Lab Studies
- Serum levels and urine tests for toxins such as muscarine, muscimol, and psilocybin are available but are rarely helpful or necessary in clinical practice. They are more applicable to forensic investigations.
- Laboratory studies can be helpful in identifying complications of hallucinogenic mushroom abuse, which may include hepatotoxicity with repeated use, acute renal failure, and rhabdomyolysis.
Procedures
- Prepare mushroom specimens, if available, for identification. However, an experienced mycologist rather than a physician should make definitive identification. With hallucinogenic mushrooms, definitive identification seldom is necessary.
- Slice the mushroom stem from the cap very close to the gills and lay the cap on paper with gills down to make a spore print.
- Make prints on black and white paper. These can be sent to the regional poison control center or its designee for analysis. Whole mushrooms can be sent.
- Samples should include, if possible, the deeply rooted portion of fungus as well as cap and gills.
- Do not package samples in plastic because they may decompose rapidly. Place samples in a paper bag with an absorbant, such as a piece of filter paper, to prevent condensation.
- Exact mushroom identification is ascertained in less than 3% of cases.
- The widespread availability of digital cameras now makes it possible to rapidly transmit images of mushroom samples to mycologists by means of the Internet. Although making a definitive identification by this method may not be possible, ruling out certain species may be possible.
Prehospital Care
Prehospital care primarily is supportive with attention to ABCs.
Emergency Department Care
ED care primarily is supportive.
- Consider gastric lavage if ingestion occurred within approximately 1 hour of presentation. However, no data exist to support efficacy in this setting.
- Consider activated charcoal.
- Provide agitated patients with a quiet nonthreatening environment.
- Consider intravenous fluids if signs of volume depletion are present.
- Do not treat fever with antipyretics; fever probably is caused by agitation and increased motor activity.
- Benzodiazepines may be used for sedation and treatment of panic attacks, hallucinations, and seizures.
Consultations
Contact the regional poison center for consultation, referral, and, if necessary, assistance in mushroom identification.
The goal of pharmacotherapy is to reduce morbidity, prevent complications, and neutralize the toxin.
Drug Category: GI decontaminants
These agents are the preferred method when GI decontamination is desired. They are generally mixed and given with a cathartic (eg, 70% sorbitol), except in young pediatric patients in whom electrolyte disturbances may be of concern.
| Drug Name | Activated charcoal (Liqui-Char) |
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| Description | Most useful if administered within 2 h of ingestion. Limited outcome studies exist, especially when administration is >1 h after ingestion. Administration of charcoal by itself (in aqueous solution), as opposed to coadministration with a cathartic, is becoming the current practice standard because no studies have shown benefit from cathartics and, while most drugs and toxins are adsorbed within 30-90 min, laxatives take hours to work. Dangerous fluid and electrolyte shifts have occurred when cathartics are used in small children.
When ingested dose is known, charcoal may be given at 10 times ingested dose of agent over 1 or 2 doses. For maximum effect, administer within 30 min of ingesting poison. |
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| Adult Dose | 1 g/kg PO/NG (50-75 g usual dose)
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| Pediatric Dose | 1 g/kg PO/NG (12.5-25 g usual dose)
<2 years: Cathartic administration not recommended |
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| Contraindications | Documented hypersensitivity; poisoning or overdosage of mineral acids and alkalies; unprotected airway with absent gag reflex |
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| Interactions | May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix with sherbet, milk, or ice cream (decreases adsorptive properties) |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Protect airway prior to administration in patients with absent gag reflex or depressed level of consciousness; when considering repeat dosing, monitor for active bowel sounds to minimize risk |
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Drug Category: Benzodiazepines
These agents prevent seizure recurrence and terminate clinical and electrical seizure activity.
| Drug Name | Diazepam (Valium) |
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| Description | Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.
Individualize dosage and increase cautiously to avoid adverse effects. |
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| Adult Dose | 5-10 mg IV q10-15min until symptoms resolve; not to exceed 30 mg |
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| Pediatric Dose | 30 days to 5 years: 0.2-0.5 mg IV (slowly) q2-5min until symptoms resolve; not to exceed 5 mg
>5 years: 1 mg IV (slowly) q2-5min until symptoms resolve; not to exceed 10 mg |
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| Contraindications | Documented hypersensitivity; hypotension; acute narrow-angle glaucoma |
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| Interactions | Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, H1 blockers, barbiturates, alcohols, and MAOIs |
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| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity) |
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| Drug Name | Lorazepam (Ativan) |
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| Description | DOC for treatment of status epilepticus (persists in CNS longer than diazepam). Rate of injection should not exceed 2 mg/min. May be administered IM if unable to obtain vascular access. |
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| Adult Dose | 0.044 mg/kg (2-4 mg) IV, titrate to effect
Status epilepticus: 4 mg IV over 2-5 min; may repeat second dose in 10-15 min, if needed; not to exceed 8 mg |
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| Pediatric Dose | Children: 0.05 mg/kg IV (range, 0.02-0.1 mg/kg)
Adolescents: Administer as in adults
Status epilepticus:
Neonates: 0.05 mg/kg over 2-5 min; may repeat in 10-15 min, if needed
Infants and children: 0.1 mg/kg over 2-5 min, with second dose of 0.05 mg/kg IV at 10-15 min, if needed; not to exceed 4 mg
Adolescents: 0.7 mg/kg; not to exceed 4 mg, given slowly over 2-5 min, with second dose in 10-15 min, if needed |
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| Contraindications | Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma |
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| Interactions | Alcohol, phenothiazines, barbiturates, and MAOIs increase CNS toxicity |
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| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | Monitor for respiratory depression with high or repeated doses; contains benzyl alcohol, which may be toxic to infants in high doses; caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, Parkinson disease, or patients who may have inhibition of benzodiazepine metabolism and clearance (eg, using nicotine, taking cimetidine) |
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| Drug Name | Midazolam (Versed) |
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| Description | Used as alternative in termination of refractory status epilepticus. Because water soluble, takes approximately 3 times longer than diazepam to peak EEG effects. Thus, clinician must wait 2-3 min to fully evaluate sedative effects before initiating procedure or repeating dose. Has twice the affinity for benzodiazepine receptors than diazepam. May be administered IM if unable to obtain vascular access. |
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| Adult Dose | 0.01-0.05 mg/kg (usually 0.5-4 mg, not to exceed 10 mg) IV given slowly over several min; may repeat q10-15min until adequate response achieved |
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| Pediatric Dose | <32 weeks: 0.5 mcg/kg/min IV infusion
>32 weeks: 1 mcg/kg/min IV infusion
Children: 0.05-0.2 mg/kg IV over 2-3 min, followed by 1-2 mcg/kg/min continuous infusion
Status epilepticus (refractory to standard therapy), >2 months and children: 0.15 mg/kg followed by continuous infusion of 1 mcg/kg/min, titrating dose upward q5min until seizures controlled |
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| Contraindications | Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma; sensitivity to propylene glycol (diluent) |
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| Interactions | Sedative effects may be antagonized by theophyllines; narcotics, cimetidine, ethanol, and erythromycin may accentuate sedative effects because of decreased clearance; reduce dose of thiopental by 15% when using together |
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| Pregnancy | D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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| Precautions | Caution in congestive heart failure, pulmonary disease, renal impairment, hepatic failure, neuromuscular disease, hypotension, and patients >60 y; monitor for respiratory depression with high or repeated doses; consider lower dosages in patients with organic brain syndrome and those who may have inhibition of benzodiazepine metabolism and clearance (eg, using nicotine, taking cimetidine) |
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Further Inpatient Care
- With good supportive care, most patients recover within 6-8 hours and may be discharged from the ED at that time, provided no complicating issues exist and they return to a safe environment.
- Psychiatric consultation and evaluation may be needed for persistent psychotic symptoms.
Complications
- In addition to CNS sequelae, hallucinogenic mushrooms may affect other organ systems. In one case of psilocybin intoxication, an 18-year-old man developed a cardiac dysrhythmia and myocardial infarction. Another case report describes a 25-year-old man who developed rhabdomyolysis and acute renal failure followed by posterior encephalopathy and cortical blindness after ingesting hallucinogenic mushrooms.
Patient Education
- Bickel M, Ditting T, Watz H, Roesler A, Weidauer S, Jacobi V. Severe rhabdomyolysis, acute renal failure and posterior encephalopathy after 'magic mushroom' abuse. Eur J Emerg Med. Dec 2005;12(6):306-8. [Medline].
- Borowiak KS, Ciechanowski K, Waloszczyk P. Psilocybin mushroom (Psilocybe semilanceata) intoxication with myocardial infarction. J Toxicol Clin Toxicol. 1998;36(1-2):47-9. [Medline].
- Brvar M, Mozina M, Bunc M. Prolonged psychosis after Amanita muscaria ingestion. Wien Klin Wochenschr. May 2006;118(9-10):294-7. [Medline].
- Carter OL, Pettigrew JD, Burr DC, et al. Psilocybin impairs high-level but not low-level motion perception. Neuroreport. Aug 26 2004;15(12):1947-51. [Medline].
- Clilton WS. The chemistry and mode of action of mushroom toxins. In: Spoerke DG, Rumack BH, eds. Handbook of Mushroom Poisoning. 2nd ed. CRC Press, LLC; 1994:165-223.
- Fischbein CB, Mueller GM, Leacock PR, et al. Digital imaging: a promising tool for mushroom identification. Acad Emerg Med. Jul 2003;10(7):808-11. [Medline].
- Goldfrank L, Flomenbaum N, Lewin N. Goldfrank's Toxicologic Emergencies. 4th ed. Appleton & Lange; 1990:575-85.
- Hanes KR. Serotonin, psilocybin, and body dysmorphic disorder: a case report. J Clin Psychopharmacol. Apr 1996;16(2):188-9. [Medline].
- Hyde C, Glancy G, Omerod P, et al. Abuse of indigenous psilocybin mushrooms: a new fashion and some psychiatric complications. Br J Psychiatry. Jun 1978;132:602-4. [Medline].
- McDonald A. Mushrooms and madness. Hallucinogenic mushrooms and some psychopharmacological implications. Can J Psychiatry. Nov 1980;25(7):586-94. [Medline].
- McPartland JM, Vilgalys RJ, Cubeta MA. Mushroom poisoning. Am Fam Physician. Apr 1997;55(5):1797-800, 1805-9, 1811-2. [Medline].
- Miller OK. Mushrooms of North America. Dutton; 1982:368.
- Raff E, Halloran PF, Kjellstrand CM. Renal failure after eating "magic" mushrooms. CMAJ. Nov 1 1992;147(9):1339-41. [Medline].
- Riley SC, Blackman G. Between Prohibitions: Patterns and Meanings of Magic Mushroom Use in the UK. Subst Use Misuse. 2008;43(1):55-71. [Medline].
- Rimsza ME, Moses KS. Substance abuse on the college campus. Pediatr Clin North Am. Feb 2005;52(1):307-19, xii. [Medline].
- Satora L, Pach D, Ciszowski K, Winnik L. Panther cap Amanita pantherina poisoning case report and review. Toxicon. Apr 2006;47(5):605-7. [Medline].
- Sticht G, Kaferstein H. Detection of psilocin in body fluids. Forensic Sci Int. Sep 11 2000;113(1-3):403-7. [Medline].
Toxicity, Mushroom - Hallucinogens excerpt Article Last Updated: Jul 9, 2008
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