AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Cortinarius orellanus, the poznan cort mushroom, is one of approximately 10 types of mushrooms that can cause fatal poisonings. Thousands of mushroom species are increasingly studied and collected by amateur mushroom hunters. About 100 of these can cause serious illness, but only a handful cause death.

People become sick after ingesting mushrooms for several reasons. They may have ingested toxin-containing mushrooms or mushrooms causing Antabuse-type reactions to alcohol; they may experience difficulty digesting large amounts of mushrooms or immunologic reactions to mushroom derived antigens.

Cortinarius species that may contain the orellanine toxin include C orellanus, Cortinarius speciosissimus, Cortinarius rainierensis, Cortinarius callisteus, Cortinarius gentilis (deadly cort; in Europe, gentle cort), Cortinarius splendens, Cortinarius cinnamomeus group, and Cortinarius semisanguineus group. The most common of these in North America is probably C gentilis, although C orellanus and C speciosissimus are most often implicated in documented exposures. Presence of C orellanus in North America remains unconfirmed.

Orellanine is the major toxin found in these mushrooms. Orellanine (3,3',4,4'-tetrahydroxy-2,2'-bipyridine-1,1'-dioxide) is a colorless, crystalline, nephrotoxic compound. Orelline is a possibly toxic product of orellanine.

Three other polypeptides have been identified (ie, cortinarin A, cortinarin B, cortinarin C). At least 2 of these appear to be nephrotoxic in experimental animals.

Mushroom identification is beyond the scope of this text, but existence of corts is one of the many reasons not to eat little brown mushrooms (LBMs).

Pathophysiology

Patients with orellanine exposure may experience early symptoms because of other components of the mushroom; orellanine appears to be renal specific. Inhibition of alkaline phosphatase decreases production of adenosine triphosphate and disrupts cellular metabolism. Reaction is specific to cells of proximal tubules and seems to cause almost no reaction in glomeruli. Results are tubulointerstitial nephritis and renal failure, with concomitant symptoms and complications.

Frequency

United States

In 2004, a total of 2,438,644 toxic substance exposures and 1,183 deaths were reported to the American Association of Poison Control Centers' (AAPCC) Toxic Exposure Surveillance System. Mushroom exposures accounted for 8,601 cases and 5 fatalities.¹

• In the same 2004 report, only 3 exposures were attributed to the Cortinarius group; however, since more than 81% of mushroom exposures fell into the unknown mushroom category, Cortinarius exposures certainly may be higher. No deaths were reported in the Cortinarius group, and 2 moderate outcomes were noted; in the unknown group, 1 death and 29 major outcomes were documented.¹
• In 2003, orellanine-containing mushrooms accounted for 3 reported exposures but no deaths.²
• In 2002, orellanine-containing mushrooms accounted for 4 reported exposures but no deaths.³
• In 2001, orellanine-containing mushrooms accounted for 2 reported exposures but no deaths.⁴
• In 2000, orellanine-containing mushrooms accounted for 1 reported exposure but no deaths.⁵
• In 1999, orellanine-containing mushrooms accounted for 2 reported exposures but no deaths.⁶
• In 1998, orellanine-containing mushrooms accounted for 3 reported exposures but no deaths.⁷
• In 1997, orellanine-containing mushrooms accounted for no reported exposures.⁸
• In 1996, orellanine-containing mushrooms accounted for 8 reported exposures but no deaths.⁹
• Unknown mushroom type makes up the majority of exposures each year, usually accounting for well over 80% of mushroom exposures, but deaths in this group remain remarkably low (0-2 per year since 1996).
• Another study published in May 2000 used data from the National Center for Health Statistics and found no difference when compared to AAPCC data in numbers of deaths caused by mushroom exposures.¹⁰

International

No accurate database exists, but mushroom gathering is more common in Eastern and Western Europe than in North America. Most documented cases of orellanine toxicity are from Europe.

Mortality/Morbidity

Few data are available to estimate incidence of orellanine poisoning. Most reported cases of renal failure are from Europe. The AAPCC last reported a recognized Cortinarius exposure with a major effect in outcome category (ie, exposure resulted in life-threatening signs or symptoms or resulted in significant residual disability) in 1999. Since 1999 no outcomes have occurred in the major category and only 3 total in the moderate class (ie, signs or symptoms more pronounced, more prolonged, or more systemic in nature than minor symptoms usually indicating the need for some form of treatment, but the patient had no residual disability).

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

History of exposure is of utmost importance; without it, diagnosing mushroom or orellanine poisoning is unlikely. History of mushroom ingestion may be very remote, particularly with orellanine, since early gastrointestinal symptoms may not be severe enough for patients to seek medical attention. Patients with symptoms of renal failure may not present until 1-3 weeks after exposure. The emergency physician should routinely inquire about mushroom ingestion whenever a patient presents with gastroenteritis. A shorter latent period before onset of illness suggests more severe toxicity and greater risk of more severe renal failure than delayed onset of illness. Improvement in renal injury may occur within several weeks to months; however, renal injury may last months to years and patient may require chronic hemodialysis or renal transplant.

• Important details of ingestion include the following:
  • Time of ingestion and, most importantly, time from ingestion to onset of symptoms (onset typically delayed)
  • Amount ingested
  • If co-ingestion of other types of mushrooms occurred
  • If other people ingested the same mushrooms and, if so, their reactions or symptoms
  • Where the mushrooms were picked
• Gastrointestinal symptoms
• • Nausea and vomiting
  • Abdominal pain
  • Diarrhea or constipation
  • Symptoms are usually mild and observed 24-48 hours postingestion.
• Renal symptoms
• • Flank pain
  • Intense thirst (sometimes described as burning)
  • Polyuria or oliguria
  • Anuria (rare)
  • Acute renal failure may occur anytime from 36 hours to 2 weeks postingestion.
• Systemic symptoms
• • Anorexia
  • Chills
  • Myalgias
  • Dysgeusia
  • Rash
• Neurologic
• • Somnolence
  • Lassitude
  • Headache
  • Paresthesias
  • Tinnitus
  • Seizures (rare)

Physical

Patients with orellanine induced renal failure may have a paucity of findings on physical examination.

• Assess volume status
• • With anorexia and polyuria, volume depletion may be present.
  • With anuric renal failure, volume overload is possible.
• Neurologic
• • With modest degrees of renal dysfunction, mental status may be relatively preserved.
  • With more advanced renal failure, depressed mentation, confusion, or coma may occur.
  • Myoclonus and asterixis suggest uremia in this setting.
• Gastrointestinal: By time of presentation, abdominal symptoms may have resolved.
• Renal: Flank tenderness may be present.
• Other findings: Signs of uremia (eg, pericarditis, pleuritis, volume overload) may be present.

Causes

Risk factors include ingesting mushrooms of the Cortinarius group that contain the renal toxin orellanine. Severity is partially proportional to amount of toxin ingested.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Obtain electrolytes, BUN, creatinine, and glucose levels.
• Administer liver function tests.
• Consider CBC and coagulation studies. Findings may be normal, but anemia may be observed with prolonged renal insufficiency and coagulopathy may complicate uremia.
• Urinalysis
• • Microscopic hematuria and leukocyturia is common.
  • Gross hematuria is rare.
  • Albuminuria may be present.

Other Tests

• A 12-lead electrocardiogram is useful if hyperkalemia or other comorbidities is suspected.
• Assistance by an experienced mycologist is essential for mushroom identification. A regional poison center or local university may be able to assist in this regard. A reference lab may be able to test for orellanine if a food specimen is available.
• • Since a considerable delay between ingestion and presentation (days) usually exists, it is unlikely that gastric specimens will be of any use.
  • Examine for mushroom type or orellanine toxin if any prepared food is still available.
  • It may be possible to have additional mushrooms collected and identified if patient is able to describe area where the mushrooms were foraged.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

Routinely assess, stabilize acute life-threatening conditions, and initiate appropriate therapy.

Emergency Department Care

• Stabilize acute life-threatening conditions with resuscitative measures, including ABCs, coma protocols, and fluid resuscitation.
• Since patients often present days after ingestion, there is little value exists for acute gastrointestinal decontamination measures such as activated charcoal or lavage.
• • Activated charcoal might be of benefit in the event of very recent orellanine mushroom ingestion.
  • Contraindications and cautions include delayed presentation, multiple episodes of emesis, and depressed level of consciousness.
• Correct shock and dehydration.
• Monitor urine output.
• Consider an antiemetic for ongoing nausea and vomiting.
• Seizures occur very rarely but, when present, the drug of choice is a benzodiazepine followed by phenytoin.
• Urgent hemodialysis may be necessary for significant renal failure or electrolyte disturbances.
• • Early hemoperfusion or hemodialysis, soon after ingestion and before any evidence of renal injury, has been advocated. Scant data exist on this early intervention and clinical efficacy is uncertain.

Consultations

• Consult nephrology for urgent hemodialysis, if needed, and for ongoing assistance with inpatient management.
• Consult regional poison control center for assistance in locating a mycologist.
• A toxicology consultation, if available, is useful.
• Expert assistance from a mycologist may be useful in mushroom identification.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Drug Category: GI decontaminant

Empirically used to adsorb toxin in GI tract. A cathartic is used to enhance movement of toxin through the GI tract. However, no evidence indicates that cathartics increase the efficacy of activated charcoal.

Drug Category: Benzodiazepines

Depresses all levels of CNS (eg, limbic formation, reticular formation), possibly by increasing activity of GABA.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Admit all symptomatic patients for further management and observation.
• Intermittent hemodialysis may be necessary if renal failure is severe.

Further Outpatient Care

• Early management of an orellanine exposure without signs of renal injury is undefined. Consider outpatient management only after careful consultation with a toxicologist and/or nephrologist and if close follow-up is possible.

Transfer

• Patient should be in a facility that has nephrology specialists and hemodialysis capability.

Deterrence/Prevention

• General education regarding dangers of foraging for and ingesting unknown mushrooms is important.

Prognosis

• Short latent period before onset of illness and renal injury portents more severe renal insult and prolonged period of renal failure than delayed onset of illness.
• Relatively mild degrees of renal insufficiency may resolve within weeks to months. Some may be treated expectantly without need for hemodialysis. In more severe cases, renal failure can persist months to years requiring chronic hemodialysis or renal transplant.

Patient Education

• For excellent patient education resources, visit eMedicine's Poisoning Center and Poisoning - First Aid and Emergency Center. Also, see eMedicine's patient education articles Poisoning and Activated Charcoal.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider diagnosis
• Failure to elicit history
• Treating for mushroom poisoning when patient has an allergic reaction, bacterial food poisoning, or another basis for acute renal failure
• Being misled by 6-hour symptom timeline. Patient may have consumed 2 or more types of mushrooms and may be ill from one type before the 6-hour mark. Another toxic mushroom such as an orellanine or amanita-containing mushroom also may have been ingested.
• Discharging a patient who appears to have recovered without arranging close follow-up by a regional poison control center or patient's primary care physician

Special Concerns

• Pediatrics: Children are more susceptible to dehydration than adults.
• Geriatrics: Comorbidities in the geriatric group lead to higher susceptibility of dehydration and other complications.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Watson WA, Litovitz TL, Rodgers GC, et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2005;23(5):589-666. [Medline].
2. Watson WA, Litovitz TL, Klein-Schwartz W, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2004;22(5):335-404. [Medline].
3. Watson WA, Litovitz TL, Rodgers GC, et al. 2002 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2003;21(5):353-421. [Medline].
4. Litovitz TL, Klein-Schwartz W, Rodgers GC, et al. 2001 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2002;20(5):391-452. [Medline].
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6. Litovitz TL, Klein-Schwartz W, White S, et al. 1999 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2000;18(5):517-74. [Medline].
7. Litovitz TL, Klein-Schwartz W, Caravati EM, et al. 1998 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1999;17(5):435-87. [Medline].
8. Litovitz TL, Klein-Schwartz W, Dyer KS, et al. 1997 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1998;16(5):443-97. [Medline].
9. Litovitz TL, Smilkstein M, Felberg L, et al. 1996 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1997;15(5):447-500. [Medline].
10. Hoppe-Roberts JM, Lloyd LM, Chyka PA. Poisoning mortality in the United States: comparison of national mortality statistics and poison control center reports. Ann Emerg Med. May 2000;35(5):440-8. [Medline].
11. Haddad LM, Winchester JF. Clinical Management of Poisoning and Drug Overdose. 2^nd ed. WB Saunders; 1990:581-90.
12. Lincoff G, Mitchell DH. Toxic and Hallucinogenic Mushroom Poisoning: A Handbook for Physicians. New York: Van Nostrand Reinhold; 1977.
13. Mitchel DH, Trestrail JH. Poisondex. Micromedex Inc;1997:94.
14. Rumack BH, Spoerke DG. Handbook of Mushroom Poisoning Diagnosis and Treatment. 2^nd ed. CRC Press LLC; 1994.
15. Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine: A Comprehensive Study Guide. 4^th ed. McGraw-Hill; 1996.
16. Yildirim C, Bayraktaroglu Z, Gunay N, Bozkurt S, Köse A, Yilmaz M. The use of therapeutic plasmapheresis in the treatment of poisoned and snake bite victims: an academic emergency department's experiences. J Clin Apher. Dec 2006;21(4):219-23. [Medline].

Article Last Updated: Feb 29, 2008