View Abstract

A6933 - Hepatorenal Syndrome Secondary to Mushroom Poisoning
Author Block: V. R. Thakkar1, D. Harrington1, A. Iftikhar2, P. Trivedi1, A. Adial3, J. M. Mann4; 1New York Presbyterian/Queens, Flushing, NY, United States, 2Pulmonary and Critical care, New york Presbyterian Queens, Flushing, NY, United States, 3Pulmonary, New York Presbyterian/Queens, Flushing, NY, United States, 4New York Presbyterian/Queens, Bayside, NY, United States.
Introduction
There are over 5,000 estimated species of mushrooms worldwide, some edible and some poisonous because of the toxins they include. In most cases of mushroom poisoning, it is hard to isolate the type of mushroom because of the difficulty in identifying the mushroom. The severity of mushroom poisoning may depend on the location of where the mushroom grows, the amount of toxin delivered, and the genetic characteristics of the mushroom. In our case, patient presented to the emergency department with a 1-day history of nausea, vomiting, and diarrhea after eating wild mushrooms growing in his backyard.

Case
A 55-year old male with no PMH presented to the ED with 1-day history of nausea, vomiting, and diarrhea. This occurred after eating wild mushrooms growing in his backyard. He previously ate the mushrooms 2 weeks ago but did not have any symptoms. After ingesting the same mushrooms again, he began to have multiple episodes of watery diarrhea, followed by nausea and multiple episodes of non-bloody, non-bilious emesis associated with burning epigastric pain. He denied any alcohol ingestion, Tylenol, or herbal use. LFTs peaked at AST >5250, ALT>6250, INR 1.28. His creatinine was 3.70, with an unknown baseline. Infectious markers were negative. Patient was started on penicillin G, and N-Acetylcysteine (NAC) as per Poison Control recommendations. Overtime his LFTs were resolving but patient was transferred to higher center for a possible liver transplant.

Discussion
Among mushrooms, only 20%–25% have been named and only 3% of these are poisonous. Because of the relatively high number of under reported cases, the exact incidence of mushroom poisoning cannot be precisely estimated; however, amatoxin poisoning is a worldwide problem. In Western Europe, approximately 50–100 fatal cases are reported every year. The "deadly white Amanitas" are most commonly involved in human exposures and fatalities. Liver studies are typically normal in most acute mushroom exposures, but following ingestion of mushrooms containing amatoxin or gyromitrin toxins, liver enzymes begin to rise approximately 24 to 36 hours after ingestion. Thrombocytopenia, coagulopathy, hyperbilirubinemia, or hyperammonemia with encephalopathy are signs of progressive toxicity in such patients. They may also be associated with gastrointestinal bleed, acidosis, hypoglycemia, and renal failure signifying hepatorenal syndrome - markers for poor prognosis. Milk thistle is currently being studied as a treatment for mushroom poisoning. If there is high suspicion for mushroom poisoning, early transfer to a liver transplant center has to be considered.