Author:
Updated:
30 September, 2024
In the Nordic countries, approximately 10,000 different fungi grow in nature, of which only about a hundred are edible. Fungi grow not only in the soil but also on stumps and trees, on plants and other biological organisms, and many other places. The total number of species on Earth is estimated to be over a million. Fungi consist of root threads, a mycelium, and a fruiting body. It is usually the fruiting body that we refer to as a mushroom and is the part that is eaten.
Mushroom Poisoning
Mushroom poisoning usually occurs after ingesting poisonous mushrooms mistaken for edible ones. In rare cases, poisoning may occur in other ways, such as by smoking hallucinogenic mushrooms or inhaling fumes during the boiling of false morels. Some common edible mushrooms include chanterelle, truffle, porcini (Boletus edulis), button mushroom, shiitake (oak mushroom), and oyster mushroom.
It is estimated that 50-200 people in Sweden seek medical attention for suspected mushroom poisoning each year. Severe poisonings are rare, but a few serious cases occur annually. Death is very uncommon and occurs sporadically.
Mushroom poisoning is most common during mushroom season, i.e., in the autumn. However, poisonings can occur year-round, for example, the false morel is a spring mushroom. Chanterelles, sometimes confused with deadly webcap (Cortinarius rubellus), typically grow late in autumn. In the event of poisoning, contact the Poison Information Center for advice. Save the mushrooms for identification by an expert. In recent years, there have been several cases of serious mushroom poisoning among newly arrived immigrants, both in Sweden and other countries like Germany and the USA. Inedible Swedish mushrooms are often mistaken for edible mushrooms from their home countries.
CLASSIFICATION and DIAGNOSIS
Several poisonous mushrooms grow in Sweden, with the most toxic being:
- Destroying Angel (found in coniferous forests, especially spruce. Can be confused with forest button mushrooms)
- Death Cap (grows in oak and beech forests. Can be confused with green brittlegill)
- Deadly Galerina (grows on decayed wood. Can be confused with the ringed honey mushroom)
- Deadly Webcap (grows in mossy spruce forests. Can be confused with funnel chanterelles)
- False Morel (grows in forest clearings, also in sandy soil. Can be confused with the true morel).
Poisonous mushrooms are usually grouped according to the toxins they contain. The main groups of toxins are cytotoxins, neurotoxins, and gastrointestinal irritants (see Table 1).
Cytotoxins
Cytotoxins include the poisonous substances orellanine, amatoxin, and gyromitrin. Cytotoxic mushrooms include false morel, Destroying Angel, Death Cap, Deadly Galerina, and Deadly Webcap. Destroying Angel and Death Cap (amatoxin) are highly toxic and cause several severe poisonings each year, sometimes even fatalities. Deadly Webcap primarily causes kidney damage (orellanine). Amatoxin and orellanine cause cellular damage, especially in the liver, intestines, and kidneys. These mushrooms also contain hemolysins that can cause bleeding in the skin and intestines.
Ingesting cytotoxic mushrooms is usually associated with a longer latency period between ingestion and symptom onset compared to neurotoxic and gastrointestinal-irritating mushrooms. The time between ingestion and the onset of symptoms can provide clues to the type of poisoning. Cytotoxic mushrooms generally have a latency period of 8-24 hours from ingestion to symptom onset. In some cases, the latency period can be longer when symptoms result from organ damage, with symptoms appearing 3-7 days later.
Neurotoxins
Neurotoxins include substances such as muscarine, ibotenic acid, muscimol, muscazone, psilocybin, and psilocin. Neurotoxic substances are found in certain mushrooms, such as funnel caps, thread mushrooms, smooth mushrooms, and fly agaric (red, brown, and panther mushrooms). Among the most well-known neurotoxic mushrooms is the red fly agaric, which contains muscimol, ibotenic acid, muscazone, and muscarine. The toxic funnel mushroom contains muscarine and is also known as poisonous funnel mushroom and meadow funnel mushroom. Red-brown root truffle can cause dizziness, vomiting, and visual hallucinations.
Neurotoxic mushrooms primarily cause central nervous system and sensory symptoms. Muscarine leads to cholinergic symptoms such as increased salivation and bronchial obstruction, while ibotenic acid, muscimol, and muscazone cause anticholinergic symptoms. The latency period from ingestion to symptom onset is shorter for neurotoxins than for cytotoxins, typically ½-2 hours, but sometimes longer. Red and brown fly agaric and panther mushrooms primarily cause symptoms such as heart palpitations, dilated pupils, and nausea. Muscimol and ibotenic acid levels are highest during spring and early summer. Muscarinic mushrooms cause increased sweating, low pulse, and respiratory failure.
Hallucinogenic mushrooms can be used as intoxicants in the same way as narcotic drugs. Most commonly, different smooth mushrooms containing psilocybin or psilocin are used. Some hallucinogenic mushrooms grow naturally in Sweden, such as the red fly agaric and Liberty Cap. Hallucinogenic mushrooms can be purchased online and delivered via regular mail. Some users take mushrooms together with other drugs, such as cannabis, LSD, or ecstasy. Mushroom poisoning can cause acute psychosis with intense hallucinations and aggressive behavior. Case reports describe bizarre elements.
Gastrointestinal Irritants
There are numerous gastrointestinal irritants among mushrooms that primarily cause gastrointestinal symptoms. These are the most common mushroom poisonings. They occur, for example, in livid entoloma (Entoloma sinuatum), poisonous button mushrooms, and false chanterelle. Symptoms mainly consist of nausea, abdominal pain, stomach cramps, vomiting, and diarrhea.
The latency period from ingestion to symptom onset is generally short, 2-4 hours (i.e., much shorter than for cytotoxins), and symptoms usually subside within a day. It is important to note that some neurotoxins also have gastrointestinal-irritating effects, such as muscarine and muscazone.
Other
A few toxins do not fall under any of the three main groups mentioned above. The most important of these is coprine (and coprine-like toxins), which can cause an antabuse-like reaction with flushing, sweating, tachycardia, and blood pressure drop when consumed with alcohol. Coprine is found, for example, in the inky cap mushroom (Coprinus atramentarius).
The oyster mushroom can cause an allergic reaction after repeated ingestion. Consumption of certain Asian mushrooms (Shiitake – Lentinus edodes (Shiitake)) can cause a migrating erythema over the torso and limbs 12 hours to 5 days after ingestion.
Förgiftningssymptom, toxintyp och latenstid för olika giftsvampar
| Svampnamn | Latinskt namn | Toxin | Symtom | Latenstid till symtom |
|---|---|---|---|---|
| Lömsk flugsvamp | Amanita phalloides | Amatoxin, cyklopeptider | Illamående, yrsel, magont, kräkningar, intensiva vattentunna diarréer, lever- och njurskada, allmän sjukdomskänsla, matthet, feber, elektrolytrubbningar, takykardi, medvetandesänkning och grumlat medvetande, förvirring, oro, hyperglykemi, hypotension, blödningar i tarm och hud | 4 – 24 timmar |
| Vitgul flugsvamp | Amanita citrina, Amanita mappa | Cytotoxin | Röd och Brun flugsvamp: ½-2 timmar avseende neurotoxiska symtom. | |
| Vit flugsvamp | Amanita virosa | |||
| Röd flugsvamp | Amanita muscaria | |||
| Brun flugsvamp | Amanita regalis | |||
| Panterflugsvamp | Amanita pantherina | |||
| Gifthätting | Galerina marginata | |||
| Stenmurkla | Gyromitra esculenta | Gyromitrin, monometylhydrazin | Illamående, magont, kräkningar, yrsel, utmattning, dubbelseende, diarré, lever- och njurskada, hemolys, kramper | 5 – 8 timmar |
| Lömsk biskopsmössa | Gyromitra ambigua | Cytotoxin | ||
| Toppig giftspindling | Cortinarius rubellus, speciosissimus | Orellanin | Törst, trötthet, huvudvärk, frossa, magont, njursmärtor, muskelvärk (ryggsmärtor), låg urinproduktion (initialt polyuri), njursvikt, uremi, illamående, kräkningar. Kan ge bestående njurskada | 2 – 14 dygn |
| Orangebrun giftspindling | Cortinarius orellanus | Cytotoxin | ||
| Vissa trådskivlingar | Inocybe-arter | Muskarin (Neurotoxin) | Illamående, kräkningar, magont, diarréer, svettningar, oro, ångest, ökat saliv- och tårflöde, mios, bradykardi, rinorré, bronkorré, bronkobstruktivitet (huvudsakligen ökad kolinerg aktivitet), yrsel, huvudvärk. | 30 minuter – 2 timmar |
| Sidentrådskivling | Inocybe geofylla | Muskarin (Neurotoxin) | 30 minuter – 2 timmar | |
| Gifttråding | Inocybe erubescens | Muskarin (Neurotoxin) | 30 minuter – 2 timmar | |
| Topptråding | Inocybe fastigiata | Muskarin (Neurotoxin) | 30 minuter – 2 timmar | |
| Pudrad trattskivling | Clitocybe nebularis | Muskarin (Neurotoxin) | 30 minuter – 2 timmar | |
| Gifttrattskivling | Clitocybe dealbata = Clitocybe agrestis | Muskarin (Neurotoxin) | 30 minuter – 2 timmar | |
| Lövtrattskivling | Clitocybe phyllophila | Muskarin (Neurotoxin) | 30 minuter – 2 timmar | |
| Vissa bitterskivlingar | Gymnopilus-arter | |||
| Vissa fränskivlingar | Hebeloma-arter | |||
| Vissa hättor | Mycena-arter | |||
| Röd flugsvamp | Amanita muscaria | Isoxazolderivat; ibotensyra, muskimol, muskazon, muskarin | Förvirring, medvetandesänkning, oro, yrsel, påverkad tids- och rumsuppfattning, hallucinationer, mydriasis, torra slemhinnor, agitation, hjärtklappning, i sällsynta fall kramper, illamående, kräkningar, diarré (huvudsakligen ökad antikolinerg aktivitet) | 30 minuter – 2 timmar |
| Brun flugsvamp | Amanita regalis | Neurotoxin | ||
| Panterflugsvamp | Amanita pantherina | Neurotoxin | ||
| Toppslätskivling | Psilocybe semilanceata | Psilocybin, Psilocin | Ångest, oro, förvirring, påverkad tids- och rumsuppfattning, overklighetskänsla, hallucinationer, agitation, psykotiska symtom, takykardi, palpitationer. Krävs vanligen intag av många svampar för att ge allvarliga symtom. | 15 minuter – 2 timmar |
| Vissa brokingar | Panaeolus-arter | Neurotoxin | ||
| Kantbroking | Panaeolus subbalteatus | |||
| Vissa bitterskivlingar | Gymnopilus-arter | |||
| Vissa sköldskivlingar | Pluteus-arter | |||
| Blågrå skölding | Pluteus salicinus | |||
| Vissa hättingar | Conocybe-arter | |||
| Giftchampinjon | Agaricus xantoderma | Mag-tarmirriterande toxiner | Illamående, magont, magkramper, kräkningar, diarré, oro | 2-4 timmar |
| Pärlchampinjon | Agaricus placomyces | Pluggskivling kan ge upphov till ett s k paxillussyndrom: en allergisk reaktion med immunohemolys och DIC. Kan orsaka njursvikt och chock. | ||
| Djävulssopp | Boletus satanas | |||
| Eldsopp | Boletus luridus | |||
| Vissa rödskivlingar | Entoloma-arter | |||
| Bolmörtskivling | Enteloma sinuatum | |||
| Vissa fränskivlingar | Hebeloma-arter | |||
| Vissa riskor | Lactarius-arter | |||
| Pluggskivling | Paxillus involutus | |||
| Vissa fingersvampar | Ramaria-arter | |||
| Vissa kremlor | Russula-arter | |||
| Giftkremla | Russula emetica | |||
| Vissa rottryfflar | Scleroderma-arter | |||
| Vissa musseroner | Tricholoma-arter | |||
| Rättikmusseron | Tricholoma album | |||
| Gallmusseron | Tricholoma virgatum | |||
| Kastanjemusseron | Tricholoma albobrunneum | |||
| Svavelgul slöjskivling | Hypholoma fasciculare | |||
| Grå bläcksvamp | Coprinus atramentarius | Koprin (antabusliknande) | Vid samtidigt alkoholintag: illamående, huvudvärk, svettning, blodtrycksfall, bröstsmärtor, andnöd, ångest, oro, hudrodnad (flush) | 15 minuter – 7 dygn |
Förväxlingsrisk mellan ätliga och oätliga svampar
| Ätlig svamp | Kännetecken | Kan förväxlas med oätlig svamp | Kännetecken |
|---|---|---|---|
| Föränderlig tofsskivling | Utstående fjäll på foten. Växer i klungor på stubbar. | Gifthätting | Klockformad välvd hatt. Brun till gulbrun. Beige till ljusbruna skivor. |
| Grönkremla | Saknar ring. Välvd till utbredd hatt. Vit till brunfläckig fot. Vitt kött. | Lömsk flugsvamp | Välvd utbredd grönaktig hatt. Vita till gröngula skivor under hatten. Vit grönaktig fot. Tunn ring. |
| Ängschampinjon (vit skivling) | Gråvita eller bruna skivor under hatten. Halvklotformad eller utbredd hatt. | Vit flugsvamp | Vita skivor under hatten. Vit eller gulbrun hatt, säcklik strumpa vid basen av foten. Växer främst i mossig granskog. |
| Trattkantarell | Tunn navlad till trattformad hatt. Ovansidan är gulbrun till brunsvart. Ihålig fot som är brungul till gul. | Toppig giftspindling | Rödbrun till gulbrun hatt. Vanligen toppig hatt men kan vara tillplattad. Rödbrun hög och fast fot. Gula sicksackband på foten. |
| Kantarell | Gul, åsar under hatten, har ej skivor. Kryddig smak och doft. Oregelbunden hattkant och åsar på undersidan hatten. Växer i barr- och lövskog. Fast i konsistensen. | Narrkantarell (Falsk kantarell) | Tunna tätt sittande riktiga skivor, fint filtluden hattöversida. Mjuk och sladdrig i konsistensen. Tunnköttig hatt, ihålig fot. Tydlig gräns mellan hatt och fot. |
| Silkesmusseron | Har ej ring eller strumpa. Vit till gräddvit, sidenglänsande och klibbar vid väta. Vita skivor | Vit flugsvamp | Vit eller gulbrun hatt, säcklik strumpa vid basen av foten. Vita skivor under hatten. Växer främst i mossig granskog. |
| Skogschampinjon | Gråvita eller bruna skivor under hatten. Halvklotformad eller utbredd hatt. Karaktäristiskt kugghjulsband under ringen. | Vit flugsvamp | Vit eller gulbrun hatt, säcklik strumpa vid basen av foten. Vita skivor under hatten. Växer främst i mossig granskog. |
| Stolt fjällskivling | Mörka hattfjäll. Brunvattrad fot. Vackert brunfjällig hatt. Täta vita skivor under hatten. | Panterflugsvamp | Hatt som ung halvklotformad, gråbrun till olivbrun med vita grynlika hyllerester (vita prickar). |
| Stenmurkla | Brun hatt, skrynklig liknande en hjärna. Hattkanten är inrullad i foten. | Toppmurkla | Vackert vindlad hatt med håligheter. Toppig hatt. Vit grynig fot. |
Identification
In cases of suspected acute mushroom poisoning, it is crucial to identify the mushroom early. Without in-depth knowledge of mushrooms, expert assistance is usually required for both macroscopic and microscopic identification. Contact details can be obtained from the Poison Information Center in Stockholm or the botanical departments at universities around the country.
Link to: Mushroom Guide with images of various poisonous and edible mushrooms
The medical history is very important in the acute management of mushroom poisoning, especially in terms of mushroom identification and estimating the time between mushroom ingestion and symptom onset. The medical history should extend further back in time; as mentioned above, the latency period for some cytotoxins can be up to 2-3 weeks.
If a group of people has eaten the same dish, but only some have become ill, this does not rule out mushroom poisoning. For example, the deadly webcap is so toxic that a single specimen can make those who ingest pieces sick, while the others remain healthy. The toxin in deadly webcaps, like some other toxins, is heat-stable and withstands both boiling and freezing.
Symptoms of Mushroom Poisoning
- stomach pain
- stomach cramps
- nausea
- vomiting
- diarrhea, often severe, may contain blood
- clouded consciousness, reduced alertness
- heart palpitations
- large pupils
- headache
- general malaise, fatigue
- joint and muscle pain
- anxiety, restlessness
- depression
Cytotoxin
- Mushrooms containing amatoxins cause abdominal pain, nausea, vomiting, and profuse watery diarrhea (cholera-like) 6-12 hours after ingestion. These symptoms usually last up to 24 hours. After 2-3 days, symptoms of liver damage appear, potentially progressing to fulminant liver failure within 3-7 days.
- The latency period in cytotoxic poisonings is longer than for the other toxins, typically 8-24 hours.
- Symptoms can emerge gradually (2 days to several weeks later) due to secondary organ damage with acute liver failure or uremia.
- Poisoning with false morel can cause pyridoxine deficiency with CNS involvement. Mucous membranes, liver, and kidneys may also be affected, and acute hemolysis may occur.
Neurotoxin
- Nausea, intoxication, confusion, euphoria, delirium, hallucinations, excitation, hyperreflexia, and in severe cases, generalized seizures.
- Anxiety, agitation, and depression are common.
- Symptoms/signs from muscarinic effects include; miosis, bradycardia, hyper/hypotension, flushing, sweating, bronchial obstruction, increased salivation, bronchorrhea, and in severe cases, pulmonary edema. Particularly, ingestion of some thread mushrooms and funnel mushrooms (genera Inocybe and Clitocybe), such as the toxic funnel mushroom (= meadow funnel mushroom), can cause this clinical picture.
Gastrointestinal Irritants
- Gastrointestinal symptoms, in severe cases, persistent vomiting and diarrhea.
- Symptoms are often very bothersome but short-lived, usually within 24 hours.
- Hospitalization is rarely necessary if the ingestion of mushrooms containing only gastrointestinal irritants can be confirmed.
- Some toxins, such as the one in livid entoloma, are exclusively gastrointestinal irritants, while others, such as muscarine, are both neurotoxic and gastrointestinal irritants.
- It is important to remember that gastrointestinal symptoms after mushroom ingestion do not always indicate acute mushroom poisoning. Mushrooms are easily contaminated by bacteria and parasites and, like other foodstuffs, can cause food poisoning. Many people fall ill each year after consuming spoiled or improperly prepared edible mushrooms.
Coprine
- Sweating
- Flushing
- Blood pressure drop
TREATMENT
- Identification of the mushroom (call an expert)
- All generally affected patients should be treated in a hospital
- Take Hb, LPK, CRP, platelets, PK/INR, creatinine, liver function tests, and urinalysis. If necessary, administer fluids, such as Ringer’s acetate.
- Adequate fluid replacement, insert at least one IV line, and provide abundant rehydration (2-3 liters of Ringer’s acetate) aiming for good urine output.
- Careful monitoring of fluid balance, electrolyte levels, kidney function, and liver function. Correct electrolyte disturbances.
- Gastric lavage can be performed in the early stages (within 6-8 hours after mushroom ingestion, ideally within one hour). It should not be performed in cases of persistent vomiting.
- Medical charcoal (Carbomix) orally, 50 g x 4 (10-25 g for children) can be given up to 2-3 days after ingesting a poisonous mushroom. Charcoal is administered in repeated doses over a day.
- Silibinin (Legalon Sil, licensed preparation from Madaus/Schering-Plough) is administered in cases of poisoning with Destroying Angel, Death Cap, and Deadly Galerina. Dosage: 20 mg/kg/day for 2 days divided into 4 doses (5 mg silibinin/kg per infusion). The infusion is administered over 2 hours with 4-hour intervals. Silibinin is an extract from the plant Carduus marianus, Milk Thistle or St. Mary’s Thistle (Eng: Milk Thistle).
- Benzylpenicillin (benzylpenicillin) in high doses (5 g x 4) for 3 days in cases of poisoning with Destroying Angel, Death Cap, or Deadly Galerina) if silibinin is not available
- Acetylcysteine (Acetylcysteine) intravenously in cases of poisoning with Death Cap. Inhalation solution acetylcysteine 200 mg/ml is administered slowly intravenously over 1 hour at 150 mg/kg in 200 ml glucose infusion solution 50 mg/ml. Then 50 mg/kg over 4 hours and 100 mg/kg over the next 16 hours (diluted in the same glucose solution as above). A total of 300 mg/kg is administered over 20 hours. There is some scientific support that acetylcysteine should be administered for at least 48 hours in cases of poisoning with amatoxins.
- Antiemetics for nausea, such as Zofran (ondansetron) 4 mg x 1 or Kytril (granisetron) 1 mg x 1
- Benzodiazepines for anxiety or seizures (injection Stesolid (diazepam) 5-10 mg intravenously as needed)
- Atropine (atropine), 1-2 mg intravenously for cholinergic symptoms. Note that typical doses of 0.5-1 mg are often insufficient. Sometimes more than 1-2 mg is required, the symptoms guide the dosage. Avoid atropine in cases of poisoning with isoxazole derivatives .
- Correction of acidosis, buffer with sodium bicarbonate
- In cases of hemolysis, alkalinize the urine with sodium bicarbonate
- Pyridoxine hydrochloride (Pyridoxine) in cases of false morel ingestion. Dosage: 1.5-2 g per day (25 mg/kg) intravenously as a single dose or in two doses, depending on symptoms
- Hemoperfusion (hemodialysis with charcoal filter) or forced diuresis can be considered in the early stages (within 36 hours) in cases of poisoning with Deadly Webcap.
- Treatment of kidney failure.
- Treatment of liver failure, Phytomenadione (Konakion) 10 mg x 2 intravenously. Consider MARS treatment in cases of acute liver failure. Consider liver transplantation in severe cases of liver failure.
Antidotbehandling vid vissa svampförgiftningar
| Svampnamn | Antidot 1 | Antidot 2 | Antidot 3 |
|---|---|---|---|
| Vit flugsvamp | Aktivt kol | Silibinin | alt. Acetylcystein |
| Lömsk flugsvamp | Aktivt kol | Silibinin | Acetylcystein |
| Gifthätting | Aktivt kol | Silibinin | alt. Acetylcystein |
| Stenmurkla | Aktivt kol | Pyridoxin | |
| Muskarinhaltiga svampar (ff a arterna Inocybe och Clitocybe ) | Aktivt kol | Atropin |
Gastric lavage and administration of medical charcoal are the most important initial measures in cases of mushroom poisoning, but they must be given shortly after mushroom ingestion for good effect (please see above for details). Charcoal is non-toxic and safe to drink for those who are not unconscious.
Active antidotes are available for poisoning with Destroying Angel, Death Cap, Deadly Galerina, false morel, and muscarine-containing mushrooms (see Table 2 above).
Silibinin (Legalon Sil) is believed to prevent toxin uptake in liver cells and reduce the risk of liver damage. It may also increase glutathione levels in the liver.
Acetylcysteine should be administered in cases of liver damage following poisoning with amatoxin-containing mushrooms. Side effects include a sensation of warmth and flushing. Benzylpenicillin also reduces the risk of liver damage and should be administered if silibinin is not available in cases of poisoning with Destroying Angel, Death Cap, or Deadly Galerina. Note that high doses of benzylpenicillin can cause generalized seizures. An alternative to benzylpenicillin is cefuroxime. The rest of the treatment is primarily symptomatic.
In cases of poisoning with neurotoxic mushrooms (e.g., psilocybe species), the patient should be cared for in a calm and quiet room. Confusion and other psychiatric symptoms are treated symptomatically with sedatives and neuroleptics, such as olanzapine or droperidol.
Kidney damage from mushroom poisoning often leads to manifest kidney failure with uremia, treated with dialysis or kidney transplantation. Acute liver damage can lead to fulminant liver failure with poor prognosis 3-7 days after ingesting poisonous mushrooms. Fulminant liver cell damage from mushroom poisoning has been treated with acute liver transplantation. Acute liver failure following mushroom poisoning is treated in the usual way, but note the possibility of antidote treatment. Treatment with dialysis and charcoal filters in a MARS system can be tested. Patients with kidney or liver damage following mushroom poisoning should be treated in an intensive care unit.
Death from mushroom poisoning is very rare but does occur, especially among small children, often secondary to acute liver failure.
Follow-up after severe mushroom poisoning should include monitoring liver and kidney function.
ICD-10
- Toxic effect of ingested mushrooms T62.0
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