Author:
Kai Knudsen
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.
Symptoms of fungi poisoning type of toxin and latency for different symptoms
| Mushrooms Name | Latin name | Toxin | Symptoms | Time to symptoms |
|---|---|---|---|---|
| Death cap | Amanita phalloides | Amatoxin, Cyclopeptides | Nausea, dizziness, stomach pain, vomiting, intense waterproof diarrhea, liver and kidney damage, general malaise, fatigue, fever, electrolyte disturbances, tachycardia, lowering of consciousness and blurred consciousness, confusion, anxiety, hyperglycemia, hypotension, bleeding in the intestine and skin | 4 – 24 hours |
| False death cap Citron Amanita | Amanita citrina, Amanita mappa | Cytotoxin | Red and Royal fly agaric: ½-2 hours for neurotoxic symptoms. | |
| Destroying angel | Amanita virosa | |||
| Fly agaric | Amanita muscaria | |||
| Royal fly agaric or the king of Sweden Amanita | Amanita regalis | |||
| Panther cap and false blusher | Amanita pantherina | |||
| Funeral bell Deadly skullcap Deadly Galerina | Galerina marginata | |||
| Brain mushroom Turban fungus | Gyromitra esculenta | Gyromitrin, monomethylhydrazin | Nausea, stomach pain, vomiting, dizziness, fatigue, double vision, diarrhea, liver and kidney damage, hemolysis, seizures | 5 – 8 hours |
| False morel mushroom Sneaky bishop's hat | Gyromitra ambigua | Cytotoxin | ||
| Deadly webcap | Cortinarius rubellus, speciosissimus | Orellanin | Thirst, fatigue, headache, chills, stomach pain, kidney pain, muscle pain (back pain), low urine output (initial polyuria), kidney failure, uremia, nausea, vomiting. May cause permanent kidney damage | 2 – 14 days |
| Fools webcap | Cortinarius orellanus | Cytotoxin | ||
| Certain inocybe genus | Inocybe-arter | Muscarinic (Neurotoxin) | Nausea, vomiting, stomach ache, diarrhea, sweating, anxiety, anxiety, increased saliva and tear flow, miosis, bradycardia, rhinorrhea, bronchitis, bronchial obstruction (mainly increased cholinergic activity), dizziness, headache. | 30 minutes – 2 hours |
| Earthy inocybe | Inocybe geofylla | Muscarinic (Neurotoxin) | 30 minutes – 2 hours | |
| Red-staining inocybe | Inocybe erubescens | Muscarinic (Neurotoxin) | 30 minutes – 2 hours | |
| Top thread (?) | Inocybe fastigiata, Inocybe rimosa | Muscarinic (Neurotoxin) | 30 minutes – 2 hours | |
| Clouded agaric Cloud funnel | Clitocybe nebularis | Muscarinic (Neurotoxin) | 30 minutes – 2 hours | |
| Ivory funnel | Clitocybe dealbata = Clitocybe agrestis | Muscarinic (Neurotoxin) | 30 minutes – 2 hours | |
| Frosty Funnel mushroom | Clitocybe phyllophila | Muscarinic (Neurotoxin) | 30 minutes – 2 hours | |
| Bitter gilled mushrooms | Gymnopilus species | |||
| From gilled mushrooms Family Hymenogastraceae | Hebeloma -species | |||
| Saprotrophic mushrooms | Mycena -liberty cap | |||
| Fly agaric | Amanita muscaria | soxazole; ibotenic acid, muscimol, muscazone, muscarin | Confusion, lowering of consciousness, anxiety, dizziness, affected time and space perception, hallucinations, mydriasis, dry mucous membranes, agitation, palpitations, rarely convulsions, nausea, vomiting, diarrhea (mainly increased anticholinergic activity) | 30 minutes – 2 hours |
| Royal fly agaric or the king of Sweden Amanita | Amanita regalis | Neurotoxic | ||
| Panther cap and false blusher | Amanita pantherina | Neurotoxic | ||
| Liberty cap | Psilocybe semilanceata | Psilocybin, Psilocin | Anxiety, anxiety, confusion, affected time and space perception, feeling of unreality, hallucinations, agitation, psychotic symptoms, tachycardia, palpitations. Usually, the intake of many fungi is required to produce serious symptoms. | 15 minutes – 2 hours |
| Small, black-spored, saprotrophic agarics | Panaeolus-species | Neurotoxic | ||
| Banded mottlegill, Weed Panaeolus or subbs | Panaeolus subbalteatus | Neurotoxic | ||
| Fungal family Strophariaceae | Gymnopilus-species | Neurotoxic | ||
| Pluteus family | Pluteus-species | Neurotoxic | ||
| Knackers Crumpet | Pluteus salicinus | Neurotoxic | ||
| Conocybe-family | Conocybe-species | Neurotoxic Psilocybin, Psilocin | ||
| Yellow-staining mushroom Yellow-stainer | Agaricus xantoderma | Gastrointestinal irritating toxins | Nausea, stomach pain, abdominal cramps, vomiting, diarrhea, anxiety | 2-4 hours |
| Eastern Flat-topped Agaricus | Agaricus placomyces | Eastern Flat-topped Agaricus may cause a so-called paxillus syndrome: an allergic reaction with immunohemolysis and DIC. May cause kidney failure and shock. | ||
| Satan's bolete or Devil's boletus | Boletus satanas | |||
| Lurid bolete | Boletus luridus Suillellus luridus | |||
| Family of terrestrial pink-gilled mushrooms | Entoloma-species | |||
| Livid entoloma, livid agaric, livid pinkgill, leaden entoloma, and lead poisoner | Enteloma sinuatum | |||
| Family Hymenogastraceae | Hebeloma-species | |||
| Milk-caps | Lactarius-species | |||
| Brown roll-rim, common roll-rim, or poison pax | Paxillus involutus | |||
| Some coral fungi Family Gomphaceae | Ramaria-species | |||
| Some brittle gills | Russula-species | |||
| The sickener, emetic russula, or vomiting russula | Russula emetica | |||
| Earth balls | Scleroderma-species | |||
| Some tricholoma species Wood blewit St George's mushroom | Tricholoma-species | |||
| White knight | Tricholoma album | |||
| Ashen knight | Tricholoma virgatum | |||
| Brown knightly mushroom | Tricholoma albobrunneum | |||
| Sulphur tuft, sulfur tuft or clustered woodlover | Hypholoma fasciculare | |||
| Common ink cap or inky cap | Coprinus atramentarius | Coprin (antabuse-like) | At the same time alcohol intake: nausea, headache, sweating, drop in blood pressure, chest pain, shortness of breath, anxiety, anxiety, flushing | 15 minutes – 7 days |
Likelihood of confusion between edible and inedible fungi
| Edible fungi | Feature | May be confused with inedible fungi | Feature |
|---|---|---|---|
| Sheathed woodtuft | Outstanding scales on the foot. Grows in clusters on stumps. | Funeral bell | Clock shaped arched hat. Brown to tan. Beige to light brown discs. |
| Grass-green Russula, the tacky green Russula, or the green Russula | No ring. Arched to widespread hat. White to brownish foot. White meat. | Death Cap | Arched widespread greenish hat. White to green-yellow discs under the hat. White greenish foot. Thin ring. |
| Field mushroom or, in North America, meadow mushroom. | Gray-white or brown discs under the hat. Hemispherical or widespread hat. | Destroying Angel | White discs under the hat. White or yellow-brown hat, sack stocking at the base of the foot. Growing mainly in mossy spruce forest. |
| Yellowfoot, winter mushroom, or Funnel Chanterelle | Thin navel to funnel-shaped hat. The top is yellow-brown to brownish-black. Hollow foot that is brownish to yellow. | Deadly webcap | Maroon to yellowish-brown hat. Usually top hat but can be flattened. Maroon tall and firm foot. Yellow zigzag band on the foot. |
| Chanterelle | Yellow, ridges under the hat, do not have discs. Spicy taste and aroma. Irregular hat edge and ridges on the underside of the hat. Grows in coniferous and deciduous forest. Stuck in the consistency. | False chanterelle | Thin tightly seated real sheets, finely felt hat top. Soft and clever in texture. Thin meat hat, hollow foot. Clear border between hat and foot. |
| Dove-coloured tricholoma | Do not have ring or sock. White to cream white, lateral and sticky when wet. White discs | Destroying angel | White or yellow-brown hat, sack stocking at the base of the foot. White discs under the hat. Growing mainly in mossy spruce forest. |
| Scaly Wood Mushroom, Blushing Wood Mushroom or Pinewood Mushroom | Gray-white or brown discs under the hat. Hemispherical or widespread hat. Characteristic gear band under the ring. | Destroying angel | White or yellow-brown hat, sack stocking at the base of the foot. White discs under the hat. Growing mainly in mossy spruce forest. |
| Parasol mushroom | Dark hat mountains. Brown-watered foot. Beautiful brownish hat. Dense white discs under the hat. | Panther cap | Hat like young hemisphere-shaped, gray-brown to olive brown with white grainy shelf remains (white dots). |
| Turban fungus | Brown hat, crumpled like a brain. The hat edge is rolled into the foot. | Black morel | Beautifully wrapped hat with cavities. Top hat. White grainy foot. |
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.
Antidote at some mushroom poisoning
| Mushrooms Name | First antidote | Second antidote | Third antidote |
|---|---|---|---|
| Destroying Angel | Activated charcoal | Silibinin | N-Acetylcysteine |
| Death Cap | Activated charcoal | Silibinin | N-Acetylcysteine |
| Funeral bell | Activated charcoal | Silibinin | N-Acetylcysteine |
| False morel | Activated charcoal | Pyridoxine | |
| Mushroom-containing fungi (above all the species Inocybe and Clitocybe) | Activated charcoal | 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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