Acute renal failure following collective intoxication by Cortinarius orellanus

Nephrotoxic Mushroom Poisoning: Global Epidemiology, Clinical Manifestations, and Management

Because mushroom poisonings are increasing worldwide after ingestions of known, newly described, and formerly considered edible species, the objectives of this review are to describe the global epidemiology of nephrotoxic mushroom poisonings, to identify nephrotoxic mushrooms, to present a toxidromic approach to earlier diagnoses of nephrotoxic mushroom poisonings based on the onset of acute renal failure, and to compare the outcomes of renal replacement management strategies. Internet search engines were queried with the keywords to identify scientific articles on nephrotoxic mushroom poisonings and their management during the period of 1957 to the present. Although hepatotoxic, amatoxin-containing mushrooms cause most mushroom poisonings and fatalities, nephrotoxic mushrooms, most commonly Cortinarius species, can cause acute renal insufficiency and failure. Several new species of nephrotoxic mushrooms have been identified, including Amanita proxima and Tricholoma equestre in Europe and Amanita smithiana in the United States and Canada. In addition, the edible, hallucinogenic mushroom Psilocybe cubensis has been noted recently via mass spectrometry as a rare cause of acute renal insufficiency. Renal replacement therapies including hemodialysis are often indicated in the management of nephrotoxic mushroom poisonings, with renal transplantation reserved for extracorporeal treatment failures.

Human Poisoning from Poisonous Higher Fungi: Focus on Analytical Toxicology and Case Reports in Forensic Toxicology

Several families of higher fungi contain mycotoxins that cause serious or even fatal poisoning when consumed by humans. The aim of this review is to inventory, from an analytical point of view, poisoning cases linked with certain significantly toxic mycotoxins: orellanine, α- and β-amanitin, muscarine, ibotenic acid and muscimol, and gyromitrin. Clinicians are calling for the cases to be documented by toxicological analysis. This document is therefore a review of poisoning cases involving these mycotoxins reported in the literature and carries out an inventory of the analytical techniques available for their identification and quantification. It seems indeed that these poisonings are only rarely documented by toxicological analysis, due mainly to a lack of analytical methods in biological matrices. There are many reasons for this issue: the numerous varieties of mushroom involved, mycotoxins with different chemical structures, a lack of knowledge about distribution and metabolism. To sum up, we are faced with (i) obstacles to the documentation and interpretation of fatal (or non-fatal) poisoning cases and (ii) a real need for analytical methods of identifying and quantifying these mycotoxins (and their metabolites) in biological matrices.

Human and experimental toxicology of orellanine

Orellanine is a nephrotoxic toxin produced by some mushroom species of the Cortinarius genus, typically found in Europe and North America. The nephrotoxicity of Cortinarius orellanus is well known and was first recognized in the 1950s when this mushroom was identified as the cause of a mass poisoning in Poland. Typically, onset of symptoms is delayed for 1-2 weeks after ingestion. Some patients suffer mild gastrointestinal discomfort in the latency period before developing signs of renal impairment due to severe interstitial nephritis, acute focal tubular damage, and interstitial fibrosis. There is no specific antidote to orellanine poisoning. The mainstay of treatment is the prevention of secondary complications of kidney failure, adequate dialysis and, in the case of incomplete recovery, management of chronic renal insufficiency. : In this work, we aim to review about Cortinarius species, including epidemiological studies, chemical structure, toxicokinetics, toxic doses, mechanisms of toxicity, diagnosis, prognosis, and treatment options.

Analysis of the mushroom nephrotoxin orellanine and its glucosides

Orellanine is a nephrotoxin found in various Cortinaceae mushroom species. Unintentional consumption after these species were confused with edible mushrooms such as Cantharellus tubaeformis has caused several casualties. In this work, a quantitative HPLC-ESI-MS/MS method for total orellanine in Cortinarius rubellus, spiked blood plasma, and a mushroom stew prepared from C. tubaeformis with the addition of a single specimen of C. rubellus is presented. The existence of mono- and diglucosylated orellanine in C. rubellus was also proven, although quantitative analysis could not be obtained for the glucosides due to rapid hydrolyzation to orellanine in the extract. Extraction with 3 M HCl or water mainly yielded orellanine, while MeOH or acidified MeOH mainly extracted mono- and diglucosylated orellanine. The highest recovery of total orellanine was obtained with 3 M HCl, which was subsequently used for quantitative analysis. A C₁₈ HPLC column and low pH in the eluents retained all these toxins. Orellanine could be detected at a 4.9 ng/mL level in all extracts, which is well below the threshold for acute toxic effects. Additionally, the fragmentation pattern of orellanine upon electrospray MS/MS was probed. The method described is useful for two important applications. First, it allows quantitative analysis of processed food products that may be contaminated by orellanine from Cortinaceae mushrooms. Second, orellanine is currently being evaluated as a potential cure of metastatic renal cancer, and this work provides a method for monitoring orellanine at low concentrations within the therapeutic interval in blood serum.

High-dose antioxidant therapy and steroids might improve the outcome of acute renal failure from intoxication by Cortinarius rubellus: report of two cases

Only a small number of cases with favourable outcome after acute renal failure due to intoxication by Cortinarius sp. have been reported in the literature, and approximately half of the patients develop chronic renal failure and dialysis-dependency. We report the case of a couple with acute renal failure after accidental intake of Cortinarius rubellus and a favourable outcome after treatment with high-dose antioxidant therapy with N-acetylcysteine and steroids. Dialysis was never necessary in both patients and renal function was almost normal at the end of follow-up. Underdiagnosis of this rare cause of acute renal failure is likely due to the fact that affected patients develop symptoms of intoxication after a delay of 2–30 days. In patients with unclear acute renal failure with or without gastrointestinal symptoms, intoxication from Cortinarius sp. should be considered as a differential diagnosis. Early treatment with high-dose antioxidant therapy and steroids might be effective in reducing the risk of chronic renal failure.

Ingestion of a newly described North American mushroom species from Michigan resulting in chronic renal failure: Cortinarius orellanosus

BACKGROUND

Some mushrooms in the genus Cortinarius are well known to cause acute and chronic renal failure. Until now, there have been no confirmed cases of renal failure due to the ingestion of a Cortinarius mushroom in North America. We describe a case of a woman who ingested mushrooms found under an oak tree in western Michigan and developed chronic renal failure.

METHODS

Phylogenetic analysis of the internal transcribed spacer (ITS) regions of nuclear-encoded ribosomal RNA was performed between an unconsumed sample of the Michigan specimens, a control sample of Cortinarius orellanus (JFA9859) from Europe, and other closely related ITS sequences of Cortinarius retrieved from GenBank. An additional gene region, rpb2, was also sequenced for comparison.

RESULTS

Phylogenetic analysis revealed the Michigan material to be closely related to, but distinct from, other ITS sequences of the Orellani clade in Cortinarius. Divergence is less at the rpb2 locus. No historical taxa from North America are known to match the identification of the Michigan material.

CONCLUSION

The mushrooms ingested by the patient were confirmed to be a new species of Cortinarius closely related to C. orellanus. We introduce a newly described North American species, Cortinarius orellanosus, capable of causing renal failure after ingestion.

[End stage renal disease after ingestion of mushrooms]

This case report describes a 56 year old patient with acute renal failure caused by a mushroom poisoning. Unspecific symptoms like a gastroenteritis followed by kidney insuffiency lead to the diagnosis of an orellanus syndrome. The toxin can be proved by thin layer chromatography in renal biopsy. Fast processing of hemoperfusion may avoid lasting kidney damage and dialysis.

Mycotoxins revisited: Part II

Mushrooms are ubiquitous in nature. They are an important source of nutrition, however, certain varieties contain chemicals that can be highly toxic to humans. Industrially cultivated mushrooms are historically very safe, whereas foraging for mushrooms or accidental ingestion of mushrooms in the environment can result in serious illness and death. The emergency department is the most common site of presentation for patients suffering from acute mushroom poisoning. Although recognition can be facilitated by identification of a characteristic toxidrome, the presenting manifestations can be variable and have considerable overlap with more common and generally benign clinical syndromes. The goal of this two-part article is to review the knowledge base on this subject and provide information that will assist the clinician in the early consideration, diagnosis and treatment of mushroom poisoning. Part I reviewed the epidemiology and demographics of mushroom poisoning, the physical characteristics of the most toxic varieties, the classification of the toxic species, and presented an overview of the cyclopeptide-containing mushroom class. Part II is focused on the presentation of the other classes of toxic mushrooms along with an up-to-date review of the most recently identified poisonous varieties.

Syndromic diagnosis and management of confirmed mushroom poisonings

OBJECTIVE

To assess the evolving global epidemiology of mushroom poisoning and to identify new and emerging mushroom poisonings and their treatments, a descriptive analysis and review of the world's salient scientific literature on mushroom poisoning was conducted.

DATA SOURCE

Data sources from observation studies conducted over the period 1959-2002, and describing 28,018 mushroom poisonings since 1951, were collected from case reports, case series, regional descriptive studies, meta-analyses, and laboratory studies of mushroom poisonings and the toxicokinetics of mycotoxins.

STUDY SELECTION

Studies included in the review were selected by a MEDLINE search, 1966-2004, an Ovid OLDMEDLINE search, 1951-1965, and a medical library search for sources published before 1951.

DATA EXTRACTION

To better guide clinicians in establishing diagnoses and implementing therapies, despite confusing ingestion histories, data were extracted to permit an expanded syndromic classification of mushroom poisoning based on presentation timing and target organ systemic toxicity.

DATA SYNTHESIS

The final 14 major syndromes of mushroom poisoning were stratified first by presentation timing and then by target organ systemic toxicity and included early (<6 hrs), late (6-24 hrs), and delayed syndromes (> or =1 day). There were eight early syndromes (four neurotoxic, two gastrointestinal, two allergic); three late syndromes (hepatotoxic, accelerated nephrotoxic, erythromelalgia); and three delayed syndromes (delayed nephrotoxic, delayed neurotoxic, rhabdomyolysis). Four new mushroom poisoning syndromes were classified including accelerated nephrotoxicity (Amanita proxima, Amanita smithiana), rhabdomyolysis (Tricholoma equestre, Russula subnigricans), erythromelalgia (Clitocybe amoenolens, Clitocybe acromelalgia), and delayed neurotoxicity (Hapalopilus rutilans). In addition, data sources were stratified by three chronological time periods with >1,000 confirmed mushroom ingestions reported and tested for any statistically significant secular trends in case fatalities from mushroom ingestions over the entire study period, 1951-2002.

CONCLUSIONS

Since the 1950s, reports of severe and fatal mushroom poisonings have increased worldwide. Clinicians must consider mushroom poisoning in the evaluation of all patients who may be intoxicated by natural substances. Since information on natural exposures is often insufficient and incorrect, a new syndromic classification of mushroom poisoning is recommended to guide clinicians in making earlier diagnoses, especially in cases where only advanced critical care, including organ transplantation, may be life saving.

Mycotoxins revisited: Part I

Mushrooms are ubiquitous in nature. They are an important source of nutrition; however, certain varieties contain chemicals that can be highly toxic to humans. Industrially cultivated mushrooms are historically very safe, but foraging for mushrooms or accidental ingestion of mushrooms in the environment can result in serious illness and death. The emergency department is the most common site of presentation for patients suffering from acute mushroom poisoning. Although recognition can be facilitated by identification of a characteristic toxidrome, the presenting manifestations can be variable and have considerable overlap with more common and generally benign clinical syndromes. The goal of this two-part article is to review the knowledge base on this subject and provide information that will assist the clinician in the early consideration, diagnosis and treatment of mushroom poisoning. Part I, presented in this issue of the Journal, reviews the epidemiology and demographics of mushroom poisoning, the physical characteristics of the most toxic varieties, the classification of the toxic species, and an overview of the cyclopeptide-containing mushroom class. Part II, to be published in the next issue of the Journal, will be focused on the presentation of the other classes of toxic mushrooms along with an up-to-date review of the most recently identified poisonous varieties.

Treatment of intoxication with Cortinarius speciosissimus using an antioxidant therapy

The authors present the case reports of a 30-year-old man and his 29-year-old wife who ingested a mushroom meal containing Cortinarius speciosissimus. Features of this intoxication include gastrointestinal symptoms such as nausea, vomiting, and diarrhea as well as back pain. The toxin orellanine is nephrotoxic and can lead to acute renal failure. A long symptom-free interval of 2 to 21 days is characteristic of this poisoning. The diagnosis can be made by mycologic testing or by toxicologic analysis of a renal biopsy specimen. Reported therapeutic options include hemodialysis, plasmapheresis, or drug therapy with corticosteroids, all of which have yielded variable results. Here the authors report the use of antioxidant therapy in 2 patients with acute renal failure caused by Cortinarius speciosissimus intoxication.

The risk for mild kidney function decline associated with illicit drug use among hypertensive men

BACKGROUND

Few studies have examined the deleterious effect of illicit drug use on kidney function.

METHODS

Six hundred forty-seven patients enrolled in the Hypertension Clinic of the Veterans Administration Medical Center of New Orleans, LA, were interviewed regarding illicit drug use and followed up for a median of 7 years to determine the incidence of mild kidney function decline (increase in serum creatinine level > or = 0.6 mg/dL [> or =53.0 micromol/L]) between 1977 and 1999.

RESULTS

Twenty-three percent of study participants reported the use of illicit drugs: 22.7%, marijuana; 6.7%, cocaine or crack; 9.3%, amphetamines; 3.1%, psychedelics; and 4.3%, heroin. After adjustment for age, race, education, income, smoking, alcohol consumption, systolic blood pressure, use of antihypertensive medications, body mass index, and history of diabetes and dyslipidemia, relative risk for mild kidney function decline associated with any drug use was 2.3 (95% confidence interval, 1.0 to 5.1). After similar adjustments, risks for mild kidney function decline were 3.0 (95% confidence interval, 1.1 to 8.0) and 3.9 (95% confidence interval, 1.1 to 14.4) times greater among persons who had used cocaine and psychedelics, respectively. Use of marijuana, amphetamines, heroin, and other drugs was associated with elevated, but not statistically significant, risks for mild kidney function decline.

CONCLUSION

Our study documented a significant, positive, and independent association between illicit drug use and risk for mild kidney function decline. This finding indicates that interventions aimed at helping patients discontinue illicit drug use and maintain a drug-free lifestyle may have an important role in delaying and/or preventing the onset of kidney disease in hypertensive men.

Cytotoxic fungi—an overview

Among fungal toxins causing organ damage in the human body, amatoxins and orellanine remain exceptional. Amatoxins, a group of bicyclic octapeptides occurring in some Amanita, Galerina and Lepiota species, induce deficient protein synthesis resulting in cell death, but might also exert toxicity through inducing apoptosis. Target organs are intestinal mucosa, liver and kidneys. Poisoning will result in dehydration and electrolyte derangement, liver necrosis and possibly kidney damage. In established poisoning the mainstay of treatment is optimum symptomatic and supportive care. No specific treatment is available, but some pharmaceuticals, like silibinin, benzylpenicillin and acetylcysteine, might have a role in limiting the extent of hepatic damage. Orellanine is a nephrotoxic bipyridine N-oxide found in some Cortinarius species. Its mechanism of action is not fully understood, but it has been shown to inhibit protein synthesis and to generate free oxygen radicals. As early symptoms often are lacking or vague, poisoning may initially be overlooked or misinterpreted and the patients usually present with established renal damage. Supportive care is the only therapeutic option. Tricholoma equestre might contain a myotoxin and repeated ingestion may cause significant rhabdomyolysis. Ingestion of Amanita smithiana and A. proxima has been reported to result in kidney damage. Gyromitrin, a toxic compound that is converted to hydrazines in the stomach, occurs in some Gyromitra species. It is mainly neurotoxic, but may also induce moderate hepatic damage and haemolysis.

Main features of Cortinarius spp. poisoning: a literature review

INTRODUCTION

Cortinarius spp. poisoning is characterized by a delayed acute renal failure. The main features of this severe poisoning are still poorly known and often overlooked. The aim of this literature review is a better description of Cortinarius spp. poisoning.

MATERIALS AND METHODS

The main medical databases were searched: Abstracts of Mycology, Current Contents, Medline, Pascal, Micromedex Poisindex, Toxicology abstracts, Toxline. All case reports that included a description of the clinical features of Cortinarius spp. poisoning were studied.

RESULTS

245 cases were collected and 90 cases could be analyzed in details. Gastrointestinal disorders are the main symptoms of the prerenal phase of the poisoning. They appear a few days after the ingestion of the mushrooms (median 3 days). The renal phase is delayed (median 8.5 days). Moderate and transient hepatic abnormalities have been reported. A severe hepatic failure can be ruled out. Muscular lesions are highly questionable. Treatment is supportive. No specific treatment can be recommended. Acute renal failure progressed towards chronic renal failure in half of the cases; intermittent hemodialysis or kidney transplantations were necessary in 70% of those cases.

CONCLUSION

Cortinarius spp. poisoning is severe. Ingestion of Cortinarius species must be systematically suspected whenever tubulo-interstitial nephritis is diagnosed, especially as mushrooms may have been ingested 1-2 weeks before.

End-stage renal failure from mushroom poisoning with Cortinarius orellanus: report of four cases and review of the literature

Mushrooms of the ubiquitous Cortinarius species (Cs) contain nephrotoxins that can cause acute and chronic renal failure by an unknown pathomechanism. Typical is a long symptom-free interval before the onset of clinical disease. A causal form of therapy is not known. Early hemodialysis can improve the prognosis of this potentially life-threatening condition. Diagnosis of Cs poisoning can be made by detecting the responsible toxin--orellanine--in plasma or renal tissue by fluorimetry after thin-layer chromatography or by identifying the spores of left-over mushrooms as Cs. Renal histology shows nonspecific changes such as tubular dilatation and flattening of the epithelium and signs of interstitial edema followed by interstitial fibrosis. We present four cases of Cs poisoning with different outcomes and a review of the literature.

Renal failure caused by mushroom poisoning

BACKGROUND

In the Pacific Northwest region of the US and in southwestern British Columbia, Canada, isolated cases of renal failure have occurred following ingestion of wild mushrooms. We report four cases in which toxic mushrooms were mistaken for the edible pine mushroom or matsutake (Tricholoma magnivelare).

CASE REPORTS

Gastrointestinal symptoms started five to eight hours after ingestion and continued for several days. Three of the four patients were found to be in renal failure when they presented to the emergency department 5-6 days post ingestion. One patient, an elderly diabetic, had renal dysfunction the day following ingestion. All patients received hemodialysis and supportive care and regained renal function.

DISCUSSION

Symptoms and time of onset are similar to those reported in previous cases of Amanita smithiana poisoning. This suggests that the mushroom involved in these cases may also be Amanita smithiana which contains nephrotoxic compounds. In one of the cases, stem ends of the mushrooms were available for examination. Cellular elements conforming to those described as being present in the species Amanita smithiana were seen on light microscopy.

CONCLUSION

Mushroom field guides warn against mistaking Amanita smithiana for pine mushrooms. They are similar in size, color and habitat. It appears possible that Amanita smithiana mushrooms were eaten instead of pine mushrooms in these cases.

Liver transplantation after severe poisoning due to amatoxin-containing Lepiota--report of three cases

Four cases of severe Lepiota poisoning, including three which developed toxic fulminant hepatitis treated by orthotopic hepatic transplantation, are reported here. The toxicity of the Lepiota is discussed as well as the indications for hepatic transplantation in poisonings due to amatoxin-containing mushrooms.

Clinical symptomatology and management of mushroom poisoning

Among poisonous mushrooms, a small number may cause serious intoxication and even fatalities in man. Humans may become symptomatic after a mushroom meal for rather different reasons: (1) ingestion of mushrooms containing toxins, (2) large amounts of mushrooms may be hard to digest, (3) immunological reactions to mushroom-derived antigens, (4) ingestion of mushrooms causing ethanol intolerance, and (5) vegetative symptoms may occur whenever a patient realizes that there might be a possibility of ingestion of a toxic mushroom after a mushroom meal. Based on the classes of toxins and their clinical symptoms, seven different types of mushroom poisoning can be distinguished: (1) phalloides, (2) orellanus, (3) gyromitra, (4) muscarine, (5) pantherina, (6) psilocybin, and (7) gastrointestinal mushroom syndrome. Two other entities of adverse reactions to mushrooms are (8) coprinus and (9) paxillus syndrome. Phalloides, orellanus, gyromitra and paxillus syndrome may lead to serious poisoning, which generally requires treatment of the patient in an intensive care unit. Diagnosis of mushroom poisoning is primarily based on anamnestic data, identification of mushrooms from leftovers of the mushroom meal, spore analysis, and/or chemical analysis. Therapeutic strategies include primary detoxification by induced emesis, gastric lavage and activated charcoal, secondary detoxification, symptomatic treatment and rarely specific antidotes. Owing to progressing fulminant hepatic failure, lethality associated with phalloides syndrome is still high (5-20%). Basic treatment includes administration of silibinin and penicillin G, although controlled studies on its therapeutic efficacy are still lacking. In serious phalloides syndrome, orthotopic liver transplantation has to be considered. Fortunately, the prognosis in most other mushroom poisonings is excellent.