Amanita phalloides 23.May.2022-Expires: 7 days - Do not archive IDENTIFICATION Correct identification of the mushroom/s is imperative for optimal risk assessment. Consider and enquire about the possibility that more than one type of mushroom was ingested. If the identity is uncertain, or the patient’s signs and symptoms differ from those listed, or are delayed in onset, seek advice from a reliable source such as your local Poisons Information Center.   Further information on unidentified mushrooms can also be found by following the below link:   Unknown Mushroom Ingestion.   FAMILY NAME Amanitaceae   GENUS NAME Amanita   SPECIES NAME Amanita phalloides   COMMON NAME(S) Amanite phalloide Deadly amanita Death cap Death cap mushroom Deathcap amanita Deathcap mushroom Green death cap Oronge verte Stinking amanita   IMAGE Click here for full-size image   To search for more images, please click on the following link that will take you to Google Images. The content of this site is not controlled by TOXINZ and care should be used when assessing this information.   Google Images   HABITAT Amanita phalloides occurs mainly in deciduous and mixed deciduous forests, especially under oak trees but also near hornbeam or beech. The fungus avoids colder localities.[1]   USES This mushroom is poisonous, however it may be mistaken for other edible mushrooms. INTERVENTION CRITERIA Intervention Level Child and Adult Medical assessment, observation, and, if appropriate, decontamination, is recommended for: - Any ingestion of a cyclopeptide mushroom - Exposures with intent to self-harm   Observation Period Observation at Home All patients require medical attention.   Medical Observation Any patient known to have ingested this type of mushroom must be admitted for monitoring and treatment, certainly those with symptoms or deranged biochemistry.   Investigations If it is suspected that the patient has ingested cyclopeptide mushrooms, every effort should be made to get the mushroom identified by a mycologist. When possible, a sample of the mushroom should be collected for identification. A whole mushroom, including the stalk and its base is preferable. The sample should be placed in a paper (not plastic) bag and then put in a sturdy container to protect the mushroom from damage. If the mushroom needs to be stored, it should be placed in the refrigerator, not the freezer.   Diagnostic Tests Wieland (Meixner) Test:[2]   Determines presence of amatoxin Methods - Perform indoors away from sunlight and excessive heat - Squeeze a small drop of fungus juice onto a piece of pulp paper i.e. newspaper, phone book page - Encircle wet stop with pencil to mark location - Dry the spot with warm air - Add a drop of concentrated hydrochloric acid to the dry spot The presence of amatoxins is indicated by the formation of a blue color   False positives - Use a control without amatoxins so false positives can be identified - A false positive reaction can occur at high temperatures or exposure to sunlight - Psilocybin, bufotenine, and certain terpines can give false positives[3][4]   This test is limited but can be helpful in the rapid testing in cases of suspected cyclopeptide poisoning.   Admission Criteria Any patient who has ingested cyclopeptide mushrooms must be admitted.   Furthermore, any patient who has ingested an unknown mushroom but has features or biochemical changes indicative of cyclopeptide poisoning must be admitted.   The admission hospital will require the following resources: Specific antidotes Advanced care/ICU Enhanced elimination   TREATMENT TREATMENT SUMMARY Any patient suspected of ingesting cyclopeptide-containing mushrooms should be admitted to hospital. Initial management consists of vigorous monitoring and replacement of expected fluid losses, which may be several liters per day.[5] Along with fluid replacement correction of metabolic disturbances such as acidosis, hypoglycemia, and electrolyte imbalances should be undertaken. The patient should be hemodynamically monitored and biochemical parameters followed closely.   Due to the low oral bioavailability of cyclopeptide mushrooms and the difficulty humans have in digesting large amounts of mushrooms, single dose activated charcoal may be given up to 12 hours following ingestion.[6][7] The use of multiple dose activated charcoal in the enhanced elimination of amatoxins is indicated up to 48 hours post-ingestion due to the extensive enterohepatic circulation of these toxins.[8] It is important that a good renal output is established during the first 48 hours following ingestion.   Supportive care is the mainstay of management. Although there is no clinically proven antidote for cyclopeptide mushroom poisoning, common therapies used have included silibinin, N-Acetylcysteine, benzylpenicillin, thioctic acid, and steroids. None of the antidotes used have undergone randomized, prospective clinical trials. Silibinin and N-Acetylcysteine appear to be the treatments of choice and should be considered in the management of these poisonings.[9][10][11][12] Efficacy has not been shown for the other therapies.[10] Benzylpenicillin, thioctic acid, and steroids are no longer recommended.[10]   Use of sedating drugs is not recommended due to their impact on the assessment of mental function/encephalopathy. Acute hepatic failure is a well-recognized concern and transplantation may be required.[13][14]   Advice should be sought from a specialist liver transplant unit if: The International Normalized Ratio (INR) is greater or equal to 2 at 24 hours or, 3 at any time or Creatinine is greater or equal to 200 umol/L (2.2 mg/dL) or pH is less than or equal to 7.3 or bicarbonate less than or equal to 18 mmol/L (18 mEq/L) or Blood pressure is low after volume loading (mean arterial pressure less than or equal to 60 mmHg) or The patient becomes encephalopathic   Early discussion of patients with a liver transplant unit is essential. Advice may be given and a decision to transport dependent upon results. In general it is considered desirable to transport patients prior to development of grade 2 encephalopathy.   Emergency Stabilization Ensure adequate cardiorespiratory function Correct hypovolemia Decontamination Ingestion Single dose activated charcoal Antidote(s) Silibinin Acetylcysteine Enhanced Elimination Maintain good renal output Multiple dose activated charcoal Supportive Care Monitoring Gastrointestinal Gastrointestinal irritation Cardiovascular Hypovolemia Hepatic Acute hepatic failure Renal Acute kidney injury Metabolic Metabolic acidosis Hypoglycemia Fluid and electrolytes Electrolyte abnormalities Hematologic Coagulopathy Neurologic Seizure EMERGENCY STABILIZATION Ensure Adequate Cardiopulmonary Function Correct Hypovolemia Immediately establish secure intravenous access.   Profound hypotension may occur requiring volume replacement. CHILD Hypotension in children is determined by age and systolic blood pressure   Age Hypotension if Systolic Blood Pressure (mm Hg) is: 0 to 28 days < 60 1 to 12 months < 70 1 to 10 years < 70 + (age in years x 2) > 10 years < 90   Administer an isotonic crystalloid fluid 10 mL/kg IV over 5 to 10 minutes   If the systolic blood pressure does not return to the normal range, give a further 10 mL/kg body weight of the isotonic crystalloid over 5 to 10 minutes.   The intraosseous route can be used if IV access is difficult or delayed.   ADULT Administer a bolus of isotonic crystalloid fluid if systolic blood pressure is less than 100 mmHg.   Isotonic crystalloid fluid dose: 20 mL/kg IV over 5 to 10 minutes   If the systolic blood pressure does not return to the normal range, give a further 10 mL/kg body weight normal saline over 5 to 10 minutes.   The intraosseous route can be used if IV access is difficult or delayed.   Emergency Monitoring Seizure activity Blood pressure Heart rate ECG Fluid balance Serum electrolytes Renal function Liver function   DECONTAMINATION Ingestion Single Dose Activated Charcoal Administer activated charcoal up to 12 hours following a potentially toxic ingestion.   Single dose activated charcoal[15] CHILD 1 to 2 g/kg orally ADULT 50 to 100 g orally   ANTIDOTE(S) Silibinin Animal studies have shown that silibinin (Milk thistle) prevents the uptake of amatoxins by hepatocytes, reducing enterohepatic circulation and therefore enhancing renal elimination. Furthermore, silibinin stimulates DNA-dependent RNA polymerases, leading to an increase in RNA synthesis.[16] However, controlled human studies are still pending. Unfortunately, silibinin is not widely available.   Indications Silibinin is indicated in:[17] All patients presenting with cyclopeptide mushroom ingestion   Dose and Administration Silibinin dose:[18][19]   CHILD IV Initial dose 5 mg/kg IV over 1 hour Maintenance dose of 20 mg/kg as a continuous infusion   ADULT IV Initial dose 5 mg/kg IV over 1 hour Maintenance dose of 20 mg/kg as a continuous infusion   Treatment should be continued for up to 72 hours, or until significant declines in INR and liver function tests are apparent.   Precautions Documented hypersensitivity to silibinin. Pregnancy Recommended doses could be administered during pregnancy without being harmful to the fetus.[20]   Adverse Effects Silibinin appears to be well tolerated. However the following adverse effects have been reported following administration:[21][10] Gastrointestinal upset (nausea, vomiting, diarrhea, abdominal pain) Intermittent episodes of sweating Arthralgia Pruritus Headache Urticaria Weakness   Acetylcysteine Animal studies indicate that sublethal doses of amatoxins deplete hepatic glutathione content.[22] N-acetylcysteine is thought to serve as a glutathione precursor and consequently, the administration of N-acetylcysteine in cyclopeptide mushroom poisoning may prevent reduced glutathione levels and subsequent hepatocellular damage.[11][23] Additionally N-acetylcysteine has been shown to reduce morbidity and mortally in severe hepatic failure irrespective of origin.[24] It is therefore recommended in cyclopeptide mushroom poisoning.   Indications N-acetylcysteine should be administered in:[20] All patients presenting with cyclopeptide mushroom ingestion   Dose and Administration While acetylcysteine is recommended to be administered intravenously in 5% dextrose in water, 1/2 normal (0.45%) saline or normal saline (0.9%) may be substituted if necessary.[25] In children there is a risk of hyponatremia with 5% dextrose alone[26] and therefore normal (0.9%) saline should be used.   CHILD[27]   It is recommended that acetylcysteine dose for children be calculated for actual body weight.   Children < 14 years old: 200 mg/kg in 7 mL/kg (up to 500 mL) of normal saline over 4 hours Followed by 100 mg/kg in 14 mL/kg (up to 1,000 mL) of normal saline over 16 hours   Children 14 years and older: As per adults   Closely monitor fluid and electrolyte balance.   ADULT[28][29][27]   It is recommended that acetylcysteine dose for adults be calculated for actual body weight rounded up to the nearest 10 kg with a ceiling weight of 110 kg.   Administer: 200 mg/kg in 500 mL of 5% dextrose over 4 hours Followed by 100 mg/kg in 1,000 mL of 5% dextrose over 16 hours   Link to acetylcysteine dosing table for adults.   Precautions Pregnancy Acetylcysteine should be administered to pregnant patients following the standard adult regimen. Transplacental transport of acetylcysteine is not thought to be clinically significant,[30] however, delay in initiation of acetylcysteine treatment is associated with increased incidence of spontaneous abortion and fetal death.[31] Acetylcysteine is not considered teratogenic.[32]   Adverse Effects Anaphylactoid Reaction Six to 23% of patients receiving IV acetylcysteine develop an anaphylactoid reaction.[33][34] These do not represent an immunological (allergic) reaction; rather, they are thought due to a direct dose-dependent effect on histamine release and generally occur within the first two hours of an infusion.   History of previous anaphylactoid reaction to acetylcysteine does not contraindicate use. If there is concern of recurrence of the reaction the patient may be pre-treated 15 minutes before commencement of the infusion with an antihistamine.[35]   Effects range from mild flushing to urticaria, angioedema, or bronchospasm. Hypotension may occasionally occur. Asthmatics appear more at risk. However, effects are usually easily managed and there is no reason to withhold acetylcysteine from any patient when indicated.[35]   Management recommendations for acetylcysteine induced anaphylactoid reaction   Hyponatremia Hyponatremia has been reported in children if administered acetylcysteine in 5% dextrose following adult protocols for dilution of infused dose.[26]   ENHANCED ELIMINATION Maintain Good Urine Output  Significant amounts of amatoxins are eliminated in the urine,[16] especially during the 48 hours following ingestion.[6] Therefore, maintenance of a good urine output (~200 mL/h) should be ensued, particularly during the first 48 hours.[9] Forced diuresis with a loop diuretic does not increase amatoxin excretion and should be avoided.[10]   Multiple Dose Activated Charcoal Multiple dose activated charcoal should be administered within 48 hours of ingestion to remove any unabsorbed material and to interrupt the enterohepatic circulation of amatoxins.[6][8][12][36] Amatoxins are easily absorbed though the intestinal tract and rapid hepatic uptake occurs via the bile salt transport system. Approximately 60% if the absorbed dose is excreted into the bile, returning to the liver via enterohepatic circulation.[37]   Multiple dose activated charcoal dose CHILD 0.5 to 1 g/kg bolus/every 2 to 4 hours ADULT 25 to 50 g bolus/every 2 to 4 hours   Administer orally or via nasogastric tube and continue until signs of clinical and biochemical improvement.[38] Charcoal should not be administered to a patient with ileus or bowel obstruction.   Other Forms of Enhanced Elimination Other forms of enhanced elimination including plasmapheresis,[39] peritoneal dialysis,[40] hemodialysis,[41] and hemoperfusion[42][43] have occasionally yielded success but the results are inconsistent.[44] No prospective clinical trial comparing groups of patient treated with and without elimination techniques has been reported and overall these methods are generally no longer recommended.[9] However, hemoperfusion may be of some benefit for patients with pre existing renal disease or if initiated early (within 24 hours) following poisoning.[9][45][42] Hemodialysis should be instituted if renal failure occurs.   SUPPORTIVE CARE Monitoring Cardiac function including: Blood pressure Heart rate 12 lead ECG Renal function including: Serum urea Serum creatinine Renal output Serum electrolytes including: Sodium Potassium Calcium Liver function tests including: ALT AST INR Serum bilirubin Urinary urobilinogen Full blood count including: Prothrombin time Fibrinogen Intracranial pressure Blood gas analysis Blood glucose   Gastrointestinal Gastrointestinal Irritation The amatoxins of cyclopeptide mushrooms target cells with high mitotic indices such as the gastrointestinal mucosa. Symptoms include abdominal pain, nausea, vomiting, and cholera-like diarrhea.[46] Patients will require robust supportive care including IV fluids, electrolyte replacement, and antiemetics.[36][17] In the absence of fluid replacement vomiting and diarrhea may induce rapid dehydration, hemoconcentration, and hypovolemic shock.[47]   Observe patient for: Nausea Vomiting Abdominal pain Hematemesis Diarrhea   Monitor: Blood pressure Fluid balance Serum electrolytes (if severe GI symptoms) Acid-base balance (if severe GI symptoms)   Manage gastrointestinal irritation following standard treatment protocols.   Cardiovascular Hypovolemia Hypovolemia may occur due to the large fluid and electrolyte losses that occur as a result of significant vomiting and diarrhea exhibited in the initial gastrointestinal stage of cyclopeptide poisoning. Correction of fluid and electrolyte abnormalities is mandatory.[48]   Monitor: Blood pressure Renal output Renal function   Manage hypovolemia following standard treatment protocols. Hepatic Acute Hepatic Failure Cyclopeptide mushrooms contain amatoxins, liver toxins that cause liver necrosis with acute hepatic failure and subsequent complications, including hepatic coma, coagulation disorders, and renal failure.[9] Clinical signs of hepatocellular damage usually develop on the third to fourth day after ingestion. Clinical presentation may only include a mild jaundice and hepatomegaly.[46] Elevated liver enzyme levels and elevated bilirubin are common.[17] In severe cases, hepatitis follows a fulminant course with marked jaundice and hepatic coma accompanied by renal failure and cardiovascular collapse.[49]   Liver transplants have become a well established option in the treatment of liver failure due to amatoxins.[50] Advice should be sought from a liver transplant unit if the International Normalized Ratio (INR) is greater or equal to 2 at 24 hours or 3 at any time; or, if the patient becomes encephalopathic.   Monitor: Hepatic enzymes International normalized ratio (INR) Serum bilirubin Plasma glucose Serum pH Serum electrolytes Serum creatinine Serum urea   Manage acute hepatic failure following standard treatment protocols.   Renal Acute Kidney Injury Two kinds of renal failure may be observed following cyclopeptide mushroom ingestion. During the gastrointestinal phase of poisoning, a functional renal failure is frequent.[51] It is associated with hypovolemia and is secondary to fluid losses and hypoperfusion of the kidneys. Rapid and aggressive treatment of dehydration and hypovolemia should reverse this form of renal failure.   The second kind of renal failure may arise during the hepatorenal phase of poisoning, either occurring secondary to severe hepatitis[52] or to direct toxic renal damage.[9] Renal failure occurring in this phase usually resolves as hepatic function improves but may require hemodialysis as a supportive measure.   Patients should be monitored for the onset of acute kidney injury: Urine output Serum creatinine Blood urea nitrogen (urea) Proteinuria   Manage acute kidney injury following standard treatment protocols.   Metabolic Metabolic Acidosis During the initial gastrointestinal phase of cyclopeptide mushroom poisoning, metabolic acidosis may occur due to fluid and electrolyte imbalances, particularly large losses of sodium bicarbonate. In contrast, metabolic acidosis in the late stages of cyclopeptide mushroom poisoning is typically a consequence of hepatic failure and should be treated as such.[51]   Monitor: Blood gases Plasma lactate   Manage metabolic acidosis following standard treatment protocols.   Hypoglycemia In severe hepatic failure, glucose metabolism is often disturbed resulting in hypoglycemia.[53] Patients with evidence of hepatic dysfunction should be monitored for hypoglycemia.   Monitor serum glucose.   Manage hypoglycemia following standard treatment protocols.   Fluid and Electrolytes Electrolyte Abnormalities The gastrointestinal phase of cyclopeptide mushroom poisoning often results in dehydration with electrolyte imbalance, including hypokalemia, hyponatremia, and hypochloremia.[51] Electrolyte replacement, either oral or parenteral, should be guided by symptomatology, ECG findings, and repeat serum levels.   Monitor serum electrolytes.   Manage serum electrolyte abnormalities following standard treatment protocols.   Hematologic Coagulopathy Coagulopathy occurs as a consequence of acute hepatic failure with cyclopeptide toxicity. Coagulopathy should be managed in conjunction with hepatic failure. Fresh frozen plasma (FFP) or coagulation factor replenishment may be required.   Monitor: International normalized ratio (INR) Activated partial thromboplastin time (aPTT)   Manage coagulopathy following standard treatment recommendations. Neurologic Seizures Neurological symptoms occur secondary to acute hepatic failure and may include seizures, encephalopathy, somnolence, confusion, and coma.[54] Seizures should respond to treatment with benzodiazepines. If benzodiazepines fail to control the seizures, then barbiturates can be administered.   Observe the patient closely for onset of seizure activity.   Toxic seizure may be managed following these (hyperlinked) recommendations.   DISCHARGE CRITERIA Discharge after development of hepatic or renal failure, or other consequences, should follow standard protocols for those conditions.   FOLLOW UP Standard protocols should be used for follow-up of patients suffering hepatic or renal failure, including advice that patients should abstain from alcohol for six weeks to allow regeneration of the liver.   PROGNOSIS In the early part of the 20th century mortality was up to 70%.[55] Since the 1970's with more advanced medical supportive care and the introduction of more specific treatment protocols, overall mortality diminished to below 25%.[56][57][58] Furthermore, recent retrospective analysis's have shown overall mortalities as low as 4.8%[59] and 1.8%.[60]   The prognosis is poorer with large doses, a short latency period between ingestion and onset of symptoms, severe coagulopathy, an age below 10 years, or in patients who present to hospital more than 36 hours post ingestion.[56][60][61][62] A fatal outcome is predicted if the prothrombin index is less than 25% combined with serum creatinine greater than 106 mmol/L from day 3 to 10.[50]   SIGNS AND SYMPTOMS Cyclopeptide mushroom ingestion produces the Phalloides syndrome, which typically exhibits a quadriphasic course, and appears to be dose related.   Phase 1 and 3 are latent periods where the patient generally feels relatively well. Phase 2 begins approximately 12 hours after mushroom ingestion and consists predominantly of severe gastrointestinal symptoms, which leads to significant water and electrolyte loss. The final phase is hepatorenal, where severe hepatotoxicity may occur and hepatic and renal failure can ensue. In fatal cases, death may occur six to 16 days following ingestion.[63]   Routes of Exposure Cyclopeptide mushrooms are usually ingested in fresh condition. Poisoning typically occurs as a result of amateur mushroom gatherers mistaking the mushrooms for various edible varieties. The toxins remain stable when boiled, thus poisoning is possible whether the mushrooms are eaten raw or cooked.[64]   Onset/Duration of Symptoms Symptoms following the ingestion of amatoxin-containing mushrooms occur in four phases.   NOTE: Time frames may vary considerably to those listed below.   Latent asymptomatic phase (< 24 hours and usually up to 12 hours post-ingestion) No symptoms Gastrointestinal phase (6 to 24 hours post-ingestion) Abdominal pain Vomiting Severe diarrhea Hypovolemia Electrolyte disturbances Acid-base disturbance Period of well-being (24 to 48 hours post-ingestion) Hepatic and renal function deteriorates Hepatic phase (3 to 5 days post-ingestion) LFT increases Acute hepatic failure Acute renal failure   In fatal cases, death may occur 6 to 16 days following ingestion due to hepatic and/or renal failure.[63]   Severity of Poisoning Mild Cyclopeptide Toxicity Moderate Cyclopeptide Toxicity Severe Cyclopeptide Toxicity Nausea Vomiting Diarrhea Abdominal pain Electorlyte imbalances Hypoglycemia Right upper quadrant tenderness Hepatitis Renal dysfunction Metabolic acidosis Coagulopathy Fulminant hepatic failure Acute renal failure Hepatic encephalopathy Death   ACUTE EFFECTS (ORGAN SYSTEM) Gastrointestinal Nausea[45] Vomiting[45][65] Diarrhea[65] (may be severe)[45] Abdominal pain[66][36][45][48]   Hepatic Jaundice[67] Hepatomegaly[46] Elevated liver enzymes[12][68] Increased International Normalized Ratio (INR)[12][60] Coagulopathy[49] Hepatic encephalopathy[67] Hepatic coma (in severe cases)[48][56][67][69]   Renal Oliguria[69] Anuria[68] Hematuria[48] Acute tubular necrosis[70] Renal failure[71]   Neurologic Neurological symptoms are believed to be secondary to hepatorenal failure.   Somnolence[67] Confusion[68] Encephalopathy[54] Seizure[69] Raised intracranial pressure[72] Neuropathy[54] Coma[67]   Cardiovascular Tachycardia[70][73] Hypotension[48] Cardiomyopathy[74]   Fluid and Electrolytes Dehydration[69] Hypovolemia[9] Hypokalemia[9] Hyponatremia[75] Hypochloremia Hypocalcemia[51]   Hematologic Hypofibrinogenemia[5] Hypoprothrombinemia[76] Coagulopathy[53] Epistaxis[77] Gastrointestinal hemorrhage[5] Impaired synthesis of clotting factors[78]   Metabolic Hypoglycemia[72][79] Metabolic acidosis[79] Lactic acidosis[9][10][12][45][51]   Respiratory Hyperventilation Hypoventilation Apnea Hemorrhagic pulmonary alveolitis[80] Adult respiratory distress syndrome[81] Respiratory arrest[69]   Hormonal Hyperinsulinism[51] Hyperparathyroidism[51] Hypothyroidism[51] Elevated serum calcitonin levels[51]   Dermatologic Pallor[45] Jaundice[71] Icteric sclera   TOXICITY The toxic content of fungi may vary from year to year due to various factors that affect growth, such as available moisture and spring temperatures.[82] Thus, it is difficult to establish an association between the severity of symptoms and the ingestion of a specific amount of fungus material.   HUMAN Acute Effects are dose-dependent. The following list is an approximate guide of how to evaluate the dose taken:   The minimal lethal dose of amatoxins in adults is: <0.1 mg/kg[83]   Concentrations of 5 to 15 mg amatoxins per gram of dried mushroom have been found.[83][84] This means that the following amounts of mushroom could kill a healthy adult:[55][84] Amanita 1 cap Galerina 15 to 20 caps Lepiota 30 caps   Prognosis appears to be primarily determined by the quantity of mushroom eaten (dose of toxins per kg body weight). Therefore, mortality is far higher in children under 10 years of age than in adults.[56]   ANIMAL Acute AMATOXIN   LD50 IP, Rat 4 mg/kg[85] Death occurs in 2 to 5 days LD50 IP, Mouse 0.3 mg/kg[85]   LD50 IV, Dog 0.1 mg/kg[85]   PHALLOTOXIN   LD50 IP, Mouse 2.5 mg/kg[85]   REPRODUCTION PREGNANCY Amatoxins do not cross the placenta following maternal exposure to cyclopeptide mushrooms.[86] Fetal abnormality has not been reported following ingestion during the second or third trimester. While abortion is not recommended, fetal risk cannot be excluded and monitoring of the fetus should be intensified.   There have been a number of cases of maternal intoxication not causing any significant effects to the fetus.[87][20][88][89][90]   A 22-year-old woman in the 11th week of pregnancy inadvertently ingested Amanita phalloides. Treatment consisted of intravenous hydration, and administration of silymarine and N-acetylcysteine. No fetal damage was observed and the birth and development of the infant proceeded without incident.[20] Another case reported a 26 year old woman in the 22nd week of pregnancy suffering Amanitia phalloides poisoning. The patient was treated successfully and went on to deliver a normal healthily baby.[88]   In contrast, in one reported case of poisoning in the first trimester, the mother developed toxic hepatitis. She was successfully managed, however, a therapeutic abortion was performed because of speculated fetal toxicity. The fetal liver was found to be consistent with cyclopeptide poisoning. Treatment carried out on the mother was not mentioned.[91]   LACTATION It is unknown if the ingestion of these mushrooms results in excretion of amatoxins into breast milk. Breast-feeding patients who have ingested cyclopeptide mushrooms should be advised to avoid breast feeding.   FERTILITY It is unknown if exposure to, or ingestion of, this fungus causes impaired fertility.   TOXIC COMPONENTS Cyclopeptide mushrooms contain three classes of toxin; amatoxins, phallotoxins, and virotoxins. Amatoxins are responsible for the majority of effects seen following the ingestion of cyclopeptide mushrooms.[9]   Amatoxins Phallotoxins Virotoxins   Alpha amanitin Beta amanitin Gamma amanitin Epsilon amanitin Amanin Amaninamide Amanullin Amanullinic acid Proamanullin   Phalloidin Phalloin Prophalloin Phallisin Phallicin Phallacidin Phallisacin   Viroidin Alloviroidin Desoxoviroidin [Ala]viroidin [Ala]deoxoviroidin Viroisin Desoxoviroisin[92]   Amatoxins are very stable, mushrooms remain toxic even after long periods of storage. They are also thermostable and not removed by cooking or freezing.[79][64]   Plant Content All parts of cyclopeptide mushrooms are poisonous. Amatoxin concentrations vary greatly within and between cyclopeptide mushroom species.   The following concentrations of amatoxins expressed in mg/g of dry tissue have been reported:   Amanita phalloides 2 to 7.3 Amanita verna 0.4 to 4.6 Amanita virosa 1.2 to 2.6 Amanita bisporigera 2.4 Galerina autumnalis 0.8 to 1.5 Galerina marginata 0.4   TOXIC MECHANISM Cyclopeptide-containing mushrooms are responsible for producing the phalloides syndrome, a syndrome that is responsible for approximately 90% of all lethal mushroom poisonings.[93] Cyclopeptide mushrooms contain three classes of toxin; amatoxins, phallotoxins, and virotoxins. Amatoxins are responsible for the majority of toxic effects seen following the ingestion of these mushrooms.[9]   Amatoxins are bicyclic octapeptides with an indole-(R)-sulphoxide bridge that inhibit RNA polymerase II, thus affecting mRNA synthesis.[36][68] This interferes in the transcription of DNA and leads to cellular necrosis in cells with high rates of protein synthesis, and where initial exposure to high doses of the toxins occurs (i.e., the intestinal mucosa, the hepatocytes of the liver, and the proximal tubules of the kidney).[9][94] The most significant injury is hepatic necrosis. This mechanism is thought to account for the delayed onset of severe gastroenteritis and the long latency period of the hepatic phase of intoxication.[16]   Phallotoxins are bicyclic hepatapeptides with an indole/thio-ether bridge.[95] It is probable that the phallotoxins play no role in human poisoning, as they are not absorbed from the gastrointestinal tract.[10][96] When administered parenterally to laboratory animals, phallotoxins destroy the endoplasmic reticulum and mitochondria of the liver cells and induce necrosis of hepatocytes. Phalloidin increases the permeability of the plasma membrane of hepatocytes by binding to the actin G of plasma membranes and polymerizing actin G irreversibly.[97] Phallatoxins are approximately one-tenth as toxic as the amatoxins.   Finally, viratoxins are monocyclic hepatapeptides, which are thought to be comparable in their biological activity to that of the phallotoxins in regard to their affinity for F-actin and their toxic action in mice.[98] Virotoxins are not thought to exert any toxicity after ingestion in humans.[9]   BIOLOGICAL LEVELS - TOXIC Serum levels of amatoxins are not readily available,[9][68] do not correlate with severity of poisoning,[10] and are not necessary for clinical management.   SI Unit Conversion To convert an alfa-amanitin concentration expressed in mg/L into mmol/L: Multiply the mg/L by 0.0011   To convert an alfa-amanitin concentration expressed in mmol/L into mg/L: Multiply the mmol/L by 918.97   To convert an beta-amanitin concentration expressed in mg/L into mmol/L: Multiply the mg/L by 0.0011   To convert an beta-amanitin concentration expressed in mmol/L into mg/L: Multiply the mmol/L by 919.95   To convert an phalloidin concentration expressed in mg/L into mmol/L: Multiply the mg/L by 0.0013   To convert an phalloidin concentration expressed in mmol/L into mg/L: Multiply the mmol/L by 788.87   Toxic Serum Concentrations Concentrations of amatoxins can be detected in some patients up to 30 hours post ingestion.   Amatoxin toxic plasma concentrations   In a group of 29 patients serum amatoxins were detectable in 65% of patients. Concentrations were: 0.5 to 2.4 ug/L[6]   In patients with Amanita phalloides intoxication serum alfa amantin concentrations were: 70 to 90 ug/L[99]   Another study of 45 patients with Amanita phalloides poisoning, demonstrated plasma alfa amatoxin concentrations of: 8 to 190 ug/L[100]   Toxic Urine Concentrations Urine amatoxin detection could potentially be suitable for the early diagnosis of poisoning.[101] However, there is no information on the relationship between urine levels and severity of poisoning.[9]   Amatoxin toxic urine concentrations   In a group of 29 patients urinary amatoxins were detectable. Concentrations were: 0.5 to 56 ug/L[6]   Urinary amatoxins were detectable in 15 out of 24 patients in another study. Concentrations were: < 4800 ug/L[100]   KINETICS ABSORPTION Oral Absorption Amatoxins: Rapidly absorbed from the GI tract following oral administration[9] Phallotoxins: Not absorbed from the GI tract following oral administration[100] Onset of Action Amatoxins: Delayed 6 to 24 hours[102]   DISTRIBUTION Distribution High concentrations are found in the gastroduodenal fluid up to 100 hours after ingestion[100] Volume of Distribution Unknown in humans 160 to 290 mL/kg in dogs[103] Plasma Protein Binding Amatoxins are not bound to albumin[103][104] Lipid Solubility Does not cross the placenta Amatoxins do not cross the placenta[86]   METABOLISM Metabolism In experimental studies, no metabolites could be detected after administration of radioactive amanitin[103]   ELIMINATION Excretion Amatoxins are excreted in large quantities in the urine in the first days following ingestion.[100] In dogs 83 to 88% was recovered in the urine Amatoxins may be detected in urine as early as 90 to 120 minutes post ingestion, however can be detected in urine up to 96 hours post ingestion In dogs <10% recovered in bile Amatoxins excreted in bile may be reabsorbed via enterohepatic recirculation[103] Half-life Therapeutic Eliminated very quickly from serum In a group of patients, amatoxins disappeared rapidly in serum In two patients only, amatoxins could still be detected in serum after the 36 hours post ingestion[100]   DESCRIPTION PLANT ATTRIBUTES Amanita phallodies has a large round cap 5 to 15 cm in diameter. The cap is light greenish-olive to greenish-yellow colored with white gills and spores. The stalk is white with grayish-olive scales, 8 to 15 cm long and 1 to 2 cm thick. Near the top of the stalk 1 to 1.5 cm below the cap, the remains of the partial veil are seen as a skirtlike, floppy annulus (ring). At the base of the stalk is a large white membranous volva.[1]   CAS NUMBER Amanitin: 11030-71-0 Alfa-amanitin: 23109-05-9 Beta-amanitin: 21150-22-1 Gamma-amanitin: 21150-23-2 Epsilon-amanitin: 21705-02-2 Amanullin: 21803-57-6 Amanullinic acid: 54532-45-5 Amaninamide: 58311-65-2 Amanin: 21150-21-0 Proamanullin: 54532-46-6 Phalloidin: 17466-45-4 Phalloin: 28227-92-1 Phallisin: 19774-69-7 Phallacidin: 26645-35-2 Phallacin: 53568-40-4 Phallisacin: 58286-46-7 Viroidin: 53568-33-5 Viroisin: 74113-57-8   PHYSICOCHEMICAL PROPERTIES ALFA-AMANITIN: Molecular Weight 918.98 918.98% degrees C[105] Melting Point 254 to 255 254 to 255% degrees C[105]   BETA-AMANITIN: Molecular Weight 919.96 919.96% degrees C[105] Melting Point 300 300% degrees C[105] Solubility Water: soluble[105] Ethanol: soluble[105] Methanol: soluble[105]   PHALLOIDIN: Hexahydrate needles   Molecular Weight 788.88 788.88% degrees C[106] Melting Point 280 to 282 280 to 282% degrees C[106] Solubility Water (hot): soluble[106] Water (freezing): practically insoluble[106] Ethanol: easily soluble[106] Methanol: easily soluble[106] Butanol: easily soluble[106] Pyridine: freely soluble[106]   REFERENCES [1] Bresinsky A, Besl H. 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