Sun21November0735PM 6

A 38-year-old man is admitted to the Emergency department with severe lethargy, nausea, vomiting and jaundice. He is normally fit and well but went out mushroom picking in the woods a few days earlier, using a book he received as a birthday present to identify mushrooms.

On examination he looks unwell, he has jaundiced sclera and extensive bruising over his arms, legs and abdomen. He is tender in the right upper quadrant.

Investigations show:

Hb 104 g/L (130-180)

WCC 11.5 ×109/L (4-10)

PLT 155 ×109/L (130-400)

Na 137 mmol/L (135-145)

K 4.9 mmol/L (3.5-5.5)

Cr 139 µmol/L (70-120)

Urea 9.1 mmol/L (2.5-8)

AST 2990 U/L (0-35)

Bilirubin 82 pmol/L (<26)

Albumin 33 g/L (35-50)

INR 4.2 -

Which is the most likely cause of his presentation?

(Please select 1 option)

Orellanine poisoning

Amatoxin poisoning Correct

Norleucine poisoning

Muscarine poisoning

Psilocybin poisoning

Explanation

Amatoxin poisoning is recognised to lead to presentation with hepatorenal syndrome around three days after ingestion of mushrooms. Amanita phalloides is the best known mushroom containing amatoxin, and may be confused with edible field mushrooms. Interventions include activated charcoal, administration of which is repeated, N-acetylcysteine, and milk thistle.

Muscarine poisoning is characterised by increased salivation, perspiration, and lacrimation within 30 minutes of mushroom ingestion.

Norleucine poisoning is associated with transient liver impairment, although renal failure associated with norleucine exposure is progressive.

Orellanine poisoning is associated with renal failure, and psilocybin poisoning is associated with hallucinations and neurological symptoms.

If mushroom poisoning is suspected, it is often helpful for patients to bring in a sample of what they have eaten. Atlases can be used to identify the causative agent.