Exclusives, Patient Care, Top Story

The Mushroom Chronicles: The Case of the Poisonous Omelet

On a summer afternoon in suburban Virginia, one BLS and two ALS ambulances are dispatched to an apartment complex for three people experiencing severe abdominal pain with nausea, vomiting and diarrhea onset three hours ago.

Dispatch states that the patients picked, cooked and ate mushrooms from their neighborhood courtyard around 10:00 a.m. The family is from out of the country; mother and father are in their sixties and a son who is in his thirties. They said they picked the mushrooms and cooked them in an omelet, and that after breakfast, each of them became ill. Symptoms started with severe abdominal pain, followed by nausea, vomiting and diarrhea.

Upon EMS arrival, all three patients are lying on the kitchen room floor in the fetal position with copious amounts of vomitus around them. The mother and father are actively vomiting and the son is dry heaving.

The mother is attended to first; she’s alert and oriented with airway, breathing and circulation (ABC) intact, and her skin is pale and diaphoretic. She’s tachycardic with a heart rate of 116 beats per minute, normotensive blood pressure and O2 saturation of 97% on room air.

She explains that the pain came on after a few hours of eating, was sharp in nature, and radiated throughout all quadrants with a 10 out of 10 on the pain scale, followed by nausea and vomiting. As she resumes vomiting, IV access is established, and she’s given 4 mg of Zofran and a normal saline infusion.

During transport, the patient remains stable and she improves en route with no complications noted. Her nausea subsides and she states that she feels better but was still distressed. On arrival, a report was given to the ED nurse.

The patient’s other family members had similar prehospital courses.

Hospital Course

On arrival to the hospital ED, the patients’ conditions remain unchanged. While symptomatic treatment and work-up is in process, the ED physician requests that EMS go back to the patients’ apartment courtyard to collect mushrooms for identification. The ED physician also contacts Poison Control.

The medics go back to the courtyard and send pictures of the mushrooms to the ED physician.

The ED physician confirms with the three patients that these were similar to the mushrooms they ingested. The ED physician contacts Poison Control again; where a mycologist identifies the mushrooms as Chlorophyllum molybdites, which is a severe GI irritant, but ultimately doesn’t cause liver failure or death.

All three patients improve with symptomatic care and are subsequently discharged home. (See Figure 1.)

Figure 1: Case timeline shows strong coordination and communication between EMS, the ED and Poison Control

Mushroom Toxicity

It can be very difficult to distinguish non-toxic from toxic mushrooms. This can be all the more difficult when mushroom foragers are in different geographic locations of the country or world than they’re used to. The 64 year-old father in this case had just immigrated to the United States and was used to picking mushrooms in his own country. It’s also important to note that poisonous mushrooms often resemble edible mushrooms at some point in their growth.1

Chlorophyllum molybdites (green-spored Lepiota) is the most common cause of human poisoning by mushrooms in the U.S. Symptoms usually occur within 1–3 hours of ingestion and self-resolve.2 However, there are many toxidromes associated with mushroom poisoning, with a variety of times of symptom onset. For example, muscarinic poisonings present with SLUDGE (salivation, lacrimation, urination, diarrhea, gastrointestinal upset, emesis) symptoms shortly after ingestion, which can be improved with atropine.

Mushrooms with isoxazole can cause gastrointestinal and central nervous system symptoms, which atropine actually worsens. Psilocybin mushrooms are used recreationally for their LSD-type substances. In general, delayed onset of symptoms tends to predict more severe poisoning, as can be seen with mushrooms containing gyromitrin and amatoxins, both of which are associated with onset of gastrointestinal symptoms at least two hours after ingestion and subsequent renal and liver failure.3 (See Figure 2.)

Figure 2: Mushroom toxidromes
Onset and symptoms vary by mushroom ingested, with delayed onset associated with poorer outcomes.

Given the wide variety of toxicities and potential for long-lasting organ damage, as soon as there’s suggestion of a mushroom poisoning, patients should be brought to the hospital for definitive care. Ideally, the suspected mushroom should be identified in order to better coordinate with hospital providers and Poison Control.

EMS Role in Public Health

In this case, EMS personnel played an invaluable role in helping identify the causative mushroom to tailor treatment and provide prognosis. This is just one example of how EMS providers can provide important information for the immediate treatment and disposition for patients in the ED. This becomes even more crucial in settings when a delay in treatment may worsen the prognosis and outcome.

Other public health examples where EMS has a vital role include exposures to carbon monoxide, lead or pesticides; exposure to foodborne diseases (defined by the Centers for Disease Control and Prevention [CDC] as two or more cases of similar illness resulting from common ingestion of a food), and waterborne diseases (defined by the CDC as two or more cases of a similar illness resulting from common exposure to water or water-associated chemicals).4 (See Figure 3.)

Figure 3: CDC public health conditions and outbreaks
Categories of conditions and outbreaks provided by the Centers for Disease Control and Prevention, 2017 data.

Take-Home Points

  • Mushroom poisoning, although rare, is relevant even in suburban areas, as they can be picked, purchased in a store or bought online;
  • Mushroom toxidromes vary in onset and symptomatology; prompt transport to hospitals for definitive care is important;
  • Continued coordination with the in-hospital treatment team is another example of extension of the role of EMS within the continuum of care; and
  • EMS providers play an invaluable role in identifying toxic exposures that can affect multiple patients (e.g., carbon monoxide poisoning, foodborne disease outbreaks and waterborne disease outbreaks).

Acknowledgement: Special thanks to Scott Weir, MD, and Dan Avstreih, MD, as well as the Fairfax County Fire and Rescue Department for caring for these patients and helping to put this article together.

References

1. Flomenbaum NE, Goldfrank LR, Hoffman RS, et al: Goldfrank’s toxicologic emergencies, 8th ed. McGraw­Hill: New York, 2006.

2. Volk T. (August 1999) Tom Volk’s fungus of the month for August 1999. TomVolkFungi.net. Retrieved Dec. 22, 2018 from,  from https://botit.botany.wisc.edu/toms_fungi/aug99.html.

3. Mushroom poisoning syndromes (n.d.) North American Mycological Association. Retrieved Dec. 22, 2018 from https://www.namyco.org/mushroom_poisoning_syndromes.php.

4. Thomas K, Jajosky R, Coates RJ, et al. Summary of notifiable noninfectious conditions and disease outbreaks: Surveillance data published between April 1, 2016 and January 31, 2017 — United States. MMWR Morb Mortal Wkly Rep. 2017 Aug 11;64(54):1-6. doi: 10.15585/mmwr.mm6454a1.