Thousands of mushroom species are studied and collected by amateur mushroom hunters, but only a handful cause death. False morel mushrooms (eg, Gyromitra esculenta, Gyromitra ambigua, Gyromitra infula) can cause fatal poisonings.[1] These mushrooms are found on the ground or on rotten wood, are orange-brown to brown, have no gills, and have convoluted brainlike caps that are occasionally saddle-shaped. Gyromitra species fruit in the spring, and most poisonings occur during spring or early summer.
Some Gyromitra mushrooms contain hydrazones, including the toxin gyromitrin (N -methyl-N-formylhydrazone). Gyromitrin rapidly decomposes in the stomach to form acetaldehyde and N-methyl-N-formylhydrazine, which is converted to monomethylhydrazine (MMH) by slow hydrolysis. MMH is a water-soluble toxin that causes gastroenteritis, hemolysis, methemoglobinemia, hepatorenal failure, seizures, and coma. MMH is employed in rocket fuel and causes similar toxicity in aerospace industry workers. Cooking can render these mushrooms less toxic, although not reliably so. MMH is volatile and the fumes from cooking may cause toxicity.
Neurotoxicity
MMH exposure is similar to that of isoniazid in that it generates functional pyridoxine deficiency by inhibition of pyridoxine kinase. Pyridoxine kinase inhibition interferes with production of pyridoxal phosphate, an essential cofactor for a number of enzymatic steps, including glutamic acid decarboxylase (GAD).
Gamma-aminobutyric acid (GABA), the primary inhibitory neurotransmitter of the brain, is produced from glutamate (an excitatory neurotransmitter) by the enzyme GAD. MMH also may inhibit GAD directly. The resultant GABA deficiency, with loss of inhibitory neurotransmission, may lead to seizures.
Gastrointestinal toxicity
Inhibition of diamine oxidase in intestinal mucosa may be responsible for GI effects. Association of individual variability in acetylation rates (eg, slow vs fast acetylators) in hepatotoxicity is not well established.[2]
Hematopoietic toxicity
Hemolysis and methemoglobinemia can occur. Resultant hemoglobinuria may cause renal failure.
In 2017, the American Association of Poison Control Centers (AAPCC) Toxic Exposure Surveillance System reported 5781 single exposures to mushroom and 2 fatalities.[3] Unknown mushroom type makes up the majority of exposures each year, usually accounting for well over 80% of mushroom exposures, but deaths in this group remain remarkably low (0-2 per year since 1996).[3, 4, 5, 6, 7, 8, 9, 10]
In the same 2017 report, MMH-containing mushrooms accounted for 24 exposures and no fatalities.[3]
No adequate international database exists. In the past, gyromitrin-containing mushrooms have been associated with significant mortality in Eastern Europe.
Children are more sensitive to gyromitrin toxicity than adults. Overall about 60% of mushroom exposures are in children younger than 6 years. Although with Gyromitra species specifically, in 2017 children younger than 6 years account for less than 1% of exposures.[3]
Most patients fully recover after 2-5 days of a gastric illness. Mortality rates from 10-40% have been reported; however, death from gyromitrin-containing mushrooms in North America is exceedingly rare. Toxicity of gyromitrin-containing mushrooms varies by region and season.
Complications of MMH poisoning include:
Aspiration pneumonia
Rhabdomyolysis
Renal failure secondary to hemolysis and rhabdomyolysis
Inform patients that Gyromitra mushrooms are toxic and potentially lethal.
For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Poisoning and Activated Charcoal.
MMH poisoning may occur after ingestion of fresh, dried, or raw gyromitrin-containing mushrooms or with inhalation of vapors while cooking gyromitrin-containing mushrooms.
Severity depends on amount of toxin ingested. Amount of toxin greatly varies among mushrooms, and significant variation in individual susceptibility exists. Raw mushrooms have more toxin than cooked mushrooms. Fresh mushrooms have more toxin than dry mushrooms. Environmental factors appear to influence the amount of toxin, which varies regionally in these mushrooms. Michigan has a large number of Gyromitra mushrooms.
Determining history of mushroom exposure is helpful. Query patients presenting with gastroenteritis about mushroom collecting, cooking, and ingestion.
Onset of symptoms typically is delayed with gyromitrin poisoning. GI symptoms typically occur 6-10 hours after ingestion; however, symptoms may begin earlier with severe poisonings. Symptoms may be delayed 48 hours with mild poisonings. Inhalation exposure characteristically produces symptoms within 2 hours of exposure. GI phase of toxicity may be followed by neurologic and hepatorenal toxicity.
Details of ingestion and progression of symptoms are helpful in differentiating ingestions of different mushroom types. Ask the following questions to ascertain specific history:
When were the mushrooms ingested (or when was patient exposed to vapors of cooking mushrooms)?
When did each symptom begin?
Where were the mushrooms found?
Were other species ingested?
Did others become ill after eating the mushrooms?
Clinical history includes the following:
GI symptoms are prominent, with complaints of abdominal pain, bloating, vomiting, and diarrhea.
Other complaints (eg, weakness, dizziness, headache, confusion, seizures) may be caused by volume depletion, anemia, and renal, hepatic, or neurologic toxicity.
Typical duration of symptoms is 1-2 days but may be as long as 5 days.
Electrolytes, BUN, creatinine, and glucose: Patients often are dehydrated. Assess renal function of patients with hemolysis. Hyperglycemia may be present as an acute stress reaction; however, sudden hypoglycemia is a greater concern than hyperglycemia with hepatic injury.
Complete blood count and/or peripheral blood smear: Assess for anemia from hemolysis or blood loss.
Hepatic transaminases and serum bilirubin: Findings may be normal at presentation; however, if hepatic injury exists it becomes abnormal within days of exposure. Bilirubin may be elevated from hemolysis or liver toxicity. Methemoglobin levels: Measure by co-oximetry (determine need for methylene blue treatment).
Tests for hemolysis
The following for hemolysis may be performed:
Urinalysis: Positive dip test for blood without RBCs on microscopic analysis suggests either hemolyzed blood (hemoglobinuria) or myoglobin.
Free plasma hemoglobin increases with hemolysis.
Serum haptoglobin decreases with hemolysis.
Blood smears: Heinz body formation is observed with special stains, and bite cells are observed with Wright stain.
If a specimen of the ingested mushroom is available, save it in a paper bag for potential identification. An experienced mycologist may identify the mushroom. Save any food specimen or gastric contents (from emesis); further testing for gyromitrin toxin occasionally may be performed.
Gas-liquid chromatography, gas mass spectrometry, and thin-layer chromatography can be used to identify hydrazone and hydrazine compounds.
Initiate supportive care and decontamination as follows:
ABCs and coma protocols
Correction of fluid and electrolyte imbalances
Antiemetics (if needed)
Dextrose (if needed)
Consideration of activated charcoal (although with typical delayed presentation of poisoning by Gyromitra species, value from this intervention is unlikely)
Administer IV fluids to maintain brisk urine output and prevent renal damage from hemolysis.
Treat seizures with both pyridoxine (vitamin B-6) and benzodiazepines.[11] Although limited cases exist in which pyridoxine was used as an antidote for gyromitrin-containing mushroom poisoning, pyridoxine is the antidote of choice for isoniazid-induced seizures, which are due to hydrazine and hydrazone metabolites of isoniazid interfering with GABA synthesis.
Phenobarbital has been demonstrated to increase metabolism of hydrazines to toxic metabolites and should be avoided. Phenobarbital metabolism may be decreased if liver failure from gyromitrin toxicity has occurred.
Methemoglobinemia involves oxygen and methylene blue. Methemoglobin cannot transport oxygen; functional anemia results. Modest levels of methemoglobinemia may be tolerated with supportive care. With higher levels (eg, >20%) and associated symptoms, such as mental status changes, dyspnea, ischemic chest pain, or acidosis, consider treatment with methylene blue.
Anemia due to hemolysis may require blood transfusion.
Theoretically, folinic acid may be beneficial. Hydrazines inhibit metabolism of folic acid to tetrahydrofolate.
Admit all symptomatic patients in whom gyromitrin poisoning is suspected for further management and monitoring. Monitor patients for dehydration, neurologic toxicity, and liver or renal failure. Consider patients who have developed seizures, coma, severe methemoglobinemia, or hemolysis for intensive care unit admission.
Patients with gyromitrin ingestion who seek medical care, are asymptomatic 8 hours after ingestion, and are without clinical or laboratory signs of toxicity may be considered for discharge. Early follow-up care for reevaluation must be in place at the time of discharge. Instruct patients to return immediately if they become symptomatic. Instruct patients to keep themselves well hydrated.
Consultation with a regional poison control center and toxicologist may be helpful. They may assist in contacting a mycologist for mushroom identification. Obtain a gastroenterology consultation if evidence of liver dysfunction is present.
Clinical Context:
Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water. For maximum effect, administer within 30 min of ingesting poison.
Clinical Context:
Sedative hypnotic with short onset of effects and relatively long half-life. May depress all levels of CNS, including limbic and reticular formation, by increasing action of GABA, which is a major inhibitory neurotransmitter in the brain. Monitoring patient's blood pressure after administering dose is important. Adjust prn.
Clinical Context:
Used as alternative in termination of refractory status epilepticus. Because water soluble, takes approximately 3 times longer than diazepam to peak EEG effects. Thus clinician must wait 2-3 min to fully evaluate sedative effects before initiating procedure or repeating dose. Has twice the affinity for benzodiazepine receptors than diazepam. May be administered IM if unable to obtain vascular access.
Reed Brozen, MD, Director of Air Transport, Associate Professor, Department of Emergency Medicine, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center
Disclosure: Nothing to disclose.
Coauthor(s)
Marcus J Hampers, MD, MBA, Instructor, Department of Medicine, Dartmouth Medical School; Consulting Staff, Department of Internal Medicine, Section of Hospital Medicine, Department of Anesthesiology, Section of Critical Care Medicine, and Department of Emergency Medicine, Dartmouth Hitchcock Medical Center
Disclosure: Nothing to disclose.
Specialty Editors
John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals
Disclosure: Nothing to disclose.
Chief Editor
Sage W Wiener, MD, Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center
Disclosure: Nothing to disclose.
Additional Contributors
B Zane Horowitz, MD, FACMT, Professor, Department of Emergency Medicine, Oregon Health and Sciences University School of Medicine; Medical Director, Oregon Poison Center; Medical Director, Alaska Poison Control System
Disclosure: Nothing to disclose.
Acknowledgements
Michael Hodgman, MD Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare
Michael Hodgman, MD is a member of the following medical societies: American College of Medical Toxicology, American College of Physicians, Medical Society of the State of New York, and Wilderness Medical Society
Disclosure: Nothing to disclose.
References
Keahi Horowitz. Toxicity, Mushroom, Gyromitra. B Horowitz. StatPearls. December 21, 2017. Treasure Island (FL): StatPearls Publishing LLC; 2018 Jan.
Mary Brown. Vitamin, B6 (Pyridoxine), Deficiency. Kevin Beier. StatPearls. December 8, 2017. Treasure Island (FL): StatPearls Publishing LLC; 2018 Jan.
