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Abstract
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BACKGROUND & AIMS: Acute liver failure following ingestion of toxic mushrooms is a significant medical problem. Most exposures to toxic mushrooms produce no symptoms or only mild gastroenteritis, but some lead to severe hepatic necrosis and fulminant hepatic failure requiring liver transplantation. We aimed to assess mortality from mushroom poisoning and identify variables associated with survival and liver transplantation.
METHODS: We collected information from 27 patients (13 male; median age, 47 years) admitted to the emergency department within 24 hrs of ingesting wild mushrooms. They developed severe liver injury (serum levels of transaminases above 400 IU/L) and were treated with activated charcoal and N-acetylcysteine at a tertiary medical center in San Francisco, California, from January 1997 through December 2014. Viral hepatitis, autoimmune liver disease, acetaminophen, salicylate toxicity, and chronic liver diseases were ruled out for all patients. We analyzed patient demographics, type and amount of mushroom ingested, time since ingestion, presenting symptoms, laboratory values, and therapies administered. A good outcome was defined as a survival without need for liver transplant. A poor outcome was defined as death or liver transplant. Positive predictive values were calculated, and the χ2 test was used to analyze dichotomous variables.
RESULTS: Liver injury was attributed to ingestion of Amanita phalloides in 24 patients and Amanita ocreata in 3 patients. Twenty-four of the patients ingested mushrooms with meals, 3 patients for hallucinogenic purpose. At 24-48 hrs after ingestion, all patients had serum levels of alanine aminotransferase ranging from 554 to 4546 IU/L (median, 2185 IU/L). Acute renal impairment developed in 5 patients. Twenty-three patients survived without liver transplantation and 4 patients had poor outcomes (1 woman underwent liver transplantation on day 20 after mushroom ingestion and 3 women died from hepatic failure). Of the 23 patients with peak levels of total bilirubin level of 2 mg/dL or more during hospitalization, only 4 had a poor outcome. No men but 4 women had a poor outcome. Peak serum level of aspartate aminotransferase below 4000 IU/L, peak international normalized ratio below 2, and a value of serum factor V above 30% identified patients with good outcomes with a 100% positive predictive value; if these peak values were used as a cutoff, 10/27 patients (37%), 7/27 patients (26%), and 6/12 (50%), respectively, could have avoided transfer to a transplant center.
CONCLUSION: In an analysis of 27 patients with hepatocellular damage due to mushroom (Amanita) poisoning and peak levels total bilirubin above 2 mg/dL, the probability of liver transplantation or death is 17%, fulfilling Hy's law. Patients with peak levels of aspartate aminotransferase below 4000 IU/L can be monitored in a local hospital, whereas patients with higher levels should be transferred to liver transplant centers. Women and older patients were more likely to have a poor outcome than men and younger patients.
Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.
Language: en |