Toxic Fungi of Western North America

by Thomas J. Duffy, MD

Outline and summary of treatment for poisoning by amatoxins

  1. Identify the mushroom. Do a Meixner test if possible, but proceed with treatment on the basis of the patient’s history. Do not delay for examination of the mushroom or a Meixner test. More then one mushroom species may have been ingested.
  2. Intravenous line with a goal of 150-200 ml/hr output of urine.
  3. Wash out the stomach if within 6 hours of food and proceed with one of the methods to capture the re-circulation of amatoxin in the bile (gastric tube, gastroduodenal tube or duodenal tube for delivery of activated charcoal 50-100 grams (1 mg/kg body weight approximately) at once and then 10-30 grams every 2-4 hours—see above for details if there is evidence of ileus or it is elected to place a tube within the duodenum.
  4. Alternate considerations are early hemoperfusion with resin cartridges in severe ileus, direct cannulation of the common bile duct under endoscopic control or simple suction of fluid from the duodenum near the opening of the common bile duct (usually the second portion of the duodenum).
  5. ICU monitoring of blood volume, input and output as well as cardiac, renal and hepatic function, blood cultures, electrolytes, blood glucose, coagulation studies (including thromboplastin time and fibrin split products) and other lab studies as noted above.
  6. Hematology consultation in the event of coagulation problems.
  7. Availability of renal dialysis and transfer to a liver transplant center if indicated.
  8. Standard treatment of hepatic failure, awareness of cerebral edema and seizures.
  9. Consideration of massive Penicillin G early for heavily poisoned patients, if the cardiovascular status is stable and the potential problems with this treatment are recognized.
  10. Trial of intravenous silibinin (Legalon®) while monitoring changes in liver function tests.
  11. Consideration of treatment with liver growth factors for severely ill patients. Use of these growth factors is experimental, but probably safer than Penicillin G, which has been widely used in Europe.