Challenges in the early diagnosis of patients with acute liver failure induced by amatoxin poisoning

Abstract

Rationale:Acute liver failure (ALF) induced by amatoxin-containing mushrooms accounts for more than 90% of deaths in patients suffering from mushroom poisoning. However, due to the fact that most hospitals cannot identify the species of mushrooms involved, or detect amatoxins, the early diagnosis of amatoxin intoxication remains a significant challenge in clinical practice.Patient concerns:Two patients were had ingested wild mushrooms 15 hours before admission. Six hours prior to admission they experienced nausea, vomiting, weakness, abdominal pain and diarrhea. The species of mushrooms they had consumed could not be identified.Diagnoses:According to their delayed gastroenteritis, the two patients were clinically diagnosed with amatoxin poisoning. One week after the patients were discharged, the species of the mushrooms was identified as Amanita fuliginea and the diagnosis was confirmed.Interventions:The two patients were treated with silibinin, penicillin G and plasma exchange.Outcomes:Although the two patients progressed to ALF they fully recovered and were discharged on day 10 after admission.Lessons:Our case reports suggested that patients with unidentified wild mushroom intoxication with delayed gastroenteritis could be clinically diagnosed with amatoxin poisoning; in such cases, liver coagulation function should be frequently evaluated. Early diagnosis and treatment are crucial for survival in patients with ALF induced by amatoxin poisoning.

Timing of liver transplantation for pediatric acute liver failure due to mushroom poisoning: a case report and literature review

“…Patients with amatoxin-induced ALF have a poor prognosis, and LT is the only lifesaving therapy. In the pretransplantation era, the survival rate was 10-30%; however, transplantation has greatly improved the survival rate to 87% [10,12]. At present, reports on LT for PALF caused by mushroom poisoning are mainly from developed countries [13].…”

“…After the toxin enters the intestinal tract, amatoxin binds to DNA-dependent RNA polymerase II, inhibits protein synthesis, and induces the production of cytokines, ultimately resulting in the death of hepatocytes [7,10]. The clinical course of amatoxin poisoning is classically divided into four consecutive phases.…”

“…Approximately 400 of these are toxic to humans. Over 90% of fatal mushroom poisonings in the world occur after ingestion of Amanita species [ 8 – 10 ]. There are two distinct groups of toxins isolated from Amanita : phallotoxins and amatoxins.…”

Acute Liver Failure

“…86 Likewise, ALF induced by amatoxin-containing mushroom can also be treated by penicillin G, silibinin, and plasma exchange combination regimen. 87 In specialized centers, further therapeutic modalities for critical ALF patients include the application of artificial liver support devices such as MARS (molecular adsorbent recirculating system) or fractionated plasma separation and adsorption. 57,[88][89][90] In general, MARS and fractionated plasma separation and adsorption might have the potential to increase the probability of short-term survival of patients with ALF or ACLF and can be introduced for bridging to liver transplantation; 91 MARS therapy seems to successfully replace hepatic function in ALF, thereby allowing time for spontaneous recovery or transplantation.…”

Rapid, Sensitive, and Accurate Point-of-Care Detection of Lethal Amatoxins in Urine

“…There are only a few laboratories capable of testing biological specimens for amatoxins to confirm human or animal exposures, and even when available, test results might not be available soon enough to help guide treatment. Although there are no FDA-approved antidotes, early diagnosis, aggressive immediate supportive care, and a range of potential therapies can potentially improve patient outcomes [6][7][8][9][10][11].…”