Clinical recovery of 5 dogs from amatoxin mushroom poisoning using an adapted Santa Cruz protocol for people

Abstract

Objective: To describe the clinical course, treatment, and outcome of 5 dogs following ingestion of toxic Amanita spp. mushrooms containing amatoxins using an adapted version of the Santa Cruz protocol developed for people.Case series summary: Five dogs were presented with clinical signs compatible with amanitin toxicity with witnessed ingestion noted in 3 of 5 dogs. Clinical findings included acute onset vomiting and diarrhea, lethargy, and hepatopathy including signs of fulminant hepatic failure (increased liver enzyme activities, hyperbilirubinemia, prolonged clotting times, and hypoglycemia were noted among these cases). Urine toxicological screening confirmed the presence of Amanita toxins in 4 cases with expert mycologist speciation in the fifth. Core interventions included percutaneous biliary drainage, use of octreotide, and early nil per os orders. All dogs survived to discharge with this treatment strategy.New or unique information provided: This case series describes the use of a modified version of the Santa Cruz protocol to address amatoxin-induced fulminant hepatic failure in dogs. The protocol was safe, well tolerated, and all patients made a full clinical recovery. K E Y W O R D Sacute kidney injury, Amanita toxins, canine, hepatic failure INTRODUCTIONMushrooms containing amatoxins can cause significant morbidity and mortality when ingested. A novel protocol under clinical trial investigation in people (the Santa Cruz protocol) aims to minimize the need for liver transplantation by combining aggressive diuresis, octreotide, nil per os (NPO) orders, and an IV preparation of silibinin for hepatic pro-

Amanita Mushroom Toxin Poisoning in Los Angeles County

“… 17 , 18 While octreotide has been proposed to slow enterohepatic recirculation by inhibiting gallbladder contraction, there is minimal evidence in human and nonhuman cases. 6 , 7 Our use of gallbladder drainage with octreotide was influenced by worsening biochemical values while awaiting silibinin. Ultimately, our bridging strategy to avoid the sequelae of acute liver failure depended on expert advice, which should be obtained from clinical hepatologists and toxicologists.…”

“…A hepatology consultation was requested, and temporizing measures of amatoxin detoxification were implemented, given the patient's worsening biochemical status. IV octreotide was administered to minimize gallbladder contraction 6 , 7 and slow enterohepatic recirculation of amatoxin. Subsequently, a percutaneous cholecystostomy drain was placed to remove amatoxin-laden bile.…”

Early diagnosis of amanitin exposure (amatoxicosis) in a dog with a point‐of‐care diagnostic test

“…In a case review of 59 dogs suffering from amatoxicosis, 95% developed hypoglycemia 1 . Fresh frozen plasma, which is frequently used as part of the treatment protocol in cases of amatoxicosis, 1,18 was not indicated in this dog, as a coagulopathy was not documented.…”

“…6,8 Techniques that have been considered include activated charcoal to bind toxin, octreotide to reduce gallbladder motility, cholestyramine to adsorb bile acids, and also direct biliary drainage. 10,12,25 A recent case series of 5 dogs that suffered from amatoxicosis 18 describes a protocol of treatment focused on therapeutic cholecystocentesis, coupled with therapies to suspend enterohepatic circulation, that is, not giving anything by mouth and administering octreotide.…”

“…A recent case series of 5 dogs that suffered from amatoxicosis 18 describes a protocol of treatment focused on therapeutic cholecystocentesis, coupled with therapies to suspend enterohepatic circulation, that is, not giving anything by mouth and administering octreotide. While the 5 dogs in this series did survive, no controlled or retrospective studies have shown improved survival in human or veterinary patients that undergo this type of decontamination.…”