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ORIGINAL ARTICLE
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 29-34

Mushroom poisoning and outcome of patients admitted in a tertiary care hospital in North East India


1 AIIMS, Bhopal, India
2 North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGRIHMS), Shillong, India
3 Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India

Date of Submission15-Sep-2020
Date of Decision10-Jan-2021
Date of Acceptance03-Feb-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
Dr. Devinder Mohan Thappa
Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry 605006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_53_20

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  Abstract 


Background: Of the estimated 5000 existing mushroom species, only 200 to 300 have been established to be edible and safe, whereas 50 to 100 species are known to be poisonous for human consumption. The toxicity profile of most other species has not been investigated. Consuming mushrooms gathered in the wild is risky, as most of the mushroom poisoning reported are due to accidental ingestion of poisonous mushrooms, which are often misidentified. To study the clinical characteristics of patients who got admitted with mushroom poisoning in North Eastern Indra Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong over the past 5 years. Methods: A retrospective study of case records of patients admitted with mushroom poisoning over 5 years in a tertiary care regional institute of northeastern India (NEIGRIHMS, Shillong) was carried out. Data collection was done using a pre-designed proforma. Results: Fifty-three patients were admitted with mushroom poisoning during the study period of 5 years (2014–2019). Maximum number (16; 30.19%) of the patients belonged to the age group of 11 to 20 years. A two and a half months old baby on breast milk is the youngest patient admitted with mushroom poisoning. Out of 53 patients with mushroom poisoning, 33 (62.26%) reported in six clusters, and 20 (37.74%) were admitted as individual mushroom poisoning patients. The majority, 40 (75.47%), of the patients survived and got discharged. Nine (16.98%) patients died due to complications of poisoning, and four (7.55%) patients left against medical advice. Most of the cases (21, 39.62%) were from Ri-Bhoi district. Most (17, 32.07%) of the mushroom poisoning occurred during the month of May, which coincided with the peak time of mushroom production in the state of Meghalaya. Conclusions: Wild mushroom is a part of routine food consumption in the tribal population of Meghalaya. Nearly 75% of the patients admitted with mushroom poisoning recovered, whereas 16.98% died due to poisoning complications.

Keywords: Intoxication, oral ingestion, poisonous, wild mushrooms


How to cite this article:
Pandita KK, Topno N, Thappa DM. Mushroom poisoning and outcome of patients admitted in a tertiary care hospital in North East India. J Med Trop 2021;23:29-34

How to cite this URL:
Pandita KK, Topno N, Thappa DM. Mushroom poisoning and outcome of patients admitted in a tertiary care hospital in North East India. J Med Trop [serial online] 2021 [cited 2021 Sep 19];23:29-34. Available from: https://www.jmedtropics.org/text.asp?2021/23/1/29/314858




  Introduction Top


Mushroom is a fleshy reproductive structure of some species of fungi. Millions of microspores are formed in the form of the grills or pores underneath the mushroom cap. These spores germinate to form a network of mycelium when they fall on a suitable substrate. The mushrooms pop up from the mycelium under suitable conditions. Mushrooms form an essential nutrition source in the terrestrial food chain as they are rich in fiber and energy. However, many strains of mushrooms contain toxins that can cause human sickness and death. Of the estimated 5000 existing mushroom species, only 200 to 300 have been established to be edible and safe, whereas 50 to 100 species are known to be poisonous for human consumption. The toxicity profile of most other species has not been investigated.[1],[2] Consuming mushrooms gathered in the wild is risky and should not be consumed unless the consumer has enough knowledge to identify mushrooms. Most of the mushroom poisoning reported has been accidental oral ingestion of misidentified poisonous mushrooms.[3] Mushroom poisoning (also called mycetism) in humans has been described since time immemorial (“Rigveda” at least 3500 BC and “Atharvaveda” at least 1500 BC).4 The poisonous nature is because of protoplasmic poisons, neurotoxins, and gastrointestinal irritants.[5],[6]

There have been reports of mushroom poisoning in recent years due to accidental consumption of poisonous mushrooms containing alpha-amanitin.[7] In the year 2018, Soltaninejad reported the death of 19 patients due to wild mushroom poisoning in Iran.[3] Poisoning due to Amanita species caused 144 deaths in China during 1994 to 2016.[8] Amanita phalloides is the most poisonous mushroom, which causes severe hepatotoxicity.[9]

Mushrooms are used in many cuisines and have been an integral part of the diet of many tribes and ethnic groups, who consume nearly 285 species of wild mushrooms.[1],[2],[3],[4],[5],[6],[7],[8] In India, mushrooms are widely consumed, especially in the hilly regions of Jammu and Kashmir, Himachal Pradesh, Uttarakhand, and Northeastern states.[10] Dried mushrooms from Kashmir, India, are consumed as delicacies in the Punjab, India as khumb, gucchi, or dhingri without any untoward side effects.[10] Mushroom poisoning in these states is an unrecognized public health problem.

Even though many such cases get reported in local newspapers, it remains vastly under-reported in the medical literature.[5] Here, we report a retrospective data analysis of the outcome of mushroom poisoning encountered in North Eastern Indra Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS) over the past 5 years.


  Materials and methods Top


We retrospectively evaluated the case records of patients with mushroom poisoning over five years (2014–2019) who were admitted to a tertiary care regional institute of northeastern India, a 580 bedded tertiary care referral hospital located in Shillong, India. The medical records of all cases of mushroom poisoning cases admitted to the hospital from August 1, 2014 to July 31, 2019 were retrieved from the institute’s medical records section after an administrative approval at the medical superintendent level. The data were collected and entered in a predesigned proforma. Descriptive statistics were utilized to analyze the data.


  Results Top


Out of 11 districts of Meghalaya, patients from only five districts reported to NEIGRIHMS for treatment during the study period. Fifty-three patients were admitted with mushroom poisoning during the study period of 5 years (2014–2019). There were 34 (64.15%) males and 19 (35.85%) females with a male:female ratio of 1.79:1. In our study, most of the patients (44 cases) presented nausea, vomiting, and diarrhea within 48 hours. Nine patients who reported later than 48 hours had a presentation of acute hepatic failure, renal failure and/or multi-organ failure with intensive care requirements, and a bad prognosis.

As depicted in [Table 1], the most typical age group to be affected with mushroom poisoning was 11 to 20 years, as seen in 16 (30.19%) cases. The oldest patient admitted with mushroom poisoning was a 60-year-old male, and the youngest patient was a two-and-a-half-month-old baby who was breastfed. Out of 53 patients, 33 (62.26%) reported in six clusters. The most significant cluster of eight patients with mushroom poisoning patients was the family members of a single family where the members consumed wild mushroom pickles. Twenty patients (37.74%) were admitted as individual cases of mushroom poisoning.
Table 1: Profile of mushroom poisoning cases at NEIGRIHMS.

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The majority, 40 (75.47%), of the patients survived and got discharged. Nine (16.98%) patients died due to complications of poisoning, and four (7.55%) patients left against medical advice.

[Table 2] details the year-wise patient distribution of cases of mushroom poisoning during the study period. Cases of mushroom poisoning were received from five of 11 districts of the state of Meghalaya, and most of the cases (21, 39.62%) were received from Ri-Bhoi district. Most of the cases of mushroom poisoning occurred during the year 2017 to 2018 (16 cases), followed by 2018 to 2019 (15 cases).
Table 2: District and year-wise distribution of mushroom poisoning cases.

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[Table 3] shows the month-wise distribution of the patients admitted to the hospital during the study period. Most (17, 32.07%) of the cases of mushroom poisoning were recorded during the month of May, which coincides with the peak time of mushroom production in Meghalaya.
Table 3: Month-wise distribution of patients.

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  Discussion Top


Meghalaya is a hilly state and one of the seven states of Northeast India. Mawsynram, the wettest place on the Earth, is located in the state’s East Khasi Hills district. The monsoon season usually starts in May till mid-October. Wild mushroom is a part of routine food among the tribal population due to easy availability in the surroundings. However, due to misidentification, they might consume poisonous mushrooms resulting in morbidity and mortality. The most common complaint of mushroom poisoning in our study was gastrointestinal disturbance following consumption of brown mushrooms collected from the hills. In our study, 53 cases of mushroom poisoning were reported over a span of 5 years with a male to female ratio of 1.79:1, and most of the patients were 11 to 20 years old. The previous case series from India included 15 cases of Amanita phalloides poisoning[11] with the significant clinical presentation with nausea, vomiting, diarrhea, jaundice, and hepatic or renal failure after 48 hours, or both. The early rise in serum alanine transaminase/aspartate transaminase levels was associated with high mortality. The species identification and toxin analysis could not be performed due to the non-availability of the mushroom specimen; however, the clinical presentation was similar to amanita poisoning in our study. Amanita toxicity is characterized by an asymptomatic incubation period followed by the gastrointestinal and hepatotoxic phases, leading eventually to multi-organ failure and death. Ganzert et al.[12] retrospectively analyzed the outcome of a large series of amatoxin intoxication cases and found that predictors of death were the prothrombin index combined with the serum creatinine level on 3 to 10 days after ingestion. Overall, the prognosis of amanitin induced acute liver failure remains relatively low.

Clinical phases of amatoxin poisoning consist of stages 1 to 4.[13] Stage 1 is asymptomatic and has a lag phase of 0 to 24 hours. This is followed by stage 2 of gastrointestinal symptoms (6–24 h) of nausea, vomiting, crampy abdominal pain, and severe secretory diarrhea. Stage 3 of apparent convalescence (24–72 h) consists of asymptomatic, worsening hepatic and renal function indices. Finally, stage 4 of acute liver failure (4–9 days) of hepatic and renal failure/multi-organ failure/death.[13]

Diagnosis is based on a careful assessment of history, circumstantial evidence linking mushroom ingestion to the onset of symptoms. The identification by an experienced mycologist of the remaining mushrooms can be crucial for diagnosis. In the absence of these, the diagnosis is mainly clinical and can best be probable. Since no specific antidote to amatoxins is currently available, management is mostly supportive.[13] Severe acute liver failure is a grade I indication for liver transplantation. Supportive measures including correcting dehydration, electrolyte abnormalities, and metabolic acidosis caused by the gastrointestinal intoxication phase remain the cornerstone. The specific treatments consist of detoxification procedures including gastric lavage, multidose activated charcoal, and extracorporeal purification using Molecular Adsorbent Recirculating System (MARS). Other supportive drugs include Silibinin, Penicillin G, and free radical scavengers such as N-acetylcysteine.[13]

In a retrospective study conducted in Switzerland, 51 cases of mushroom poisoning were reported over 17 years of study with a male:female ratio of 0.76:1, all in the age range from 15 to 79 years.[6] In our series, the death rate was 16.98% (nine deaths out of 53 cases), whereas a series of mushroom poisoning in North India reported nearly 100% fatality.[13] Deaths in mushroom poisoning are due to hepatic, renal, and/or multi-organ failure as a result of late reporting. The high rate of mortality in the hospital setting may be because only serious patients report to the hospital. Most patients either do not seek medical help or are treated at a primary or secondary level of a health facility. Various other studies show the mortality rate due to mushroom poisoning ranging from 1% to 21%.[14],[15],[16] Schmutz et al.[17] in a retrospective study of 11 years, found no death among 86 patients of mushroom poisoning in Lausanne University Hospital. One of Iran’s studies reported an outbreak of mushroom poisoning, resulting in a fatality rate of 1.5%.[3] Age-specific death rate was higher, 4 (30.77%) in the age group of 0 to 10 years in our study, but none of the patients above 41 years of age expired among the patients reported during the study period. A case series from Assam has reported high mortality in patients aged less than 10 years (83%) or more than 50 years (100%).[18]

The monsoon months, which mark the mushroom bloom, witness many poisoning cases, but few are reported, and the rest are undocumented due to lack of confirmatory evidence. In our study, the most number of cases occurred in the month of May. The outbreak of mushroom poisoning in Iran in 2018 was also reported in the month of April to May. People have also reported making pickles of wild mushrooms, which may be the reason for off-season reporting of mushroom poisoning sporadic incidents, as was observed in our series. Patients seeking hospital care later than 48 hours of mushroom poisoning had a bad prognosis in our series. Similar results were reported in other case series from India.[13],[19],[20]

Recently, White et al.[21] have proposed a new clinical classification of mushroom poisoning consisting of six major groups based on key clinical features. Notably, gastrointestinal symptoms are common to many of these mushroom poisoning syndromes. Group 1 includes the following cytotoxic mushroom poisoning related to specific major internal organ pathology: primary hepatotoxicity (amatoxins), primary nephrotoxicity (amino hexadienoic acid), and delayed primary nephrotoxicity (orellanines). Group 2 includes neurotoxic mushroom poisoning such as hallucinogenic mushrooms (psilocybins and related toxins), autonomic-toxicity mushrooms (muscarines), CNS-toxicity mushrooms (ibotenic acid/muscimol), and morel neurologic syndrome (Morchella spp.). Group 3 consists of myotoxic mushroom poisoning with rhabdomyolysis as the primary feature, rapid onset (Russula spp.), and delayed onset (Tricholoma spp.). Group 4 is of metabolic, endocrine, and related toxicity mushroom poisoning such as GABA-blocking mushroom poisoning (gyromitrins), disulfiram-like in response to alcohol intake (coprines), polyporic mushroom poisoning-purple colored urine diagnostic feature (polyporic acid), multi-organ illness in trichothecene mushroom poisoning (Podostroma spp.), hypoglycemic mushroom poisoning (Trogia venenata), hyperprocalcitoninemia mushroom poisoning (Boletus satanas), and pancytopenic mushroom poisoning (Ganoderma neojaponicum). Group 5 consists of gastrointestinal irritant mushroom poisoning that causes gastrointestinal effects without causing other clinically significant effects. Group 6 consists of miscellaneous adverse reactions to mushrooms such as Shiitake mushroom dermatitis, erythromelagic mushrooms (Clitocybe acromelagia), Paxillus syndrome (Paxillus involutus), and encephalopathy syndrome (Pleurocybella porrigens).[21]

Most of the toxic varieties of mushrooms contain more than one of the following classes of toxins: monomethylhydrazines, cyclopeptides, ibotenic acid, psilocybin, coprine, muscarine, and unknown.[22] The clinical syndromes of the patients are generally dependent upon the predominant toxin and are as under.[22],[23]

Gastrointestinal-delayed onset

It is caused mainly by the Amanita and the Gyromitra groups and accounts for more than 95% of the fatalities. Clinical features and stages related to Amanita group discussed above. The symptoms related to Gyromitra are milder and fatalities rarer. Both types of mushrooms are found to contain the following two groups of poisons: (i) phalloidin, heptapeptide responsible for the early symptoms of Amanita poisoning, and (ii) the amanitotoxin, which inhibits RNA polymerase responsible for the production of mRNA.[23]

Autonomic nervous system-rapid onset (Muscarine poisoning)

Autonomic nervous system-rapid onset (Muscarine poisoning) is caused by mushrooms of the genus lnocyhe and Clitocybe containing muscarine that binds to postsynaptic receptors producing an exaggerated cholinergic response within 30 minutes to 2 hours after consumption. The symptoms are found to subside within 6 to 24 hours.[23]

Coprine ingestion

The genera Coprinus atramentarius (Inky Cap mushroom) and Clitocybe claviceps contain coprine, which like disulfiram inhibits the metabolism of acetaldehyde. Coprine intoxication becomes apparent after ingestion of alcohol and may occur up to 5 days after the ingestion of mushrooms in susceptible individuals. Patients present with tachycardia, tingling of face and trunk, and hyperemia. The symptoms are self-limiting and subside within a few hours.[23]

Central nervous system-rapid onset (Ibotenic and muscimol intoxication)

Patients present with obtundation, lethargy, agitation, and hallucinations as well as seizures. Muscimol and ibotenic acid causing above are contained in Amanita muscaria (Fly Agaric) and A. pantherina (Panther Cap). [23]

Indole intoxication

Euphoria and hallucinations, tachycardia, and seizures develop within 30 minutes of ingestion. Psilocybin and psilocin causing above are found in mushrooms of the genus Psilocybe and Copelandia. [23]

Gastrointestinal rapid onset

Acute gastrointestinal symptoms that are generally self-limiting and respond to supportive therapy are caused by many mushrooms such as Green Gill (Chlorophyll molybdites), Gray Pink gill (Entolama lividum), and other associated genera.[23]

Our cases belonged to gastrointestinal delayed onset type.

Limitations of the study

  1. Retrospective study and hence the species identification and toxin analysis could not be done.
  2. The patients were diagnosed based on history, signs, and symptoms following consumption of wild mushrooms.



  Conclusion Top


Mushroom poisoning is a health care concern in the hilly state of Meghalaya. These poisoning cases rarely reach a health care facility where they could be documented. Nearly 75% of the patients admitted with mushroom poisoning recovered and were discharged from the hospital, whereas 16.98% of patients died due to complications of poisoning. Hence, people residing in hilly and far-flung areas where these wild mushrooms are readily available need to be made aware of the dangerous consequences of consuming wild mushrooms through electronic and print media. Regular field visits by health officials regarding the identification of these wild mushroom species need to be undertaken.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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