Wild mushroom poisoning: A case study of amatoxin-containing mushrooms and implications for public health.

Wild mushroom poisoning is a global public health concern, with mushrooms containing amatoxins being the main cause of fatalities. Mushrooms from the genus Amanita and Galerina contain amatoxins. Here we present a case of wild mushroom poisoning that affected three individuals, resulting in two fatalities. Within 10-15 hours after consumption, they experienced symptoms of gastroenteritis such as vomiting, abdominal pain, and diarrhea. One individual sought medical attention promptly and recovered, while the other two sought medical help nearly two or three days after the onset of symptoms, by which time their conditions had already worsened and led to their deaths. The mushrooms were identified belonging to genus Galerina, and laboratory test revealed variations in toxin levels among mushrooms collected from different parts of the decaying stump. The higher levels of α-amanitin, ß-amanitin, and γ-amanitin were detected near the base of the tree stump, but trace levels of α-amanitin were found near the top of the stump, while ß-amanitin and γ-amanitin were undetectable. This case emphasizes the importance of seeking immediate medical attention when experiencing delayed-onset gastrointestinal symptoms, as it may indicate more severe mushroom poisoning, particularly amatoxin poisoning. Timely and appropriate treatment is equally important. Additionally, consuming different units of the mushrooms in the same incident can lead to varying prognoses due to differences in toxin levels.

Effects of interrupting the enterohepatic circulation in amatoxin intoxications.

BACKGROUND: Interruption of the enterohepatic circulation is regarded as an effective way to treat patients with amatoxin poisoning. Nonetheless, its effectiveness has not yet been systematically evaluated. Therefore, we performed a systematic review to investigate the role of enterohepatic circulation on patient outcome and clinical laboratory values. We specifically sought to evaluate the effect of activated charcoal, which absorbs drugs and toxins in the gastrointestinal tract. METHODS: A previously established database with data extracted from case reports and series from literature, supplemented with recent publications, was used. Patient characteristics, outcome, and laboratory values were evaluated. RESULTS: We included 133 publications describing a total of 1,119 unique cases. Survival was 75 per cent in the control group (n = 452), whereas in the group treated with single or multiple doses of activated charcoal (n = 667) survival was 83 per cent (P < 0.001, odds ratio 1.89 [95 per cent confidence interval 1.40-2.56]). Furthermore, no difference in peak values of alanine aminotransferase and aspartate aminotransferase activities were observed, whereas peak values of total serum bilirubin concentration and international normalized ratio were statistically significantly reduced in patients treated with activated charcoal. DISCUSSION: The ability of activated charcoal to enhance the elimination of amatoxin through interruption of the enterohepatic circulation offers a potentially safe and inexpensive therapy for patients in the post-absorptive phase. LIMITATIONS: Limitations include the potential for publication bias, the lack of universal confirmation of amatoxin concentrations, and the inability to directly measure enterohepatic circulation of amatoxin. CONCLUSION: Treatment with activated charcoal in patients with amatoxin poisoning was associated with a greater chance of a successful outcome. Additionally, activated charcoal was associated with a reduction in markers of liver function, but not markers of liver injury.

Acute hepatic and kidney injury after ingestion of Lepiota brunneoincarnata: Report of 2 cases.

Lepiota brunneoincarnata is a highly toxic mushroom species known to cause acute liver failure. However, there are limited reports investigating L. brunneoincarnata causing acute hepatic and renal damage. The present article reports 2 cases of L. brunneoincarnata poisoning in a mother and son from Chuxiong City, Yunnan Province, China. Both patients presented with gastrointestinal symptoms approximately 8-9 h after ingesting the suspect mushrooms and sought medical attention 27-28 h post-ingestion, both exhibiting acute hepatic and kidney injuries. Morphological and molecular biology studies confirmed the species of the mushrooms as L. brunneoincarnata. Liquid chromatography-tandem mass spectrometry analysis revealed mean fresh-weight concentrations of 123.5 µg/g α-amanitin and 45.7 µg/g ß-amanitin in the mushrooms. The patients underwent standard treatments, including multiple-dose activated charcoal, oral silibinin capsules, N-acetylcysteine, penicillin G, hemoperfusion, and plasma exchange. One patient recovered completely and was discharged after 16 days of hospitalization. The other patient exhibited gradual improvement in liver and renal function; however, renal function deteriorated 9 days after ingestion, and the patient declined renal replacement therapy and returned home 14 days post-ingestion. The patient was then re-hospitalized due to oliguria and edema in both lower extremities. Renal biopsy revealed acute tubular necrosis, inflammatory cell infiltration, minor glomerular capsular fibrosis, loss of microvilli in the renal tubular epithelial cells, and interstitial edema. The patient underwent 2 rounds of continuous renal replacement therapy, which eventually resulted in improvement, and was discharged 31 days after mushroom consumption. It is noteworthy that this patient had already progressed to chronic kidney insufficiency 11 months after intoxication.

Simple and rapid detection of three amatoxins and three phallotoxins in human body fluids by UPLC-MS-MS and its application in 15 poisoning cases.

Amatoxins and phallotoxins are toxic cyclopeptides found in the genus Amanita and are among the predominant causes of foodborne sickness and poisoning-related fatalities in China. This study introduces and validates a simple, rapid and cost-effective ultra-performance liquid chromatography-mass spectrometry method for the simultaneous determination and quantification of α-amanitin, ß-amanitin, γ-amanitin, phallisacin, phallacidin and phalloidin in human blood and urine. Quick therapeutic decision-making is supported by a 9 min chromatographic separation performed on a Waters Acquity UPLC HSS T3 column (100 mm × 2.1 mm, 1.8 µm) using a gradient of high-performance liquid chromatography (HPLC)-grade water and methanol:0.005% formic acid. The analyte limit of quantification was 1-3 ng/mL in blood and 0.5-2 ng/mL in urine. Calibrations curves, prepared by spiking drug-free blood and urine, demonstrated acceptable linearity with mean correlation coefficients (r) greater than 0.99 for all phallotoxins and amatoxins. Acceptable intraday and interday precision (relative standard deviation <15%) and accuracy (bias, -4.8% to 13.0% for blood and-9.0% to 14.7% for urine) were achieved. The validated method was successfully applied to analyze 9 blood samples and 2 urine samples testing positive for amatoxins and/or phallotoxins. Amatoxins and/or phallotoxins were identified in each whole blood sample at a range of 1.12-5.63 ng/mL and in two urine samples from 1.01-9.27 ng/mL. The method has the benefits of simple sample preparation (protein precipitation) and wide analyte coverage, making it suitable for emergency quantitative surveillance toxicological analysis in clinics and forensic poisoning practice.

A label-free electrochemical immunosensor based on decorated cellulose nanofibrous membrane for point-of-care diagnosis of amanitin poisoning via human urine.

α-Amanitin (AMN) is one of the deadliest toxins from mushrooms, present in the deadly mushroom species Amanita phalloides. It is a bicyclic octapeptide and represents up to 40% of the amatoxins in mushrooms, damaging the liver and kidneys. Current methods of detecting amatoxins are time-consuming and require the use of expensive equipment. A novel label-free electrochemical immunosensor was successfully developed for rapid detection of α-amanitin, which was fabricated by immobilization of anti-α-amanitin antibodies onto a functionalized cellulose nanofibrous membrane-modified carbon screen-printed electrode. An oxidation peak of the captured amanitin on the tethered antibodies was observed at 0.45 V. The performance of the nanofibrous membrane on the electrode and necessary fabrication steps were investigated by electrochemical impedance spectroscopy (EIS) and cyclic voltammetry (CV). Due to its unique structural features and properties such as high specific surface area and microporous structure, the nanofibrous membrane as an immunosensor matrix for antibody tethering improved the electrochemical performance of the immunosensor by more than 3 times compared with cast membranes. Under the optimal conditions, the assembled immunosensor exhibited high sensitivity toward α-amanitin detection in the range of 0.009-2 ng mL-1 with a limit of detection of 8.3 pg mL-1. The results clearly indicate that the fabricated nanofiber-based-immunosensor is suitable for point-of-care detection of lethal α-amanitin in human urine without any pretreatment within 30 min.

Amanitins: The Most Poisonous Molecules of the Fungal World.

Among the toxic metabolites of the fungal world, those that, due to their strong biological effect, can seriously (even fatally) damage the life processes of humans (and certain groups of animals) stand out. Amatoxin-containing mushrooms and the poisonings caused by them stand out from the higher fungi, the mushrooms. There are already historical data and records about such poisonings, but scientific research on the responsible molecules began in the middle of the last century. The goals of this review work are as follows: presentation of the cosmopolitan mushroom species that produce amanitins (which are known from certain genera of four mushroom families), an overview of the chemical structure and specific properties of amanitins, a summary of the analytical methods applicable to them, a presentation of the "medical history" of poisonings, and a summary of the therapeutic methods used so far. The main responsible molecules (the amanitins) are bicyclic octapeptides, whose structure is characterized by an outer loop and an inner loop (bridge). It follows from the unusual properties of amanitins, especially their extreme stability (against heat, the acidic pH of the medium, and their resistance to human, and animal, digestive enzymes), that they are absorbed almost without hindrance and quickly transported to our vital organs. Adding to the problems is that accidental consumption causes no noticeable symptoms for a few hours (or even 24-36 h) after consumption, but the toxins already damage the metabolism of the target organs and the synthesis of nucleic acid and proteins. The biochemical catastrophe of the cells causes irreversible structural changes, which lead to necrotic damage (in the liver and kidneys) and death. The scientific topicality of the review is due to the recent publication of new data on the probable antidote molecule (ICR: indocyanine green) against amanitins. Further research can provide a new foundation for the therapeutic treatment of poisonings, and the toxicological situation, which currently still poses a deadly threat, could even be tamed into a controllable problem. We also draw attention to the review conclusions, as well as the mycological and social tasks related to amanitin poisonings (prevention of poisonings).

Amatoxin poisoning caused by Galerina sulciceps, a species with no prior record of identification in Japan: a case report.

A 60-year-old man presented with acute gastroenteritis, hypovolemic shock, acute renal failure (BUN/Cr, 56.7/4.24 mg/dl), and aspiration pneumonia. The previous day, he ingested 30 caps of mushrooms of an unknown species. The patient was treated with a massive intravenous infusion, renal replacement therapy, and antimicrobial agents. Late-onset mild liver injury peaked on day 11 (AST/ALT, 62/67 IU/l). Acute renal failure improved once before worsening, with the worst symptoms on day 19 (BUN/Cr, 99/6.61 mg/dl). Thereafter, the patient showed gradual improvement, and renal replacement therapy was discontinued on day 23. His general condition improved fully and he was transferred to another hospital for rehabilitation on day 47. The mushrooms were later identified as Galerina sulciceps by the Basic Local Alignment Search Tool, and toxicologic analysis using liquid chromatography-tandem mass spectrometry revealed an average of 85 ppm α-amanitin and 330 ppm ß-amanitin in the tissue of the mushrooms brought in by the patient's family. Galerina sulciceps is distributed mainly in tropical and subtropical regions of Southeast Asia and had never been identified before in Japan. The heat of fermentation generated by the thick layer of wood chips on the ground or global warming may have contributed to its growth in Japan. Interestingly, our patient did not have liver dysfunction, which is one main and typical amatoxin poisoning symptom. Variation in clinical presentation may be attributed to the different ratios of α-amanitin to ß-amanitin in different mushroom species.

Determination of protein-bound α-amanitin in mouse plasma: A potential new indicator of poisoning with the mushroom toxin α-amanitin.

Approximately 70%∼90% of mushroom poisoning deaths are caused by the class of mushroom toxins known as amatoxins. However, the rapid elimination of amatoxins from plasma within 48 h after mushroom ingestion limits the practical value of plasma amatoxin analysis as a diagnostic indicator of Amanita mushroom poisoning. To increase the positive detection rate and extend the detection window of amatoxin poisoning, we developed a new method to detect protein-bound α-amanitin based on the hypothesis that RNAP II-bound α-amanitin released from the tissue into the plasma could be degraded by trypsin hydrolysis and then detected by conventional liquid chromatography-mass spectrometry (LC‒MS). Toxicokinetic studies on mice intraperitoneally injected with 0.33 mg/kg α-amanitin were conducted to obtain and compare the concentration trends, detection rates, and detection windows of both free α-amanitin and protein-bound α-amanitin. By comparing detection results with and without trypsin hydrolysis in the liver and plasma of α-amanitin-poisoned mice, we verified the credibility of this method and the existence of protein-bound α-amanitin in plasma. Under the optimized trypsin hydrolysis conditions, we obtained a time-dependent trend of protein-bound α-amanitin in mouse plasma at 1-12 days postexposure. In contrast to the short detection window (0-4 h) of free α-amanitin in mouse plasma, the detection window of protein-bound α-amanitin was extended to 10 days postexposure, with a total detection rate of 53.33%, ranging from the limit of detection to 23.94 µg/L. In conclusion, protein-bound α-amanitin had a higher positive detection rate and a longer detection window than free α-amanitin in mice.

[Determination of five amanita peptide toxins in poisonous mushrooms by ultra performance liquid chromatography-quadrupole electrostatic field orbitrap high resolution mass spectrometry].

Food poisoning by toxic mushrooms occurs frequently worldwide. It is one of the most common food poisoning events and the main cause of death. Amanita peptide toxins are the most common lethal toxins in poisonous mushrooms. Presently, a novel method based on ultra performance liquid chromatography-quadrupole electrostatic field orbitrap high resolution mass spectrometry (UPLC-Q/Orbitrap HRMS) was developed for the determination of five amanitapeptide toxins (α-amanitin, ß-amanitin, γ-amanitin, phalloidin, and phallacidin). Because the isotope summit of α-amanitin affects the detection of ß-amanitin, it cannot be distinguished by low resolution mass spectrometry. Therefore, experimental conditions including chromatography and mass spectrometry were explored in detail. The five peptide toxins were extracted from poisonous mushrooms with pure water and filtered through a 0.22 µm teflon microporous membrane. The procedure was rapid, simple, and environmentally friendly. Chromatographic separation was performed on a strong polarity HSS T3 column (100 mm×2.0 mm, 2.1 µm) with gradient elution using acetonitrile and 5 mmol/L ammonium acetate containing 0.1% (v/v) formic acid as mobile phases at a flow rate of 0.3 mL/min. The column temperature was set to 40 ℃. The analytes were ionized using a heating electrospray ionization source and collected in positive ion mode. Full scanning/data-dependent secondary mass spectrometry (Full mass-ddMS2) mode was used for qualitative analysis of the targets within 10 min. The target ion selective scan (Targeted-SIM) mode was used for quantification by external standard calibration. The measured and theoretical values of the exact mass and the MS2 fragment ions of the five compounds were within an error of 5×10-6. Method validation was performed according to the criteria recommended by the Chinese National Standard. All the compounds showed an excellent linear relationship in the range of 1.0-20.0 µg/L. The correlation coefficients (r) ranged from 0.9974 to 0.9989. The limit of detection was 0.006 mg/kg for all five compounds. Recoveries ranged from 81.8% to 102.4%. There was no matrix effect in the blank mushroom sample for the five compounds, and the relative standard deviations ranged from 3.2% to 8.3%. This method provides abundant compound characteristic mass information, such as retention time, exact mass, fragment ions, and other information. The data can be used to identify suspected compounds based on the extracted ion flow diagram and isotope distribution information. Comparison between the actual exact mass and the theoretical exact mass, combined with the fragment ions enables identification of the structures of unknown compounds and collision methods, which can be confirmed in the absence of standard materials. In this study, the isomer of γ-amanitin was identified as amaninamide. The novel method is simple, accurate, specific, and sensitive. The method permits the rapid qualitative and quantitative detection of compound in public health emergency settings and will provide reliable technical support for the rapid screening of such toxic compounds and the structural locking of unknown toxins in the future.

Mechanism and treatment of α-amanitin poisoning.

Amanita poisoning has a high mortality rate. The α-amanitin toxin in Amanita is the main lethal toxin. There is no specific detoxification drug for α-amanitin, and the clinical treatment mainly focuses on symptomatic and supportive therapy. The pathogenesis of α-amanitin mainly includes: α-amanitin can inhibit the activity of RNA polymeraseII in the nucleus, including the inhibition of the largest subunit of RNA polymeraseII, RNApb1, bridge helix, and trigger loop. In addition, α-amanitin acts in vivo through the enterohepatic circulation and transport system. α-Amanitin can cause the cell death. The existing mechanisms of cell damage mainly focus on apoptosis, oxidative stress, and autophagy. In addition to the pathogenic mechanism, α-amanitin also has a role in cancer treatment, which is the focus of current research. The mechanism of action of α-amanitin on the body is still being explored.

The occurrence of ansamers in the synthesis of cyclic peptides.

α-Amanitin is a bicyclic octapeptide composed of a macrolactam with a tryptathionine cross-link forming a handle. Previously, the occurrence of isomers of amanitin, termed atropisomers has been postulated. Although the total synthesis of α-amanitin has been accomplished this aspect still remains unsolved. We perform the synthesis of amanitin analogs, accompanied by in-depth spectroscopic, crystallographic and molecular dynamics studies. The data unambiguously confirms the synthesis of two amatoxin-type isomers, for which we propose the term ansamers. The natural structure of the P-ansamer can be ansa-selectively synthesized using an optimized synthetic strategy. We believe that the here described terminology does also have implications for many other peptide structures, e.g. norbornapeptides, lasso peptides, tryptorubins and others, and helps to unambiguously describe conformational isomerism of cyclic peptides.

Results of diagnostics and treatment of amanita phalloides poisoning in Slovakia (2004-2020).

The paper presents results of AI diagnostics and treatment across the period of 2004-2020 pointing to the efficacy of two particular protocols. METHOD: Quantitative determination of amanitins in blood (ATOs) and urine (ATOu) performed by the original ELISA kit, indicated upon mycological history and clinical symptoms of poisoning. ATOu positive cases were recommended our protocol; ATOu negative results excluded amanitin poisoning. RESULTS: out of 2876 fungal poisonings registered in Slovakia during the subjected period, were 698 AI suspected cases. In 557 of them, was AI reliably excluded, in 141 confirmed. Urinary ATOu correlated with the severity of poisoning in the range of 6-47 h after mushroom ingestion, without false negativity. Serum ATOs had no diagnostic value. 129 patients with confirmed AI received full treatment protocol with antidotes of penicillin plus silibinin. In this group died two patients of acute kidney injury in the early stages of poisoning and 127 patients were recovered. Silibinin without penicillin was used in 12 patients. One of them undergone liver transplantation and four patients died of fulminant liver failure, respectively intracranial hemorrhage. Treatment failure in the PNC + silibinin protocol was 1.5 % (2 of 127 patients), silibinin alone being 41.7 % (5 of 12 patients, p = 0.00058). CONCLUSION: Early diagnostics of amanitin intoxication based on mycological and clinical history and subsequent determination of urinary amanitin levels (ATOu) allows early initiation of treatment. The use of treatment protocol with antidotes of PNC and silibinin is of high therapeutic efficacy. The omission of PNC from the treatment protocol significantly worsens patients' prognosis.

Amanitin intoxication: effects of therapies on clinical outcomes - a review of 40 years of reported cases.

BACKGROUND AND AIMS: Amanita phalloides poisoning causes severe liver damage which may be potentially fatal. Several treatments are available, but their effectiveness has not been systematically evaluated. We performed a systematic review to investigate the effect of the most commonly used therapies: N-acetylcysteine (NAC), benzylpenicillin (PEN), and silibinin (SIL) on patient outcomes. In addition, other factors contributing to patient outcomes are identified. METHODS: We searched MEDLINE and Embase for case series and case reports that described patient outcomes after poisoning with amanitin-containing Amanita mushrooms. We extracted clinical characteristics, treatment details, and outcomes. We used the liver item from the Poisoning Severity Score (PSS) to categorize intoxication severity. RESULTS: We included 131 publications describing a total of 877 unique cases. The overall survival rate of all patients was 84%. Patients receiving only supportive care had a survival rate of 59%. The use of SIL or PEN was associated with a 90% (OR 6.40 [3.14-13.04]) and 89% (OR 5.24 [2.87-9.56]) survival rate, respectively. NAC/SIL combination therapy was associated with 85% survival rate (OR 3.85 [2.04, 7.25]). NAC/PEN/SIL treatment group had a survival rate of 76% (OR 2.11 [1.25, 3.57]). Due to the limited number of cases, the use of NAC alone could not be evaluated. Additional analyses in 'proven cases' (amanitin detected), 'probable cases' (mushroom identified by mycologist), and 'possible cases' (neither amanitin detected nor mushroom identified) showed comparable results, but the results did not reach statistical significance. Transplantation-free survivors had significantly lower peak values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total serum bilirubin (TSB), and international normalized ratio (INR) compared to liver transplantation survivors and patients with fatal outcomes. Higher peak PSS was associated with increased mortality. CONCLUSION: Based on data available, no statistical differences could be observed for the effects of NAC, PEN or SIL in proven poisonings with amanitin-containing mushrooms. However, monotherapy with SIL or PEN and combination therapy with NAC/SIL appear to be associated with higher survival rates compared to supportive care alone. AST, ALT, TSB, and INR values are possible predictors of potentially fatal outcomes.

Toxin screening of Pseudosperma umbrinellum (Agaricals, Basidiomycota): First report of phalloidin in Inocybaceae mushroom.

Pseudosperma species are widely distributed worldwide. Many of them cause poisoning incidents every year, and the toxin responsible for poisoning is muscarine, which could stimulate the parasympathetic nervous system. This study established a method using multiwalled carbon nanotube purification and liquid chromatography-tandem mass spectrometry for the targeted screening of mushroom toxins (muscarine, isoxazole derivatives, tryptamine alkaloids, three amatoxins and three phallotoxins) from Pseudosperma umbrinellum, a common poisonous mushroom distributed in north and northwestern China. Surprisingly, in addition to muscarine, phalloidin was also detected in P. umbrinellum, and the contents were 3022.2 ± 604.4 to 4002.3 ± 804.6 mg/kg (k = 2; p = 95%) muscarine and 5.9 ± 1.2 to 9.3 ± 1.8 mg/kg (k = 2; p = 95%) phalloidin.

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

OBJECTIVE: To describe the rapid diagnosis, treatment, and clinical course of a dog that ingested an amanitin-containing mushroom. CASE SUMMARY: A 2-month-old female intact Australian Shepherd presented with diarrhea and vomiting, along with a possible mushroom exposure. Upon presentation, the dog's urine was collected and tested positive by a point-of-care rapid diagnostic test specific for detecting amanitins, the causative agents of amatoxicosis. NEW OR UNIQUE INFORMATION PROVIDED: This is the first reported case of amatoxicosis that was diagnosed using a point-of-care test prior to starting treatment. An early diagnosis helps to guide early treatment decisions in this frequently fatal toxicosis.

Ultrasensitive paper sensor for simultaneous detection of alpha-amanitin and beta-amanitin by the production of monoclonal antibodies.

Amanitin (AMA) is responsible for human fatalities after ingestion of poisonous mushrooms, thus, a rapid and accurate detection method is urgently needed. Here, gold nanoparticle-based immunosensor with monoclonal antibody against AMA was constructed for rapid detection of alpha- and beta-amanitin (α- and ß-AMA) in mushroom, serum and urine samples. Under optimized conditions, the visual limits of detection (vLOD) and calculated LOD for α-AMA and ß-AMA in mushroom were 10 ng/g, 20 ng/g, and 0.1 ng/g, 0.2 ng/g, respectively. Analysis of wild mushroom samples was also performed using a strip scan reader in the 10 min range. Furthermore, in mushrooms containing amatoxins results were confirmed and compared with those determined by liquid chromatography tandem mass spectrometry. Thus, this immunosensor provided a useful monitoring tool for rapid detection and screening of mushroom samples and in serum and urine from subjects who accidentally consumed AMA-containing mushrooms.