Current fatality rate of suspected cyclopeptide mushroom poisoning in the United States.

OBJECTIVE: This study was designed to determine the fatality rate of suspected cyclopeptide-containing mushroom ingestions reported to the National Poison Data System (NPDS). BACKGROUND: Although silibinin reportedly improves survival in suspected cyclopeptide-containing mushroom ingestions, the greater than 20% untreated fatality rate that is often cited is based on decades-old data. An ongoing open-label silibinin trial will likely use historical cases as comparators. A recent single poison control center (PCC) study showed a fatality rate of 8.3%. This study was designed to validate those findings in the NPDS. METHODS: This study was an 11-year (1/1/2008-12/31/2018) retrospective review of suspected cyclopeptide-containing mushroom ingestions reported to NPDS. Inclusion and exclusion criteria were the same as the ongoing silibinin trial: Age >2-years-old; history of eating foraged mushrooms; gastrointestinal symptoms within 48 h of mushroom ingestion; and aminotransferases above the upper limit of normal within 48 h after ingestion. Each original participating PCC confirmed eligibility, diagnosis, treatment, and outcome on included cases. RESULTS: During the study period, 8,953 mushroom exposures were reported to NPDS, of which 296 met inclusion criteria. The PCC survey response rate was 60% (28/47 PCCs), and the individual case response rate was 59% (174/296). Twenty-six cases were subsequently excluded leaving 148 included cases. The overall mortality rate was 8.8% (13/148). Mortality in silibinin/silymarin-treated vs untreated cases was 9.5% (4/42), vs 8.5% (9/106), respectively. A mycologist identified mushrooms in 16.9% of cases (25/148), of which 80% (20/25) were cyclopeptide-containing. Among these confirmed cases, the mortality rate was 10% (1/10) in both silibinin/silymarin-treated and untreated cases. CONCLUSIONS: The contemporary mortality rate of patients with presumed cyclopeptide-mushroom poisoning is only 8.8%. This likely represents improved supportive care for patients with acute liver injury and should be considered the current standard for historical controls in the United States.

Toxicopathology induced by microcystins and nodularin: a histopathological review.

Cyanobacteria are present in all aquatic ecosystems throughout the world. They are able to produce toxic secondary metabolites, and microcystins are those most frequently found. Research has displayed a negative influence of microcystins and closely related nodularin on fish, and various histopathological alterations have been observed in many organs of the exposed fish. The aim of this article is to summarize the present knowledge of the impact of microcystins and nodularin on the histology of fish. The observed negative effects of cyanotoxins indicate that cyanobacteria and their toxins are a relevant medical (due to irritation, acute poisoning, tumor promotion, and carcinogenesis), ecotoxicological, and economic problem that may affect both fish and fish consumers including humans.

A concept study on identification and attribution profiling of chemical threat agents using liquid chromatography-mass spectrometry applied to Amanita toxins in food.

Accidental or deliberate poisoning of food is of great national and international concern. Detecting and identifying potentially toxic agents in food is challenging due to their large chemical diversity and the complexity range of food matrices. A methodology is presented whereby toxic agents are identified and further characterized using a two-step approach. First, generic screening is performed by LC/MS/MS to detect toxins based on a list of selected potential chemical threat agents (CTAs). After identifying the CTAs, a second LC/MS analysis is performed applying accurate mass determination and the generation of an attribution profile. To demonstrate the potential of the methodology, toxins from the mushrooms Amanita phalloides and Amanita virosa were analyzed. These mushrooms are known to produce cyclic peptide toxins, which can be grouped into amatoxins, phallotoxins and virotoxins, where α-amanitin and ß-amanitin are regarded as the most potent. To represent a typical complex food sample, mushroom stews containing either A. phalloides or A. virosa were prepared. By combining the screening method with accurate mass analysis, the attribution profile for the identified toxins and related components in each stew was established and used to identify the mushroom species in question. In addition, the analytical data was consistent with the fact that the A. virosa specimens used in this study were of European origin. This adds an important piece of information that enables geographic attribution and strengthens the attribution profile.

Pathologic findings and toxin identification in cyanobacterial (Nodularia spumigena) intoxication in a dog.

A 3-year-old Cairn Terrier dog that had been in contact with sea water containing cyanobacteria (blue-green algae) was euthanized because of acute hepatic failure and anuria after a 5-day illness. Histologic findings included lytic and hemorrhagic centrilobular hepatocellular necrosis and renal tubular necrosis. The cyanotoxin nodularin was detected in liver and kidney by high-performance liquid chromatography-mass spectrometry. Nodularin is a potent hepatotoxin produced by the algal species Nodularia spumigena. The intensity of algal blooms has increased during the past decades in the Baltic Sea region, thus increasing the risk for intoxications in domestic and wild animals. The authors describe the pathologic findings of cyanobacterial toxicosis in a dog with direct identification of the toxin from organ samples.

Cyanobacterial poisoning in livestock, wild mammals and birds--an overview.

Poisoning of livestock by toxic cyanobacteria was first reported in the 19th century, and throughout the 20th century cyanobacteria-related poisonings of livestock and wildlife in all continents have been described. Some mass mortality events involving unrelated fauna in prehistoric times have also been attributed to cyanotoxin poisoning; if correct, this serves as a reminder that toxic cyanobacteria blooms predate anthropogenic manipulation of the environment, though there is probably general agreement that human intervention has led to increases in the frequency and extent of cyanobacteria blooms. Many of the early reports of cyanobacteria poisoning were anecdotal and circumstantial, albeit with good descriptions of the appearance and behaviour of cyanobacteria blooms that preceded or coincided with illness and death in exposed animals. Early necropsy findings of hepatotoxicity were subsequently confirmed by experimental investigations. More recent reports supplement clinical and post-mortem findings with investigative chemistry techniques to identify cyanotoxins in stomach contents and tissue fluids.

Sublethal exposure from microcystins to renal insufficiency patients in Rio de Janeiro, Brazil.

In November 2001, a cyanobacterial bloom dominated by Microcystis and Anabaena occurred in the Funil Reservoir and the Guandu River, both of which supply drinking water to Rio de Janeiro, Brazil. Using ELISA, microcystins were detected at a concentration of 0.4 microg/L in the drinking water, whereas a concentration of 0.32 microg/L was detected in activated carbon column-treated water for use at the renal dialysis center of Clementino Fraga Filho Hospital (HUCFF) at the Federal University of Rio de Janeiro. A total of 44 hemodialysis patients who received care at this center were believed to be exposed. Initial ELISA analyses confirmed the presence of serum microcystin concentrations > or = 0.16 ng/mL in 90% of serum samples collected from these patients. Twelve patients were selected for continued monitoring over the following 2-month period. Serum microcystin concentrations ranged from < 0.16 to 0.96 ng/mL during the 57 days after documented exposure. ELISA-positive samples were found throughout the monitoring period, with the highest values detected 1 month after initial exposure. ESI LC/MS analyses indicated microcystins in the serum; however, MS/MS fragmentation patterns typical of microcystins were not identified. LC/MS analyses of MMPB for control serum spiked with MCYST-LR. and patient sera revealed a peak at retention time of 8.4 min and a mass of 207 m/z. These peaks are equivalent to the peak observed in the MMPB standard analysis. Taken together ELISA, LC/MS, and MMPB results indicate that these renal dialysis patients were exposed to microcystins. This documents another incident of human microcystin exposure during hemodialysis treatment.

Guidance values for microcystins in water and cyanobacterial supplement products (blue-green algal supplements): a reasonable or misguided approach?

This article reviews current scientific knowledge on the toxicity and carcinogenicity of microcystins and compares this to the guidance values proposed for microcystins in water by the World Health Organization, and for blue-green algal food supplements by the Oregon State Department of Health. The basis of the risk assessment underlying these guidance values is viewed as being critical due to overt deficiencies in the data used for its generation: (i) use of one microcystin congener only (microcystin-LR), while the other presently known nearly 80 congeners are largely disregarded, (ii) new knowledge regarding potential neuro and renal toxicity of microcystins in humans and (iii) the inadequacies of assessing realistic microcystin exposures in humans and especially in children via blue-green algal food supplements. In reiterating the state-of-the-art toxicology database on microcystins and in the light of new data on the high degree of toxin contamination of algal food supplements, this review clearly demonstrates the need for improved kinetic data of microcystins in humans and for discussion concerning uncertainty factors, which may result in a lowering of the present guidance values and an increased routine control of water bodies and food supplements for toxin contamination. Similar to the approach taken previously by authorities for dioxin or PCB risk assessment, the use of a toxin equivalent approach to the risk assessment of microcystins is proposed.

Protective efficacy and the recovery profile of certain chemoprotectants against lethal poisoning by microcystin-LR in mice.

The cyclic peptide toxins microcystins and nodularins are the most common and abundant cyanotoxins present in diverse water systems. They have been the cause of human and animal health hazards and even death. Development of suitable chemoprotectants against microcystin is essential considering the human health importance. In the present study, three agents cyclosporin-A (10mg/kg), rifampin (25mg/kg) and silymarin (400mg/kg) pre-treatment gave 100% protection against lethal dose of microcystin-LR (100 microg/kg). Various biochemical parameters were evaluated to study the recovery profile of protected animals at 1, 3, 7 and 14 days post-toxin treatment. There was significant depletion of hepatic glutathione in protected animals compared to control group till 7 days post-treatment but normalised by 14 days. Similarly enhanced hepatic lipid peroxidation, inhibition of protein phosphatase activity was observed till 3-7 days post-treatment in protected animals. Elevated levels of enzymes alanine amino transferase, lactate dehydrogenase and sorbitol dehydrogenase were observed in serum at 1 day post-treatment. All the biochemical variables reached control levels by 14 day post-treatment. Immunoblotting analyses of liver homogenates showed microcystin-protein phosphatase adduct in liver samples of toxin treated as well as antidote-protected animals. The adduct could be seen even after 14 days post-toxin treatment. The study shows that though cyclosporin-A, rifampin and silymarin could offer 100% protection against microcystin-LR induced lethality many of the toxic manifestations are persistent and could not be reversed till 7 days.

Cap mushroom poisonings.

This paper presents species of fungi of high toxicity. Their consumption might have serious consequences for health and in many cases it might lead to death. Toxic compounds present in fungi have also been characterised, mechanisms of their toxic activity have been presented and clinical symptoms of poisoning have been described. Hallucinogenic mushrooms have also been mentioned as they have recently become a serious problem: many people use them to intoxicate themselves. There are also species of mushrooms that can be consumed under certain conditions since they can occasionally trigger off serious disturbances for the functioning of organisms.

Human intoxication by microcystins during renal dialysis treatment in Caruaru-Brazil.

In February 1996, an outbreak of illness occurred at a hemodialysis clinic in Caruaru, Pernambuco State-Brazil. At this clinic 116 (89%) of 131 patients experienced visual disturbances, nausea, vomiting, and muscle weakness, following routine haemodialysis treatment. Subsequently, 100 patients developed acute liver failure. As of December 1996, 52 of the deaths could be attributed to a common syndrome now called 'Caruaru Syndrome'. Examination of previous years' phytoplankton counts showed that cyanobacteria were dominant in the water supply reservoir since 1990. Analyses of carbon and other resins from the clinic's water treatment system plus serum and liver tissue of patients led to the identification of two groups of hepatotoxic cyanotoxins: microcystins (cyclic heptapeptides) in all of these samples and cylindrospermopsin (alkaloid hepatotoxic) in the carbon and resins. Comparison of victims symptoms and pathology with animal studies on these two cyanotoxins, leads us to conclude that the major contributing factor to death of the dialysis patients was intravenous exposure to microcystins, specifically microcystin-YR, -LR and -AR. In 2000, a review of the Brazilian regulation for drinking water quality, promoted by Brazilian Health Ministry with collaboration of PAHO, incorporated cyanobacteria and cyanotoxins into this new regulation as parameters that must to be monitored for water quality control.

Impact of a toxic and a non-toxic strain of Microcystis aeruginosa on the crayfish Procambarus clarkii.

The occurrence of cyanobacteria in many water bodies where crayfish such as Procambarus clarkii are abundant leads to the possibility of toxin accumulation and food chain transfer. This paper describes the accumulation and depuration of microcystins from a microcystin and a non-microcystin producing strain of Microcystis aeruginosa, on the survivorship, growth and nutritional status of P. clarkii. Crayfish larvae were resistant to cyanobacteria and their toxins, surviving cyanobacteria densities during acute exposures. Juvenile crayfish tolerated toxic cyanobacteria better than non-toxic ones. This effect was also observed when analysing nutritional status of crayfish fed toxic and non-toxic cyanobacteria with the former having better lipid and protein contents than those fed non-toxic Microcystis. P. clarkii accumulated up to 2.9 microg MCYST/dry crayfish weight and the depuration pattern was similar to that observed for mussels by other authors. Due to the fact that the major part of the toxin is accumulated in the intestine and in the hepatopancreas, there is no significant risk in terms of human health if these parts are removed prior to crayfish consumption. Nevertheless, their use in dairy food and the possible transference of toxins along food chains should not be disregarded.

Toxicology and evaluation of microcystins.

This paper reviews the toxicity and tumor-promoting properties of microcystins. Methods for screening and/or identification of microcystins in environmental samples are discussed and compared. Specific emphasis is placed on newly developed extraction/detection methods, e.g., solid phase microextraction (SPME) technique, and capillary electrophoresis coupled with laser-induced fluorescence detection. The results of a kinetic analysis of the effects of microcystins on phosphorylase-a binding to phosphatase-2A using a surface plasmon resonance biosensor are also presented.

Preference of mice to consume Microcystis aeruginosa (toxin-producing cyanobacteria): a possible explanation for numerous fatalities of livestock and wildlife.

Cyanobacteria often produce severe illness and in some cases spectacular fatality on livestock and wildlife world-wide. Heavy cyanobacterial waterblooms usually form patches of dense surface scum, and terrestrial animals drinking such concentrated dirty froth can consume a fatal dose. Surprisingly, animals do not avoid swallowing concentrated microbial scum. Different experiments of drink selection were performed with laboratory mice to determine why animals drink these concentrated scum. These experiments showed that animals elected to consume dense cultures of the toxic cyanobacteria Microcystis aeruginosa in preference to limpid water. When M. aeruginosa cells were supplied ad libitum, mice avidly swallowed these toxic cyanobacteria until this led to their death. Mice were unable to detect the phycotoxin (microcystin). In contrast, mice did not select cultures containing other non-toxic phytoplanktonic organisms. Observations in nature suggest that this preference in the consumption of toxic cyanobacteria is common among other animal species.

Blue-green algae toxicosis in cattle.

Twenty-four of 175 heifers died after ingesting water from a stock pond containing blue-green algae (genus Microcystis) in southern Colorado. Affected cattle were found dead or had signs of nervousness, and were recumbent, weak, anorectic, and hypersensitive to noise when first examined. All cattle died within 3 days after the onset of signs. At necropsy, the rumen contained blue-green algae, and the liver was larger than normal, friable, and dark red. The most important histologic lesion was hepatocyte degeneration and necrosis. Intraperitoneal administration of lyophilized cell material from the bloom caused hepatic necrosis and death in mice, and water from the pond had clumps of cells surrounded by a clear calyx, consistent with the appearance of organisms of the genus Microcystis. Samples of pond water were examined by means of high-pressure liquid chromatography; microcystin-LR, one of the hepatotoxins produced by Microcystis spp, was found. Chromatography may be useful in the diagnosis of blue-green algae toxicosis.

Fatal microcystin intoxication in haemodialysis unit in Caruaru, Brazil.

BACKGROUND: After a drought in February, 1996, all 126 patients in a haemodialysis unit in Caruaru, north-east Brazil, developed signs and symptoms of acute neurotoxicity and subacute hepatotoxicity following the use of water from a lake with massive growth of cyanobacteria (blue-green algae). 60 patients died. METHODS: Besides recording clinical details and outcome at follow-up, we arranged laboratory, radiological, and histological investigations on the patients and toxicological studies of serum and haemodialysis water filters. FINDINGS: The acute presentation was with malaise, myalgia and weakness, nausea and vomiting, and tender hepatomegaly, with a range of neurological symptoms from tinnitus, vertigo, headaches, and deafness to blindness and convulsions. Liver injury ranged from abnormal liver-function test results to rapidly progressive and fatal hepatic failure. Biochemical investigations revealed gross hyperbilirubinaemia, abnormal liver enzyme activities, and hypertriglyceridaemia, but there was no evidence of haemolysis or microangiopathy. Histology revealed a novel acute toxic hepatitis with diffuse panlobular hepatocyte necrosis, neutrophil infiltration, canalicular cholestasis, and regenerative multinucleate hepatocytes. Samples of serum, dialysis filters, and water-treatment columns contained microcystins, the highly toxic low-molecular-weight hepatotoxins produced by cyanobacteria. INTERPRETATION: Cyanobacteria present water-borne hazards to health via drinking water and recreational water. Haemodialysis presents an additional high-risk exposure route: when they enter directly into the circulation, microcystins can lead to fatal clinical syndromes ranging from acute neurotoxic illness to subacute liver failure.

Toxins of Amanita phalloides.

The most poisonous mushroom toxins are produced by Amanita phalloides (death cap). The occurrence and chemistry of three groups of toxins (amatoxins, phallotoxins and virotoxins) are summarized. The concentration and distribution of toxins in certain species are variable, with the young fruit body containing lower, and the well-developed fungus higher concentrations, but there is a high variability among specimens collected in the same region. Regarding phallotoxins, the volva (the ring) is the most poisonous. The most important biochemical effect of amatoxins is the inhibition of RNA polymerases (especially polymerase II). This interaction leads to a tight complex and the inhibition is of a non-competitive type. Non-mammalian polymerases show little sensitivity to amanitins. The amatoxins cause necrosis of the liver, also partly in the kidney, with the cellular changes causing the fragmentation and segregation of all nuclear components. Various groups of somatic cells of emanation resistance have been isolated, including from a mutant of Drosophila melanogaster. The phallotoxins stimulate the polymerization of G-actin and stabilize the F-actin filaments. The interaction of phallotoxins occurs via the small, 15-membered ring, on the left side of the spatial formula. The symptoms of human poisoning and the changes in toxin concentrations in different organs are summarized. Conventional therapy includes: (1) stabilization of patient's condition with the correction of hypoglycaemia and electrolytes; (2) decontamination; and (3) chemotherapy with different compounds. Finally, certain antagonists and protective compounds are reviewed, bearing in mind that today these have more of a theoretical than a practical role.

Biliary excretion of biochemically active cyanobacteria (blue-green algae) hepatotoxins in fish.

Previous reports demonstrated that microcystin and related cyanobacteria polypeptides are rapidly cleared from plasma and accumulate in liver tissue. In the present study, we have used their ability to inhibit protein phosphatases to show that these cyanobacteria hepatotoxins are excreted into the bile of experimentally poisoned rainbow trout. At various times after oral administration of hepatotoxic Microcystis aeruginosa, bile samples were analysed for microcystin content by methanol extraction and protein phosphatase assays. An inhibitory principle that specifically suppressed protein phosphatase activity was detected in all bile samples removed between 1 and 72 h after oral exposure to toxic algae. These results indicate that biochemically active microcystin molecules are excreted into the biliary tract of poisoned fish.

Enzymatic analysis of liver samples from rainbow trout for diagnosis of blue-green algae-induced toxicosis.

Microcystin and related toxic peptides produced by cyanobacteria (blue-green algae) are potent and selective inhibitors of protein phosphatases 1 and 2A. We adapted existing enzymatic techniques to analyze the liver of rainbow trout after oral administration of hepatotoxic cyanobacteria. Liver tissue was removed 3 and 12 hours after treatment, and phosphatase activity was determined in liver extracts, using a specific phosphoprotein substrate. In all samples from fish exposed to toxic cyanobacteria, phosphatase activity was suppressed, whereas the control enzyme, lactate dehydrogenase, present in the same liver extract, was not affected by cyanobacteria. Thus, experimental poisoning by hepatotoxic cyanobacteria resulted in an abnormally low ratio of phosphatase to lactate dehydrogenase activity in the liver extracts. These results indicate that specific inhibition of phosphatases 1 and 2A may provide a useful diagnostic tool to determine the early effects of cyanobacteria toxic peptides directly in liver samples from poisoned animals. Although this test was developed with rainbow trout, it should be possible to extend the analysis of liver phosphatase activity to other species, including sheep and cattle, which are frequently affected by hepatotoxic cyanobacteria.

Isolation and characterization of microcystins from laboratory cultures and environmental samples of Microcystis aeruginosa and from an associated animal toxicosis.

Six microcystins were identified in a laboratory culture of the cyanobacterium (blue-green alga) Microcystis aeruginosa PCC 7813 using high-performance liquid chromatography coupled with diode array detection (HPLC-DAD) and mass spectrometry (LC-MS). The toxins were purified and further characterized by amino acid analysis and tandem mass spectrometry (MS-MS). The presence of the previously reported microcystin-LR and microcystin-LY was confirmed. Two further microcystins were characterized as microcystin-LW and microcystin-LF. Another two toxins were partially characterized and are believed to be an analog of microcystin-LR (molecular weight 1008) and microcystin-LM (molecular weight 969). Natural bloom material of M. aeruginosa collected from 2 reservoirs was found to have similar microcystin profiles using HPLC-DAD and LC-MS, indicating the widespread occurrence of these microcystin variants. In addition, the presence of 5 of the microcystins was confirmed in the rumen contents of a lamb by LC-MS and LC-MS-MS, providing the first report of microcystins identified in an animal suspected of being poisoned by cyanobacterial hepatotoxins.