Ground Glass-Like Inclusions: Associated with Liver Toxicity.

OBJECTIVE: The etiology of ground glass-like inclusions is heterogenous and the pathology has been described in various conditions including HBV infection, Lafora's disease, fibrinogen storage disease, type IV glycogenosis, and alcohol reversion therapy. Similar ground glass-like inclusions are also associated with immunosuppressed conditions and multiple medications, for which the clinical significance is still unclear. Additional cases, some with previously unreported unique etiologies, and their follow-up were described in this study. MATERIALS AND METHODS: Eleven cases were examined between 2008 and 2019 for this study. The clinical data and histologic slides were reviewed. All of the cases were negative for Hepatitis B virus. None of the patients declared alcohol intake or a history of epilepsy. RESULTS: Liver histology showed mild lobular inflammation in most of the cases (72%). Ground glass-like hepatocytes were distributed in the patchy-panlobular, periportal, and centrizonal pattern at 55%, 27%, and 18%, respectively. Clinical history revealed medication use in nine (82%) patients including NSAIDs, steroids, and chemotherapy. Ground glass-like inclusions were related to herbal toxicity in two of the patients. Liver function tests were elevated in all of the cases. Follow-up data revealed four patients with malignancy who died of their cancer. Seven patients showed resolution of elevated liver enzymes with a median follow-up period of 37 months (range 7-132 months). CONCLUSIONS: Medication is the most relevant etiology for the development of these inclusions. Ground glass-like inclusions may also seen in herbal toxicity. Transplantation was not an etiologic factor in our patients. Most of the patients displayed an indolent course with resolution of the elevated transaminases.

Energy disorders caused by mitochondrial dysfunction contribute to α-amatoxin-induced liver function damage and liver failure.

Mushroom toxicity is the main branch of foodborne poisoning, and liver damage caused by amatoxin poisoning accounts for more than 90 % of deaths due to mushroom poisoning. Alpha-amatoxin (α-AMA) has been considered the primary toxin from amatoxin-containing mushrooms, which is responsible for hepatotoxicity and death. However, the mechanism underlying liver failure due to α-AMA remains unclear. This study constructed animal and cell models. In the animal experiments, we investigated liver injury in BALB/c mice at different time points after α-AMA treatment, and explored the process of inflammatory infiltration using immunohistochemistry and western blotting. Then, a metabonomics method based on gas chromatography mass spectrometry (GCMS) was established to study the effect of α-AMA on liver metabonomics. The results showed a significant difference in liver metabolism between the exposed and control mice groups that coincided with pathological and biochemical indicators. Moreover, 20 metabolites and 4 metabolic pathways related to its mechanism of action were identified, which suggested that energy disorders related to mitochondrial dysfunction may be one of the causes of death. The significant changes of trehalose and the fluctuation of LC3-II and sqstm1 p62 protein levels indicated that autophagy was also involved in the damage process, suggesting that autophagy may participate in the clearance process of damaged mitochondria after poisoning. Then, we constructed an α-AMA-induced human normal liver cells (L-02 cells) injury model. The above hypothesis was further verified by detecting cell necrosis, mitochondrial reactive oxygen species (mtROS), mitochondrial permeability transition pore (mPTP) opening, mitochondrial membrane potential (Δψ m), and cellular ATP level. Collectively, our results serve as direct evidence of elevated in vivo hepatic mitochondrial metabolism in α-AMA-exposed mice and suggest that mitochondrial dysfunction plays an important role in the early stage of α-AMA induced liver failure.

In vitro mechanistic studies on α-amanitin and its putative antidotes.

α-Amanitin plays a key role in Amanita phalloides intoxications. The liver is a major target of α-amanitin toxicity, and while RNA polymerase II (RNA Pol II) transcription inhibition is a well-acknowledged mechanism of α-amanitin toxicity, other possible toxicological pathways remain to be elucidated. This study aimed to assess the mechanisms of α-amanitin hepatotoxicity in HepG2 cells. The putative protective effects of postulated antidotes were also tested in this cell model and in permeabilized HeLa cells. α-Amanitin (0.1-20 µM) displayed time- and concentration-dependent cytotoxicity, when evaluated through the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) reduction and neutral red uptake assays. Additionally, α-amanitin decreased nascent RNA synthesis in a concentration- and time-dependent manner. While α-amanitin did not induce changes in mitochondrial membrane potential, it caused a significant increase in intracellular ATP levels, which was not prevented by incubation with oligomycin, an ATP synthetase inhibitor. Concerning the cell redox status, α-amanitin did not increase reactive species production, but caused a significant increase in total and reduced glutathione, which was abolished by pre-incubation with the inhibitor of gamma-glutamylcysteine synthase, buthionine sulfoximine. None of the tested antidotes [N-acetyl cysteine, silibinin, benzylpenicillin, and polymyxin B (PolB)] conferred any protection against α-amanitin-induced cytotoxicity in HepG2 cells or reversed the inhibition of nascent RNA caused by the toxin in permeabilized HeLa cells. Still, PolB interfered with RNA Pol II activity at high concentrations, though not impacting on α-amanitin observed cytotoxicity. New hepatotoxic mechanisms of α-amanitin were described herein, but the lack of protection observed in clinically used antidotes may reflect the lack of knowledge on their true protection mechanisms and may explain their relatively low clinical efficacy.

Mushroom intoxication, a fatal condition in Romanian children: Two case reports.

RATIONALE: Approximately 5000 species of wild mushroom are reported worldwide, of which 100 are documented as poisonous and <10 are fatal. The clinical picture of patients with wild mushroom intoxication depends mostly on the type of ingested mushroom, ranging from mild gastrointestinal symptoms to organ failure and death. PATIENT CONCERNS: We report 2 children, sister and brother admitted in our clinic for gastrointestinal symptoms: abdominal pain, nausea, vomiting, and diarrhea after wild mushroom ingestion. DIAGNOSIS: The laboratory tests revealed hepatic cytolysis syndrome, hyperbilirubinemia, impaired coagulation status, hypoalbuminemia, hypoglycemia, and electrolytic unbalances in both cases. Abdominal ultrasound showed hepatomegaly and ascites. INTERVENTION: After admission, both cases received penicillin by vein, activated charcoal, liver protectors, glucose, and electrolytes perfusions. Nevertheless, their status worsened and required the transfer to the pediatric intensive care unit for appropriate supportive measure. Therefore, therapeutic plasma exchange was initiated along with N-acetyl cysteine and hemostatic drugs. OUTCOMES: Despite all these therapeutic interventions, both cases developed hepatorenal syndrome and died after a couple of days from ingestion. LESSONS: Mushroom poisoning remains a public health problem in developing countries. Preventable strategies and education regarding the consumption of wild type mushrooms are essential for decreasing the morbidity and mortality rates in these areas.

Toxicity of muscimol and ibotenic acid containing mushrooms reported to a regional poison control center from 2002-2016.

BACKGROUND: Amanita muscaria (AM) and A. pantherina (AP) contain ibotenic acid and muscimol and may cause both excitatory and sedating symptoms. Gastrointestinal (GI) symptoms are not classically described but have been reported. There are relatively few reported cases of poisoning with these mushrooms in North America. METHODS: This is a retrospective review of ingestions of ibotenic acid and muscimol containing mushrooms reported to a United States regional poison center from 2002-2016. Cases were included if identification was made by a mycologist or if AM was clearly described. RESULTS: Thirty-four cases met inclusion criteria. There were 23 cases of AM, 10 AP, and 1 A. aprica. Reason for ingestion included foraging (12), recreational (6), accidental (12), therapeutic (1), self-harm (1), and unknown (2). Of the accidental pediatric ingestions 4 (25%) were symptomatic. None of the children with a symptomatic ingestion of AM required admission. A 3-year-old male who ingested AP had vomiting, agitation, and lethargy and received benzodiazepines. He was intubated and had a 3-day ICU stay. There were 25 symptomatic patients. All but one patient developed symptoms within 6 h. Six patients had symptoms for less than 6 h while 15 had symptoms lasting less than 24 h. Ingestions of AP were more symptomatic than AM with regard to the presence of any GI symptoms (80% vs. 35%), central nervous system (CNS) depression (70% vs. 35%), and CNS excitation (70% vs. 35%) respectively. Five patients were intubated. No patients experienced hypotension, seizures, acute kidney injury, or hepatotoxicity. No deaths were reported. DISCUSSION: Ingestion of ibotenic acid/muscimol containing mushrooms often produces a syndrome with GI upset, CNS excitation, and CNS depression either alone or in combination. Ingestion of AP was associated with a higher rate of symptoms compared to AM.

Mushroom Poisoning-A 17 Year Retrospective Study at a Level I University Emergency Department in Switzerland.

The consequences of mushroom poisoning range from mild, mostly gastrointestinal, disturbances to organ failure or even death. This retrospective study describes presentations related to mushroom poisoning at an emergency department in Bern (Switzerland) from January 2001 to October 2017. Gastrointestinal disturbances were reported in 86% of the 51 cases. The National Poisons Information Centre and mycologists were involved in 69% and 61% of the cases, respectively. Identification of the mushroom type/family was possible in 43% of the cases. The most common mushroom family was Boletaceae (n = 21) and the most common mushrooms Xerocomus chrysenteron (n = 7; four being part of a cluster), Clitocybe nebularis, Lepista nuda and Lactarius semisanguifluus (n = 5 each, four being part of a cluster). Poisonous mushrooms included Amanita phalloides (n = 3, all analytically confirmed), Boletus satanas (n = 3), Amanita muscaria (n = 2) and Amanita pantherina (n = 2). There were no fatalities and 80% of the patients were discharged within 24 h. Mushroom poisoning does not appear to be a common reason for emergency consultation and most presentations were of minor severity and related to edible species (e.g., due to incorrect processing). Nevertheless, poisonous mushrooms and severe complications were also recorded. Collaboration with a poison centre and/or mycologists is of great importance, especially in high risk cases.

Toxicity and toxicokinetics of Amanita exitialis in beagle dogs.

In this study, the toxicology of A. exitialis, a lethal mushroom found in China, and the toxicokinetics of peptide toxins contained in it were evaluated. Beagles were fed A. exitialis powder (20 or 60 mg/kg) in starch capsules, after which they were assessed for signs of toxicity, as well as biochemical and pathological changes. Ultra-performance liquid chromatography-electrospray ionization-tandem mass spectrometry was used to assay the peptide toxins. The total peptide toxins in A. exitialis was 3482.6 ±â€¯124.94 mg/kg. The beagles showed signs of toxicity, such as vomiting and diarrhea, at 12-48 h following ingestion of A. exitialis. Furthermore, alanine transaminase and aspartate transaminase levels in plasma, as well as prothrombin time and activated partial thromboplastin time peaked at 36 h post A. exitialis ingestion. Furthermore, total bilirubin and alkaline phosphatase levels peaked at 48 h after A. exitialis ingestion. Three dogs that were administered 60 mg/kg A. exitialis died at 24-72 h after ingesting the capsules. Additionally, liver histopathological examinations showed hemorrhagic necrosis of hepatocytes. α-Amanitin, ß-amanitin, and phallacidin were rapidly absorbed and eliminated from plasma after A. exitialis was ingested. A long latency period (12-24 h post A. exitialis ingestion) was observed in the dogs before the onset of gastrointestinal symptoms. There was acute liver damage thereafter. Gastric lavage and enhanced plasma clearance methods such as hemodialysis, hemoperfusion, or plasma exchange may be ineffective in removing amatoxins from blood at 12 h post A. exitialis ingestion. Enhanced excretion of amatoxins in urine could be effective within 2 days after ingestion of A. exitialis because amatoxins in 0-2 d urine accounted for more than 90% of the total urine excretion.

Investigation and analysis of Galerina sulciceps poisoning in a canteen.

INTRODUCTION: Guizhou Province in China has an abundant resource of wild mushrooms, including numerous poisonous species which contain various toxins. The mortality rate from wild mushroom poisoning has been high in this area in recent years. Galerina sulciceps is a dangerously toxic mushroom which can be fatal if ingested. METHODS: we report on an epidemiological investigation of G. sulciceps poisoning which occurred in Duyun City of Guizhou Province. The characteristics of this species, its toxicity, observed clinical features, laboratory data, treatment modality, and prognosis were investigated in order to provide a reference point for the prevention and treatment of this kind of mushroom poisoning. RESULTS: Thirteen employees showed toxic symptoms after ingesting wild mushrooms the previous day in a company canteen. Clinical manifestation varied from gastroenteritis to hepatic and renal dysfunction. Most of the 13 patients presented with nausea, vomiting, abdominal pain, diarrhea, and elevated levels of biochemical indices of hepatic and renal function, during which transaminase concentration peaked within 48-72 h. At 48 hours post-ingestion, all patients had hemodialysis, in addition to supportive care for hepatic and renal injury with oral Silibinin and Shenshuaining. All acute renal injury had resolved by day 10, and liver transaminases had trended toward normal in all patients and they were discharged. At follow-up in 30 days, both liver and renal function had completely recovered in all. CONCLUSION: This poisoning occurs as a result of unintentional consumption of G. sulciceps, which is relatively rare in mushroom poisonings. All patients recovered fully after timely diagnosis and treatment. To prevent wild mushroom poisoning, the best preventive measure is to educate the public not to gather and eat any unidentified wild mushrooms.

Features of Patients With Severe Hepatitis Due to Mushroom Poisoning and Factors Associated With Outcome.

BACKGROUND & AIMS: Acute liver failure after ingestion of toxic mushrooms is a significant medical problem. Most exposures to toxic mushrooms produce no symptoms or only mild gastroenteritis, but some lead to severe hepatic necrosis and fulminant hepatic failure requiring liver transplantation. We aimed to assess mortality from mushroom poisoning and identify variables associated with survival and liver transplantation. METHODS: We collected information from 27 patients (13 male; median age, 47 years) admitted to the emergency department within 24 hours of ingesting wild mushrooms. They developed severe liver injury (serum levels of transaminases greater than 400 IU/L) and were treated with activated charcoal and N-acetylcysteine at a tertiary medical center in San Francisco, California from January 1997 through December 2014. Viral hepatitis, autoimmune liver disease, acetaminophen, salicylate toxicity, and chronic liver diseases were ruled out for all patients. We analyzed patient demographics, time since ingestion, presenting symptoms, laboratory values, and therapies administered. A good outcome was defined as survival without need for liver transplant. A poor outcome was defined as death or liver transplant. Positive predictive values were calculated, and the χ2 test was used to analyze dichotomous variables. RESULTS: Liver injury was attributed to ingestion of Amanita phalloides in 24 patients and Amanita ocreata in 3 patients. Twenty-four of the patients ingested mushrooms with meals and 3 patients for hallucinogenic purpose. At 24-48 hours after ingestion, all patients had serum levels of alanine aminotransferase ranging from 554 to 4546 IU/L (median, 2185 IU/L). Acute renal impairment developed in 5 patients. Twenty-three patients survived without liver transplantation, and 4 patients had poor outcomes (1 woman underwent liver transplantation on day 20 after mushroom ingestion, and 3 women died of hepatic failure). Of the 23 patients with peak levels of total bilirubin of 2 mg/dL or more during hospitalization, only 4 had a poor outcome. Peak serum level of aspartate aminotransferase less than 4000 IU/L, peak international normalized ratio less than 2, and a value of serum factor V greater than 30% identified patients with good outcomes with 100% positive predictive value; if these peak values were used as a cutoff, 10 of 27 patients (37%), 7 of 27 patients (26%), and 6 of 12 patients (50%), respectively, could have avoided transfer to a transplant center. CONCLUSIONS: In an analysis of 27 patients with hepatocellular damage due to mushroom (Amanita) poisoning and peak levels of total bilirubin greater than 2 mg/dL, the probability of liver transplantation or death is 17%, fulfilling Hy's law. Patients with peak levels of aspartate aminotransferase less than 4000 IU/L can be monitored in a local hospital, whereas patients with higher levels should be transferred to liver transplant centers. Women and older patients were more likely to have a poor outcome than men and younger patients.

Acute Toxicity Study and the In Vitro Cytotoxicity of a Black Lingzhi Medicinal Mushroom, Amauroderma rugosum (Agaricomycetes), from Malaysia.

Amauroderma rugosum is a wild medicinal mushroom also known as budak cendawan sawan. Members of the indigenous Malaysian Temuan community wear the fresh stipes as a necklace to prevent epileptic seizure and unremitting crying by babies. In our previous studies, A. rugosum exhibited significant antioxidant and anti-inflammatory activities. The aim of this study was to determine the toxicity (in the event that a stipe is accidentally bitten) and cytotoxicity of this mushroom on Sprague-Dawley rats and selected cell lines. A. rugosum was orally administered to test chemicals according to Organisation for Economic and Co-operation and Development guidelines (TG 425, adopted October 3, 2008). Blood samples were hematologically and biochemically analyzed and multiple tissue sections from each organ were examined using light microscopy. Cytotoxicity of various A. rugosum extracts was also determined against MCF-7 and A-549 cell lines. Our results showed that oral administration of a single dose of mycelial powder (2000 mg/kg) had no adverse effect on the growth rate or hematological and clinical biochemical parameters. Histological studies showed that the treatments did not induce any pathological changes in the organs of the tested animals. All the treated rats survived beyond the 14-day observation period. Methanol and cold and hot water extracts of the freeze-dried mycelial culture of A. rugosum exhibited no or little cytotoxic effect against the MCF-7 and A-549 cell lines.

Improved Tissue-Based Analytical Test Methods for Orellanine, a Biomarker of Cortinarius Mushroom Intoxication.

Orellanine (OR) toxin is produced by mushrooms of the genus Cortinarius which grow in North America and in Europe. OR poisoning is characterized by severe oliguric acute renal failure, with a mortality rate of 10%-30%. Diagnosis of OR poisoning currently hinges on a history of ingestion of Cortinarius mushrooms and histopathology of renal biopsies. A key step in the diagnostic approach is analysis of tissues for OR. Currently, tissue-based analytical methods for OR are nonspecific and lack sensitivity. The objectives of this study were: (1) to develop definitive HPLC and LC-MS/MS tissue-based analytical methods for OR; and (2) to investigate toxicological effects of OR in mice. The HPLC limit of quantitation was 10 µg/g. For fortification levels of 15 µg/g to 50 µg/g OR in kidney, the relative standard deviation was between 1.3% and 9.8%, and accuracy was within 1.5% to 7.1%. A matrix-matched calibration curve was reproduced in this range with a correlation coefficient (r) of 0.97-0.99. The limit of detection was 20 ng/g for LC-MS/MS. In OR-injected mice, kidney OR concentrations were 97 ± 51 µg/g on Day 0 and 17 ± 1 µg/g on termination Day 3. Splenic and liver injuries were novel findings in this mouse model. The new tissue-based analytical tests will improve diagnosis of OR poisoning, while the mouse model has yielded new data advancing knowledge on OR-induced pathology. The new tissue-based analytical tests will improve diagnosis of OR poisoning, while the mouse model has yielded new data advancing knowledge on OR-induced pathology.

Amanita phalloides poisoning: Mechanisms of toxicity and treatment.

Amanita phalloides, also known as 'death cap', is one of the most poisonous mushrooms, being involved in the majority of human fatal cases of mushroom poisoning worldwide. This species contains three main groups of toxins: amatoxins, phallotoxins, and virotoxins. From these, amatoxins, especially α-amanitin, are the main responsible for the toxic effects in humans. It is recognized that α-amanitin inhibits RNA polymerase II, causing protein deficit and ultimately cell death, although other mechanisms are thought to be involved. The liver is the main target organ of toxicity, but other organs are also affected, especially the kidneys. Intoxication symptoms usually appear after a latent period and may include gastrointestinal disorders followed by jaundice, seizures, and coma, culminating in death. Therapy consists in supportive measures, gastric decontamination, drug therapy and, ultimately, liver transplantation if clinical condition worsens. The discovery of an effective antidote is still a major unsolved issue. The present paper examines the clinical toxicology of A. phalloides, providing the currently available information on the mechanisms of toxicityinvolved and on the current knowledge on the treatment prescribed against this type of mushrooms. Antidotal perspectives will be raised as to set the pace to new and improved therapy against these mushrooms.

Shiitake dermatitis.

Shiitake Dermatitis is a skin eruption that resembles whiplash marks and occurs after consumption of raw shiitake mushrooms. It is caused by a toxic reaction to lentinan, a thermolabil polysaccharide which decomposes upon heating. We report the second case of this dermatitis in Brazil. A 25-year-old man presented with linearly arranged erythematous, pruritic papules on the trunk and limbs, after ingestion of a salad containing raw shiitake mushrooms. The eruption was self-limited, resolving within 10 days of onset. The recognition of this entity gains importance due to the increased consumption of shiitake mushrooms in occidental countries.

Shiitake dermatitis recorded by French Poison Control Centers - new case series with clinical observations.

CONTEXT: Shiitake (Lentinula edodes) is an edible mushroom which was initially grown in Japan and China and is now sold on the European market. Flagellate erythema may arise following shiitake consumption and was first described in Japan in 1974. OBJECTIVE: This paper reports a French shiitake dermatitis case series. METHODS: The findings of retrospective study of shiitake dermatitis cases, reported to French Poison Control Centres (PCC) from January 2000 to December 2013, are reported. RESULTS: Among 32 exposed patients, 15 presented flagellate urticarial lesions after raw shiitake consumption. The first case of this series was reported in 2006 and the last nine cases were reported as of 2012. After shared meals, no symptoms were reported among guests, who preferred cooked shiitake to the raw mushroom. In this series, rashes appeared 12 h to 5 days (median: 24 h) after raw shiitake ingestion. Linear and itchy urticarial lesions formed on the trunk, arms, and legs within a few hours and persisted for 3-21 days. In four cases, rash and pruritus were either triggered or worsened by sun exposure. Eleven patients received corticosteroids, antihistamines, or both. All patients completely recovered. CONCLUSION: Due to the rapidly increasing consumption of exotic food in Western countries, it is no surprise that cases of shiitake dermatitis are now appearing in Europe. The mechanism of shiitake dermatitis is thought to be toxic and due to lentinan, a polysaccharide component of the mushroom. There is no specific validated treatment for shiitake dermatitis. Health professionals and the general population should be aware of both the risk associated with raw shiitake consumption and of the good prognosis of this very spectacular and uncomfortable toxic dermatitis.

Shiitake dermatitis: a report of 3 cases and review of the literature.

Shiitake mushroom-induced toxicoderma, or shiitake dermatitis, is a widely recognized phenomenon in Japan, China, and Korea but only recently has been reported outside of Asia. Affected individuals develop a characteristic pattern of whiplike, linear, erythematous wheals within 1 to 2 days after consumption of raw or cooked shiitake mushrooms. Lentinan, a polysaccharide component of shiitake mushrooms with antitumor properties, is thought to instigate a toxic reaction, resulting in the appearance of a rash. Shiitake dermatitis is self-limited and typically resolves within days to weeks of its appearance.

Erythromelalgia associated with Clitocybe acromelalga intoxication.

CONTEXT: Erythromelalgia is a rare disorder characterized by reddening, severe burning pain, and swelling of the extremities. Food poisoning by Clitocybe acromelalga, a poisonous mushroom, is known to induce erythromelalgia; however, its treatment protocol remains unclear. We describe here three cases of erythromelalgia following the consumption of C. acromelalga with varying clinical courses. CASE DETAILS: Of the three patients, the first patient presented 22 days after the onset of erythromelalgia; although he was treated with aspirin, numbness in the limbs persisted as sequela. Patient 2 presented at 3 days after the symptomatic onset and was immediately treated with high-dose intravenous nicotinic acid, with a dramatic symptomatic improvement. Patient 3, who had milder symptoms, spontaneously recovered within a week without any treatment. DISCUSSION: The clinical manifestations and varying clinical courses associated with C. acromelalga toxicity are discussed here, with the pathogenesis of this mycotoxin and a potential treatment. Detailed interviews of such patients are important, particularly because of the remarkably slow course of this mycotoxin as compared with common food poisonings. Treatment with intravenous nicotinic acid was associated with improvement in one patient. We believe that this painful disorder might thus be treatable, although the mechanism underlying the treatment remains unclear.