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CHEST

Volume 146, Issue 4, October 2014, Pages e126-e129
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Selected Reports
Survival Following Investigational Treatment of Amanita Mushroom Poisoning: Thistle or Shamrock?

https://doi.org/10.1378/chest.13-1573Get rights and content

Abstract

We report the first case, to our knowledge, of amatoxin hepatotoxicity in Iowa and explore the ethical and decisional challenges of offering an investigational treatment of a rare disease. Acute liver failure due to ingestion of amatoxin-containing mushrooms is a relatively rare entity. Once amatoxin poisoning is identified, there is no clearly effective treatment, leading to a broad range of theoretically beneficial, anecdotally successful, or investigational options. The evolution of hepatotoxicity led us to offer investigational treatment with silibinin, an extract of Mediterranean milk thistle. We explore the pitfalls in medical decision-making experienced by both the patient and the physician in the face of ambiguity. The patient did well following silibinin infusion, but we are left uncertain as to whether the patient truly responded to treatment or was simply destined to recover.

Section snippets

Case Report

A 71-year-old man presented with progressive nausea, vomiting, diarrhea, and weakness 48 h after having ingested wild mushrooms while camping in northwestern Iowa. The following day, nausea, vomiting, and profuse, watery diarrhea led him to seek medical attention. Vital signs and physical examination results were normal. Abnormal chemistry levels included elevated aspartate aminotransferase, 2,313 IU/L (normal range, 15-37 IU/L); alanine aminotransferase, 2,730 IU/L (normal range, 12-78 IU/L);

Discussion

Patients diagnosed early with amatoxin poisoning have the best chance of surviving and generally require symptomatic treatment only. Patients identified later have a much higher probability of death. When faced with severe morbidity or high mortality, physicians and patients often consider nonapproved therapies. When given a bleak prognosis, such patients are often willing to accept the risks associated with experimental treatments in exchange for hope of cure, prolongation of life, or

Conclusions

We report the successful treatment of the first case of Amanita mushroom toxicity in the state of Iowa. We found ourselves faced with a deteriorating patient, no proven treatment, and the question of whether we should offer an experimental therapy or trust only in our supportive management. The patient recovered after treatment with multiple-dose activated charcoal, N-acetylcysteine, and penicillin, and experimental treatment with silibinin, prompting him and his physicians to believe that the

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

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      Citation Excerpt :

      Although the toxin is adsorbed by charcoal, the delayed presentation of patients limits the clinical utility of gastrointestinal decontamination.5 To facilitate elimination, multi-dose activated charcoal can be used, because the amatoxin undergoes enterohepatic circulation; however, extracorporeal measures, specifically hemodialysis, have unfortunately proven ineffective in eliminating the toxin.5,6,9 There is no specific antidote, and adjunct pharmacologic therapy focuses on the oxidant effects of the toxin as well as its uptake via hepatic transporters.10

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    Copyright © 2014 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.