title: Features of Patients With Severe Hepatitis Due to Mushroom Poisoning and Factors Associated With Outcome.
abstract: OBJECTIVE
  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 χ2test 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.
authors.affiliation: Department of Gastroenterology and Hepatology, California Pacific Medical Center, San Francisco, California. Electronic address: bonacim08@gmail.com.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Bonacini
authors.affiliation: Palo Alto Medical Foundation, Mountain View, California.
authors.forename: Katerina
authors.initials: K
authors.lastname: Shetler
authors.affiliation: National Kidney and Transplant Institute, Manila, Philippines.
authors.forename: Ira
authors.initials: I
authors.lastname: Yu
authors.affiliation: Washington University, St Louis, Missouri.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Osorio
authors.affiliation: Department of Transplantation, California Pacific Medical Center, San Francisco, California.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Osorio
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006505:Hepatitis / Q000150:complications* / Q000209:etiology / Q000473:pathology* / Q000601:surgery; D006801:Humans; D017093:Liver Failure / Q000209:etiology / Q000401:mortality*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009145:Mushroom Poisoning / Q000150:complications / Q000401:mortality* / Q000473:pathology*; D012189:Retrospective Studies; D012495:San Francisco; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult
keywords: Amanita ocreata; Amanita phalloides; Hepatotoxicity; Liver Failure; Liver Transplantation; Mushroom Poisoning; Mycetismus