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Acute poisoning with Tricholoma equestre

Article in Przegla ̧d Lekarski · January 2009

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 CLINICAL NOTES – DONIESIENIA KLINICZNE

Jacek Sein ANAND1

Pawe³ CHWALUK2,3
Ostre zatrucie G¹sk¹ zielonk¹
Micha³ SUT4

Acute poisoning with Tricholoma equestre

Pomerania Center of Toxicology, Gdañsk,

1
Four cases, including three adults W pracy przedstawiono cztery oso-
Poland and one child, suffering from acute by, w tym trzy doros³e oraz dziecko, u
Head: Wojciech Waldman MD, PhD poisoning with Tricholoma equestre których dosz³o do znacznej rabdomio-
were described. The patients had lizy w przebiegu zatrucia Tricholoma
2
Unit of Internal Diseases, Regional Hospital
in Bia³a Podlaska, Poland
eaten from 100 to 400 grams of the equestre. Pacjenci spo¿ywali od 100
Head: Jolanta Siwek-Iwanicka MD mushroom within a few consecutive do 400 g grzyba przez kilka kolejnych
meals. After consuming about 1000 dni. Po spo¿yciu ok. 1000 g Tricholo-
Department of Anatomy
3 grams of Tricholoma equestre for 3-4 ma equestre dosz³o u nich do pojawie-
University of Physical Education in Bia³a days, the subjects developed fatigue, nia siê os³abienia, bólów miêœni, zaœ
Podlaska, Poland muscle weakness, myalgia, and in two w dwóch przypadkach ostrej niewydol-
Head: Jan Rowiñski MD, PhD cases acute respiratory failure with the noœci oddechowej, która wymaga³a
need of respiratorotherapy. Maximal respiratoroterapii. Poziomy CPK u do-
Mater Infirmorum Hospital Belfast
4

General and Hepatobiliary Surgery Ward

serum CK was 48136 U/L in the adults ros³ych pacjentów siêga³y 48136 U/L,
and 306 U/L in children. Maximal se- zaœ u dzieci 306 U/L. Najwy¿sze war-
rum levels of AST and ALT were 802 toœci ASPAT i ALAT wynosi³y odpo-
U/L and 446 U/L in adults and 39 U/L, wiednio 802 U/L i 446 U/L u osób doro-
Additional key words: and 56 U/L in a child. All routine bio- s³ych oraz 39 U/L i 56 U/L u dziecka.
acute intoxication chemical tests were within normal Wszystkie rutynowe testy biochemicz-
Tricholoma equestre range. No other causes of ne nie wykazywa³y wiêkszych odchy-
rhabdomyolysis
rhabdomyolysis such as parasitic or leñ od normy. Nie znaleziono równie¿
Dodatkowe s³owa kluczowe:
viral infections, immune diseases, ¿adnych innych przyczyn rabdomioli-
ostre zatrucie trauma or exposure to medications zy, w tym m.in. chorób paso¿ytniczych,
G¹ska zielonka were found. Patient, aged 72 yrs., who wirusowych, immunologicznych, ura-
rabdomioliza developed acute respiratory failure, zów, a tak¿e niepo¿¹danego dzia³ania
died in the second day of hospitaliza- leków. Pacjent lat 72, u którego dosz³o
tion. In other patients all the above do ostrej niewydolnoœci oddechowej,
mentioned symptoms and biochemical zmar³ w drugiej dobie leczenia. U po-
abnormalities disappeared from 2 to 3 zosta³ych pacjentów wszystkie objawy
weeks of hospitalization. Physicians kliniczne oraz biochemiczne ust¹pi³y
should be aware of the possibility of po ok. 2-3 tygodniach leczenia. Leka-
appearance of rhabdo-myolysis after rze powinni zawsze pamiêtaæ o mo¿li-
repeated consumption of large quan- woœci wyst¹pienia rabdomiolizy w
tities of Tricholoma equestre. przebiegu wielokrotnego spo¿ycia du-
¿ej dawki Tricholoma equestre.

Introduction were found. Maximal serum CK activity was 18150 U/L

in the mother and 48136 U/L in the son. Maximal serum
We present four cases, including three levels of AST and ALT were 802 U/L and 446 U/L, in the
adults and one child, who were admitted to mother and 2002 U/L and 454 U/L, in the son. Other
the hospital from 2002 to 2008 because of hepatic, renal and coagulation tests, as well as electro-
lyte levels, including potassium values, were normal. All
rhabdomyolysis caused by excessive con-
symptoms disappeared within 3 weeks of supportive
sumption of Tricholoma equestre. treatment, however, the muscle weakness lasted for
about 2-3 months more.
Case report Case number three: A five-year-old male child was
Case number one and two: Mother and her son, admitted to the clinic because of deep coma, cyanosis
aged 48 and 20 years, respectively, were admitted to and convulsions. All theses symptoms appeared about
the hospital because of the following symptoms: fatigue, 4 hours after the last meal containing Tricholoma eques-
striated muscle weakness, myalgia especially in mus- tre. Medical history revealed that the child had been eat-
cles of the legs, loss of appetite, mild nausea, and pro- ing about 300-400 grams of this mushroom daily for the
fuse sweating. All symptoms appeared approximately 48 four consecutive days. Physical examination revealed
hours after the last meal containing Tricholoma eques- deep coma (4 score GCS), regular heart rate about 120/
tre, which had been eaten by the family recently (last min, blood pressure 110/60 mmHg, and breath rate about
nine consecutive meals). The average dish contained 6/min. There were: bilateral, positive Babiñski sign and
Adres do korespondencji: about 100-300 grams of this mushroom. No other symp- symmetrical increase muscle tone in the neurological
Sein Anand Jacek MD PhD toms like vomiting, diarrhoea, fever or erythema were examination. No changes in computerized tomography
Pomerania Center of Clinical Toxicology observed. Physical examination revealed regular heart of the head, chest x-ray, lumbar puncture, encephalog-
ul. Kartuska 4/6 rate about 90 b./min in the mother and 85 b./min in the raphy, echocardiography and toxicological tests were
80-104 Gdañsk, Poland son, blood pressures were 140/60 mmHg, and 125/70 found. The biochemical tests showed elevated serum
e-mail: [email protected] mmHg respectively. No other important abnormalities CK activity 306 U/L (normal range 5-130 U/L for a child),

Przegl¹d Lekarski 2009 / 66 / 6 339

ALT 56 U/L (normal range 5-45 U/L for person between Discussion sive care because of acute respiratory fa-
1-19-year old), pH 7,28, BE 5,9 mEq/l, HCO3 22,9 mEq/ The most common causes of rhabdo- ilure. The high mortality rate of about 25%
l, pO2 43,9 mmHg, pCO2 59,8 mmHg. Beacuse of acute myolysis are muscle compression, neuro- was also observed by Bedry and co-wor-
respiratory insufficiency the child was intubated and res- leptic malignant syndrome, intoxication with kers [1].
piratorotherapy, lasted 34 hours, was applied. For the alcohol, amphetamine, cocaine, antihyper-
next week after that extubation, the child still presented
lipidemic drugs, antihistamines, phenothia- Conclusions
with muscle weakness which included especially the pel-
vic girdle and the urinary bladder. The boy could not sit zines, theophylline or long-term use of le- 1. Physicians should be aware of the
or stand up without help, and the bladder had to be cath- vodopa, quinidine, phenytoin, penicillamine possibility of acute intoxications after repe-
eterised to avoid urine retention. All the symptoms dis- and others [2-5]. ated consumption of large quantities of Tri-
appeared within 2-3 weeks of hospitalisation. In 2001, Bedry and co-workers observed choloma equestre.
rhabdomyolisis in twelve patients in south- 2. The clinical picture of poisonings with
Case number four: A man aged 72 was admitted to western France after excessive consump- this wild mushroom may be different in chil-
the hospital because muscle weakness, and myalgia tion of Tricholoma equestre [1]. The main dren and adults.
(especially the quadriceps), which lasted for four days. symptoms described by the authors inclu- 3. There is a delay between ingestion
All symptoms appeared about 24 hours after the last ded muscle weakness, fatigue, myalgia and onset of clinical symptoms.
meal containing Tricholoma equestre. The patient had (especially in quadriceps), facial erythema, 4. Intoxication of Tricholoma equestre is
eaten the mushroom for the last ten consecutive meals.
nausea without vomiting, and diaphoresis connected with high mortality rate (about
The average dish contained about 300-400 grams of
without fever. The same signs, except fa- 25%).
Tricholoma equestre. There were no changes in physi-
cal examination except muscle pain of both legs and cial erythema, were observed also in our
increasing problem with walking. Maximal CK activity cases. References
The biochemical results showed marked 1. Bedry R., Baudrimont I., Deffieux G. et al.: Wild-
was 44767 U/L, CKMB 888 U/L, TNI 1,9 ng/ml, AST
mushroom intoxication as a cause of rhabdomyolysis.
1894 U/L, and ALT 490 U/L. Other hepatic, renal and increase in CK, AST and ALT levels. Howe-
N Engl. J. Med. 2001, 345, 798.
coagulation tests as well as electrolyte levels, including ver, in the child, the level of these enzymes 2. Bourquia A., Jabrane A.J., Ramdani B., Zaid D.:
potassium, were normal. No changes in computerized did not correspond well with the grave clini- Toxicite' syste'mique de la paraphe'nyle'ne diamine:
tomography of the head, chest X-ray, echocardiography cal condition of the patient. quatre observations. Presse Med. 1988, 17, 1798.
and toxicological tests were found. In the second day of Quite interesting is a delay between Tri- 3. Dromer C., Verdrenne C., Billey T. et al.:
hospitalisation the patient reported pain and weakness choloma equestre consumption and rhab- Rhabdomyolyse a' la simvastatine: a' propos d'un
of the muscle of the chest, shoulders and abdomen. The cas avec revue de la litte'rature. Rev. Rhum. Mal.
domyolisis occurrence. Bedry and co-wor- Osteoartic. 1992, 59, 281.
patient complained of dyspnoea, and a few hours later
kers observed the clinical signs about 24- 4. Laaksonen R., Jokelainen K., Laakso J. et al.: The
breathing problems appeared. The patient was trans-
ferred to the ICU, intubated and connected to the respi- 72 hours after consuming the last three con- effect of simvastatin treatment on natural antioxidants
rator. About 4.5 hours later - cardiac arrest was noted secutive meals with this mushroom [1]. In in low-density lipoproteins and high-energy phospha-
our cases the symptoms appeared after ha- tes and ubiquinone in skeletal muscle. Am. J. Car-
and CRP was ineffective.
ving more than 1000 grams of Tricholoma diol. 1996, 77, 851.
5. Yagi H., el Hind A.M., Khalil S.I.: Acute poisoning
Several studies for parasites and other microorgan- equestre in less than four days. from hair dye. East. Afr. Med. J. 1991, 68, 404.
isms (trichinella, toxoplasma, coxsackievirus, HIV, HCV One of our patients died despite inten-
and HBV), as well as for systemic diseases were nega-
tive for all observed patients.

340 Przegl¹d Lekarski 2009 / 66 / 6 S. Anand Jacek et al.

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