JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
In 2015, Lin and coinvestigators reported seven cases of delayed rhabdomyolysis with one fatality in a family (age range 18-58 years) who had consumed one meal of cooked Russula subnigricans mushrooms harvested from the forests of Guizhou Province in southern China. 28 Twenty hours later, all seven family members were hospitalized with nausea, vomiting, diarrhea, dizziness, fatigue, and muscle weakness. 28 Five patients presented with myalgias in the upper legs. 28 No patient was febrile on admission. 28 Although the serum creatinine and coagulation tests were normal in all patients, serum CK levels were elevated in six patients; and all seven patients had moderate elevations in serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST). 28 In four of the six patients with elevated serum CK levels, the CK continued to rise, weakness worsened, and the urine color darkened consistent with rhabdomyolysis. 28 All four patients received hemodialysis to prevent acute kidney injury, and their serum CK levels began to decline to normal ranges by the third day of hemodialysis. 28 In the single fatal case in a 50-year-old man, weakness and myalgia with dark urine worsened during the first 12 hours after admission; hemodialysis was instituted on the second day after admission; and hyperthermia up to 40° C developed on the third day after admission. 28 Cardiac arrhythmias with QRS widening and cardiovascular collapse ensued as the serum CK levels rose to a maximum of 228,750 U/L (laboratory normal range = 38- 174 U/L), and the patient expired four days after admission. 28 Autopsy was not performed. The authors noted that most of the patients with rhabdomyolysis presented with early-onset myalgia and sustained increases in serum CK levels. 28 They recommended early recognition of rhabdomyolysis heralded by rapidly rising serum CK levels at this stage and early institution of intensive supportive care with hemodialysis. 28 In summary, descriptive epidemiological and toxicological analyses have now confirmed that nephrotoxic mushrooms can cause both reversible and irreversible acute onset and delayed acute renal failure; and a few species can cause potentially fatal rhabdomyolysis with its associated risks of acute renal failure. Patients with any potential for mushroom nephrotoxin- induced acute renal injury should be referred to medical centers equipped and staffed for immediate hemodialysis and kidney transplantation in the event that conservative supportive care measures fail and irreversible renal failure ensues.
The toxidrome that follows the consumption of nephrotoxic Cortinarius mushrooms is characterized by an often overlooked prodrome of mild gastrointestinal symptoms within hours of the mushroom meal with nausea and vomiting and, less often, with abdominal pain and diarrhea. 20 The symptoms and laboratory evidence of renal failure are delayed for days, typically less than seven days (two to four days); but occasionally up to 14 days. 20 Patients will usually present for urgent care more than two days post-ingestion with abdominal and flank pain, polyphagia, polydipsia, either polyuria or oliguria, and rising serum levels of BUN and creatinine. 20 Other general constitutional symptoms may include fever, chills, headache, anorexia, and fatigue. 20 The differential diagnosis includes pyelonephritis, glomerulonephritis, appendicitis, and pelvic inflammatory disease. 20 There are no antidotes, and recovery is slow. Renal biopsies are characterized by a tubulointerstitial nephritis with later progressive interstitial fibrosis. 20 Acute renal insufficiency will require intermittent hemodialysis. Up to 40% of patients will progress to chronic renal failure and require more frequent hemodialysis or a renal transplant. 20 Renal transplantation should not be offered too early as complete recovery has ensued even after months of intermittent hemodialysis. 30
Amanita Species and the Amanita Toxidrome
The family Amanitaceae contains about 600 species of mushrooms including some edible species, the hepatotoxic amanitin-containing species, such as A. phalloides and A. virosa, and at least 8 nephrotoxic species. Amanita mushrooms prefer a habitat of deciduous leaves, coniferous needles, and decaying wood in the dampunderstories of coniferous andoakwoodlands with chalky soils. Amanita mushrooms are typically large with ivory to dull white caps with free-hanging gills under the caps and thick often shaggy stems and delicate rings as depicted in the images of A. proxima (Figure 2) and A. smithiana (Figure 3). Most species can be found in Louisiana. The toxidrome that follows the consumption of nephrotoxic Amanita mushrooms is characterized by the early onset of gastrointestinal symptoms including nausea, vomiting, abdominal pain, and diarrhea within 12-15 minutes to 12 hours after the mushroom meal that persists for several days usually without fever. 3, 5-8 Patients will typically present in acute renal failure two to six days (typically four to five days) post-ingestion withanuria tooliguria, abdominal andflankpain, and rising levels of serum hepatic transaminases, BUN, and creatinine. 3,5-8 There are no antidotes, and recovery is relatively rapidwithin weeks. 3,5-8 Renal biopsies are characterized by tubulointerstitial lesions and minor glomerular abnormalities. 7,8 Acute renal insufficiency will require intermittent hemodialysis in 25%-50% of cases. 3,5-8 Outcomes are typically favorable with complete recovery of normal renal and hepatic function. 3,5-8 Up to 40% of patients will progress to chronic renal failure and require more frequent hemodialysis or a renal transplant. 3,5-8 Renal transplantation should not be offered too early as partial to complete recovery has ensued even after months of hemodialysis. 3, 5-8
Cortinarius Species and the Cortinarius Toxidrome
The family Cortinariaceae is the largest family of mushrooms with over 2,000 species, at least eight of which are known to be nephrotoxic. Cortinarius mushrooms prefer a habitat of needle litter in the damp understories of coniferous forests with chalky, limestone-containing soils. Cortinarius mushrooms are typically large with rusty orange to brown caps and underlying gills connected to stems without rings as depicted in the image of C. speciosissimus (Figure 1). As noted, all Cortinarius mushrooms are considered potentially nephrotoxic today, and none are recommended for human consumption in any form. Most species can be found in Louisiana.
J La State Med Soc VOL 169 NOVEMBER/DECEMBER 2017 167
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