JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
The Rhabdomyolysis-associated Toxidromes
Russula subnigricans mushrooms are native to Asia and poisonings have been reported from China, Taiwan, Japan, and Korea where they have been mistaken for the less poisonous, but apparently edible, Russula nigricans . 28 The mushrooms have large dull creamy white caps that flatten out from convex in juveniles to an everted umbrella shape with age. The gills hanging beneath the caps are attached to thick stems without rings. In the cases of delayed rhabdomyolysis following the consumption of cooked Russula subnigricans mushrooms, patients typically present with nausea, vomiting, diarrhea, dizziness, fatigue, and muscle weakness within 24 hours of the mushroom meal. 28 Most patients experience myalgias in the upper legs and remain afebrile. 28 Although the serum creatinine and coagulation tests remain normal in patients, the serum CK levels will be significantly elevated in all patients; and all patients will have mild to moderate elevations in serum alanine aminotransferase (ALT) and serum aspartate aminotransferase (AST) levels. 28 In fulminant cases, weakness and myalgia with darkening urine will worsen during the first 12 hours after hospitalization necessitating early hemodialysis. 28 In these cases, hyperthermia will develop within days. 28 Cardiac arrhythmias with QRS widening and cardiovascular collapse may ensue as
The rhabdomyolysis-associated toxidromes are very similar following ingestions of cooked meals of either Tricholoma equestre or Russula subnigricans . 4, 28 Among the differentiating features, Tricholomaequestre was formerly considered edible and its toxicity was dose-related and associated with an increasing number of mushroom meals. 4 Tricholoma equestre is a very distinctive mushroom that is bright yellow in color with a large flat yellow to yellow-green cap with gills connected to a long, thick and smooth stem of even caliber without an annulus or ring. Tricholoma equestre mushrooms are distributed worldwide and prefer a habitat of leaf litter in deciduous oak woodlands. Tricholoma equestre toxidromes are characterized by prodromes of afebrile fatigue and myalgia 24-72 hours after the last mushroommeal, worsening weakness and stiffness of the lower extremities accompanied by facial edema with erythema, mild nauseawithout vomiting, profuse sweating, and darkening urine color over three to four days. 4 In fatal cases, the serum CK levels will continue to rise and patients will develop hyperthermia, cardiac arrhythmias, worsening renal dysfunction, and cardiovascular collapse. 4
Rapid onset of GI symptoms (nausea, vomiting ± diarrhea) within 6-12 hours
Delayed onset of GI symptoms (nausea, vomiting ± diarrhea) within 24-72 hours
Delayed clinical & lab evidence of renal failure within > 2 to 14 days
Rapid clinical & lab evidence of renal failure within ≤ 2 to 4 days
Delayed onset of clinical & lab evidence of rhabdomyolysis (darkening urine & serum CK) within 3 to 5 days
Tricholoma equestre- induced rhabdomyolysis with 20% case fatality rates (as reported in Europe only)
Cortinarius species nephrotoxicity with 40% risk of chronic renal failure (CRF)
Amanita smithiana or A. proxima nephrotoxicity with 40% risk of CRF
Russula subnigricans- induced rhabdomyolysis with 20% case fatality rates (as reported in Asia only)
Figure 4: A diagnostic decision algorithm to assist clinicians in the differentiation between the early (≤ 2-4 days) or delayed (>2-14 days) onset of nephrotoxic mushroom poisonings with renal insufficiency and subsequent failure based on the initial clinical manifestations of acute (≤ 6 hours) or delayed (≥ 24-72 hours) and typically mild gastrointestinal symptoms of nausea and vomiting with or without diarrhea.
168 J La State Med Soc VOL 169 NOVEMBER/DECEMBER 2017
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