Research Information System
3rd INTERNATIONAL CONGRESS ON EMERGENCY MEDICINE “ICON-EM, Antalya, Turkey, 5 - 08 November 2023, pp.489-492
A Rare Case Resulting from Fungal Intoxication: Acute
Pancreatitis
ali halıcı1 , mehmed ulu1
1kutahya health science
university
Background
and aim: Mushrooms have been consumed by humans since the
earliest periods of history. Of the more than 10,000 mushroom species known
today, approximately 100 are thought to be poisonous(1). Mushrooms
collected from nature and consumed by local people, especially in spring,
sometimes cause intoxication. This situation is most often caused by accidental
consumption of toxic mushrooms due to their similar color and shape (2).
Although the patient's clinic varies depending on the mushroom eaten and the
toxin exposed, most cases are mild to moderate and death rarely occurs. The
most common conditions are gastroenteritis, hepatic involvement, renal
involvement and central nervous system involvement (3). While symptoms
occurring within the first 6 hours after mushroom ingestion rarely indicate
serious toxicity, symptoms occurring after 6 hours are much more likely to be associated
with lethal toxicity (1). Mushroom intoxication can rarely cause pancreatitis.
In this article, the patient who applied to the emergency department with
complaints of nausea, vomiting and abdominal pain after eating mushrooms and
was diagnosed with pancreatitis will be discussed together with her/his
clinical, laboratory results and outcome.
Case: A
61-year-old female patient had no known history of disease and applied to the
emergency department with complaints of nausea, vomiting, diarrhea and abdominal
pain. The patient was admitted to the emergency room at 08:00, and in the
anamnesis taken from the patient, it was learned that he ate 4-5 mushrooms
called "morel" at around 14:00 the previous day, and that his
complaints of nausea, vomiting, and abdominal pain began around 23:30 at night.
When the patient was admitted to the emergency department, his general
condition was good, he was conscious, his vitals were stable with TA: 110/50,
pulse: 88/min, respiratory rate 19/min, SpO2: 97. During the patient's
examination, tenderness was detected in the right upper quadrant, but no
abnormalities were detected in other examinations. When the patient's
laboratory results were examined, creatinine: 1.33, direct bilirubin: 1.12,
indirect bilirubin: 2, total bilirubin: 3.1, AST: 894, ALT: 400, GGT: 274,
amylase: 3358, lipase: 6746, WBC: 17.49, Neu: It was determined as 15.84
troponin: 12 CRP: 19.6 lactate: 3.2, INR: 1.02. No feature was detected in the
abdominal USG. The patient was consulted by gastroenterology and internal
medicine and his clinical findings were evaluated as compatible with toxic
pancreatitis. Intensive care follow-up was recommended because the patient, who
also had elevated liver enzymes, was at risk of acute hepatic failure. The
National Poison Advisory Line was called, and liver enzyme monitoring and urine
output monitoring were recommended to be completed within 5 days. The patient
was interned in the intensive care unit and was followed up in the intensive
care unit for 5 days. After his general condition was good, his vitals were
stable, and his laboratory disorders regressed, he was transferred to the
internal medicine service. The patient was followed up for 7 days in the
internal medicine service and was discharged with the recommendation of a
follow-up examination, as his clinical condition remained stable.
Gyromitra Esculenta
a: false morel mushroom
b:morel mushroom
Decisions: In mushroom intoxications, the clinical picture
varies depending on the type of mushroom and the amount of toxin consumed by
the patient. (one). Benign gastroenteritis, where symptoms typically begin
within the first 3 hours after ingestion, is one of the most common clinical
conditions. Various types of fungi can cause this condition, and patients may
complain of nausea, vomiting, abdominal pain and diarrhea. It is usually
self-limiting and may rarely lead to hypovolemic shock in the elderly and
children with low tolerance to fluid loss (4,5). Although our patient had
gastroenteritis symptoms such as nausea, vomiting, diarrhea, and abdominal
pain, which started approximately 10 hours after mushroom ingestion, this did
not cause a hemodynamic disorder. Species containing psilocybin and psilocin,
known as magic mushrooms, have 5-Hydroxytryptamine (5-HT) receptor It can cause
hallucinations by acting on it. Hallucinations occur within 1-2 hours after
ingestion and can continue for 4-12 hours depending on the amount of toxin
ingested (4). Tachycardia and dilated pupils may be detected in patients during
physical examination (6,7). The reasons why patients who consume magic
mushrooms apply to the emergency department may be anxiety, panic, and paranoia
(8). Other fungal groups that affect the central nervous system are species
containing Gyromitrin and can trigger seizures due to GABA decrease in the
central nervous system (4). No neurological symptoms or findings were observed
in our patient. Species containing muscarine may cause cholinergic toxicity,
and patients may experience abdominal pain, sweating, salivation, lacrimation,
bronchospasm, bronchorea and bradycardia, which typically begins 30 minutes
after ingestion. This effect occurs as a result of muscorin's stimulation of
postganglionic cholinergic neurons. Unlike other etiologies that cause
cholinergic toxicity, such as organophosphate poisoning, it has a benign course
and does not usually cause a lethal clinic (1,4). No symptoms or findings
suggestive of cholinergic toxicity were found in our patient's clinic.
Amatoxin-containing species cause RNA polymerase 2 enzyme inhibition and affect
protein metabolism at the cellular level and are among the most toxic fungal
species known (4,9). Amatoxins are heat resistant and their structure is not
damaged by cooking. The lethal dose is low and even a single mushroom ingestion
can be fatal (10). In the first phase, gastroenteritis occurs within 6-12 hours
after ingestion. The second phase is observed 24-36 hours after ingestion and a
regression in the patient's symptoms is detected. However, liver damage begins
at this stage and is reflected in laboratory results. The third phase occurs 48
hours after ingestion and progressive liver failure occurs. Coagulopathy,
acidosis, hepatic encephalopathy and hemorrhages are the pathologies expected
at this stage. These patients may need liver transplantation within 4-7 days,
and if this treatment cannot be achieved, death may occur (1,9). In our
patient, elevated liver enzymes were detected at the first admission, but these
values showed a continuous downward trend during follow-up and returned to
normal levels before discharge. Species containing orelenin can cause
nephrotoxicity, but this effect can be seen 1-2 weeks after ingestion. Overt
neuroleucine seen in some amanita species can also create a clinical picture
that begins with gastroenteritis and progresses to renal damage within 12-24
hours (1,4). Our patient has a moderate elevation of creatinine, which may be
due to fungal toxicity or may have occurred due to prerenal acute kidney injury
due to fluid loss. Rhabdomyolysis, disulfram-like reaction, erythromyalgia and
dermatitis are among the clinical conditions reported due to mushroom
intoxication (1,4, 11,12,13). No clinical or laboratory findings were found in
our patient that would suggest these diagnoses. Acute pancreatitis is one of
the rare clinical conditions reported very rarely as a result of mushroom
intoxication (14). Our patient's clinic, physical examination and laboratory
results are compatible with acute pancreatitis. Since no other etiological
factor was detected in the evaluations that would explain the patient's clinic,
the cause of acute pancreatitis was thought to be due to mushroom intoxication.
When looking at the literature, it was seen that the mushroom described by the
patient with the scientific name Morchella Esculenta, locally known as
"morel", is a consumable, delicious and nutritious type of mushroom
(15,16). It has been reported in the literature that the toxic mushroom with
the scientific name Gyromitra Esculenta, known locally as "false
morel", is consumed by patients mistaking it for Morchella Esculenta
(1,17,18). Although the two mushrooms are similar in shape, there is only a
difference in color. Impairment of consciousness, central nervous system
stimulation, agitation and seizures due to ingestion of toxins containing
gyromitrin. It is reported in the literature that it may cause clinical
conditions such as liver and kidney damage and methemoglobinemia (19,20). It
has also been reported in the literature that acute pancreatitis may occur very
rarely (21). The patient's clinic is expected to be seen 6-12 hours after toxin
ingestion (17). The amount of mushroom consumed determines the patient's
clinic, and central nervous system effects occur at high doses (19).
Considering all these data, it is thought that our patient's clinical picture
may be compatible with gyromitrin toxicity. ConclusionPatients with a history
of eating mushrooms periodically apply to emergency services with various
complaints. The onset of symptoms within 6 hours of mushroom ingestion may
indicate serious toxicity. Although the mushroom type popularly known as
"morel" is a nutritious mushroom that can be consumed, "false
morel", which is very similar to this mushroom in shape and color, can
cause impaired consciousness, seizures, liver and kidney damage, depending on
the amount taken. It would be useful for clinicians to keep gyromitrin toxicity
in mind in cases of idiopathic hepatitis and pancreatitis.
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Keywords
: Gyromitra
Esculenta, mushroom intoxication, pancreatitis, false morel mushroom