Over the course of two weeks, four people visited the MGUH for medical treatment due to mushroom (amantin) poisoning. One Virginia man arrived at MedStar Georgetown University Hospital (MGUH) in the early stages of liver failure after having mistakenly eaten poisonous mushrooms he handpicked from his yard.
All four cases, including their clinical course, management and outcomes were presented at Digestive Disease Week (DDW) in San Diego, the largest international gathering of physicians and researchers in the field of gastroenterology, hepatology, endoscopy and gastrointestinal surgery.
Jacqueline Laurin, M.D., a transplant hepatologist at the Georgetown Transplant Institute, a part of MGUH and Georgetown University Medical Center recalls:
"When the Virginia man arrived at his local emergency department, a clinical diagnosis of mushroom poisoning was made. He had eaten the mushrooms, gotten very ill and his liver enzymes were very elevated with signs of severe liver dysfunction."
The man was transferred to MGUH in case he would require a liver transplant. Laurin's team alerted the local Poison Control Center who referred them to a California physician, who is the leading investigator for a U.S. study, which uses an IV preparation of milk thistle seeds (silibinin) for amanitin poisoning. The drug was couriered to the hospital and the patient received silibinin that evening. Because silibinin has not yet been approved by the U.S. Food and Drug Administration (FDA), doctors administered the drug to the patient under the FDA's "emergency use" one-time exemption. Any future treatment with silibinin would have to be registered as part of a clinical study and be approved by the Georgetown University Medical Center's Institutional Review Board, a committee charged with the protection of humans in research studies.
Laurin declares: "We knew it wasn't out of the realm of possibility that another person could show up with mushroom poisoning and without a study in place, we wouldn't have the option of offering the silibinin."
Because of the increased rainfall, mushrooms were growing in greater numbers than usual, and a week later before the hospital could complete the protocol for silibinin, the hospital was presented with a second patient with mushroom poisoning. The protocol was rushed through due to the second patient's status, who was also treated with the same silibinin IV preparation as the first patient. Within a few days, two more patients arrived who also received the treatment.
According to Laurin, the first clinical symptoms of amanitin poisoning is similar to gastroenteritis, with the patient feeling nauseous, vomiting, abdominal pain and diarrhea, which is followed by a period of apparent recovery before the patient develops acute hepatitis and jaundice.
Laurin states: "Early recognition of mushroom ingestion as a cause of acute hepatitis is paramount to initiate treatment and hopefully preventing progression to acute liver failure, liver transplant, or death."
No standard guidelines exist for treating people with acute hepatitis from mushroom toxicity, and Laurin explains:
"Without a standard treatment, aggressive hydration to remove the amanitin toxin is one of few ways to reduce damage to the liver. For our recent amanitin patients, all received intravenous silibinin. We also placed a nasobiliary drain in two of the patients in an attempt to disrupt the enterohepatic pathway of amanitin and remove amanitin toxins from the body."
Maiyen Tran Hawkins, D.O., a gastroenterology fellow in the transplant hepatology inpatient service and lead author of the DDW abstract, said: "Because our hospital is affiliated with Georgetown University Medical Center, our treatment options include agents in clinical studies. That access and our team approach allowed us to quickly and successfully deliver a multi-modality treatment with IV silibinin and ERCP for nasobiliary drainage placement. We were able to prevent liver failure and all patients fully recovered without significant consequence."
"While these results appear promising, we need to know much more about silibinin, such as the timing for delivering it, what dose is most effective and whether or not a nasobiliary drainage is even necessary in combination with silibinin. I think we can point to this case series as a treatment success, but clearly more work and education needs to be done to reduce morbidity and death from amanitin poisoning."
Written By Petra Rattue