Classification    |    Detailed evidence-based information

• Substances Included Synonyms

  • Therapeutic Toxic Class

    A) Lycoperdon species are edible and found in the late summer to fall season. Upon decay these mushrooms release spores if compressed. Inhalation of these spores may lead to adverse effects.

    Specific Substances

    1) Lycoperdon Species a) Lycoperdon coelatum b) Lycoperdon gemmatum (common) c) Lycoperdon marginatum d) Lycoperdon maximum e) Lycoperdon perlatum f) Lycoperdon pyriforme (common) g) Lycoperdon saccatum h) Puffball mushroom

    Available Forms Sources

    A) USES 1) Lycoperdon species are edible and found in the late summer to fall season. Upon decay these mushrooms release spores if compressed. Inhalation of these spores may lead to adverse effects (Goldfrank, 2006).

• Overview

  • Life Support

    A) This overview assumes that basic life support measures have been instituted.

    Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE A) USES: Lycoperdon species, commonly referred to as puffball mushrooms, are round or pear-shaped mushrooms that are white, gray, or tan in color and have no stalk. These species are edible and found in the late summer to fall season often growing in clusters on decaying logs in lawns, pastures, and in wooded areas. As the mushrooms age, the interior changes from a white to yellow, them brown solid followed by a mass of dark powdery spores. Lycoperdon spores have been used as a home remedy to treat epistaxis. B) TOXICOLOGY: Inhalation of Lycoperdon spores has been associated with development of lycoperdonosis, consisting of nausea, vomiting, dyspnea, cough, shortness of breath, myalgia, fatigue, and fever. Symptoms may mimic a viral syndrome and may also lead to nasopharyngitis and pneumonitis. These are thought to be due to a foreign body hypersensitivity reaction. C) EPIDEMIOLOGY: Case reports of lycoperdonosis are rare, and a few cases of patients with nausea and vomiting following ingestion of young Lycoperdon mushrooms have been described. D) WITH POISONING/EXPOSURE 1) MILD TO MODERATE TOXICITY: Signs and symptoms typically develop only after inhalation of large amounts of Lycoperdon spores. Symptoms of nausea and vomiting typically begin 6 to 12 hours after exposure. 2) SEVERE TOXICITY: In severe cases of lycoperdonosis, fever, cough, dyspnea, fatigue, hypoxia, and pneumonitis may occur. Symptoms have been described starting 24 hours to 7 days after exposure, and may last weeks to months. 0.2.3) VITAL SIGNS A) WITH POISONING/EXPOSURE 1) FEVER: Fever (up to 103 degrees F) has been reported after inhalation of Lycoperdon spores, and is characteristic in patients who develop pneumonitis (Strand et al, 1967; Henriksen, 1976; Centers for Disease Control, 1994).

    Laboratory Monitoring

    A) Monitor serum electrolytes and renal function in patients with significant vomiting and dehydration. B) Monitor vital signs. C) Monitor pulse oximetry and obtain a chest x-ray in any patient with respiratory symptoms to evaluate for findings of reticulonodular infiltrates.

    Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE A) MANAGEMENT OF MILD TO MODERATE TOXICITY 1) Treatment consists of predominantly symptomatic and supportive care. Patients who develop significant nausea and vomiting may benefit from IV fluid hydration. There is no specific antidote to Lycoperdon toxicity. B) MANAGEMENT OF SEVERE TOXICITY 1) Patients who develop severe toxicity with fever and respiratory symptoms or pneumonitis may require supplemental oxygen, and rarely intubation. Corticosteroids have been used to treat pneumonitis, and antifungals such as amphotericin B or azole medications have been used to treat complicated cases, but efficacy is not clear. C) DECONTAMINATION 1) PREHOSPITAL: No specific gastric decontamination is required. Patients with inhalational exposure to spores should be removed to fresh air. If Lycoperdon spores contact the eyes, immediately rinse the eyes with copious amounts of water, occasionally lifting the lower and upper lids. 2) HOSPITAL: No specific gastric decontamination is required. D) AIRWAY MANAGEMENT 1) Rarely, patients with signs and symptoms of hypoxic respiratory failure may need intubation for respiratory support. E) ANTIDOTE 1) None F) ENHANCED ELIMINATION PROCEDURE 1) There is no specific role for hemodialysis or other enhanced elimination procedures. G) PATIENT DISPOSITION 1) HOME CRITERIA: Asymptomatic patients, or patients with mild gastrointestinal upset after ingestion or mild respiratory irritation after inhalation can be managed at home. 2) OBSERVATION CRITERIA: Patients with known exposure to these mushrooms, who have fever, respiratory symptoms, or significant nausea or vomiting should be evaluated at a healthcare facility. 3) ADMISSION CRITERIA: Patients with significant dehydration, fever, or respiratory symptoms should be admitted for hydration, supplemental oxygen as needed, and monitoring. Patients with severe respiratory symptoms or respiratory failure should be admitted to an ICU setting. 4) CONSULT CRITERIA: Contact your local poison center or a medical toxicologist for patients with significant symptoms, those in whom the diagnosis is in doubt, and for assistance with mushroom identification. A mycologist (may be available through your poison center, botanic garden, or local mycology society) can assist with mushroom identification. H) PITFALLS 1) Ingestion rarely causes significant toxicity; do not overtreat. Manifestations of pulmonary toxicity may be delayed. Patients who are discharged should be given careful follow-up instructions. I) PREDISPOSING CONDITIONS 1) Patients with underlying asthma or COPD may develop more severe pulmonary reactions after inhalation. J) DIFFERENTIAL DIAGNOSIS 1) Bacterial pneumonia, atypical pneumonia, viral pneumonitis, chemical pneumonitis, fungal pulmonary infection, reactive airways disease, acute lung injury/acute respiratory disease syndrome (ALI/ARDS). 0.4.3) INHALATION EXPOSURE A) If a person inhales or insufflates large amounts of Lycoperdon spores, move the exposed person to fresh air immediately. B) Corticosteroids have been used to treat pneumonitis, and antifungals such as amphotericin B or azole medications have been used to treat complicated cases, but efficacy is not clear. 0.4.4) EYE EXPOSURE A) If Lycoperdon spores contact the eyes, immediately rinse the eyes with copious amounts of water, occasionally lifting the lower and upper lids.

    Range Of Toxicity

    A) TOXICITY: Signs and symptoms typically only develop after inhalation of a large amount of spores. Two cases of patients requiring intubation have been described; both of whom had a previous diagnosis of asthma. No fatalities have been associated with lycoperdonosis.

• Clinical Effects

  • Summary Of Exposure

    A) USES: Lycoperdon species, commonly referred to as puffball mushrooms, are round or pear-shaped mushrooms that are white, gray, or tan in color and have no stalk. These species are edible and found in the late summer to fall season often growing in clusters on decaying logs in lawns, pastures, and in wooded areas. As the mushrooms age, the interior changes from a white to yellow, them brown solid followed by a mass of dark powdery spores. Lycoperdon spores have been used as a home remedy to treat epistaxis. B) TOXICOLOGY: Inhalation of Lycoperdon spores has been associated with development of lycoperdonosis, consisting of nausea, vomiting, dyspnea, cough, shortness of breath, myalgia, fatigue, and fever. Symptoms may mimic a viral syndrome and may also lead to nasopharyngitis and pneumonitis. These are thought to be due to a foreign body hypersensitivity reaction. C) EPIDEMIOLOGY: Case reports of lycoperdonosis are rare, and a few cases of patients with nausea and vomiting following ingestion of young Lycoperdon mushrooms have been described. D) WITH POISONING/EXPOSURE 1) MILD TO MODERATE TOXICITY: Signs and symptoms typically develop only after inhalation of large amounts of Lycoperdon spores. Symptoms of nausea and vomiting typically begin 6 to 12 hours after exposure. 2) SEVERE TOXICITY: In severe cases of lycoperdonosis, fever, cough, dyspnea, fatigue, hypoxia, and pneumonitis may occur. Symptoms have been described starting 24 hours to 7 days after exposure, and may last weeks to months.

    Vital Signs

    3.3.1) SUMMARY A) WITH POISONING/EXPOSURE 1) FEVER: Fever (up to 103 degrees F) has been reported after inhalation of Lycoperdon spores, and is characteristic in patients who develop pneumonitis (Strand et al, 1967; Henriksen, 1976; Centers for Disease Control, 1994).

    Respiratory

    3.6.2) CLINICAL EFFECTS A) LYCOPERDONOSIS 1) WITH POISONING/EXPOSURE a) CASE REPORT: A 14-year-old boy developed shortness of breath after inhaling Lycoperdon spores as a remedy for a nose bleed. The boy took deep nasal inhalations, as well as an oral inhalation of the spores. A few hours later he developed a fever and nasal congestion. Nausea and vomiting later developed. The patient became dyspneic. Chest X-ray revealed fine nodular infiltrations throughout both lungs. An unidentified spore formation was observed in his sputum. His clinical course worsened with increased difficulty breathing, crepitant rales, and a persistent fever requiring treatment. The patient recovered gradually after a one month hospital stay (Strand et al, 1967). b) CASE REPORT: An 8-year-old girl developed a spasmodic cough and dyspnea lasting three months in duration after inhalation of Lycoperdon spores as a remedy for nose bleeds. The girl had frequent nose bleeds for which her mother had her inhale Lycoperdon spores. Chest X-ray revealed fine nodular infiltrations through both lungs from the apexes to the bases. She gradually recovered requiring no specific treatment (Strand et al, 1967). c) CASE REPORT: A 4-year-old girl developed lycoperdonosis after having a Lycoperdon mushroom forced onto her face and into her mouth by an older child. Cough, chills, and fever developed the day following the exposure. Her clinical course worsened with increasing cough, dyspnea, fever, and anorexia. Chest X-ray revealed widespread densities in both lungs. An ash grey secretion was found in the bronchi via bronchoscopy. Chemical pneumonitis was diagnosed and treated with steroids. She required hospital admission and eventually recovered with symptomatic and supportive care (Henriksen, 1976). d) CASE SERIES: Eight teenagers, ranging from 16 to 19 years, inhaled and chewed puffball mushrooms while at a party. Within 3 to 7 days of exposure, all of the teenagers developed cough, fever (up to 103 degrees F), dyspnea, myalgia, and fatigue. Five of the individuals required hospitalization, with two (with a history of asthma) requiring intubation. Chest X-ray on all patients revealed bilateral reticulonodular infiltrates. Yeast-like structures consistent with Lycoperdon spores were found on lung biopsy of two of the patients. All patients recovered within 4 weeks from the exposure (Centers for Disease Control, 1994). B) PNEUMONITIS 1) WITH POISONING/EXPOSURE a) Massive inhalation, insufflation or chewing of spores can lead to nasopharyngitis and pneumonitis (Goldfrank, 2006).

    Gastrointestinal

    3.8.2) CLINICAL EFFECTS A) NAUSEA 1) WITH POISONING/EXPOSURE a) CASE REPORT: A 14-year-old boy developed nausea several hours after inhaling Lycoperdon spores. The boy took deep nasal inhalations, as well as oral inhalation of the spores to treat epistaxis. The nausea subsided one day after the exposure (Strand et al, 1967). b) CASE SERIES: Eight teenagers, ranging from 16 to 19 years, inhaled and chewed puffball mushrooms while at a party. Three of these individuals developed nausea and vomiting within 6 to 12 hours of exposure (Centers for Disease Control, 1994).

    Musculoskeletal

    3.15.2) CLINICAL EFFECTS A) MUSCLE PAIN 1) WITH POISONING/EXPOSURE a) MYALGIA: Eight teenagers, ranging from 16 to 19 years, inhaled and chewed puffball mushrooms while at a party. Within 3 to 7 days of exposure, all of the teenagers developed myalgias. All patients recovered within 4 weeks from the exposure (Centers for Disease Control, 1994).

• Laboratory Monitoring

  • Monitoring Parameters Levels

    4.1.1) SUMMARY A) Monitor serum electrolytes and renal function in patients with significant vomiting and dehydration. B) Monitor vital signs. C) Monitor pulse oximetry and obtain a chest x-ray in any patient with respiratory symptoms to evaluate for findings of reticulonodular infiltrates. 4.1.2) SERUM/BLOOD A) Monitor serum electrolytes and renal function in patients with significant vomiting and dehydration.

    Radiographic Studies

    A) CHEST RADIOGRAPH 1) Obtain a chest x-ray in any patient with respiratory symptoms. Bilateral reticulonodular infiltrates have been observed after inhalational exposure of Lycoperdon spores (Centers for Disease Control, 1994; Strand et al, 1967; Henriksen, 1976).

• Treatment

  • Life Support

    A) Support respiratory and cardiovascular function.

    Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE 6.3.1.1) ADMISSION CRITERIA/ORAL A) Patients with significant dehydration, fever, or respiratory symptoms should be admitted for hydration, supplemental oxygen as needed, and monitoring. Patients with severe respiratory symptoms or respiratory failure should be admitted to an ICU setting. 6.3.1.2) HOME CRITERIA/ORAL A) Asymptomatic patients, or patients with mild gastrointestinal upset after ingestion or mild respiratory irritation after inhalation can be managed at home. 6.3.1.3) CONSULT CRITERIA/ORAL A) Contact your local poison center or a medical toxicologist for patients with significant symptoms, those in whom the diagnosis is in doubt, and for assistance with mushroom identification. A mycologist (may be available through your poison center, botanic garden, or local mycology society) can assist with mushroom identification. 6.3.1.5) OBSERVATION CRITERIA/ORAL A) Patients with known exposure to these mushrooms, who have fever, respiratory symptoms, or significant nausea or vomiting should be evaluated at a healthcare facility. 6.3.3) DISPOSITION/INHALATION EXPOSURE 6.3.3.1) ADMISSION CRITERIA/INHALATION A) Patients with significant dehydration, fever, or respiratory symptoms should be admitted for hydration, supplemental oxygen as needed, and monitoring. Patients with severe respiratory symptoms or respiratory failure should be admitted to an ICU setting. 6.3.3.2) HOME CRITERIA/INHALATION A) Asymptomatic patients, or patients with mild gastrointestinal upset after ingestion or mild respiratory irritation after inhalation can be managed at home. 6.3.3.3) CONSULT CRITERIA/INHALATION A) Contact your local poison center or a medical toxicologist for patients with significant symptoms, those in whom the diagnosis is in doubt, and for assistance with mushroom identification. A mycologist (may be available through your poison center, botanic garden, or local mycology society) can assist with mushroom identification. 6.3.3.5) OBSERVATION CRITERIA/INHALATION A) Patients with known exposure to these mushrooms, who have fever, respiratory symptoms, or significant nausea or vomiting should be evaluated at a healthcare facility.

    Monitoring

    A) Monitor serum electrolytes and renal function in patients with significant vomiting and dehydration. B) Monitor vital signs. C) Monitor pulse oximetry and obtain a chest x-ray in any patient with respiratory symptoms to evaluate for findings of reticulonodular infiltrates.

    Oral Exposure

    6.5.2) PREVENTION OF ABSORPTION A) No specific gastric decontamination is required. 6.5.3) TREATMENT A) SUPPORT 1) MANAGEMENT OF MILD TO MODERATE TOXICITY a) Treatment consists of predominantly symptomatic and supportive care. Patients who develop significant nausea and vomiting may benefit from IV fluid hydration. There is no specific antidote to Lycoperdon toxicity. 2) MANAGEMENT OF SEVERE TOXICITY a) Patients who develop severe toxicity with fever and respiratory symptoms or pneumonitis may require supplemental oxygen, and rarely intubation. Corticosteroids have been used to treat pneumonitis, and antifungals such as amphotericin B or azole medications have been used to treat complicated cases, but efficacy is not clear. B) MONITORING OF PATIENT 1) Monitor serum electrolytes and renal function in patients with significant vomiting and dehydration. 2) Monitor vital signs. 3) Monitor pulse oximetry and obtain a chest x-ray in any patient with respiratory symptoms to evaluate for findings of reticulonodular infiltrates.

    Inhalation Exposure

    6.7.1) DECONTAMINATION A) If a person inhales or insufflates large amounts of Lycoperdon spores, move the exposed person to fresh air immediately. B) Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms (nausea, vomiting, cough, fever, myalgia, fatigue, shortness of breath). 6.7.2) TREATMENT A) MONITORING OF PATIENT 1) Monitor serum electrolytes and renal function in patients with significant vomiting and dehydration. 2) Monitor vital signs. 3) Monitor pulse oximetry and obtain a chest x-ray in any patient with respiratory symptoms to evaluate for findings of reticulonodular infiltrates. B) CORTICOSTEROID 1) Based on limited case reports, a course of corticosteroids may be useful in patients with pneumonitis after inhalation of Lycoperdon spores (Centers for Disease Control, 1994; Henriksen, 1976; Strand et al, 1967). Prednisone 2 mg/kg/day for 14 days with tapered dosing thereafter was used to decrease respiratory symptoms from Lycoperdon spore inhalational exposure (Strand et al, 1967). C) ANTIFUNGAL 1) Antifungal therapy (amphotericin B or azole drugs) has been used in complicated cases of inhalational Lycoperdon spore exposure (Henriksen, 1976; Centers for Disease Control, 1994). D) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

    Enhanced Elimination

    A) HEMODIALYSIS 1) There is no specific role for hemodialysis or other enhanced elimination procedures.

• Abstracts

• Range Of Toxicity

  • Summary

    A) TOXICITY: Signs and symptoms typically only develop after inhalation of a large amount of spores. Two cases of patients requiring intubation have been described; both of whom had a previous diagnosis of asthma. No fatalities have been associated with lycoperdonosis.

    Minimum Lethal Exposure

    A) Fatalities have not been reported after exposure to these mushrooms.

    Maximum Tolerated Exposure

    A) Lycoperdonosis (ie, respiratory syndrome accompanied by fever, myalgia, and fatigue) has rarely been reported after deliberate inhalation of Lycoperdon spores. Massive inhalation, insufflation or chewing of spores can lead to nausea and vomiting, nasopharyngitis, and pneumonitis within several hours of exposure (Goldfrank, 2006). B) CASE REPORT : A 14-year-old boy developed shortness of breath after inhaling Lycoperdon spores as a remedy for a nose bleed. The boy took deep nasal inhalations, as well as an oral inhalation of the spores. He later developed fever, nasal congestion, nausea and vomiting. His clinical course worsened with increased difficulty breathing, crepitant rales, and a persistent fever requiring treatment. The patient recovered gradually after a one month hospital stay (Strand et al, 1967). C) CASE REPORT: A 4-year-old girl developed lycoperdonosis after having a Lycoperdon mushroom forced onto her face and into her mouth by an older boy. Cough, chills, and fever developed the day after exposure. Her clinical course worsened with increasing cough, dyspnea, fever, and anorexia. A tentative diagnosis of chemical pneumonitis was reported. She required hospital admission and eventually recovered with symptomatic and supportive care (Henriksen, 1976). D) CASE SERIES: Eight teenagers, ranging from 16 to 19 years, inhaled and chewed puffball mushrooms while at a party. Within 3 to 7 days of exposure, all of the teenagers developed cough, fever (up to 103 degrees F), dyspnea, myalgia, and fatigue. Five of the individuals required hospitalization, with two (both with a history of asthma) requiring intubation. All patients recovered within 4 weeks from the exposure (Centers for Disease Control, 1994).

• Pharmacology Toxicology

  • Toxicologic Mechanism

    A) Lycoperdon species are edible and found in the late summer to fall season. Upon decay these mushrooms release spores if compressed. Inhalation of these spores may lead to adverse effects (Goldfrank, 2006).

• Physicochemical

• Animal Toxicology

• References

  • General Bibliography

    1) Centers for Disease Control: Respiratory illness associated with inhalation of mushroom spores--Wisconsin, 1994. MMWR Morb Mortal Wkly Rep 1994; 43(29):525-526. 2) Goldfrank LR: Mushrooms. In: Goldfrank LR, Flomenbaum N, Hoffman RS, et al, eds. Goldfrank's Toxicologic Emergencies. 8th ed., 8th ed. McGraw Hill, New York, NY, 2006, pp -. 3) Henriksen NT: Lycoperdonosis. Acta Paediatr Scand 1976; 65(5):643-645. 4) Strand RD, Neuhauser EB, & Sornberger CF: Lycoperdonosis. N Engl J Med 1967; 277(2):89-91.