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MUSHROOM-INDUCED IMMUNOHEMOLYTIC SYNDROME

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Immunohemolytic syndrome has been reported in patients following the ingestion of Paxillus involutus and possibly Boletus luridus and Clitocybe claviceps. Other mushrooms, Suillus luteus and Amanita vaginata have also caused hemolysis. Hemolysis form these latter species is rare and is not immune mediated. It is believed to be related to a heat labile hemolysin in raw or undercooked mushrooms

Specific Substances

    1) PAXILLUS INVOLUTUS
    a) Brown roll-rim
    b) Inrolled Paxillus
    c) Roll-rim fungus
    d) Poison Pax
    e) Mushrooms-induced immunohemolytic syndrome

Available Forms Sources

    A) USES
    1) Paxillus involutus has been used for pickling and salting for many years in eastern Europe. In Poland, intoxication following Paxillus involutus mushroom ingestion is the third most common type of poisoning; it can cause gastrointestinal symptoms (Benjamin, 1995).

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) GENERAL INFORMATION: Mushroom Immune Hemolytic Syndrome (MIHS) most frequently results from repeated ingestion of the brown mushroom Paxillus involutus. The mushroom has long been recognized as causing gastrointestinal irritation when consumed raw. Historically, the mushroom was thought be safe when cooked. However, MIHS can occur when consuming cooked mushrooms, as the antigen is heat-stable. Clitocybe claviceps and Boletus luridus have also been implicated.
    B) TOXICOLOGY: MIHS is caused by antibodies against the fungus in sensitized patients. Circulating immune complexes bind to erythrocytes, causing hemolysis. This leads to hemoglobinuria, oliguria, and renal failure. The renal failure is likely secondary to immune complex nephritis. MIHS usually begins with nausea and vomiting 1 to 2 hours after ingestion in an individual that has ingested the mushrooms on previous occasions.
    C) EPIDEMIOLOGY: Exposures are uncommon and severe toxicity is very rare.
    D) WITH POISONING/EXPOSURE
    1) Nausea, vomiting, diarrhea, abdominal pain and hypotension may develop 30 minutes to 3 hours after ingestion. Acute hemolysis may follow with back pain, anemia, hemoglobinuria, acute renal failure, and shock.
    0.2.21) CARCINOGENICITY
    A) Studies have shown that the Paxillus involutus mushroom contains compounds that directly damage chromosomes, causing mutagenicity and carcinogenicity.

Laboratory Monitoring

    A) Monitor vital signs.
    B) Monitor serial CBC, electrolytes, renal function, urinalysis and urine output.
    C) Monitor ECG in patients with hemolysis.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF TOXICITY
    1) Supportive care is the mainstay of treatment: IV fluids and pressors for hypotension, antiemetics for vomiting, airway control, and cardiac monitoring. Electrolyte abnormalities should be rapidly corrected. Hemodialysis may be required for acute renal failure. Steroids should be considered as in any other type III hypersensitivity reaction. Plasmapheresis has been used successfully in patients with severe hemolysis. Allergy and Immunology, hematology, and nephrology consults should be obtained in patients with evidence of hemolysis or renal injury. Urine output should be monitored for oliguria or anuria.
    B) DECONTAMINATION
    1) PREHOSPITAL: Patients should not induce vomiting at home. HOSPITAL: Consider activated charcoal if patient is presenting within 1 hour of ingestion.
    C) AIRWAY MANAGEMENT
    1) Consider intubation if CNS depression results in an inability of patient to protect the airway.
    D) ANTIDOTE
    1) There is no specific antidote.
    E) IMMUNOSUPPRESSIVE THERAPY
    1) High-dose steroids and possibly immunosuppressant drugs may be used but this should be done in conjunction with an allergist/immunologist. Plasmapheresis should be considered in very ill patients.
    F) ENHANCED ELIMINATION PROCEDURE
    1) Hemodialysis may be required due to renal failure. Plasmapheresis may be required to remove circulating immune complexes. Plasma exchange was used in one patient to remove circulating immune complexes.
    G) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients without GI symptoms may be observed at home.
    2) OBSERVATION CRITERIA: Observe symptomatic patients until symptoms resolved. Patients without GI symptoms within 4 hours of ingestion are unlikely to develop symptoms.
    3) ADMISSION CRITERIA: Moderate to severe GI symptoms or any evidence of hemolysis or renal injury warrants admission.
    4) CONSULT CRITERIA: Consult poison center for all symptomatic patients or asymptomatic patients who have shared a meal with symptomatic patients. For patients who develop hemolysis, consult with allergy/immunology, toxicology, and nephrology.
    H) PITFALLS
    1) Patients generally have eaten these mushrooms before and believe them to be safe for consumption. Many other mushrooms cause gastrointestinal symptoms and/or kidney injury. Additionally, patients frequently ingest more than one type of mushroom. An attempt should be made to identify the mushroom in consultation with a mycologist.
    I) TOXICOKINETICS
    1) Onset of symptoms is usually 30 minutes to 3 hours.
    J) PREDISPOSING CONDITION
    1) Prior ingestion of MIHS inducing species.
    K) DIFFERENTIAL DIAGNOSIS
    1) Ingestion of mushrooms that cause GI upset, hemolytic uremic syndrome, other autoimmune hemolytic anemias, G6PD deficiency.

Range Of Toxicity

    A) TOXICITY: Toxic dose is not well established. Most illnesses occur after consuming a meal made of cooked or pickled Paxillus species. The repeated dose phenomenon is likely due to sensitization rather than a theoretical dose threshold.

Clinical Effects

Summary Of Exposure

    A) GENERAL INFORMATION: Mushroom Immune Hemolytic Syndrome (MIHS) most frequently results from repeated ingestion of the brown mushroom Paxillus involutus. The mushroom has long been recognized as causing gastrointestinal irritation when consumed raw. Historically, the mushroom was thought be safe when cooked. However, MIHS can occur when consuming cooked mushrooms, as the antigen is heat-stable. Clitocybe claviceps and Boletus luridus have also been implicated.
    B) TOXICOLOGY: MIHS is caused by antibodies against the fungus in sensitized patients. Circulating immune complexes bind to erythrocytes, causing hemolysis. This leads to hemoglobinuria, oliguria, and renal failure. The renal failure is likely secondary to immune complex nephritis. MIHS usually begins with nausea and vomiting 1 to 2 hours after ingestion in an individual that has ingested the mushrooms on previous occasions.
    C) EPIDEMIOLOGY: Exposures are uncommon and severe toxicity is very rare.
    D) WITH POISONING/EXPOSURE
    1) Nausea, vomiting, diarrhea, abdominal pain and hypotension may develop 30 minutes to 3 hours after ingestion. Acute hemolysis may follow with back pain, anemia, hemoglobinuria, acute renal failure, and shock.

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) CASE REPORT: A couple became ill after eating a mushroom meal. The husband developed hemolytic anemia and experienced severe chest and lower back pain, hypotension, and some permanent loss of vision ascribed to central retinal necrosis. The wife ingested only a couple of caps and experienced low back pain and mild anemia (Benjamin, 1995).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) Hypotension may occur within 30 minutes to 3 hours of a mushroom meal (Benjamin, 1995).
    b) CASE REPORT: A couple became ill after eating a mushroom meal. The husband developed hemolytic anemia and experienced severe chest and lower back pain, hypotension, and some permanent loss of vision ascribed to central retinal necrosis. The wife ingested only a couple of caps and experienced low back pain and mild anemia (Benjamin, 1995).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) GASTROINTESTINAL TRACT FINDING
    1) WITH POISONING/EXPOSURE
    a) Nausea, vomiting, diarrhea, and abdominal pain may occur within 30 minutes to 3 hours of a mushroom meal (Diaz, 2005; Benjamin, 1995).

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) HEMOLYTIC ANEMIA
    1) WITH POISONING/EXPOSURE
    a) Immunohemolytic anemia usually occurs following the repeated long-term ingestion of Paxillus involutus mushroom. Nausea, vomiting, diarrhea, abdominal pain, and hypotension may occur within 30 minutes to 3 hours of a mushroom meal. It is followed by an acute immune complex-mediated hemolytic anemia, possibly in response to a common Paxillus and Boletus antigenic protein constituent, involutin. The patient may develop acute hemolysis, hemoglobinuria, oliguria, anuria, and acute renal failure from immune-complex nephritis (Diaz, 2005; Benjamin, 1995; Flammer & Gallen, 1983).
    b) CASE REPORT: After ingesting cooked Paxillus involutus mushrooms repeatedly, a 37-year-old patient developed hemolysis with reversible shock symptoms, and acute renal failure. Following plasma exchange and hemodialysis, he recovered without further sequelae (Winkelmann et al, 1986).
    c) CASE REPORT: After repeatedly eating the mushroom Paxillus involutus, a 49-year-old man died 3.5 days after developing hemolysis and circulatory shock leading to acute renal failure, acute respiratory failure and disseminated intravascular coagulation. Posmortem exam showed intravascular coagulopathy in the lungs, kidneys, adrenals, myocardium, liver and spleen. In addition, extensive fat emboli to both lungs were observed. In the patient's serum, an IgG antibody against Paxillus involutus extract was found (Winkelmann et al, 1982).
    d) CASE REPORT- A couple became ill after eating a mushroom meal. The husband developed hemolytic anemia and experienced severe chest and lower back pain, hypotension, and some permanent loss of vision ascribed to central retinal necrosis. The wife ingested only a couple of caps and experienced low back pain and mild anemia (Benjamin, 1995).

Carcinogenicity

    3.21.2) SUMMARY/HUMAN
    A) Studies have shown that the Paxillus involutus mushroom contains compounds that directly damage chromosomes, causing mutagenicity and carcinogenicity.
    3.21.3) HUMAN STUDIES
    A) CARCINOMA
    1) The Paxillus involutus mushroom contains compounds that directly damage chromosomes, potentially causing mutagenicity and carcinogenicity (Benjamin, 1995).

Genotoxicity

    A) Studies have shown that the Paxillus involutus mushroom contains compounds that directly damage chromosomes, potentially causing mutagenicity and carcinogenicity (Benjamin, 1995).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor vital signs.
    B) Monitor serial CBC, electrolytes, renal function, urinalysis and urine output.
    C) Monitor ECG in patients with hemolysis.
    4.1.2) SERUM/BLOOD
    A) HEMAGGLUTINATION TESTS
    1) In several patients with the acute Paxillus syndrome, convalescent serum immunoglobulin G antibodies to a Paxillus extract containing involutin have been detected by hemagglutination inhibition testing (Diaz, 2005; Benjamin, 1995; Winkelmann et al, 1986).

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) Moderate to severe GI symptoms or any evidence of hemolysis or renal injury warrants admission.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Patients without GI symptoms may be observed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult poison center for all symptomatic patients or asymptomatic patients who have shared a meal with symptomatic patients. For patients who develop hemolysis, consult with allergy/immunology, toxicology, and nephrology.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Observe symptomatic patients until symptoms resolved. Patients without GI symptoms within 4 hours of ingestion are unlikely to develop symptoms.

Monitoring

    A) Monitor vital signs.
    B) Monitor serial CBC, electrolytes, renal function, urinalysis and urine output.
    C) Monitor ECG in patients with hemolysis.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) ACTIVATED CHARCOAL
    1) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
    a) Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).
    1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
    2) The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.2) PREVENTION OF ABSORPTION
    A) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.3) TREATMENT
    A) SUPPORT
    1) MANAGEMENT OF TOXICITY: Supportive care is the mainstay of treatment: IV fluids and pressors for hypotension, antiemetics for vomiting, airway control, and cardiac monitoring. Electrolyte abnormalities should be rapidly corrected. Hemodialysis may be required for acute renal failure. Steroids should be considered as in any other type III hypersensitivity reaction. Plasmapheresis has been used successfully in patients with severe hemolysis. Allergy and Immunology, hematology, and nephrology consults should be obtained in patients with evidence of hemolysis or renal injury. Urine output should be monitored for oliguria or anuria.
    2) Save all emesis and stools in refrigerator (DO NOT FREEZE) for possible microscopic study and analysis.
    3) HISTORY OF CURRENT ILLNESS
    a) The following questions should be asked in taking the medical history regarding the exposure of the patient to the mushroom:
    1) At what time were the mushrooms eaten?
    2) When was the onset of symptoms after the ingestion?
    3) Was the mushroom eaten at more than one meal?
    4) Were the mushrooms eaten again later and, if so, were they reheated?
    5) Was the mushroom eaten raw or cooked?
    6) Was any alcohol consumed within 24 hours of the meal?
    7) Was more than one kind of mushroom ingested?
    8) How were the mushrooms stored between collection and preparation?
    9) What was the condition of the mushrooms at the time of preparation?
    10) How were the mushrooms prepared (i.e. raw, sauteed, fried, steamed)?
    11) Are ALL persons who ate the mushroom ill?
    12) Are persons in the group who ate NONE of the mushroom ill?
    13) Other important questions regarding the mushroom include:
    a) What kind of substrate was it growing on (eg; wood, soil)?
    b) What kind of tree(s) was it growing near?
    c) What time of year was the mushroom collected?
    B) MONITORING OF PATIENT
    1) Monitor vital signs.
    2) Monitor serial CBC, electrolytes, renal function, urinalysis and urine output.
    3) Monitor ECG in patients with hemolysis.
    C) CORTICOSTEROID
    1) Corticosteroids have been used to treat patients with immune mediated hemolysis (Benjamin, 1995; Olesen, 1991).

Enhanced Elimination

    A) HEMODIALYSIS
    1) Hemodialysis is useful for patients who develop acute renal failure secondary to hemolysis. There is no information regarding the effectiveness of hemodialysis or hemoperfusion for the removal of toxins from plasma (Benjamin, 1995).
    2) After ingesting cooked Paxillus involutus mushrooms repeatedly, a 37-year-old patient developed hemolysis with reversible shock, and acute renal failure. Free hemoglobin and immune complex levels were lowered by 60% to 75% after plasma exchange. Acute renal failure was successfully treated with hemodialysis. Following supportive therapy, he recovered without further sequelae (Winkelmann et al, 1986).
    B) PLASMAPHERESIS
    1) Plasmapheresis may be required to remove circulating immune complexes (Olesen, 1991).

Range Of Toxicity

Summary

    A) TOXICITY: Toxic dose is not well established. Most illnesses occur after consuming a meal made of cooked or pickled Paxillus species. The repeated dose phenomenon is likely due to sensitization rather than a theoretical dose threshold.

Minimum Lethal Exposure

    A) CASE REPORT: After repeatedly eating Paxillus involutus, mushrooms, a 49-year-old man died 3.5 days later following the development of hemolysis and circulatory shock leading to acute renal failure, acute respiratory failure and disseminated intravascular coagulation. Postmortem exam showed intravascular coagulopathy in the lungs, kidneys, adrenals, myocardium, liver and spleen. In addition, extensive fat emboli to both lungs were observed. In the patient's serum, an IgG antibody against Paxillus involutus extract was found (Winkelmann et al, 1982).

Maximum Tolerated Exposure

    A) CASE REPORT: After ingesting cooked Paxillus involutus mushrooms repeatedly, a 37-year-old patient developed hemolysis with reversible shock, and acute renal failure. Following plasma exchange and hemodialysis, he recovered without further sequelae (Winkelmann et al, 1986).
    B) CASE REPORT: A couple became ill after eating a mushroom meal. The husband developed hemolytic anemia and experienced severe chest and lower back pain, hypotension, and some permanent loss of vision ascribed to central retinal necrosis. The wife ingested only a couple of caps and experienced low back pain and mild anemia (Benjamin, 1995).

Pharmacology Toxicology

Toxicologic Mechanism

    A) IMMUNOHEMOLYTIC ANEMIA
    1) Immunohemolytic anemia usually occurs following the repeated ingestion of Paxillus involutus mushroom. Nausea, vomiting, diarrhea, abdominal pain, and hypotension may occur within 30 minutes to 3 hours of a mushroom meal. It is followed by an acute immune complex-mediated hemolytic anemia, possibly initiated in response to a common Paxillus and Boletus antigenic protein constituent, involutin. The patient may develop acute hemolysis, hemoglobinuria, oliguria, anuria, and acute renal failure from immune-complex nephritis (Diaz, 2005; Benjamin, 1995; Winkelmann et al, 1986; Flammer & Gallen, 1983).

References

General Bibliography

    1) Alaspaa AO, Kuisma MJ, Hoppu K, et al: Out-of-hospital administration of activated charcoal by emergency medical services. Ann Emerg Med 2005; 45:207-12.
    2) Benjamin DR: Mushrooms poisons and panaceas: A handbook for naturalists, mycologists and physicians, W. H. Freeman and Company, New York, NY, 1995.
    3) Chyka PA, Seger D, Krenzelok EP, et al: Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43(2):61-87.
    4) Dagnone D, Matsui D, & Rieder MJ: Assessment of the palatability of vehicles for activated charcoal in pediatric volunteers. Pediatr Emerg Care 2002; 18:19-21.
    5) Diaz JH: Syndromic diagnosis and management of confirmed mushroom poisonings. Crit Care Med 2005; 33:427-436.
    6) Elliot CG, Colby TV, & Kelly TM: Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.
    7) FDA: Poison treatment drug product for over-the-counter human use; tentative final monograph. FDA: Fed Register 1985; 50:2244-2262.
    8) Flammer R & Gallen S: Hemolysis in mushroom poisoning: facts and hypotheses (German). Schweiz Med Wochenschr 1983; 113(42):1555-1561.
    9) Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.
    10) Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.
    11) Guenther Skokan E, Junkins EP, & Corneli HM: Taste test: children rate flavoring agents used with activated charcoal. Arch Pediatr Adolesc Med 2001; 155:683-686.
    12) Harris CR & Filandrinos D: Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1993; 22:1470-1473.
    13) Lampe KF & McCann MA: AMA Handbook of poisonous and injurious plants, American Medical Association, Chicago, IL, 1985.
    14) Lincoff G & Mitchel DH: Toxic & Hallucinogenic mushroom poisoning, Van Nostrand Reinhold Company, New York, NY, 1977.
    15) Miller OK Jr: Mushrooms of North America, EP Dutton Company, Inc, New York, NY, 1982.
    16) None Listed: Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42(3):243-253.
    17) Olesen LL: Poisoning with the brown roll-rim mushroom, Paxillus involutus (Danish). Ugeskr Laeger 1991; 153(6):445.
    18) Phillips R, Kibby G, & Foy N (Eds): Mushrooms of North America, Little, Brown and Company, Toronto, Canada, 1991.
    19) Pollack MM, Dunbar BS, & Holbrook PR: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981; 10:528-529.
    20) Rau NR, Nagaraj MV, Prakash PS, et al: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:918-919.
    21) Rinaldi A & Tyndalo V: The complete book of mushrooms, Crescent Books, distributed by Crown Publishers, Inc, New York, NY, 1985, pp 175.
    22) Spiller HA & Rogers GC: Evaluation of administration of activated charcoal in the home. Pediatrics 2002; 108:E100.
    23) Thakore S & Murphy N: The potential role of prehospital administration of activated charcoal. Emerg Med J 2002; 19:63-65.
    24) Winkelmann M, Borchard F, Stangel W, et al: Fatal immunohaemolytic anaemia after eating the mushroom Paxillus involutus (Article in German). Dtsch Med Wochenschr 1982; 107(31-32):1190-1194.
    25) Winkelmann M, Stangel W, Schedel I, et al: Severe hemolysis caused by antibodies against the mushroom Paxillus involutus and its therapy by plasma exchange. Klin Wochenschr 1986; 64(19):935-938.