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MUSHROOMS-MUSCARINE/HISTAMINE

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) These mushrooms are commonly referred to as POISINDEX(R) Group 4 mushrooms.

Specific Substances

    A) POSSIBLE SPECIES:
    1) Clitocybe candicans
    2) Clitocybe cerrusata
    3) Clitocybe cerrusata var.difformis (Clitocybe dilatata)
    4) Clitocybe cerussata
    5) Clitocybe dealbata - (subspecies sudorifica) (0.08%) "Sweat-Producing Clitocybe"
    6) Sweat-Producing Clitocybe - (common name for Clitocybe dealbata)
    7) Clitocybe rivulosa
    8) Clitocybe dilatata (Clitocybe cerrusata var.difformis) "Crowded White Clitocybe"
    9) Crowded White Clitocybe - (common name for Clitocybe dilatata) (Clitocybe cerrusata var.difformis)
    10) Clitocybe morbifera
    11) Entoloma rhodopolium
    12) Inocybe cincinnata
    13) Inocybe enthelella
    14) Inocybe fastigiata (0.22%) - "Straw-colored Fiber Head"
    15) Straw-colored Fiber Head (common name for Inocybe fastigiata)
    16) Inocybe geophylla (0.1%)
    17) Inocybe godeyi
    18) Inocybe lacera - "Torn Fiber Head"
    19) Torn Fiber Head - (common name for Inocybe lacera)
    20) Inocybe lanuginosa
    21) Inocybe lilacina
    22) Inocybe mixtilis
    23) Inocybe napipes
    24) Inocybe patouillardii - Inocybe erubescens
    25) Inocybe pudica - "Blushing Inocybe"
    26) Blushing Inocybe - (common name for Inocybe pudica)
    27) Inocybe rimosa - I. fastigiata
    28) Inocybe sororia - "Corn Silk Inocybe"
    29) Corn Silk Inocybe - (common name for Inocybe sororia)
    30) Inocybe subdestricta
    31) Inocybe umbrina
    32) Mycena pura

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: These mushrooms may be inadvertently ingested by amateur mushroom hunters or children exploring their environment. This includes many mushrooms of the Inocybe genus and a small number of mushrooms in the Clitocybe genus.
    B) TOXICOLOGY: Muscarine is a quaternary ammonium compound with cholinergic effects. It does not cross the blood-brain barrier. Effects are purely peripheral with no direct central nervous system toxicity. The toxin is not destroyed by cooking. Some of the muscarinic compounds have a histaminic effect.
    C) EPIDEMIOLOGY: Muscarinic mushroom poisoning is rare and severe toxicity is very rare. Deaths are not expected from muscarinic mushroom poisoning.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Symptoms are similar to cholinergic poisoning including hypersalivation, lacrimation, excessive urination, diarrhea, vomiting, abdominal pain, bronchorrhea, bronchospasm, bradycardia, excessive perspiration, miosis, blurred vision, confusion, dizziness, headache, and tremors. Profuse sweating is the most useful clinical finding to distinguish between this group and general gastrointestinal irritant mushrooms. Central effects do not occur because muscarine does not cross the blood brain barrier.
    2) SEVERE TOXICITY: Is very rare but may include hypotension, severe bronchospasm and bronchorrhea, bradycardia, acidosis, and confusion. Deaths have rarely been reported in patients with cardiac or pulmonary disease.

Laboratory Monitoring

    A) Muscarine has been analyzed in the urine and has been used for confirmation of this type of poisoning but levels are not routinely obtained and are seldom useful in clinical management of poisoning.
    B) Monitor vital signs, basic metabolic panel, ECG, and pulse oximetry in symptomatic patients.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Care is symptomatic and supportive. Treat with IV fluids and antiemetics.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Treat severe cholinergic symptoms with atropine; endpoint is drying of secretions. Treat severe bronchospasm with inhaled beta agonists and anticholinergics. Treat hypotension with IV fluids; add vasopressors if hypotension persists.
    C) DECONTAMINATION
    1) Activated charcoal is not routinely recommended as patients tend to have spontaneous emesis and are at risk for aspiration. It can be considered if administered immediately after ingestion. Because symptom onset may be 15 to 30 minutes, decontamination after symptoms have started is of questionable value.
    D) AIRWAY MANAGEMENT
    1) Endotracheal intubation should be performed in patients with excessive drowsiness, the inability to protect their own airway, or severe respiratory distress.
    E) ENHANCED ELIMINATION
    1) There is no role for enhanced elimination.
    F) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients with suspected muscarine/histamine mushroom ingestion should be referred to a healthcare facility.
    2) OBSERVATION CRITERIA: Patients should be observed in a medical facility until free of symptoms.
    3) ADMISSION CRITERIA: All patients who continue to be symptomatic should be admitted for observation.
    4) CONSULT CRITERIA: Consult a medical toxicologist for assistance with medical management.
    G) PHARMACOKINETICS
    1) Onset: Onset is within 30 to 120 minutes. Duration: Symptoms are usually short-lived, subsiding within 2 hours without treatment, but can persist for 6 to 24 hours. Metabolism: Muscarine does not contain an ester linkage; therefore, it is not metabolized by plasma cholinesterase. Excretion: Partially excreted unchanged in the urine.
    H) PITFALLS
    1) Patients may have ingested more than one species of toxic mushrooms.
    I) DIFFERENTIAL DIAGNOSIS
    1) Organophosphate poisoning, cholinergic agonist poisoning (eg, pilocarpine, bethanechol, carbachol), poisoning with cholinesterase inhibitors (eg, donepezil, tacrine, rivastigmine, galantamine), gastroenteritis.

Range Of Toxicity

    A) TOXICITY: Not well defined but toxicity is possible after ingestion of a single mushroom. Deaths have rarely been reported in patients with cardiac or pulmonary disease.

Clinical Effects

Summary Of Exposure

    A) USES: These mushrooms may be inadvertently ingested by amateur mushroom hunters or children exploring their environment. This includes many mushrooms of the Inocybe genus and a small number of mushrooms in the Clitocybe genus.
    B) TOXICOLOGY: Muscarine is a quaternary ammonium compound with cholinergic effects. It does not cross the blood-brain barrier. Effects are purely peripheral with no direct central nervous system toxicity. The toxin is not destroyed by cooking. Some of the muscarinic compounds have a histaminic effect.
    C) EPIDEMIOLOGY: Muscarinic mushroom poisoning is rare and severe toxicity is very rare. Deaths are not expected from muscarinic mushroom poisoning.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Symptoms are similar to cholinergic poisoning including hypersalivation, lacrimation, excessive urination, diarrhea, vomiting, abdominal pain, bronchorrhea, bronchospasm, bradycardia, excessive perspiration, miosis, blurred vision, confusion, dizziness, headache, and tremors. Profuse sweating is the most useful clinical finding to distinguish between this group and general gastrointestinal irritant mushrooms. Central effects do not occur because muscarine does not cross the blood brain barrier.
    2) SEVERE TOXICITY: Is very rare but may include hypotension, severe bronchospasm and bronchorrhea, bradycardia, acidosis, and confusion. Deaths have rarely been reported in patients with cardiac or pulmonary disease.

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) LACRIMATION: Excessive lacrimation may be seen and is part of a condition known as the "PSL" syndrome (perspiration, salivation, lacrimation) (Spoerke & Rumack, 1994) or "SLUDGE/BBB" (salivation, lacrimation, urination, defecation, gastrointestinal symptoms and emesis with bronchorrhea, bronchospasm and bradycardia).
    a) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 3 patients developed lacrimation (Lurie et al, 2009).
    2) BLURRED VISION: In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 3 patients developed blurred vision (Lurie et al, 2009).
    3) MIOSIS: In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 2 patients developed miosis (Lurie et al, 2009).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) Hypotension may occur (Zosel et al, 2015; Pauli & Foot, 2005; Lambert & Larcan, 1989; Lampe, 1986).
    b) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 1 patient developed hypotension (70/40 mmHg) (Lurie et al, 2009).
    B) BRADYCARDIA
    1) WITH POISONING/EXPOSURE
    a) Bradycardia may occur (Zosel et al, 2015; Pauli & Foot, 2005; Lambert & Larcan, 1989; Lampe, 1986).
    b) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 1 patient developed bradycardia (45 beats/min) (Lurie et al, 2009).
    C) TACHYCARDIA
    1) WITH POISONING/EXPOSURE
    a) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 5 patients developed tachycardia (greater than 100 beats/min), possibly secondary to mild volume depletion from vomiting, diarrhea, and hypersecretions (Lurie et al, 2009).
    D) SYNCOPE
    1) WITH POISONING/EXPOSURE
    a) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 1 patient developed syncope (Lurie et al, 2009).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) DISORDER OF RESPIRATORY SYSTEM
    1) WITH POISONING/EXPOSURE
    a) PULMONARY CONGESTION: may occur (Lambert & Larcan, 1989; Lampe, 1986).
    B) BRONCHOSPASM
    1) WITH POISONING/EXPOSURE
    a) WHEEZING: Asthmatic wheezing may occur (Lambert & Larcan, 1989; Lampe, 1986).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) HEADACHE
    1) WITH POISONING/EXPOSURE
    a) Headache can result from vasodilatory effects (Pauli & Foot, 2005; Spoerke & Rumack, 1994).
    B) TREMOR
    1) WITH POISONING/EXPOSURE
    a) Tremors may result from reduced blood supply to the brain during severe episodes of hypotension (Spoerke & Rumack, 1994).
    b) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 2 patients developed tremor (Lurie et al, 2009).
    C) RESTLESSNESS
    1) WITH POISONING/EXPOSURE
    a) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 2 patients developed restlessness (Lurie et al, 2009).
    D) DIZZINESS
    1) WITH POISONING/EXPOSURE
    a) Dizziness may result from reduced blood supply to the brain during severe episodes of hypotension (Spoerke & Rumack, 1994).
    E) COMA
    1) WITH POISONING/EXPOSURE
    a) Confusion and coma have been reported following the ingestion of wild mushrooms producing muscarine (Pauli & Foot, 2005).
    F) LACK OF EFFECT
    1) Muscarine is a quaternary ammonium compound and does not cross the blood-brain barrier. Effects are purely peripheral with no direct central nervous system toxicity (Goldfrank, 2006).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) ABDOMINAL PAIN
    1) WITH POISONING/EXPOSURE
    a) Increased peristalsis with crampy abdominal pain may be seen (Pauli & Foot, 2005; Tomini et al, 1987).
    b) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 4 patients developed abdominal pain (Lurie et al, 2009).
    B) DIARRHEA
    1) WITH POISONING/EXPOSURE
    a) Diarrhea may be seen (Zosel et al, 2015; Pauli & Foot, 2005; Spoerke & Rumack, 1994).
    b) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 4 patients developed diarrhea (Lurie et al, 2009).
    C) EXCESSIVE SALIVATION
    1) WITH POISONING/EXPOSURE
    a) Excessive salivation may occur as part of a condition known as the "PSL" syndrome (perspiration, salivation, lacrimation) or "SLUDGE/BBB" (salivation, lacrimation, urination, defecation, gastrointestinal symptoms and emesis with bronchorrhea, bronchospasm and bradycardia) (Pauli & Foot, 2005; Spoerke & Rumack, 1994).
    b) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 3 patients developed hypersalivation (Lurie et al, 2009).
    D) NAUSEA AND VOMITING
    1) WITH POISONING/EXPOSURE
    a) Nausea and vomiting are common initial symptoms after ingestion of muscarine-containing mushrooms (Zosel et al, 2015; Pauli & Foot, 2005).
    b) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 4 patients developed nausea and 8 patients developed vomiting (Lurie et al, 2009).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) EXCESSIVE SWEATING
    1) WITH POISONING/EXPOSURE
    a) Excessive perspiration may be seen as part of a condition known as the "PSL" syndrome (perspiration, salivation, lacrimation) (Pauli & Foot, 2005; Zosel et al, 2015; Spoerke & Rumack, 1994).
    b) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 6 patients developed diaphoresis (Lurie et al, 2009).
    B) FLUSHING
    1) WITH POISONING/EXPOSURE
    a) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), 1 patient developed flushing (Lurie et al, 2009).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Muscarine has been analyzed in the urine and has been used for confirmation of this type of poisoning but levels are not routinely obtained and are seldom useful in clinical management of poisoning.
    B) Monitor vital signs, basic metabolic panel, ECG, and pulse oximetry in symptomatic patients.

Methods

    A) OTHER
    1) Muscarine has been analyzed in the urine and can be used for confirmation of the type of poisoning, but specific and effective treatment should be instituted on the basis of symptoms before any laboratory work is available.
    2) Microscopic identification of the spores isolated from the stomach contents or the feces (Zilker, 1987).
    3) The description of mushrooms can be a valid help for diagnosis (Zilker, 1987).

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) All patients who continue to be symptomatic should be admitted for observation.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Patients with suspected muscarine/histamine mushroom ingestion should be referred to a healthcare facility.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a medical toxicologist for assistance with medical management.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients should be observed in a medical facility until free of symptoms.

Monitoring

    A) Muscarine has been analyzed in the urine and has been used for confirmation of this type of poisoning but levels are not routinely obtained and are seldom useful in clinical management of poisoning.
    B) Monitor vital signs, basic metabolic panel, ECG, and pulse oximetry in symptomatic patients.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) PREHOSPITAL: Activated charcoal is not routinely recommended as patients tend to have spontaneous emesis and are at risk for aspiration. It can be considered if administered immediately after ingestion. Because symptom onset may be 15 to 30 minutes, decontamination after symptoms have started is of questionable value.
    B) 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) SUMMARY: Activated charcoal is not routinely recommended as patients tend to have spontaneous emesis and are at risk for aspiration. It can be considered if administered immediately after ingestion. Because symptom onset may be 15 to 30 minutes, decontamination after symptoms have started is of questionable value.
    B) 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) MONITORING OF PATIENT
    1) Muscarine has been analyzed in the urine and has been used for confirmation of this type of poisoning but levels are not routinely obtained and are seldom useful in clinical management of poisoning.
    2) Monitor vital signs, basic metabolic panel, ECG, and pulse oximetry in symptomatic patients.
    B) ATROPINE
    1) Atropine should be administered if life threatening cholinergic symptoms exist. A test dose of 1 to 2 mg/IV is standard in an adult, in a child 0.02 mg/kg (Howland, 2006). If the patient is poisoned, no signs of atropinism will develop and the atropine may be repeated frequently. The endpoint is cessation of secretions (eg, sialorrhea and diaphoresis), NOT just dilatation of pupils.

Abstracts

Case Reports

    A) OTHER
    1) MUSHROOM POISON CASE REGISTRY
    a) MUSHROOM POISON CASE REGISTRY
    1) Mushroom poisoning cases may be reported to the North American Mycological Association's Mushroom Poisoning Case Registry. Reporting is voluntary and patient confidentiality is maintained.
    2) Forms may be obtained from the website and completed forms or questions may be sent to:
    3) Dr. Michael W. Beug, PO Box 116, Husum, WA 98623; phone: (509) 493-2237
    4) Alternatively, reports may be submitted online at www.sph.umich.edu/~kwcee/mpcr. The website also contains a list of volunteers from different regions of North America willing to assist in the identification of mushrooms.

Range Of Toxicity

Summary

    A) TOXICITY: Not well defined but toxicity is possible after ingestion of a single mushroom. Deaths have rarely been reported in patients with cardiac or pulmonary disease.

Minimum Lethal Exposure

    A) Fatality rates of 6% to 12% are described in the older literature. Most deaths occurred in children with cardiac or pulmonary disease.
    B) The lethal dose of muscarine for humans is not precisely known. Estimates range from 40 to 180 mg (Benjamin, 1995). Others have suggested a higher amount of 330 to 495 mg, equivalent to 100 to 150 grams of a fresh Inocybe mushroom (Spoerke & Rumack, 1994).
    C) CASE REPORT: An 88-year-old woman developed diaphoresis, vomiting, diarrhea, confusion, bradycardia, and hypotension after ingesting Clitocybe species mushroom. Her condition deteriorated and she developed progressive altered mental status and respiratory distress with pulmonary edema. Despite supportive care, she died within 7 hours of ingestion (Zosel et al, 2015).

Maximum Tolerated Exposure

    A) In a case series of 14 patients with Inocybe spp. poisoning (I. fastigiata, I. geophylla, and I. patouillardii), all patients recovered following supportive treatment, including atropine (Lurie et al, 2009).

Pharmacology Toxicology

Pharmacologic Mechanism

    A) L(+)muscarine and other less potent cholinergic thermostable compounds. Because of its quaternary configuration, muscarine does not cross the meningeal barrier to the central nervous system. Therefore, the cholinergic effect is entirely peripheral.
    B) Some of the muscarinic compounds have more of a histaminic effect with flushing, hypotension and asthmatic wheezing.

Toxicologic Mechanism

    A) Illudins, found in Omphalotus species along with muscarine, are cytotoxic, producing hemorrhagic lesions in animal studies. Derivatives are under study as antitumor agents. The mechanism, in part, involves binding to thiol groups such as glutathione (McMorris et al, 1990).

Animal Toxicology

Clinical Effects

    11.1.3) CANINE/DOG
    A) SUMMARY -
    1) CASE REPORT - A 14-year-old female springer spaniel developed salivation, drowsiness, capillary refill time greater than three seconds, body temperature of 36.1, increased intestinal activity, vomiting, diarrhea, and a heart rate of 100 beats per minute. The animal was better within 24 hours and was sent home two days after admission (Yam, 1993).
    2) Mushrooms found in the dog's stomach included Coprinus micaceus, Hygrocybe ceracea, Laccaria laccata, and the muscarine containing Inocybe phaeocomis.

Treatment

    11.2.1) SUMMARY
    A) GENERAL TREATMENT
    1) If the ingestion is witnessed, emesis may be of some value. Since symptoms onset may be 15 to 30 minutes, and emesis and diarrhea are symptoms, decontamination after symptoms have stated is of questionable value and should be weighed against the actual symptoms present.
    11.2.2) LIFE SUPPORT
    A) GENERAL
    1) MAINTAIN VITAL FUNCTIONS: Secure airway, supply oxygen, and begin supportive fluid therapy if necessary.
    11.2.4) DECONTAMINATION
    A) GASTRIC DECONTAMINATION
    1) GENERAL TREATMENT
    a) EMESIS -
    1) CAUTION: Carefully examine patients with chemical exposure before inducing emesis. If signs of oral, pharyngeal, or esophageal irritation, a depressed gag reflex, or central nervous system excitation or depression are present, EMESIS SHOULD NOT BE INDUCED.
    2) HORSES OR CATTLE: DO NOT attempt to induce emesis in ruminants (cattle) or equids (horses).
    3) DOGS AND CATS
    a) IPECAC: If within 2 hours of exposure: induce emesis with 1 to 2 milliliters/kilogram syrup of ipecac per os.
    b) APOMORPHINE: Dogs may vomit more readily with 1 tablet (6 milligrams) apomorphine diluted in 3 to 5 milliliters water and instilled into the conjunctival sac or per os.
    1) Dogs may also be given apomorphine intravenously at 40 micrograms/kilogram, although this route may not be as effective.
    b) ACTIVATED CHARCOAL/CATHARTIC - SMALL ANIMALS -
    1) ACTIVATED CHARCOAL: Administer activated charcoal. Dose: 2 grams/kilogram per os or via stomach tube. Avoid aspiration by proper restraint, careful technique, and if necessary tracheal intubation.
    2) CATHARTIC: Administer a dose of a saline or sorbitol cathartic such as magnesium or sodium sulfate (sodium sulfate dose is 1 gram/kilogram). If access to these agents is limited, give 5 to 15 milliliters magnesium oxide (Milk of Magnesia) per os for dilution.
    11.2.5) TREATMENT
    A) GENERAL TREATMENT
    1) ATROPINE -
    a) SMALL ANIMALS: Give atropine sulfate 0.2 milligram/kilogram intravenously, intramuscularly or subcutaneously. Rabbits: 1 to 10 milligrams/kilogram. Subsequent doses may be given based on clinical impression of degree of respiratory distress and heart rate.
    b) HORSE: Approximate dose is 0.5 to 1 milligram/kilogram given intravenously, diluted in fluids. Give atropine cautiously and do not overdose. Monitor the heart rate and mydriasis to assess effect.
    1) Bowel motility MUST be monitored constantly while using atropine in horses to prevent fatal ileus.
    2) Repeated doses may be given subcutaneously every 2 hours as needed.
    c) CATTLE: Ruminants and swine: dose is 0.5 milligram/kilogram, one-fourth given intravenously and the balance given intramuscularly or subcutaneously. Repeated doses of half this amount may be given subcutaneously every 3 to 12 hours as needed. Monitor for rumen atony in cattle and sheep.

Continuing Care

    11.4.1) SUMMARY
    11.4.1.2) DECONTAMINATION/TREATMENT
    A) GENERAL TREATMENT
    1) If the ingestion is witnessed, emesis may be of some value. Since symptoms onset may be 15 to 30 minutes, and emesis and diarrhea are symptoms, decontamination after symptoms have stated is of questionable value and should be weighed against the actual symptoms present.
    11.4.2) DECONTAMINATION
    11.4.2.2) GASTRIC DECONTAMINATION
    A) GASTRIC DECONTAMINATION
    1) GENERAL TREATMENT
    a) EMESIS -
    1) CAUTION: Carefully examine patients with chemical exposure before inducing emesis. If signs of oral, pharyngeal, or esophageal irritation, a depressed gag reflex, or central nervous system excitation or depression are present, EMESIS SHOULD NOT BE INDUCED.
    2) HORSES OR CATTLE: DO NOT attempt to induce emesis in ruminants (cattle) or equids (horses).
    3) DOGS AND CATS
    a) IPECAC: If within 2 hours of exposure: induce emesis with 1 to 2 milliliters/kilogram syrup of ipecac per os.
    b) APOMORPHINE: Dogs may vomit more readily with 1 tablet (6 milligrams) apomorphine diluted in 3 to 5 milliliters water and instilled into the conjunctival sac or per os.
    1) Dogs may also be given apomorphine intravenously at 40 micrograms/kilogram, although this route may not be as effective.
    b) ACTIVATED CHARCOAL/CATHARTIC - SMALL ANIMALS -
    1) ACTIVATED CHARCOAL: Administer activated charcoal. Dose: 2 grams/kilogram per os or via stomach tube. Avoid aspiration by proper restraint, careful technique, and if necessary tracheal intubation.
    2) CATHARTIC: Administer a dose of a saline or sorbitol cathartic such as magnesium or sodium sulfate (sodium sulfate dose is 1 gram/kilogram). If access to these agents is limited, give 5 to 15 milliliters magnesium oxide (Milk of Magnesia) per os for dilution.

References

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