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Acute poisoning with Tricholoma equestre

Article in Przegla ̧d Lekarski · January 2009

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 CLINICAL NOTES – DONIESIENIA KLINICZNE

Jacek Sein ANAND1

Pawe³ CHWALUK2,3
Ostre zatrucie G¹sk¹ zielonk¹
Micha³ SUT4

Acute poisoning with Tricholoma equestre

Pomerania Center of Toxicology, Gdañsk,

1
Poland
Head: Wojciech Waldman MD, PhD
2
Unit of Internal Diseases, Regional Hospital
in Bia³a Podlaska, Poland
Head: Jolanta Siwek-Iwanicka MD
Department of Anatomy
3 grams of Tricholoma equestre for 3-4
University of Physical Education in Bia³a
Podlaska, Poland
Head: Jan Rowiñski MD, PhD
Mater Infirmorum Hospital Belfast
4
Four cases, including three adults
and one child, suffering from acute
poisoning with Tricholoma equestre
were described. The patients had
eaten from 100 to 400 grams of the
mushroom within a few consecutive
meals. After consuming about 1000
days, the subjects developed fatigue,
muscle weakness, myalgia, and in two
cases acute respiratory failure with the
need of respiratorotherapy. Maximal
W pracy przedstawiono cztery oso-
by, w tym trzy doros³e oraz dziecko, u
których dosz³o do znacznej rabdomio-
lizy w przebiegu zatrucia Tricholoma
equestre. Pacjenci spo¿ywali od 100
do 400 g grzyba przez kilka kolejnych
dni. Po spo¿yciu ok. 1000 g Tricholo-
ma equestre dosz³o u nich do pojawie-
nia siê os³abienia, bólów miêœni, zaœ
w dwóch przypadkach ostrej niewydol-
noœci oddechowej, która wymaga³a
respiratoroterapii. Poziomy CPK u do-

General and Hepatobiliary Surgery Ward

serum CK was 48136 U/L in the adults
and 306 U/L in children. Maximal se-
rum levels of AST and ALT were 802
U/L and 446 U/L in adults and 39 U/L,
Additional key words: and 56 U/L in a child. All routine bio-
acute intoxication chemical tests were within normal
Tricholoma equestre range. No other causes of
rhabdomyolysis
rhabdomyolysis such as parasitic or
Dodatkowe s³owa kluczowe:
viral infections, immune diseases,
ostre zatrucie trauma or exposure to medications
G¹ska zielonka were found. Patient, aged 72 yrs., who
rabdomioliza developed acute respiratory failure,
died in the second day of hospitaliza-
tion. In other patients all the above
mentioned symptoms and biochemical
abnormalities disappeared from 2 to 3
weeks of hospitalization. Physicians
should be aware of the possibility of
appearance of rhabdo-myolysis after
repeated consumption of large quan-
tities of Tricholoma equestre.
ros³ych pacjentów siêga³y 48136 U/L,
zaœ u dzieci 306 U/L. Najwy¿sze war-
toœci ASPAT i ALAT wynosi³y odpo-
wiednio 802 U/L i 446 U/L u osób doro-
s³ych oraz 39 U/L i 56 U/L u dziecka.
Wszystkie rutynowe testy biochemicz-
ne nie wykazywa³y wiêkszych odchy-
leñ od normy. Nie znaleziono równie¿
¿adnych innych przyczyn rabdomioli-
zy, w tym m.in. chorób paso¿ytniczych,
wirusowych, immunologicznych, ura-
zów, a tak¿e niepo¿¹danego dzia³ania
leków. Pacjent lat 72, u którego dosz³o
do ostrej niewydolnoœci oddechowej,
zmar³ w drugiej dobie leczenia. U po-
zosta³ych pacjentów wszystkie objawy
kliniczne oraz biochemiczne ust¹pi³y
po ok. 2-3 tygodniach leczenia. Leka-
rze powinni zawsze pamiêtaæ o mo¿li-
woœci wyst¹pienia rabdomiolizy w
przebiegu wielokrotnego spo¿ycia du-
¿ej dawki Tricholoma equestre.

Introduction were found. Maximal serum CK activity was 18150 U/L

We present four cases, including three
adults and one child, who were admitted to
the hospital from 2002 to 2008 because of
rhabdomyolysis caused by excessive con-
sumption of Tricholoma equestre.
Case report
Case number one and two: Mother and her son,
aged 48 and 20 years, respectively, were admitted to
the hospital because of the following symptoms: fatigue,
striated muscle weakness, myalgia especially in mus-
cles of the legs, loss of appetite, mild nausea, and pro-
fuse sweating. All symptoms appeared approximately 48
hours after the last meal containing Tricholoma eques-
tre, which had been eaten by the family recently (last
nine consecutive meals). The average dish contained
Adres do korespondencji: about 100-300 grams of this mushroom. No other symp-
Sein Anand Jacek MD PhD toms like vomiting, diarrhoea, fever or erythema were
Pomerania Center of Clinical Toxicology observed. Physical examination revealed regular heart
ul. Kartuska 4/6 rate about 90 b./min in the mother and 85 b./min in the
80-104 Gdañsk, Poland son, blood pressures were 140/60 mmHg, and 125/70
e-mail: jacek.anand@gmail.com mmHg respectively. No other important abnormalities
in the mother and 48136 U/L in the son. Maximal serum
levels of AST and ALT were 802 U/L and 446 U/L, in the
mother and 2002 U/L and 454 U/L, in the son. Other
hepatic, renal and coagulation tests, as well as electro-
lyte levels, including potassium values, were normal. All
symptoms disappeared within 3 weeks of supportive
treatment, however, the muscle weakness lasted for
about 2-3 months more.
Case number three: A five-year-old male child was
admitted to the clinic because of deep coma, cyanosis
and convulsions. All theses symptoms appeared about
4 hours after the last meal containing Tricholoma eques-
tre. Medical history revealed that the child had been eat-
ing about 300-400 grams of this mushroom daily for the
four consecutive days. Physical examination revealed
deep coma (4 score GCS), regular heart rate about 120/
min, blood pressure 110/60 mmHg, and breath rate about
6/min. There were: bilateral, positive Babiñski sign and
symmetrical increase muscle tone in the neurological
examination. No changes in computerized tomography
of the head, chest x-ray, lumbar puncture, encephalog-
raphy, echocardiography and toxicological tests were
found. The biochemical tests showed elevated serum
CK activity 306 U/L (normal range 5-130 U/L for a child),

Przegl¹d Lekarski 2009 / 66 / 6 339

ALT 56 U/L (normal range 5-45 U/L for person between
1-19-year old), pH 7,28, BE 5,9 mEq/l, HCO3 22,9 mEq/
l, pO2 43,9 mmHg, pCO2 59,8 mmHg. Beacuse of acute
respiratory insufficiency the child was intubated and res-
piratorotherapy, lasted 34 hours, was applied. For the
next week after that extubation, the child still presented
with muscle weakness which included especially the pel-
vic girdle and the urinary bladder. The boy could not sit
or stand up without help, and the bladder had to be cath-
eterised to avoid urine retention. All the symptoms dis-
appeared within 2-3 weeks of hospitalisation.
Case number four: A man aged 72 was admitted to
the hospital because muscle weakness, and myalgia
(especially the quadriceps), which lasted for four days.
All symptoms appeared about 24 hours after the last
meal containing Tricholoma equestre. The patient had
eaten the mushroom for the last ten consecutive meals.
The average dish contained about 300-400 grams of
Tricholoma equestre. There were no changes in physi-
cal examination except muscle pain of both legs and
increasing problem with walking. Maximal CK activity
was 44767 U/L, CKMB 888 U/L, TNI 1,9 ng/ml, AST
1894 U/L, and ALT 490 U/L. Other hepatic, renal and
coagulation tests as well as electrolyte levels, including
potassium, were normal. No changes in computerized
tomography of the head, chest X-ray, echocardiography
and toxicological tests were found. In the second day of
hospitalisation the patient reported pain and weakness
of the muscle of the chest, shoulders and abdomen. The
patient complained of dyspnoea, and a few hours later
breathing problems appeared. The patient was trans-
ferred to the ICU, intubated and connected to the respi-
rator. About 4.5 hours later - cardiac arrest was noted
and CRP was ineffective.
Several studies for parasites and other microorgan-
isms (trichinella, toxoplasma, coxsackievirus, HIV, HCV
and HBV), as well as for systemic diseases were nega-
tive for all observed patients.
340
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Discussion
The most common causes of rhabdo-
myolysis are muscle compression, neuro-
leptic malignant syndrome, intoxication with
alcohol, amphetamine, cocaine, antihyper-
lipidemic drugs, antihistamines, phenothia-
zines, theophylline or long-term use of le-
vodopa, quinidine, phenytoin, penicillamine
and others [2-5].
In 2001, Bedry and co-workers observed
rhabdomyolisis in twelve patients in south-
western France after excessive consump-
tion of Tricholoma equestre [1]. The main
symptoms described by the authors inclu-
ded muscle weakness, fatigue, myalgia
(especially in quadriceps), facial erythema,
nausea without vomiting, and diaphoresis
without fever. The same signs, except fa-
cial erythema, were observed also in our
cases.
The biochemical results showed marked
increase in CK, AST and ALT levels. Howe-
ver, in the child, the level of these enzymes
did not correspond well with the grave clini-
cal condition of the patient.
Quite interesting is a delay between Tri-
choloma equestre consumption and rhab-
domyolisis occurrence. Bedry and co-wor-
kers observed the clinical signs about 24-
72 hours after consuming the last three con-
secutive meals with this mushroom [1]. In
our cases the symptoms appeared after ha-
ving more than 1000 grams of Tricholoma
equestre in less than four days.
One of our patients died despite inten-
Przegl¹d Lekarski 2009 / 66 / 6
sive care because of acute respiratory fa-
ilure. The high mortality rate of about 25%
was also observed by Bedry and co-wor-
kers [1].
Conclusions
1. Physicians should be aware of the
possibility of acute intoxications after repe-
ated consumption of large quantities of Tri-
choloma equestre.
2. The clinical picture of poisonings with
this wild mushroom may be different in chil-
dren and adults.
3. There is a delay between ingestion
and onset of clinical symptoms.
4. Intoxication of Tricholoma equestre is
connected with high mortality rate (about
25%).
References
1. Bedry R., Baudrimont I., Deffieux G. et al.: Wild-
mushroom intoxication as a cause of rhabdomyolysis.
N Engl. J. Med. 2001, 345, 798.
2. Bourquia A., Jabrane A.J., Ramdani B., Zaid D.:
Toxicite' syste'mique de la paraphe'nyle'ne diamine:
quatre observations. Presse Med. 1988, 17, 1798.
3. Dromer C., Verdrenne C., Billey T. et al.:
Rhabdomyolyse a' la simvastatine: a' propos d'un
cas avec revue de la litte'rature. Rev. Rhum. Mal.
Osteoartic. 1992, 59, 281.
4. Laaksonen R., Jokelainen K., Laakso J. et al.: The
effect of simvastatin treatment on natural antioxidants
in low-density lipoproteins and high-energy phospha-
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diol. 1996, 77, 851.
5. Yagi H., el Hind A.M., Khalil S.I.: Acute poisoning
from hair dye. East. Afr. Med. J. 1991, 68, 404.
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