#1301 Orellanine intoxication—a case report

Abstract

Abstract Background and Aims This is a case report presenting a patient with orellanine-caused acute kidney failure. Cortinarius rubellus is a mushroom containing orellanine which is a selective nephrotoxin that destroys the proximal tubule cells of the kidney. Intake of just a few mushrooms is enough to cause irreversible damage and furthermore lead to severe kidney failure. Symptoms as gastrointestinal irritation usually occur 3-7 days after intake. Anti-oxidative medication and steroids have been evaluated but have not shown any effect on the kidney damage. The aim of this case report was to raise awareness about the clinical manifestations of orellanine poisoning, diagnostic challenges, and potentially severe consequences. Method The junior doctors (IA, LT, AS) and the senior doctor (JM) took care of the patient at the ED, the internal medicine ward and the dialysis clinic. All data was extracted from the medical record. Informed consent was obtained from the patient. An attempt to analyze orellanine in the kidney biopsy was made. Results A 40-year-old male entered the emergency department with abdominal pain, fever, nausea and vomiting. The creatinine concentration was 278 µmol/L (3.14 mg/dl) where acute kidney failure due to prerenal cause was suspected. The patient was recommended to stay but declined due to personal reasons, and instead a follow-up next day was planned. The following day, the creatinine concentration was increased to 477 µmol/L (5.39 mg/dl). The junior doctor specifically asked for mushroom intake. The patient confirmed that three days before, he had been in the forest picking mushrooms, of which he consumed two raw and the rest in a stew. Acute renal failure from mushroom poisoning was now suspected. The patient was admitted, and serum creatinine increased to 817 µmol/L (9.24 mg/dl) the following day. The urine production decreased, and the patient was anuric 7 days after intake. Hemodialysis was initiated due to uremic symptoms and volume overload. After showing the patient different photos of mushrooms it was suspected that he had consumed Cortinarius Rubellus. A renal biopsy was performed 12 days after the mushroom intake, which showed a fulminant acute tubular necrosis, no sign of glomerulonephritis, vasculitis, or interstitial nephritis. The attempt to analyze orellanine in the kidney biopsy material was not successful. Orellanine would not be detected in the urine or blood samples because they were collected 72 hours after intake. The half-life of orellanine in otherwise healthy humans is considered to be around 2-4 hours. The patient stayed at the hospital for a total of 14 days. He was on hemodialysis for 14 months and was then successfully kidney transplanted. Conclusion Orellanine is a very potent toxin leading to severe damage of the kidney tubules. Due to the diagnostic challenges, it is important to keep this in mind when managing a patient with acute renal failure.