2370 Acute Liver Failure After Foraging for Wild Mushrooms: A Family Affair?

Abstract

INTRODUCTION: Ingestion of cytotoxic mushrooms is associated with a high mortality rate due to acute liver failure (ALF). Amanita phalloides (AP) and related species account for over 90% of fatal cases, and can be easily mistaken with edible species by inexperienced foragers. There is currently no gold standard of therapy, and often liver transplantation (LT) is required. We present 5 cases of mushroom ingestion and associated ALF who were treated at a quaternary LT center in Northeast Ohio. CASE DESCRIPTION/METHODS: Five members of a family were referred to our Medical Intensive Liver Unit in September 2018 after ingesting a shared meal prepared with wild mushrooms from a neighbor’s garden. Median age was 43.6 years (32-61 years) and all patients were female. All patients presented to a local hospital with nausea, vomiting, diarrhea and abdominal pain approximately 6 hours after ingestion and were transferred to our center 1 day later. Mean peak laboratory values were as follows: alanine aminotransferase 6530 U/L (range 3750-10506 U/L), aspartate aminotransferase 10974 U/L (3780-19737 U/L), bilirubin 7.2 mg/dL (4.6-11.3 mg/dL) and international normalized ratio 3.4 (1.8-7.1). Mushroom specimens were obtained for inspection and visually identified as AP. The 5 patients were treated with aggressive supportive care, including N-Acetylcysteine, octreotide and penicillin G infusions, followed by experimental silibinin obtained under emergent institutional review board approval. All patients progressed to ALF and underwent emergent LT evaluation; all 5 were listed for LT (3 as status 1A). Three patients improved with medical therapy, while 2 underwent successful LT. Pathology of the explanted livers revealed extensive necrosis. The local departments of health were notified and educational programs implemented throughout Northeast Ohio. DISCUSSION: We present 3 cases of successful medical therapy associated with transplant-free survival, and 2 cases of LT for severe ALF related to mushroom ingestion. In some Southeast Asia cultures, foraging for wild mushrooms is common practice. Mortality has been reduced in recent decades due to improved supportive and intensive care, as well as the introduction of experimental therapies. A high index of suspicion for diagnosis is important, as timing of initiation of therapy is paramount. Public education for populations in which foraging is common will be important to promote proper identification of wild toxic mushrooms.