Abstract 18434: Amanita Muscaria and Pantherina Withdrawal as a Cause of Lone Atrial Fibrillation

Abstract

Introduction: The Amanita mushroom family is known for use as a means of suicide or for psychedelic effects. The manifestations of Amanita mushroom poisoning include gastrointestinal poison, cholinergic effects and organ failure. In this paper, we will discuss the first observed study of a patient who developed new onset atrial fibrillation (AF) with rapid ventricular response (RVR) after withdrawal from accidental chronic poisoning of Amanita muscaria and pantherina over the course of three weeks. Case: A 29 year-old male with no prior past medical history presented with three days of palpitations. He began taking A. pantherina and muscaria three weeks prior to help treat sexual addiction. He started with 0.35 mcg twice a day, then doubled the dose after one week, then three days prior to presentation he started taking three grams twice per day. He noticed palpitations as he increased his dose, but then acutely worsened after he stopped taking mushrooms. In the emergency department, he was found to have new onset atrial fibrillation with rapid ventricular rate as well as frequent episodes of nonsustained ventricular tachycardia. An alcohol level and urine drug screen were unremarkable. Thyroid stimulating hormone was within range. His heart rate did not respond to intravenous diltiazem. He was transitioned to an esmolol infusion that responded with rapid improvement in heart rate as well as ventricular ectopy suppression. He eventually underwent a transesophageal echocardiogram and was transitioned to oral beta blocker therapy. He was discharged with no complications and near full recovery. Discussion: A report published in 1869 described the first description of the pharmacological effect of A. muscaria showing it is 143 times more toxic than acetylcholine due to the inability of cholinesterase to hydrolyse or inhibit its effect. The acute cardiovascular toxicities are well described, however, this case is the first description of chronic cardiac toxicity manifesting as new onset AF with RVR, caused by A. muscaria and pantherina withdrawal. We suggest that cardiovascular monitoring, including event monitors, are essential for complications of A. muscaria and pantherina . More detailed studies need to be done.