SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Amanita muscaria (A. muscaria), commonly known as fly agaric is a poisonous fungus from the Amanitaceae family. The mushroom is taken to induce psychoactive effects and hallucinations also known as a “trip”. There are a few case reports in literature that highlight the toxic effects of this species as overall incidence is rare. We highlight a rare case that describes a patient admitted to the intensive care unit after ingesting the mushroom for its psychedelic effects. CASE PRESENTATION: A 56-year-old gentleman with no past medical history presented to the emergency department after being found down following purposeful ingestion of the A. muscaria mushroom. Vitals on admission were notable for a blood pressure of 136/112, heart rate 125, respiratory rate 22 and temperature of 96 degrees. The patient was encephalopathic, agitated and combative on arrival and subsequently intubated for airway protection. Later, the patient was noted to have myoclonic jerks. Labs were significant for creatinine of 2.17 mg/dL (unknown baseline), severe anion gap metabolic acidosis, lactate of 10.8 mmol/L, creatinine kinase over 1,500 U/L with mild elevation of liver function tests. Urine drug screen was negative and salicylate level was undetectable. Computed tomography head was negative. The patient was admitted to the intensive care unit for further monitoring and was treated with supportive measures. DISCUSSION: A. muscaria contains several distinct neurotoxins that can cause a variety of symptoms. The main neurotoxins are ibotenic acid and muscarine. Ibotenic acid is an excitatory neurotransmitter that is similar to glutamic acid and contributes to the hyperactive symptoms. Muscarine is a cholinergic agonist that causes atropine like effects including dry mouth, drowsiness and coma. Symptoms manifest between thirty minutes to two hours and include dizziness, confusion, and increased sensitivity to visual stimuli. Late effects include combativeness, seizures or coma. Complications include renal failure, rhabdomyolysis, cardiac and respiratory depression. Our case describes a fifty-year-old gentleman that manifested the same symptoms of hyperactivity followed by combativeness, respiratory depression and myoclonic jerks as well as renal failure and rhabdomyolysis. Treatment is often supportive and sometimes activated charcoal can be used to decrease absorption. Because of the variety of toxins present in the mushroom, there is no clear toxidrome and this drug does not show up on routine drug screening. Therefore, early detection with careful history taking and physical exam is essential to prevent the deadly complications. CONCLUSIONS: Our case describes a rare case of intentional A. muscaria overdose. There are few cases in literature that detail the prodrome of this drug and therefore it is important to highlight its effects. Supportive care is the mainstay of treatment and prompt identification is essential. Reference #1: Coma in the course of severe poisoning after consumption of red fly agaric (Amanita muscaria). Mikaszewska-Sokolewicz MA et al. Acta Biochim Pol 2016 Feb 1. Reference #2: Fly agaric (Amanita muscaria) poisoning, case report and review. Satora, L et al. Toxicon, Volume 45, Issue 7, 1 June 2005, Pages 941-943. Reference #3: Clinical symptoms and circumastances of acute poisonings with fly agaric (Amanita muscaria) and panther cap (Amanita pantherina). Łukasik-Głebocka M et al. Przegl Lek, 68(8):449-52. 2011. DISCLOSURES: No relevant relationships by Arjan Ahluwalia, source=Web Response No relevant relationships by Timothy Coyle, source=Web Response No relevant relationships by Christopher Lenivy, source=Web Response No relevant relationships by Reema Vaze, source=Web Response No relevant relationships by Andres Zirlinger, source=Web Response