CASE REPORT jack o'lantern mushroom, poisoning
Jack O'Lantern Mushroom Poisoning The cases of seven adults who ingested jack o'lantem mushrooms are presented. All patients experienced nausea and vomiting associated with abdominal cramping, and three reported diarrhea. Four of the seven complained of weakness and dizziness. Two were diaphoretic on physical examination. All seven were given IV fluids and oral activated charcoal in a local emergency department and admitted overnight for observation. Laboratory studies showed three of the seven patients to have mildly elevated liver function tests. One patient had hypokalemia requiring potassium supplementation. All were discharged the following day with normal follow-up examinations and laboratory studies. We recommend that all patients presenting with jack o'lantern mushroom poisoning be observed and rehydrated and have baseline liver function tests and potassium levels obtained. [Vanden Hoek TL, Erickson T, Hryhorczuk D, Narasimhan K: Jack o'lantem mushroom poisoning. Ann Emerg Med May 1991;20: 559-561.]
INTRODUCTION There are few N o r t h A m e r i c a n cases of poisoning from ingestion of the jack o ' l a n t e r n m u s h r o o m (Omphalotus illudens) reported.l,z T h e predomin a n t s y m p t o m s reported in these cases were nausea and vomiting.3, 4 European case reports detail m o r e severe m u s c a r i n i c s y m p t o m s and hepatic involvement,5, 6 a fact leading s o m e to speculate that the N o r t h A m e r i c a n and European jack o ' l a n t e r n m u s h r o o m s are actually different species of the same genus. 7 We p r e s e n t a case series of seven a d u l t s w h o i n g e s t e d jack o ' l a n t e r n m u s h r o o m s . T h e reported s y m p t o m s and signs as well as significant laboratory studies and clinical courses are discussed.
Todd L Vanden Hoek, MD*t Timothy Erickson, MD*¢ Daniel Hryhorczuk, MD* Kris Narasimhan, MD, FACEP* Chicago and Park Ridge, Illinois From the Toxikon Consortium, Section of Clinical Toxicology Cook County Hospital and Medical Center, Chicago, Illinois;* Division of Emergency Medicine, Our Lady of the Resurrection Medical Center, Chicago, Illinois;t and Division of Emergency Medicine, Lutheran General Hospital, Park Ridge, Illinois.¢ Received for publication August 24, 1990. Accepted for publication October 29, 1990. Presented at the 1990 AAPCC/AACT/ ABMT/CAPCC Conference in Tucson, Arizona, September 1990. Address for reprints: Todd L Vanden Hoek, MD, 1040 North Humphrey, Oak Park, Illinois 60302.
CASE REPORTS Seven patients representing three different families presented to a local e m e r g e n c y d e p a r t m e n t in late October a p p r o x i m a t e l y four hours after all ingested sauteed m u s h r o o m s picked from a n o r t h e a s t Illinois forest preserve by one of the families. The m u s h r o o m s were thought to be Cantharellus cibarius but were later identified by a local m y c o l o g i s t as O illudens based on description and a s p e c i m e n brought in by the patients. Pertin e n t h i s t o r i c a l i n f o r m a t i o n , o c c u r r e n c e of s y m p t o m s , a n d s i g n i f i c a n t laboratory a b n o r m a l i t i e s are s u m m a r i z e d (Table 1). Patients ranged in age from 20 to 54 years (four w o m e n and three men). All experienced nausea and v o m i t i n g associated w i t h a b d o m i n a l cramping, w i t h t i m e of onset ranging from 15 to 90 m i n u t e s after ingestion. Total duration of v o m i t i n g was less t h a n eight hours in all cases. Three patients e x p e r i e n c e d w a t e r y d i a r r h e a t h a t r e s o l v e d w i t h i n 12 hours. Four complained of w e a k n e s s and dizziness. Two of the seven experienced c l a m m i ness and sweating and were found to be diaphoretic on physical examination in the ED. N o n e reported increased salivation or visual changes. Two patients were i n i t i a l l y tachycardic on p r e s e n t a t i o n to the ED, one w i t h a pulse of 120 and m i l d orthostasis. N o a b n o r m a l i t i e s on liver e x a m i n a t i o n were d o c u m e n t e d for any of the patients. All seven patients were started on IV fluids and given one 50-g dose of activated charcoal. Laboratory studies c o m p l e t e d for all seven included a
20:5 May 1991
Annals of Emergency Medicine
559/12.~
M U S H R O O M POISONING Vanden H o e k et al
TABLE 1. Summary of case reports Patient
Age (yr)
Sex
Significant History
Medication
1
45
F
None
2
20
F
3
50
4
42
5 6
7 Normal
Nausea and Vomiling
Diarrhea
Weakness
Sweating
Dizziness
None
+
4-
4-
=
4-
HepatitisB
None
+
-
4-
M
HTN
None
+
-
F
Migraines
None
+
+
47
M
None
None
+
54
M
Pepticulcer disease
Cimetidine
4-
44
F
None
None
+
-
Physical Findings
Abnormal Laboratory Findings SGOT, 85 IU/L; SGPT, 136 IU/L WBCs, 10,700
4-
m
Pulse, 104
4-
m
Pulse, 120
+
+
Diaphoretic
-
4-
Diaphoretic
SGOT, 54 IU/L; SGPT, 76 IU/L; LDH, 164 IU/L SGOT, 35 IU/L; SGPT, 51 IU/L; WBCs, 11,700 Potassium, 3.3 mEq/L
-
values: SGOT, 5 to 30 IU/L; SGPT, 5 Io 40 IU/L; WBCs, 4,500 to 10,000; LDH, 65 1o 155 lU/L; polassium, 3.5 to 50 mEq/L
TABLE 2. Summary of North American case reports No. of Reference (year)
Patients
No. of Patients Experiencing Symptoms Nausea
Vomiting
Weakness
Diarrhea
Sweating
Salivation
NR
NR
2
NR
NR
1
...
NR
NR
2
1
2
NR
NR
NR
Farlow12 (1899)
12
12
4
Seaved3 (1939)
4
4
4
3
SeaverTM (1939)
1
1
1
Boston Mycology Club15 (1963)
3
3
3
Hanrahan and Gordon1 (1984)
1
1
1
Cochran16 (1987)
16
16
16
4
2
2
5
French and Garrettson2 (1988)
16
10
8
10
5
3
...
Present study (1991) Total (% of Total) NR, not reported as + or
. . . . . .
7
7
7
4
3
2
...
60 (100)
54 (90)
44 (73)
24 (40)
13 (22)
9 (15)
5 (8)
-
CBC, prothrombin and partial thromboplastin times, electrolytes, blood urea nitrogen, creatinine, glucose, calcium, creatine phosphokinase, LDH, total bilirubin, SGOT, and SGPT levels. Three p a t i e n t s had mildly elevated SGOT and SGPT levels, and one of them also had an elevated LDH. Hepati.tis profiles were normal for all three. Two patients with a history of hepatitis B had normal liver function tests. One was found to be hypokalemic and received IV potassium supplementation. Two patients had a mild leukocytosis. All other laboratory studies were within the normal limits for the hospital laboratory. ECGs were not done. All patients were admitted overnight for observation and had complete recovery from s y m p t o m s within 12 hours of ingestion. All were discharged without complica124/560
. . . . . .
tion the following day. Repeat laboratory studies, clone within one week on the three patients with elevated SGOT and SGPT levels and the one p a t i e n t w i t h h y p o k a l e m i a , were within normal limits. DISCUSSION The jack o'lantern mushroom is an orange-to-yellowish-orange mushroom with sharp-edged gills; it grows in clusters at the base of stumps and on buried roots of oak and other dec i d u o u s wood. 8 It is c o m m o n l y found in eastern North America and across the southern United States to the Pacific Coast, with a season normally spanning July through November. The luminescence of its gills will often last 40 to 50 hours after collection, 9 a characteristic that is thought to have suggested the widely a c c e p t e d c o m m o n n a m e of jack o ' l a n t e r n , lo This b i o l u m i n e s c e n t Annals of E m e r g e n c y Medicine
property is produced by terpenoid metabolites that have been isolated from the jack o'lantern. 11 Several other sesquiterpene metabolites have been isolated from the jack o'lantern, many of which possess antitumor and antibacterial activities.It Other names given this mushroom in the medical literature since 1899 include Agaricus illudens, Clitocybe olearia, Clitocybe iHudens, Pleurotus olearius, and Omphalotus olearius. 2 We were able to find only seven reports from North America regarding ingestion of this mushroom. Farlow reported 12 cases in 1899.12 Vomiting started within two hours in four of the cases, and the other eight "suffered from terrible nausea." Seaver reported a series of four ingestions following one picking in 1939 in which two of the patients experienced a 12-hour delay before emesis ensued. 13 Seaver also reported one 20:5 May 1991
MUSHROOM POISONING Vanden Hoek et al
case that year in which the patient, after ingestion of the m u s h r o o m , suddenly felt a "heavy sensation in the s'tomach" and induced vomiting by "usual household methods. ''14 An anecdotal report in 1963 detailed ingestions by three college students that were followed by severe nausea and vomiting in all three, weakness and sweating in two, and diarrhea in one.iS One student required hospitalization. All three were asymptomatic the following day. Hanrahan and Gordon reported a case in 1984 in which only vomiting occurred.i Laboratory studies, including a CBC and serum chemistries, were normal. Admitted for observation, this patient was discharged symptom free the following morning. Cochran reported a series of 16 cases in 1987 in which all patients vomited, five exhibited salivation, two had sweating, and two experienced diarrhea.16 French and Garrettson reported a case series in 1988 of 16 campers who accidentally ingested jack o'lantern mushrooms while on a field expedition, z Eight exhibited vomiting; five had diarrhea; ten were weak, tired, or both~ and three felt clammy or sweaty. All symptoms resolved within 18 hours of ingestion. The dominant symptom in all of these reports, including our case series, was vomiting, affecting all patients within three hours of ingestion, with the exception of two cases reported by Seaver. 13 Another commonly reported symptom was weakness. For all patients, symptomatology was of short duration, and recovery was quick. With the exception of the cases reported by Cochran, muscarinic effects and diarrhea were relatively infrequent. 16 Although elevated liver function tests have been reported after Clitocybe ingestions, lz to our knowledge no reports have d o c u m e n t e d such elevation after an O illudens ingestion. Three patients in our series had such elevations, all of whom had normal levels on follow-up testing. A third patient had hypokalemia, a known complication of protracted vomiting. 18 Two of our patients had
20:5 May 1991
a mild leukocytosis, which also has been reported in European cases of jack o'lantern ingestion. 5 The North American reports of jack o'lantern poisoning, along with their symptomatology, are summarized (Table
2). In contrast with North American reports, European reports of poisoning with this m u s h r o o m are more c o m m o n and usually involve more severe symptoms. Maretic and coworkers published three reports between 1967 and 1975 detailing symptoms in 40 human beings and one dog after ingestion.5,6A 9 In the first report, symptoms began within one half to two hours after ingestion and included nausea, vomiting, diarrhea, severe headache, and vertigo, s Three patients experienced diplopia, and two had salivation. The dog vomited but recovered quickly. In the 1968 case series, 23 of 25 people experienced nausea and vomiting within 60 to 150 minutes of ingestion. 6 Other c o m m o n s y m p t o m s included salivation, dysphagia, diplopia, increased perspiration, headache, paresthesias, fatigue, and chills. Most symptoms subsided within five to six days of poisoning. In a French review of 25 cases by Brun et al, s y m p t o m o n s e t was within 45 minutes to four hours and included vomiting, vertigo, and paresthesias, zo These case reports detail m o r e f r e q u e n t l y the m u s c a r i n i c symptoms of salivation, increased perspiration, diarrhea, vertigo, and paresthesias. This fact has led some authors, such as Ammirati et al, to believe that the jack o'lantern mushrooms on the two sides of the Atlantic are different species, reserving the name O olearius for the European species, z
SUMMARY P o i s o n i n g by i n g e s t i o n of the N o r t h A m e r i c a n jack o ' l a n t e r n mushroom, illustrated by our case series, appears to be a self-limited illness with a short latency period between ingestion and emesis and with a relatively short duration of symptoms. Compared with the European
Annals of Emergency Medicine
jack o'lantem mushroom, muscarinic effects are m u c h more infrequent. We r e c o m m e n d that patients presenting with jack o']antern mushroom ingestion be observed and rehydrated and that potassium level and liver function tests be obtained.
REFERENCES 1. Hanrahan JP, Gordon MA: Mushroom poisoning: Case reports and a review of therapy, lAMA 1984;251: 1057-1061. 2. French AL, Garrettson LK: Poisoning with the North American Jack O'Lantern mushroom, Omphalotus illudens. Clin Toxicol 1988;26:81-88. 3. Lampe KF: Pharmacology and therapy of mushroom intoxication, in Rumack BH, Salzman E (eds): Mushroom Poisoning: Diagnosis and Treatment. West Palm Beach, Florida, CRC Press, I978, p I25-169. 4. Lincoff G, Mitche] DH: Toxic and Hallucinogenic Mushroom Poisoning: A Handbook for Physicians and Mushroom Hunters. N e w York, Van Nostrand Reinhold, 1977, p 74. 5. Maretic Z: Poisoning by the mushroom Clitocybe olearia Maire. Toxikon 1967;4:263-267. 6. Maretic Z, Russell FE, Golobic V: Twenty-five cases of poisoning by the mushroom Pleurotus olearius. Tax ikon 1975;13:379-38I. 7. A m m i r a t i IF, Traquair JA, Horgen PA: Poisonous Mushrooms of Northern United States and Canada. Minneapolis, University of Minnesota Press, 1985, p 290-292. 8. Lincoff GH, Knopf AA: The Audubon Society Fidd Guide to North American Mushrooms. N e w York, Chanticleer Press Inc, 1981, p 787-788. 9. Miller OK: Mushrooms of North America. N e w York, Chanticleer Press Inc, 1979, p 121-122. [0. McKnight KH, McKnight VB: A Field Guide to Mushrooms: North America. Boston, Houghton Mifflin Co, 1987, p 178-179. il. Ayer WA, Browne LM: Terpenoid metabolites of mushrooms and related Basidiomycetes. Tetrahedron I981;37:2199-2248. 12. Farlow WG: Poisoning by Agaricus illudens. Rhodora 1899~1:43-44. [3. Scarer Ff: Recent mushroom poisoning. J N Y Botanical Garden 1939;40:236-237. 14. Seaver FJ: Poisoning with Clitocybe i]hldens. Myco]ogia 1939;31:110. 15. Boston Mycology Club: The Clitocybe idhzdens affair. Boston Mycological Club Bull 1963;4:3-4. 16. Cochran KW: Poisoning due to misidentified mushrooms. Mcllvainea 1987~8:27-29. 17. McCormick DJ, Avbel AJ, Gibbons RB: Nonlethal mushroom poisoning. Ann Intern Med 1979;90:332 335. 18. Barsan WG, Baker PB: Upper gastrointestinal tract disorders, in Rosen P, Baker FJ, Barkin RM, et al (eds}: Emergency Medicine: Concepts nnd Clinical Practice, ed 2. St Louis, CV Mosby, vol 2, 1988, p 1406. 19. Maretie Z, Vrtar B: M i c e t i z a m u istri. LH Vj [968;90:631. 20. Brun A, Bayer J, Astier J, et al: Etude epidemio logiclue des intoxications par Clitocybe olearia recueillies au centre anti-poisons de Marseille de 1973 a 1977. Collect Med Leg ToxicoI Med 1978~106:135-137.
561/125
Jack O'Lantern Mushroom Poisoning The cases of seven adults who ingested jack o'lantem mushrooms are presented. All patients experienced nausea and vomiting associated with abdominal cramping, and three reported diarrhea. Four of the seven complained of weakness and dizziness. Two were diaphoretic on physical examination. All seven were given IV fluids and oral activated charcoal in a local emergency department and admitted overnight for observation. Laboratory studies showed three of the seven patients to have mildly elevated liver function tests. One patient had hypokalemia requiring potassium supplementation. All were discharged the following day with normal follow-up examinations and laboratory studies. We recommend that all patients presenting with jack o'lantern mushroom poisoning be observed and rehydrated and have baseline liver function tests and potassium levels obtained. [Vanden Hoek TL, Erickson T, Hryhorczuk D, Narasimhan K: Jack o'lantem mushroom poisoning. Ann Emerg Med May 1991;20: 559-561.]
INTRODUCTION There are few N o r t h A m e r i c a n cases of poisoning from ingestion of the jack o ' l a n t e r n m u s h r o o m (Omphalotus illudens) reported.l,z T h e predomin a n t s y m p t o m s reported in these cases were nausea and vomiting.3, 4 European case reports detail m o r e severe m u s c a r i n i c s y m p t o m s and hepatic involvement,5, 6 a fact leading s o m e to speculate that the N o r t h A m e r i c a n and European jack o ' l a n t e r n m u s h r o o m s are actually different species of the same genus. 7 We p r e s e n t a case series of seven a d u l t s w h o i n g e s t e d jack o ' l a n t e r n m u s h r o o m s . T h e reported s y m p t o m s and signs as well as significant laboratory studies and clinical courses are discussed.
Todd L Vanden Hoek, MD*t Timothy Erickson, MD*¢ Daniel Hryhorczuk, MD* Kris Narasimhan, MD, FACEP* Chicago and Park Ridge, Illinois From the Toxikon Consortium, Section of Clinical Toxicology Cook County Hospital and Medical Center, Chicago, Illinois;* Division of Emergency Medicine, Our Lady of the Resurrection Medical Center, Chicago, Illinois;t and Division of Emergency Medicine, Lutheran General Hospital, Park Ridge, Illinois.¢ Received for publication August 24, 1990. Accepted for publication October 29, 1990. Presented at the 1990 AAPCC/AACT/ ABMT/CAPCC Conference in Tucson, Arizona, September 1990. Address for reprints: Todd L Vanden Hoek, MD, 1040 North Humphrey, Oak Park, Illinois 60302.
CASE REPORTS Seven patients representing three different families presented to a local e m e r g e n c y d e p a r t m e n t in late October a p p r o x i m a t e l y four hours after all ingested sauteed m u s h r o o m s picked from a n o r t h e a s t Illinois forest preserve by one of the families. The m u s h r o o m s were thought to be Cantharellus cibarius but were later identified by a local m y c o l o g i s t as O illudens based on description and a s p e c i m e n brought in by the patients. Pertin e n t h i s t o r i c a l i n f o r m a t i o n , o c c u r r e n c e of s y m p t o m s , a n d s i g n i f i c a n t laboratory a b n o r m a l i t i e s are s u m m a r i z e d (Table 1). Patients ranged in age from 20 to 54 years (four w o m e n and three men). All experienced nausea and v o m i t i n g associated w i t h a b d o m i n a l cramping, w i t h t i m e of onset ranging from 15 to 90 m i n u t e s after ingestion. Total duration of v o m i t i n g was less t h a n eight hours in all cases. Three patients e x p e r i e n c e d w a t e r y d i a r r h e a t h a t r e s o l v e d w i t h i n 12 hours. Four complained of w e a k n e s s and dizziness. Two of the seven experienced c l a m m i ness and sweating and were found to be diaphoretic on physical examination in the ED. N o n e reported increased salivation or visual changes. Two patients were i n i t i a l l y tachycardic on p r e s e n t a t i o n to the ED, one w i t h a pulse of 120 and m i l d orthostasis. N o a b n o r m a l i t i e s on liver e x a m i n a t i o n were d o c u m e n t e d for any of the patients. All seven patients were started on IV fluids and given one 50-g dose of activated charcoal. Laboratory studies c o m p l e t e d for all seven included a
20:5 May 1991
Annals of Emergency Medicine
559/12.~
M U S H R O O M POISONING Vanden H o e k et al
TABLE 1. Summary of case reports Patient
Age (yr)
Sex
Significant History
Medication
1
45
F
None
2
20
F
3
50
4
42
5 6
7 Normal
Nausea and Vomiling
Diarrhea
Weakness
Sweating
Dizziness
None
+
4-
4-
=
4-
HepatitisB
None
+
-
4-
M
HTN
None
+
-
F
Migraines
None
+
+
47
M
None
None
+
54
M
Pepticulcer disease
Cimetidine
4-
44
F
None
None
+
-
Physical Findings
Abnormal Laboratory Findings SGOT, 85 IU/L; SGPT, 136 IU/L WBCs, 10,700
4-
m
Pulse, 104
4-
m
Pulse, 120
+
+
Diaphoretic
-
4-
Diaphoretic
SGOT, 54 IU/L; SGPT, 76 IU/L; LDH, 164 IU/L SGOT, 35 IU/L; SGPT, 51 IU/L; WBCs, 11,700 Potassium, 3.3 mEq/L
-
values: SGOT, 5 to 30 IU/L; SGPT, 5 Io 40 IU/L; WBCs, 4,500 to 10,000; LDH, 65 1o 155 lU/L; polassium, 3.5 to 50 mEq/L
TABLE 2. Summary of North American case reports No. of Reference (year)
Patients
No. of Patients Experiencing Symptoms Nausea
Vomiting
Weakness
Diarrhea
Sweating
Salivation
NR
NR
2
NR
NR
1
...
NR
NR
2
1
2
NR
NR
NR
Farlow12 (1899)
12
12
4
Seaved3 (1939)
4
4
4
3
SeaverTM (1939)
1
1
1
Boston Mycology Club15 (1963)
3
3
3
Hanrahan and Gordon1 (1984)
1
1
1
Cochran16 (1987)
16
16
16
4
2
2
5
French and Garrettson2 (1988)
16
10
8
10
5
3
...
Present study (1991) Total (% of Total) NR, not reported as + or
. . . . . .
7
7
7
4
3
2
...
60 (100)
54 (90)
44 (73)
24 (40)
13 (22)
9 (15)
5 (8)
-
CBC, prothrombin and partial thromboplastin times, electrolytes, blood urea nitrogen, creatinine, glucose, calcium, creatine phosphokinase, LDH, total bilirubin, SGOT, and SGPT levels. Three p a t i e n t s had mildly elevated SGOT and SGPT levels, and one of them also had an elevated LDH. Hepati.tis profiles were normal for all three. Two patients with a history of hepatitis B had normal liver function tests. One was found to be hypokalemic and received IV potassium supplementation. Two patients had a mild leukocytosis. All other laboratory studies were within the normal limits for the hospital laboratory. ECGs were not done. All patients were admitted overnight for observation and had complete recovery from s y m p t o m s within 12 hours of ingestion. All were discharged without complica124/560
. . . . . .
tion the following day. Repeat laboratory studies, clone within one week on the three patients with elevated SGOT and SGPT levels and the one p a t i e n t w i t h h y p o k a l e m i a , were within normal limits. DISCUSSION The jack o'lantern mushroom is an orange-to-yellowish-orange mushroom with sharp-edged gills; it grows in clusters at the base of stumps and on buried roots of oak and other dec i d u o u s wood. 8 It is c o m m o n l y found in eastern North America and across the southern United States to the Pacific Coast, with a season normally spanning July through November. The luminescence of its gills will often last 40 to 50 hours after collection, 9 a characteristic that is thought to have suggested the widely a c c e p t e d c o m m o n n a m e of jack o ' l a n t e r n , lo This b i o l u m i n e s c e n t Annals of E m e r g e n c y Medicine
property is produced by terpenoid metabolites that have been isolated from the jack o'lantern. 11 Several other sesquiterpene metabolites have been isolated from the jack o'lantern, many of which possess antitumor and antibacterial activities.It Other names given this mushroom in the medical literature since 1899 include Agaricus illudens, Clitocybe olearia, Clitocybe iHudens, Pleurotus olearius, and Omphalotus olearius. 2 We were able to find only seven reports from North America regarding ingestion of this mushroom. Farlow reported 12 cases in 1899.12 Vomiting started within two hours in four of the cases, and the other eight "suffered from terrible nausea." Seaver reported a series of four ingestions following one picking in 1939 in which two of the patients experienced a 12-hour delay before emesis ensued. 13 Seaver also reported one 20:5 May 1991
MUSHROOM POISONING Vanden Hoek et al
case that year in which the patient, after ingestion of the m u s h r o o m , suddenly felt a "heavy sensation in the s'tomach" and induced vomiting by "usual household methods. ''14 An anecdotal report in 1963 detailed ingestions by three college students that were followed by severe nausea and vomiting in all three, weakness and sweating in two, and diarrhea in one.iS One student required hospitalization. All three were asymptomatic the following day. Hanrahan and Gordon reported a case in 1984 in which only vomiting occurred.i Laboratory studies, including a CBC and serum chemistries, were normal. Admitted for observation, this patient was discharged symptom free the following morning. Cochran reported a series of 16 cases in 1987 in which all patients vomited, five exhibited salivation, two had sweating, and two experienced diarrhea.16 French and Garrettson reported a case series in 1988 of 16 campers who accidentally ingested jack o'lantern mushrooms while on a field expedition, z Eight exhibited vomiting; five had diarrhea; ten were weak, tired, or both~ and three felt clammy or sweaty. All symptoms resolved within 18 hours of ingestion. The dominant symptom in all of these reports, including our case series, was vomiting, affecting all patients within three hours of ingestion, with the exception of two cases reported by Seaver. 13 Another commonly reported symptom was weakness. For all patients, symptomatology was of short duration, and recovery was quick. With the exception of the cases reported by Cochran, muscarinic effects and diarrhea were relatively infrequent. 16 Although elevated liver function tests have been reported after Clitocybe ingestions, lz to our knowledge no reports have d o c u m e n t e d such elevation after an O illudens ingestion. Three patients in our series had such elevations, all of whom had normal levels on follow-up testing. A third patient had hypokalemia, a known complication of protracted vomiting. 18 Two of our patients had
20:5 May 1991
a mild leukocytosis, which also has been reported in European cases of jack o'lantern ingestion. 5 The North American reports of jack o'lantern poisoning, along with their symptomatology, are summarized (Table
2). In contrast with North American reports, European reports of poisoning with this m u s h r o o m are more c o m m o n and usually involve more severe symptoms. Maretic and coworkers published three reports between 1967 and 1975 detailing symptoms in 40 human beings and one dog after ingestion.5,6A 9 In the first report, symptoms began within one half to two hours after ingestion and included nausea, vomiting, diarrhea, severe headache, and vertigo, s Three patients experienced diplopia, and two had salivation. The dog vomited but recovered quickly. In the 1968 case series, 23 of 25 people experienced nausea and vomiting within 60 to 150 minutes of ingestion. 6 Other c o m m o n s y m p t o m s included salivation, dysphagia, diplopia, increased perspiration, headache, paresthesias, fatigue, and chills. Most symptoms subsided within five to six days of poisoning. In a French review of 25 cases by Brun et al, s y m p t o m o n s e t was within 45 minutes to four hours and included vomiting, vertigo, and paresthesias, zo These case reports detail m o r e f r e q u e n t l y the m u s c a r i n i c symptoms of salivation, increased perspiration, diarrhea, vertigo, and paresthesias. This fact has led some authors, such as Ammirati et al, to believe that the jack o'lantern mushrooms on the two sides of the Atlantic are different species, reserving the name O olearius for the European species, z
SUMMARY P o i s o n i n g by i n g e s t i o n of the N o r t h A m e r i c a n jack o ' l a n t e r n mushroom, illustrated by our case series, appears to be a self-limited illness with a short latency period between ingestion and emesis and with a relatively short duration of symptoms. Compared with the European
Annals of Emergency Medicine
jack o'lantem mushroom, muscarinic effects are m u c h more infrequent. We r e c o m m e n d that patients presenting with jack o']antern mushroom ingestion be observed and rehydrated and that potassium level and liver function tests be obtained.
REFERENCES 1. Hanrahan JP, Gordon MA: Mushroom poisoning: Case reports and a review of therapy, lAMA 1984;251: 1057-1061. 2. French AL, Garrettson LK: Poisoning with the North American Jack O'Lantern mushroom, Omphalotus illudens. Clin Toxicol 1988;26:81-88. 3. Lampe KF: Pharmacology and therapy of mushroom intoxication, in Rumack BH, Salzman E (eds): Mushroom Poisoning: Diagnosis and Treatment. West Palm Beach, Florida, CRC Press, I978, p I25-169. 4. Lincoff G, Mitche] DH: Toxic and Hallucinogenic Mushroom Poisoning: A Handbook for Physicians and Mushroom Hunters. N e w York, Van Nostrand Reinhold, 1977, p 74. 5. Maretic Z: Poisoning by the mushroom Clitocybe olearia Maire. Toxikon 1967;4:263-267. 6. Maretic Z, Russell FE, Golobic V: Twenty-five cases of poisoning by the mushroom Pleurotus olearius. Tax ikon 1975;13:379-38I. 7. A m m i r a t i IF, Traquair JA, Horgen PA: Poisonous Mushrooms of Northern United States and Canada. Minneapolis, University of Minnesota Press, 1985, p 290-292. 8. Lincoff GH, Knopf AA: The Audubon Society Fidd Guide to North American Mushrooms. N e w York, Chanticleer Press Inc, 1981, p 787-788. 9. Miller OK: Mushrooms of North America. N e w York, Chanticleer Press Inc, 1979, p 121-122. [0. McKnight KH, McKnight VB: A Field Guide to Mushrooms: North America. Boston, Houghton Mifflin Co, 1987, p 178-179. il. Ayer WA, Browne LM: Terpenoid metabolites of mushrooms and related Basidiomycetes. Tetrahedron I981;37:2199-2248. 12. Farlow WG: Poisoning by Agaricus illudens. Rhodora 1899~1:43-44. [3. Scarer Ff: Recent mushroom poisoning. J N Y Botanical Garden 1939;40:236-237. 14. Seaver FJ: Poisoning with Clitocybe i]hldens. Myco]ogia 1939;31:110. 15. Boston Mycology Club: The Clitocybe idhzdens affair. Boston Mycological Club Bull 1963;4:3-4. 16. Cochran KW: Poisoning due to misidentified mushrooms. Mcllvainea 1987~8:27-29. 17. McCormick DJ, Avbel AJ, Gibbons RB: Nonlethal mushroom poisoning. Ann Intern Med 1979;90:332 335. 18. Barsan WG, Baker PB: Upper gastrointestinal tract disorders, in Rosen P, Baker FJ, Barkin RM, et al (eds}: Emergency Medicine: Concepts nnd Clinical Practice, ed 2. St Louis, CV Mosby, vol 2, 1988, p 1406. 19. Maretie Z, Vrtar B: M i c e t i z a m u istri. LH Vj [968;90:631. 20. Brun A, Bayer J, Astier J, et al: Etude epidemio logiclue des intoxications par Clitocybe olearia recueillies au centre anti-poisons de Marseille de 1973 a 1977. Collect Med Leg ToxicoI Med 1978~106:135-137.
561/125
