P1927 - Unusual Cause of Acute Liver Injury: Amatoxins-Containing Mushroom Poisoning

Gin Yi Lee, MD¹, Ashley Tran, MD², Uyen To, MD^2
1Danbury Hospital, Danbury, CT; ²Yale New Haven Hospital, New Heaven, CT

Introduction: Acute liver failure due to mushroom containing amatoxins is rare. Currently, several combinations of antidotes have been used without clearly proven clinical efficacy. Liver transplantation remains the cornerstone of treatment and should be consider in those who develop fulminant liver failure. We describe a case of patient who developed acute liver injury after wild mushroom ingestion requiring treatment with silibinin.

Case Description/Methods: A healthy 34-year-old woman presented with acute generalized abdominal pain associated with nausea, vomiting, watery diarrhea and paresthesias. She reported ingesting a wild, uncooked white mushroom during a hike twelve hours prior. On presentation, she was afebrile and hemodynamically stable. Physical examination demonstrated mild epigastric tenderness but no mental status changes and asterixis. Labs revealed severe hepatocellular pattern of injury (ALT 980 IU/L, AST 658 IU/L, alkaline phosphatase 60 U/L, total bilirubin 1.6 mg/L, and direct bilirubin 0.3 mg/L). Ammonia levels were 49 umol/L and INR 1.31. Serologic evaluation was negative, including hepatitis A/B/C, CMV, EBV, HSV, autoimmune hepatitis, and Wilson’s disease. Given the description of the ingested mushroom and the patient’s constellation of symptoms, a diagnosis of acute liver injury due to amatoxin toxicity was made. She was treated with intravenous N-acetylcysteine (IV NAC), penicillin G and high dose vitamin C without clinical improvement. An emergency request for silibinin use was authorized by the U.S. Food and Drug Administration (FDA) and she was treated with a four-day course with improvement of her transaminases and coagulopathy. She was discharged in good condition with normalization of liver enzymes at outpatient follow up.

Discussion: The management of amatoxin toxicity is primarily supportive care, detoxification (gastric decontamination, biliary drainage, hemoperfusion, and extracorporeal liver support), drug therapies (penicillin G and silibinin) and liver transplantation if deemed necessary. Silibinin reduces amatoxin uptake in hepatocytes and has been reported to be more effective than penicillin G. However, silibinin is not widely available in the United States but can be obtained in eligible patients through emergency authorization from the FDA. Treatment should be considered in cases of known or suspected mushroom poisoning that do not respond to traditional therapies.


Disclosures:


Gin Yi Lee, MD¹, Ashley Tran, MD², Uyen To, MD². P1927 - Unusual Cause of Acute Liver Injury: Amatoxins-Containing Mushroom Poisoning, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.