Wednesday, March 17, 2010

Gerald O'Malley, DO: The mushroom mystery

On Tuesday morning I received an urgent phone call from a colleague who works in another ER. He told me about a patient who he saw with a possible severe mushroom ingestion and poisoning. The patient was a friend of his. My colleague had secured emergency consulting privileges for me from the medical staff president and asked me to see the patient. I was scheduled to work a moonlighting shift that evening at my friend’s shop, so I promised to stop in and see the patient before work.

Thirty minutes later I received an urgent e-mail from Dr. Kevin Osterhoudt, the director of the Philadelphia Poison Control Center about a mushroom-poisoned patient somewhere in the city.

My first thoughts were “My God – are there TWO patients? Is someone selling poisoned mushrooms on the streets of the city? Do we have a public health crisis on our hands?”

A quick phone call to Poison Control clarified the situation. One patient. No epidemic. No need to call in the health department or to shut down the farmer’s market where our patient bought her mushrooms. At least not yet — but the chase was on.
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I saw the patient a few hours later. The patient was a professional and a very health-conscious individual who rarely ate meat and bought her produce at the organic food market. Her symptoms began about three hours after eating the morels that she bought at the Reading Terminal Market. The patient and her husband were both in the ER at midnight — he was on death’s door; she was a lot worse. There were no more reports of mushroom poisoned patients in the Delaware Valley in the interim.

Abdominal pain, diarrhea, bloody vomiting, volume contraction, hypotension, dysrhythmias, acidosis…everything needed to kill a young woman. Except mushroom poisoning. There are seven or eight known toxic syndromes associated with poisonous mushrooms, but neither this patient nor her husband showed the characteristic signs of any of the known syndromes. No liver toxicity consistent with Amanita phylloides, no renal toxicity to suggest Cortinarius species or Amanita smithiana, no central nervous system toxicity to suggest Gyromitra species (the “false morels”).

What the hell was killing these people?

I called the Poison Control Center and consulted with the brilliant Dr. Fred Henretig. He agreed — didn’t sound like any mushroom he had ever heard of. I felt reassured when Fred concurred that this wasn’t a mushroom — this sounded more like some kind of pre-formed toxin like a Staphylococcal toxic shock syndrome.

The patients improved. The first 36 hours were terrifying. The next 36 hours were tense but hopeful — double and triple checking hemodynamics and fluid status and pressor dosages. The fourth and fifth days were joyful, watchful, prayerful. The critical-care specialists were heroic and never left her side. God watches out for drunks and doctors.

The mushroom questions never stopped. For the past week I’ve answered dozens of questions from family members, nurses, doctors, and Poison Center personnel about the mushroom poisoning that never was. Amazing how stories take on a life of their own.

Drs. Osterhoudt and Henretig think that it is worthwhile discussing this case at the next Poison Control Center Grand Rounds in the context of mushroom poisonings in general (rare but terrifying) and more specifically when we, as a Poison Control Center and a public resource, should pull the trigger to initiate a public health alert.

I’ve invited the patient and her husband to attend.

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