Wzorzec-przegl d lekarski-XX-2001

CLINICAL NOTES – DONIESIENIA KLINICZNE
Jacek Sein ANAND1
Pawe³ CHWALUK2,3
Micha³ SUT4
Ostre zatrucie G¹sk¹ zielonk¹
Acute poisoning with Tricholoma equestre
Pomerania Center of Toxicology, Gdañsk,
Poland
Head: Wojciech Waldman MD, PhD
1
Unit of Internal Diseases, Regional Hospital
in Bia³a Podlaska, Poland
Head: Jolanta Siwek-Iwanicka MD
2
Department of Anatomy
University of Physical Education in Bia³a
Podlaska, Poland
Head: Jan Rowiñski MD, PhD
3
Mater Infirmorum Hospital Belfast
General and Hepatobiliary Surgery Ward
4
Additional key words:
acute intoxication
Tricholoma equestre
rhabdomyolysis
Dodatkowe s³owa kluczowe:
ostre zatrucie
G¹ska zielonka
rabdomioliza
Four cases, including three adults
and one child, suffering from acute
poisoning with Tricholoma equestre
were described. The patients had
eaten from 100 to 400 grams of the
mushroom within a few consecutive
meals. After consuming about 1000
grams of Tricholoma equestre for 3-4
days, the subjects developed fatigue,
muscle weakness, myalgia, and in two
cases acute respiratory failure with the
need of respiratorotherapy. Maximal
serum CK was 48136 U/L in the adults
and 306 U/L in children. Maximal serum levels of AST and ALT were 802
U/L and 446 U/L in adults and 39 U/L,
and 56 U/L in a child. All routine biochemical tests were within normal
range. No other causes of
rhabdomyolysis such as parasitic or
viral infections, immune diseases,
trauma or exposure to medications
were found. Patient, aged 72 yrs., who
developed acute respiratory failure,
died in the second day of hospitalization. In other patients all the above
mentioned symptoms and biochemical
abnormalities disappeared from 2 to 3
weeks of hospitalization. Physicians
should be aware of the possibility of
appearance of rhabdo-myolysis after
repeated consumption of large quantities of Tricholoma equestre.
Introduction
We present four cases, including three
adults and one child, who were admitted to
the hospital from 2002 to 2008 because of
rhabdomyolysis caused by excessive consumption of Tricholoma equestre.
Case report
Adres do korespondencji:
Sein Anand Jacek MD PhD
Pomerania Center of Clinical Toxicology
ul. Kartuska 4/6
80-104 Gdañsk, Poland
e-mail: [email protected]
Przegl¹d Lekarski 2009 / 66 / 6
Case number one and two: Mother and her son,
aged 48 and 20 years, respectively, were admitted to
the hospital because of the following symptoms: fatigue,
striated muscle weakness, myalgia especially in muscles of the legs, loss of appetite, mild nausea, and profuse sweating. All symptoms appeared approximately 48
hours after the last meal containing Tricholoma equestre, which had been eaten by the family recently (last
nine consecutive meals). The average dish contained
about 100-300 grams of this mushroom. No other symptoms like vomiting, diarrhoea, fever or erythema were
observed. Physical examination revealed regular heart
rate about 90 b./min in the mother and 85 b./min in the
son, blood pressures were 140/60 mmHg, and 125/70
mmHg respectively. No other important abnormalities
W pracy przedstawiono cztery osoby, w tym trzy doros³e oraz dziecko, u
których dosz³o do znacznej rabdomiolizy w przebiegu zatrucia Tricholoma
equestre. Pacjenci spo¿ywali od 100
do 400 g grzyba przez kilka kolejnych
dni. Po spo¿yciu ok. 1000 g Tricholoma equestre dosz³o u nich do pojawienia siê os³abienia, bólów miêœni, zaœ
w dwóch przypadkach ostrej niewydolnoœci oddechowej, która wymaga³a
respiratoroterapii. Poziomy CPK u doros³ych pacjentów siêga³y 48136 U/L,
zaœ u dzieci 306 U/L. Najwy¿sze wartoœci ASPAT i ALAT wynosi³y odpowiednio 802 U/L i 446 U/L u osób doros³ych oraz 39 U/L i 56 U/L u dziecka.
Wszystkie rutynowe testy biochemiczne nie wykazywa³y wiêkszych odchyleñ od normy. Nie znaleziono równie¿
¿adnych innych przyczyn rabdomiolizy, w tym m.in. chorób paso¿ytniczych,
wirusowych, immunologicznych, urazów, a tak¿e niepo¿¹danego dzia³ania
leków. Pacjent lat 72, u którego dosz³o
do ostrej niewydolnoœci oddechowej,
zmar³ w drugiej dobie leczenia. U pozosta³ych pacjentów wszystkie objawy
kliniczne oraz biochemiczne ust¹pi³y
po ok. 2-3 tygodniach leczenia. Lekarze powinni zawsze pamiêtaæ o mo¿liwoœci wyst¹pienia rabdomiolizy w
przebiegu wielokrotnego spo¿ycia du¿ej dawki Tricholoma equestre.
were found. Maximal serum CK activity was 18150 U/L
in the mother and 48136 U/L in the son. Maximal serum
levels of AST and ALT were 802 U/L and 446 U/L, in the
mother and 2002 U/L and 454 U/L, in the son. Other
hepatic, renal and coagulation tests, as well as electrolyte levels, including potassium values, were normal. All
symptoms disappeared within 3 weeks of supportive
treatment, however, the muscle weakness lasted for
about 2-3 months more.
Case number three: A five-year-old male child was
admitted to the clinic because of deep coma, cyanosis
and convulsions. All theses symptoms appeared about
4 hours after the last meal containing Tricholoma equestre. Medical history revealed that the child had been eating about 300-400 grams of this mushroom daily for the
four consecutive days. Physical examination revealed
deep coma (4 score GCS), regular heart rate about 120/
min, blood pressure 110/60 mmHg, and breath rate about
6/min. There were: bilateral, positive Babiñski sign and
symmetrical increase muscle tone in the neurological
examination. No changes in computerized tomography
of the head, chest x-ray, lumbar puncture, encephalography, echocardiography and toxicological tests were
found. The biochemical tests showed elevated serum
CK activity 306 U/L (normal range 5-130 U/L for a child),
339
ALT 56 U/L (normal range 5-45 U/L for person between
1-19-year old), pH 7,28, BE 5,9 mEq/l, HCO3 22,9 mEq/
l, pO2 43,9 mmHg, pCO2 59,8 mmHg. Beacuse of acute
respiratory insufficiency the child was intubated and respiratorotherapy, lasted 34 hours, was applied. For the
next week after that extubation, the child still presented
with muscle weakness which included especially the pelvic girdle and the urinary bladder. The boy could not sit
or stand up without help, and the bladder had to be catheterised to avoid urine retention. All the symptoms disappeared within 2-3 weeks of hospitalisation.
Case number four: A man aged 72 was admitted to
the hospital because muscle weakness, and myalgia
(especially the quadriceps), which lasted for four days.
All symptoms appeared about 24 hours after the last
meal containing Tricholoma equestre. The patient had
eaten the mushroom for the last ten consecutive meals.
The average dish contained about 300-400 grams of
Tricholoma equestre. There were no changes in physical examination except muscle pain of both legs and
increasing problem with walking. Maximal CK activity
was 44767 U/L, CKMB 888 U/L, TNI 1,9 ng/ml, AST
1894 U/L, and ALT 490 U/L. Other hepatic, renal and
coagulation tests as well as electrolyte levels, including
potassium, were normal. No changes in computerized
tomography of the head, chest X-ray, echocardiography
and toxicological tests were found. In the second day of
hospitalisation the patient reported pain and weakness
of the muscle of the chest, shoulders and abdomen. The
patient complained of dyspnoea, and a few hours later
breathing problems appeared. The patient was transferred to the ICU, intubated and connected to the respirator. About 4.5 hours later - cardiac arrest was noted
and CRP was ineffective.
Several studies for parasites and other microorganisms (trichinella, toxoplasma, coxsackievirus, HIV, HCV
and HBV), as well as for systemic diseases were negative for all observed patients.
340
Discussion
The most common causes of rhabdomyolysis are muscle compression, neuroleptic malignant syndrome, intoxication with
alcohol, amphetamine, cocaine, antihyperlipidemic drugs, antihistamines, phenothiazines, theophylline or long-term use of levodopa, quinidine, phenytoin, penicillamine
and others [2-5].
In 2001, Bedry and co-workers observed
rhabdomyolisis in twelve patients in southwestern France after excessive consumption of Tricholoma equestre [1]. The main
symptoms described by the authors included muscle weakness, fatigue, myalgia
(especially in quadriceps), facial erythema,
nausea without vomiting, and diaphoresis
without fever. The same signs, except facial erythema, were observed also in our
cases.
The biochemical results showed marked
increase in CK, AST and ALT levels. However, in the child, the level of these enzymes
did not correspond well with the grave clinical condition of the patient.
Quite interesting is a delay between Tricholoma equestre consumption and rhabdomyolisis occurrence. Bedry and co-workers observed the clinical signs about 2472 hours after consuming the last three consecutive meals with this mushroom [1]. In
our cases the symptoms appeared after having more than 1000 grams of Tricholoma
equestre in less than four days.
One of our patients died despite inten-
Przegl¹d Lekarski 2009 / 66 / 6
sive care because of acute respiratory failure. The high mortality rate of about 25%
was also observed by Bedry and co-workers [1].
Conclusions
1. Physicians should be aware of the
possibility of acute intoxications after repeated consumption of large quantities of Tricholoma equestre.
2. The clinical picture of poisonings with
this wild mushroom may be different in children and adults.
3. There is a delay between ingestion
and onset of clinical symptoms.
4. Intoxication of Tricholoma equestre is
connected with high mortality rate (about
25%).
References
1. Bedry R., Baudrimont I., Deffieux G. et al.: Wildmushroom intoxication as a cause of rhabdomyolysis.
N Engl. J. Med. 2001, 345, 798.
2. Bourquia A., Jabrane A.J., Ramdani B., Zaid D.:
Toxicite' syste'mique de la paraphe'nyle'ne diamine:
quatre observations. Presse Med. 1988, 17, 1798.
3. Dromer C., Verdrenne C., Billey T. et al.:
Rhabdomyolyse a' la simvastatine: a' propos d'un
cas avec revue de la litte'rature. Rev. Rhum. Mal.
Osteoartic. 1992, 59, 281.
4. Laaksonen R., Jokelainen K., Laakso J. et al.: The
effect of simvastatin treatment on natural antioxidants
in low-density lipoproteins and high-energy phosphates and ubiquinone in skeletal muscle. Am. J. Cardiol. 1996, 77, 851.
5. Yagi H., el Hind A.M., Khalil S.I.: Acute poisoning
from hair dye. East. Afr. Med. J. 1991, 68, 404.
S. Anand Jacek et al.