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120 FULMINANT LIVER FAILURE IN A CHILD SECONDARY TO MUSHROOM POISONING FROM AMATOXIN-CONTAINING LEPIOTA CLYPEOLARIA: IMPORTANCE OF TIMELY CONSIDERATION FOR THE NECESSITY OF LIVER TRANSPLANTATION CM Walsh1, S Hussey1, J Hutchison2, AH Fecteau3, SC Ling1, VL Ng1 The presentation of patients poisoned with amatoxin-containing mushrooms is characterized by the acute onset of gastrointestinal symptoms, after an 8-24 hour latency period. Progressive hepatic toxicity leading to fulminant hepatic failure may ensue. Mushrooms of the genus Lepiota, similar to those of the more commonly encountered genus Amanita, contain amatoxins. We report a case of FHF resulting from wild mushroom poisoning secondary to Lepiota clypeolaria ingestion. A previously healthy 5-year-old Asian boy presented to the emergency room at a local hospital, along with his mother, grandmother and younger sister, with acute onset of vomiting, diarrhea, abdominal pain and lethargy. Approximately 12 hours earlier, he consumed 10-12 wild mushrooms that his mother had picked from a local field and cooked for the family. The grandmother and younger sister, who presented with much milder self-resolving gastrointestinal symptoms, reportedly only drank the broth in which they were prepared. The mushrooms were quickly identified as Lepiota clypeolaria by a local mycologist. Liver enzyme abnormalities and an increased INR of 1.5 in the 5-year-old boy led to transfer to our institution at 36 hours after ingestion. He was treated with intravenous penicillin G, ceftazidime, and oral silymarin, all of which are protective against amanita toxicity in animal and in vitro studies. Extracorporeal albumin dialysis was also commenced. Due to worsening and uncorrectable coagulopathy (INR 6.4, factor 7 and 5 levels <3%), he was listed for liver transplantation. Encephalopathy developed necessitating mechanical ventilation and a deceased donor organ became available over the next 36 hours.
1Divisions of Gastroenterology, Hepatology, and Nutrition; 2Critical Care Medicine; 3General Surgery, The Hospital for Sick Children; University of Toronto, Toronto, Ontario
The life-saving role of liver transplantation in FHF secondary to mushroom poisoning should be considered as soon as possible; making the prompt recognition of symptoms and early referral to specialized centers crucial. Children are more vulnerable to amatoxin poisoning than adults; likely because the amount of toxin absorbed per unit of bodyweight is often greater. Close observation, prompt treatment and timely consideration in listing children with uncorrectable coagulopathy for liver transplant, even in the absence of encephalopathy, is emphasized.