Renal and hepatic injury with elevated cardiac enzymes in Amanita phalloides poisoning: a case report

Abstract

Amatoxins are one of the most potent toxins that cause hepatic and renal failure. However, this is the first report demonstrating an elevation of cardiac enzymes in a patient with Amanita phalloides poisoning. A 56-year-old male was admitted to the emergency department (ED) 42 h after an unknown type of mushroom ingestion. Hepatic, renal function tests, amylase and cardiac enzymes (troponin I, creatine kinase (CK), CK-MB isoenzyme and myoglobin) were found elevated in his blood chemistry. The electrocardiogram disclosed sinus tachycardia. Aggressive treatment with fluids, activated charcoal, penicillin G and silibinin were started. The patient was sent to hemodialysis because of anuria. During follow-up, biochemical parameters and clinical findings improved. The patient was discharged from the hospital following the arrangement of hemodialysis schedule because of the chronic renal failure. False elevations of cardiac markers may confuse the clinicians in differantial diagnosis of myocardial infarction in ED. In our patient, amatoxins that have bound the actin filaments within myocardiocytes or renal cells and/or its effects as circulating anti-troponin antibodies might result in elevation of cardiac markers. Elevated cardiac enzyme levels without any acute coronary syndrome are probable in mushroom poisoning cases involving amatoxin ingestion. Human & Experimental Toxicology (2007) 26, 757—761

Keywords

Amanita phalloides amatoxin elevation of myocardial enzymes poisoning troponin I

References

Scheurlen C. , Spannbrucker N. , Spengler U. , Zachoval R. et al. Amanita phalloides intoxications in a family of russian immigrants. Case reports and review of the literature with a focus on orthotopic liver transplantation. Z Gastroenterol 1994; 2: 399—404.

Broussard CN , Aggarwal A. , Lacey SR , Post AB et al. Mushroom poisoning from diarrhea to liver transplantation. Am J Gastroenterol 2001; 96: 3195—8.

Williams PL , James RC , Roberts SM Principles of toxicology: environmental and industrial applications, second edition. John Wiley & Sons, Inc. 2000.

Jander S. , Bischoff J. , Woodcock BG Plasmapheresis in the treatment of Amanita phalloides poisoning: II. A review and recommendations. Ther Apher 2000; 4: 308—12.

Goldfrank LR , Mushrooms. In Goldfrank LR , Flomenbaum NE , Lewin NA , Howland MA , Hoffman RS eds. Goldfrank's toxicologic emergencies. McGraw-Hill , 2002.

Shi Y. , He J. , Chen S. , Zhang L. et al. MARS: optimistic therapy method in fulminant hepatic failure secondary to cytotoxic mushroom poisoning — a case report. Liver 2002; 22(Suppl 2): 78—80.

Brayer AF , Schneider SM Mushroom Poisoning. In Tintinalli JE , Kelen GD , Stapczynski JS eds. Emergency medicine: A comprehensive study guide. McGraw-Hill, 2004.

Klasco RK ed. POISINDEX® System (electronic version). Thomson Micromedex, Greenwood Village, Colorado, USA. (Vol. 131, expires 3/2007).

Marquardt K. Mushrooms, Amatoxin-type . In Olson KR ed: Poisoning and drug overdose . Appleton and Lange, 2004.

10.

Enjalbert F. , Rapior S. , Nouguier-Soule J. , Guillon S. et al. Treatment of amatoxin poisoning: 20-year retrospective analysis. J Toxicol Clin Toxicol 2002; 40: 715—57.

11.

Burton JR , Ryan C. , Shaw-Stiffel TA Liver transplantation in mushroom poisoning. J Clin Gastroenterol 2002; 35: 276—80.

12.

Sanhueza J. , Valdes J. , Campos R. , Garrido A. et al. Changes in the xanthine dehydrogenase/xanthine oxidase ratio in the rat kidney subjected to ischemia-reperfusion stress: preventive effect of some flavonoids. Res Commun Chem Pathol Pharmacol 1992; 78: 211—8.

13.

Bukatina AE , Kirkpatrick RD , Campbell KB Secophalloidin and phalloidin-(S)-sulfoxide as contraction modifiers for comparative study of skeletal and cardiac muscles . Tsitologiia 2000; 42: 37—41.

14.

Forro M. , Mandli T. Liver transplantation after Amanita phalloides poisoning from the viewpoint of anesthesia and intensive care based on three cases. Orv Hetil 2003; 144: 269—73.

15.

Karras DJ , Kane DL Serum markers in the emergency department diagnosis of acute myocardial infarction . Emerg Med Clin North Am 2001; 19: 321—37.

16.

Abbas NA , John RI , Webb MC , Kempson ME et al. Cardiac troponins and renal function in nondialysis patients with chronic kidney disease. Clin Chem 2005 ; 51: 2059—66.

17.

Fahie-Wilson MN , Carmichael DJ , Delaney MP , Stevens PE et al. Cardiac troponin T circulates in the free, intact form in patients with kidney failure. Clin Chem 2006; 52: 414—20.

18.

Arlati S. , Brenna S. , Prencipe L. , Marocchi A. et al. Myocardial necrosis in ICU patients with acute noncardiac disease: a prospective study. Intensive Care Med 2000 ; 26: 31—7.

19.

Khan IA , Tun A. , Wattanasauwan N. , Win MT et al. Elevation of serum cardiac troponin I in noncardiac and cardiac diseases other than acute coronary syndromes. Am J Emerg Med 1999; 17: 225—9.

20.

Roongsritong C. , Warraich I. , Bradley C. Common causes of troponin elevations in the absence of acute myocardial infarction: incidence and clinical significance . Chest 2004; 125: 1877—84.

21.

Jeremias A. , Gibson CM Narrative review: alternative causes for elevated cardiac troponin levels when acute coronary syndromes are excluded. Ann Intern Med 2005; 3: 786—91.

22.

Herman EH , Lipshultz SE , Rifai N. , Zhang J. et al. Use of cardiac troponin T levels as an indicator of doxorubicin-induced cardiotoxicity. Cancer Res 1998; 15: 195—7.

23.

Skulec R. , Belohlavek J. , Kovarnik T. , Kolar J. et al. Serum cardiac markers response to biphasic and monophasic electrical cardioversion for supraventricular tachyarrhythmia-a randomised study. Resuscitation 2006; 70: 423—31.

24.

Lopez Haldon J. , Martinez Martinez A. , Ordonez A. , Marques J. et al. Hypothyroidism and myocardial damage in cardiac donors. Rev Esp Cardiol 2001; 54: 735—40.

25.

Kamijo Y. , Soma K. , Aoyama N. , Fukuda M. et al. Myocardial infarction with acute insulin poisoning—a case report. Angiology 2000; 51: 689—93.

26.

Zhu BL , Oritani S. , Quan L. , Li DR et al. Two suicide fatalities from sodium cyanide ingestion: differences in blood biochemistry. Chudoku Kenkyu 2004 ; 17: 65—8.

27.

Zhu BL , Ishikawa T. , Michiue T. , Li DR et al. Postmortem cardiac troponin T levels in the blood and pericardial fluid. Part 1. Analysis with special regard to traumatic causes of death. Leg Med (Tokyo) 2006; 8: 86—93.

28.

Mahajan N. , Mehta Y. , Rose M. , Shani J. et al. Elevated troponin level is not synonymous with myocardial infarction . Int J Cardiol 2006; 28: 442—9.

29.

Quenot JP , Le Teuff G. , Quantin C. , Doise JM et al. Myocardial injury in critically ill patients: relation to increased cardiac troponin I and hospital mortality. Chest 2005; 128: 2758—64.

30.

Van Bockel EA , Tulleken JE , Ligtenberg JJ , Zijlstra JG Troponin in septic and critically ill patients . Chest 2004; 125: 1877—84.

31.

Fitzmaurice TF , Brown C. , Rifai N. , Wu AH et al. False increase of cardiac troponin I with heterophilic antibodies. Clin Chem 1998; 44: 2212—4.

32.

Galambos C. , Brink DS , Ritter D. , Chung HD et al. False-positive plasma troponin I with the AxSYM analyzer. Clin Chem 2000; 46: 1014—5.

33.

Eriksson S. , Pettersson K. Beliefs in cardiac troponin testing. Clin Chem 2005; 51: 755—6.

34.

Eriksson S. , Halenius H. , Pulkki K. , Hellman J. et al. Negative interference in cardiac troponin I immunoassays by circulating troponin autoantibodies. Clin Chem 2005; 51: 839—47.

35.

Panteghini M.

Selection of antibodies and epitopes for cardiac troponin immunoassays: should we revise our evidence-based beliefs?

Clin Chem 2005; 51: 803—4.