Mushroom (Amatoxin) Poisoning Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Time of onset of GI symptoms
   Time of onset of GI symptoms after eating wild mushrooms? (Amatoxin-containing mushrooms (Amanita etc., a major lethal cause of wild-mushroom poisoning in China). Alpha-amanitin inhibits RNA polymerase II → hepatocyte apoptosis. Phases: 1) latency 6–12 h (asymptomatic, the delayed onset is the key, distinguishing it from early-onset benign gastrointestinal mushroom toxicity), 2) GI phase (6–24 h, cholera-like severe vomiting/diarrhea, fluid loss), 3) pseudo-recovery (24–72 h, symptoms ease but transaminases rise), 4) hepatic-renal failure (3–5+ days, acute liver failure, coagulopathy, multi-organ failure).)
   • GI symptoms starting >6 h after ingestion (suspect amatoxin) → >6 h onset → amatoxin management
   • GI symptoms starting <6 h after ingestion (usually benign) → <6 h onset · usually benign
2. [End] <6 h onset · usually benign
   GI symptoms within <6 h of ingestion: usually early-onset benign gastrointestinal mushroom toxicity (but mixed ingestion can mask it) — fluids, supportive care, observe; if a second wave of symptoms appears later or transaminases rise, treat as amatoxin. Contact a poison control center.
3. [End] >6 h onset → amatoxin management
   GI symptoms only after >6 h (suspect amatoxin): contact poison control early. Aggressive fluids to correct electrolytes, maintain urine output 100–200 mL/h; multidose activated charcoal (interrupt enterohepatic circulation); specific therapy (limited evidence): IV silibinin (silybin, not an oral supplement), N-acetylcysteine, high-dose penicillin G; enhanced clearance (MARS/albumin dialysis, plasma exchange). Correct coagulopathy, monitor LFTs/INR; progression to acute liver failure → transfer early to a liver transplant center (assess by King's College criteria, transplant confers survival benefit).

Source guidelines & references

• Amatoxin mushroom poisoning (UpToDate); liver transplant (HKMJ)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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