Amanita phalloides heads north

Amanita phalloides is a highly toxic cyclopeptide mushroom. It is hypothesized to be an exotic introduced from Europe. On the North American west coast it was collected from various counties surrounding San Franscisco in 1977. The fungus is now abundant in California in both urban landscapes and undisturbed forests. In contrast, in the Pacific Northwest (PNW) collections are few and sporadic. Collections have been made in Ashland and Portland, OR and DNA analyses have confirmed collections from Seattle, WA in 1999. In Canada, the first collection of A. phalloides occurred in Mission, BC in 1997 and subsequently in Victoria and Chilliwack, BC. Collections from Victoria, BC in 2002 were confirmed with DNA analyses. We report the first case of poisoning in BC, and possibly Canada. In August 2003, a 46-year-old male presented to ER with nausea, vomiting, abdominal pain, and diarrhea 45 H following a meal of 2 cooked mushrooms collected from beneath an English oak tree (Quercus robur) in his yard in Victoria, BC. He thought they were puffballs. Six H after exposure he experienced fatigue and mild nausea. Symptoms progressed over 12-24 H and included vomiting, profuse diarrhea and abdominal pain. Admission bloodwork showed AST 964, ALT 1703, alk phos 91, GGT 20, total bili 18 ( mu mol/L), INR 1.1, PTT 29. Electrolytes, protein, albumin, BUN and SCr were normal. Routine urinalysis was positive for WBCs, hyaline casts, epithelial cells, calcium oxalate crystals, mucus and protein 0.3 g/L. Toxicity from A. phalloides ingestion was suspected. Treatment included MDAC, IV N-acetylcysteine and oral milk thistle supplements. The patient was hospitalized for 4 days and AST and ALT decreased to 131 and 1470, respectively. INR peaked on hospital day 3 at 1.3 and upon discharge was 1.1. The mushroom was identified as A. phalloides. The recent discovery of A. phalloides in the PNW is a public health concern. Mushroom collectors may mistake it for an edible and pediatric exposures are possible. A. phalloides ingestion should be considered in symptomatic cases of mushroom exposures in the PNW region, including BC.