Amanita daple intoxication, manifesting as stroke

Accurately identifying the difference between heavy ethanol intoxication and concussion or other damage to the brain caused by blunt objects is a common challenge for paramedics in the field. Many brain injuries are caused by consumption of alcohol, and there are almost no differences between acute alcohol abuse (nauzea, vomitus, cephalea, amnesia) and commotio celebri. Intoxication caused by specific types of mushrooms that have effects on the CNS can appear identical to the influence of alcohol. What is not well known is that intoxication caused by mushrooms can also manifest itself in similar ways as morfologic changes in the brain. This paper describes two cases of poisoning which imitated pathological morphologic brain modification which was treated as a master brain stroke. It was only later discovered that the cause was an intoxication by Amanita pantherina. Amanita dapple (Amanita pantherina) contains the toxic substance muskarin, but this relatively small amount does not play any great vital importance. The main important toxic substances are isoxazols volatile iboten acid (α-amino-3-hydroxy-5-octoisoxazol acid), which can be boiled into muscimol. It is 5-10 times more toxic than iboten acid itself. Iboten acid is structurally similar to glutamic acid, which serves as a carrier signal in the nervous system. In the second phase of its operation, however, the transmission of signals is blocked (is stopped). The structure of muscimol is similar to gamaaminobutyric acid. The first symptoms of poisoning appear typically from 30 minutes to 2 hours after consumption of the mushroom, are fully developed after 2-3 hours, and usually last 4-8 hours. Isoxazols cause toxic psychosis. This is very similar to the effects of alcohol, and in most cases ends with sleepiness. Deep coma is a fairly rare, but can come about as a result of other complications. Objective diagnosis is based on laboratory tests using a toxin separation method. To detect iboten acid and muscimol in biological material one can use the method of gas chromatography with mass spectroscopy (1,2)

* Correspondence address:

Jan Krajsa, M.D., Ph.D. Institute of Forensic Medicine

Tvrdého 2a, CZ-662 99, Brno, Czech Republic. e-mail: jan.krajsa@fnusa.cz

tel: +420 543 185 837

Received: November 20, 2024

Accepted: January 5, 2025

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Case 1

Woman, 72-years old, brain stroke 2 years ago with dominate clinical symptoms ataxia, vomiting and visual hallucination. After treatment all symtoms were rearranged “ad integrum“. Now, after collaps was transported to the hospital. When Medical rescue service arrived at the place of collaps, she was conscious, with good contact, stable vital functions, without fever and normoglycemic. During transport to the hospital quantitative consciousness got worse and after admission to the Emergency department, the clinical status deteriorated to a state where the patient was able to communicate only with a few incoherent words. Glasgow Coma Scale – GCS 12, disquiet and myoclonia is developing quickly. The preliminary diagnosis was a brain stroke, that’s why CT scan of the brain, including angiography of intra and extracranial blood vessels, was indicated. CT scan didn’t confirm a development of new pathological changes to compare with a CT scan of the brain from 2015. Next worsening of consciousness to GCS 5 led to endotracheal intubation and artificial ventilation. Nasogastric tube was placed to the stomach. With regard to case history and time from collaps, which was 110 minutes, neurologist indicates systemic intravenous administration of Actilyse (to dissolve possible trombus). Later patient’s family completes a case history and marginaly informs doctor about consumption of mushrooms from their house garden. The information is so serious, that in this time doctor takes a sample of food from nasogastric tube to a toxicological investigation. After consultation with toxicological centre, doctor declares for suspicion from poisoning of Amanita pantherina. Patient in this time was located on the Department of anaesthesiology, resuscitation and intensive care medicine. After 36 hours the patient is fully conscious and fulfilled criterions for extubation. During a followup investigation by a neurologist the patient had stable circulation, was fully oriented and herself confirms the mistake of eating a wrong species of mushrooms.