Name That Poisonous Beast! (part 4)

It’s the final part of “Name that Poisonous Beast!”.  Today, we’re going to take a walk in the garden.

Name this poisonous beast!

A)

And it’s seedy neighbor:

B)

• A) Death cap mushroom (Amanita phalloides): amatoxin and phallotoxin
  • Phallotoxin: n/v/d, abd pain 6-12h after ingestion, supportive care, improve within hours
  • Amatoxin
    • Heat-stable, water insoluble, not destroyed by drying
    • Lethal dose: 0.1 mg/kg
    • Interferes w/DNA and RNA transcription, affects areas with high protein synthesis
      • Liver, kidneys, brain, pancreas, testes
    • Clinical course: 3 stages
      • Stage 1 (onset 6-12h): Abd cramping, vomiting, profuse watery diarrhea (hypotension/tachy)
      • Stage 2 (onset 24-48h): clinical improvement, but ongoing liver/renal damage
        • Inc AST/ALT/bili/LDH/ALP, inc PT/INR, inc Cr, jaundice
        • Can induce pancreatitis, hypoglycemia
      • Stage 3 (2-6 days): Severe coagulopathy, renal failure, encephalopathy (2/2 hepatic failure; confusion/agitation, seizures, coma), fulminant hepatic failure
    • Treatment: MDAC, IVF, electrolyte repletion, HD in renal failure, liver transplant
      • NAC: loading dose 150mg/kg IV; 4h infusion 12.5mg/kg/h, 16h infusion 6.25mg/kg/h
      • Consider high dose penicillin G, vitamin C, cimetidine
• B)  Jimsonweed (Datura stramonium): belladonna alkaloids (hyoscyamine, hyoscine, atropine, and scopolamine); anticholinergic
  • Others with belladonna alkaloids: Datura (angel’s trumpet, thorn apple), Hyoscyamus niger (henbane), Atropa belladonna (deadly nightshade), Mandragora officinarum (mandrake)
  • Symptoms occur 30-60 min post-ingestion and continue 24-48h 2/2 delayed GI emptying
    • Hot as a hare: hyperthermia
    • Blind as a bat: photophobia, blurred vision, mydriasis/cycloplegia
    • Dry as a bone: dry MM/skin, dysphagia/dysarthria, anhidrosis
    • Red as a beet: flushed skin
    • Mad as a hatter: delirium, confusion, agitation, hallucinations, seizures, coma
    • Full as a flask: urinary retention, delayed gastric emptying
    • Additional: tachycardia/tachydysrhythmias, tachypnea
  • Treatment: activated charcoal, supportive care/benzos
    • Physostigmine with peripheral AND moderate central toxicity; have atropine nearby
      • Dose: 0.5-2mg slow IVP, if no response repeat q20min
        • If initial dose effective,  may give additional 1-4mg q30-60min PRN
      • Contraindicated in TCA, cocaine, quinidine, procainamide users