With the increased interest and awareness of all things "organic" there has been an increase over the last few decades in foraging for wild mushrooms¹ as ingredients for gourmet meals. This practice has however not surprisingly come with a high price, an increase in mushroom poisoning (mycetism) cases.

In 2006, the American Association of Poison Control Centers (AAPCC) reported a total of 9,183 poisonings involving mushrooms; fortunately only resulting in two deaths.² Identification of the mycotoxin is challenging due to its structural diversity and the initial unspecific symptoms of poisoning that the patient presents with. However, rapid identification is crucial for treatment and survival.

Structural Diversity and Clinical Symptoms
Mycotoxins can be classified according to their structure and respective clinical symptoms into eight categories, of which the cyclopeptides are considered the most notorious toxins.³ Amanita phalloides, commonly known as the death cap mushroom, accounts for over 90% of all mushroom fatalities. The principle toxin is the thermo-stable, bicyclic octapeptide a-amanitine (Figure 1, A). The ingestion of one death cap mushroom can cause hepatic failure and death in an adult. The four stages of cyclopeptide mycetism are characterized by an initial latent stage lasting between 6-24 hours with no symptoms, followed by the second stage, in which nausea and vomiting combined with intense abdominal cramps as well as diarrhea and hypotension are predominant. Since the symptoms are rather unspecific, a misdiagnosis of gastroenteritis might result in a fatal ending. Changes in liver enzymes and renal impairment are the parameters that determine cyclopeptide poisoning in the third stage, especially since the gastrointestinal symptoms usually subside and the patient feels better. The fourth stage is characterized by hepatic, renal, and multi-organ failure, resulting in death 6-16 days post-ingestion. The other categories of mycotoxins (Figure 1, B-G) are rarely fatal, but most of them cause either predominantly gastrointestinal symptoms (monomethylhydrazine, orellanine, disulfiram-like reaction, and GI-specific irritants), hallucinations (muscimol, ibotenic acid, and hallucinogenic indoles), or cholinergic symptoms (muscarine).Most of these symptoms present much earlier (usually within three hours) compared to cyclopeptide toxins and last shorter (up to three days post-ingestion). Another category of small molecule mycotoxins are biocontaminants such as food-borne toxins from Aspergillus or Claviceps fungi.⁴ Critical for treatment and outcome is the close monitoring of the patient and elucidation of ingested mycotoxin. The primary treatment for all mushroom poisonings is supportive care and gastric decontamination with activated charcoal.