A ten-year retrospective California Poison Control System experience with possible amatoxin mushroom calls

Figures & data

Table 1. Patient characteristics stratified by those that develop the composite outcome of organ failure requiring transplant, hemodialysis, and/or death compared to patients who did not develop the composite endpoint.

Variable	No failure/death n = 56 (91.8%)	All failure/death n = 5 (8.2%)	Total sample n = 61 (100%)	P value^a
Age (in years)	34.0 [23.2]	33.1 [20.9]	33.9 [22.9]	0.934
Sex				0.170
Male	40 (71.4)	2 (40.0)	42 (68.9)
Female	16 (28.6)	3 (60.0)	19 (31.1)
Exposure – cooked vs. raw				0.643
Cooked	17 (30.4)	2 (40.0)	19 (31.1)
Raw	39 (69.6)	3 (60.0)	42 (68.9)
Exposure – group vs. single				0.671
Group	27 (48.2)	3 (60.0)	30 (49.2)
Single	29 (51.8)	2 (40.0)	31 (50.8)
Co-ingestion with alcohol				0.642
Yes	5 (8.9)	0 (0.0)	5 (8.2)
No	51 (91.1)	5 (100)	56 (91.8)
Exposure – other potential liver toxins				0.605
Yes	9 (16.1)	1 (20.0)	10 (16.4)
No	47 (83.9)	4 (80.0)	51 (83.6)

Data are presented as number (%) or mean [standard deviation].

^a Wilcoxon rank sum test for continuous variables, Fisher’s Exact test for categorical variables.

Figure 1. Cases of amatoxin‐containing mushroom case as a function of year and quarter of the year. A total of 46 out of 61 occurred during quarters 4 and 1. Only nine out of 61 were reported during second quarters and six out of 61 in third quarters. A large outbreak was noted in the fourth quarter of 2016.

Table 2. Symptom and laboratory characteristics: Patients who ingested mushrooms and developed the composite outcome of organ failure requiring liver transplant, hemodialysis, and/or death compared to patients who did not reach the composite endpoint.

Variable	No failure/death n = 56 (91.8%)	All failure/death n = 5 (8.2%)	Total sample n = 61 (100%)	P value^a
Initial symptoms - nausea				0.567
Yes	37 (66.1)	3 (60.0)	40 (65.6)
No	19 (33.9)	2 (40.0)	21 (34.4)
Initial symptoms - vomiting				0.660
Yes	34 (60.7)	3 (60.0)	37 (60.7)
No	22 (39.3)	2 (40.0)	24 (39.3)
Initial symptoms – diarrhea				0.642
Yes	33 (58.9)	2 (40.0)	35 (57.4)
No	23 (41.1)	3 (60.0)	26 (42.6)
Initial symptoms – abdominal or flank pain				0.516
Yes	28 (50.0)	3 (60.0)	31 (50.8)
No	28 (50.0)	2 (40.0)	30 (49.2)
Multiple organ signs/symptoms (e.g., respiratory failure, disseminated intravascular coagulation, liver failure, acute tubular necrosis, etc.)				0.170
Yes	16 (28.6)	3 (60.0)	19 (31.1)
No	40 (71.4)	2 (40.0)	42 (68.9)
Multiple organ symptoms Noted				0.074
Yes	11 (19.6)	3 (60.0)	14 (23.0)
No	45 (80.4)	2 (40.0)	47 (77.0)
Initial abnormal liver function tests				0.024*
Yes	25 (44.6)	5 (100.0)	30 (49.2)
No	31 (55.4)	0 (0.0)	31 (50.8)
Initial abnormal international normalized ratio				0.006*
Yes	9 (16.1)	4 (80.0)	13 (21.3)
No	47 (83.9)	1 (20.0)	48 (78.7)
Initial lactate concentration elevated				0.642
Yes	5 (8.9)	0 (0.0)	5 (8.2)
No	51 (91.1)	5 (100.0)	56 (91.8)
Diagnostics used to confirm diagnosis (e.g., mushroom identification, assay, polymerase chain reaction, unknown)				0.322
Yes	12 (21.4)	2 (40.0)	14 (23.0)
No	44 (78.6)	3 (60.0)	47 (77.0)

Data are presented as number (%); * = statistically significant P < 0.05.

^a Wilcoxon rank sum test for continuous variables, Fisher’s Exact test for categorical variables.

Table 3. Treatment characteristics: Patients who ingested mushrooms and developed organ failure, requiring liver transplant, died and/or required hemodialysis compared to patients who did not reach the composite endpoint.

Variable	No failure/death n = 56 (91.8%)	All failure/death n = 5 (8.2%)	Total sample n = 61 (100%)	P value^a
Intravenous fluid				0.060
Yes	29 (51.8)	5 (100.0)	34 (55.7)
No	27 (48.2)	0 (0.0)	27 (44.3)
Acetylcysteine				0.003*
Yes	15 (26.8)	5 (100.0)	20 (32.8)
No	41 (73.2)	0 (0.0)	41 (67.2)
Activated charcoal				0.252
Yes	10 (17.9)	2 (40.0)	12 (19.7)
No	46 (82.1)	3 (60.0)	49 (80.3)
Multiple-dose activated charcoal				0.468
Yes	6 (10.7)	1 (20.0)	7 (11.5)
No	50 (89.3)	4 (80.0)	54 (88.5)
Octreotide				0.185
Yes	8 (14.3)	2 (40.0)	10 (16.4)
No	48 (85.7)	3 (60.0)	51 (83.6)
Benzylpenicillin				0.563
Yes	8 (14.3)	1 (20.0)	9 (14.8)
No	48 (85.7)	4 (80.0)	52 (85.2)
Silibinin				0.060
Yes	10 (17.9)	3 (60.0)	13 (21.3)
No	46 (82.1)	2 (40.0)	48 (78.7)

Data are presented as number (%); * = statistically significant P < 0.05.

^a Wilcoxon rank sum test for continuous variables, Fisher’s Exact test for categorical variables.

Table 4. Unadjusted odds ratios: patients who ingested mushrooms and developed organ failure requiring liver transplant, hemodialysis and/or died compared to patients who did not develop the composite endpoint.

Variable	P-value^a	Unadjusted odds ratio (95% confidence interval)
Patient Characteristics
Age (in years)	0.932	0.99 (0.96 − 1.04)
Sex (female)	0.168	3.75 (0.57 − 24.59)
Exposure (cooked)	0.657	1.53 (0.23 − 10.0)
Exposure (group)	0.616	1.61 (0.25 − 10.39)
Co-ingestion with alcohol	n/a	1 (n/a)
Exposure with other potential liver toxins	0.821	1.31 (0.13 − 13.08)
Symptoms and laboratory values
Initial symptoms - nausea	0.785	0.77 (0.12 − 5.01)
Initial symptoms - vomiting	0.975	0.97 (0.15 − 6.28)
Initial symptoms – diarrhea	0.421	0.46 (0.72 − 3.00)
Initial symptoms – abdominal or flank pain	0.670	1.50 (0.23 − 9.68)
Multiple organ signs/symptoms (e.g., respiratory failure, disseminated intravascular coagulation, liver failure, acute tubular necrosis, etc.)	0.168	3.75 (0.57 − 24.59)
Multiple organ symptoms noted	0.062	6.13 (0.91 − 41.31)
Initial abnormal liver function tests	not applicable	1 (not applicable)
Initial abnormal international normalized ratio	0.010	20.89 (2.09 − 209.27)
Initial lactate concentration elevated	Not applicable	1 (not applicable)
Diagnostics used to confirm diagnosis (e.g., mushroom identification, assay, polymerase chain reaction, unknown)	0.356	2.44 (0.37 − 16.34)
Treatment
Intravenous fluid	not applicable	1 (not applicable)
Acetylcysteine	not applicable	1 (not applicable)
Activated charcoal	0.252	3.07 (0.45 − 20.82)
Multiple-dose activated charcoal	0.540	2.08 (0.20 − 21.83)
Octreotide	0.161	4.00 (0.58 − 27.82)
Benzylpenicillin	0.731	1.50 (0.15 − 15.20)
Silibinin	0.048	6.9 (1.01 − 46.85)

^a Variables with P < 0.20 considered for multivariable logistic regression.

Figure 2. Area under the receiver operating characteristic (ROC) curve. The receiver operating characteristic curve for fitted logistic regression predicting organ failure or death is shown. This model achieved an observed area under the receiver operating curve (AUC) of 0.8964.

Table 5. Adjusted odds ratios of variables used in best fit model. Patients who ingested mushrooms and developed organ failure or died compared to patients who did not develop organ failure or die.

Variable	Adjusted odds ratio (95% confidence interval)
Sex (female)	4.40 (0.47 − 41.02)
Multiple organ signs/symptoms (e.g., respiratory failure, disseminated intravascular coagulation, liver failure, acute tubular necrosis, etc.)	0.44 (0.02 − 9.02)
Multiple organ symptoms noted	2.91 (0.15 − 56.38)
Initial abnormal international normalized ratio	19.13 (1.26 − 291.25)