To the Editor,
Around 42 million kilograms of wild mushrooms are eaten in Spain each year. Mushroom poisoning is an increasingly common medical emergency. Annually, 400 people are hospitalised with this diagnosis. Depending on the latent period (around six hours), clinical symptoms can be classified as short- or long-incubation syndrome. The latter are the most severe, and include gyromitra, orellanus and phalloides syndrome.1
The orellanus syndrome is produced by several species from the genus Cortinarius that contains toxins, orellanines, with a marked renal tropism. After a long period without any symptoms (3-17 days), the patient presents with polyuria and severe renal failure, which is often irreversible.2-4 We present a case of mushroom poisoning with signs of orrellanus syndrome.
We present the case of an 83-year-old male patient with history of arterial hypertension (AHT), dyslipidaemia and a haemorrhagic stroke in 2006. He underwent surgery for rectal neoplasia in 2000, and received chemotherapy and adjuvant radiotherapy. The patient came to the emergency department due to vomiting and liquid bowel movements, with no other symptoms. The only event that the patient referred was having eaten wild mushrooms that he had picked 4 days before. The biochemistry found: glucose: 130 mg/dl; urea: 240 mg/dl; creatinine: 4.62 mg/dl; glutamate-pyruvate transaminase (GPT): 3903IU/l; glutamate-oxaloacetate transaminase (GOT): 868IU/l; bilirubin: 0.80mg/dl; amylase: 86IU/l, CK: 86IU/l; sodium: 134mEq/l; potassium: 5.1mEq/l; ionic calcium: 1.12mmol/l; and lactate: 1.3mmol/l. The blood gases showed a pH of 7392 and HCO3 of 15.1mEq/l. The haemogram showed thrombocytopenia with 69x103/µl of platelets; the rest of the haemogram and coagulation were normal. The abdominal ultrasound did not show any changes. Given that it was suspected that the patient had mushroom poisoning, he was admitted to the intensive care unit (ICU). Intensive fluid therapy was started, with sibilin and penicillin G. The patient was haemodynamically stable throughout his hospital stay, with good diuresis forced with mannitol during the first few hours, and then spontaneously. After 48 hours in the ICU he was transferred to the medical ward, where his hepatic function continued to improve, but he had polyuria and gradual deterioration of kidney function (reaching creatinine levels of 10.6mg/dl 13 days after admission). He was therefore indicated renal replacement therapy. Kidney biopsy was not performed given that he was considered a high-risk patient. Complementary examinations were also performed, with the following results: negative antinuclear antibodies (ANA), anti-neutrophil cytoplasmic antibodies (ANCA), anti-DNA and anti-glomerular basement membrane antibodies. The serology tests for hepatitis B virus (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) were negative. The C3 and C4 proteinogram and Ig assessment were within normal limits. Basic urine test: normal. Microalbuminuria: 36µg/min. Negative Bence-Jones proteinuria.
Although the orellanus toxin is not common in our area,5 the clinical symptoms described for delayed polyuric renal failure after wild mushroom consumption, with interstitial failure data, match with orellanus syndrome.2,4 The patient was indicated continuous treatment with regular haemodialysis every 48 hours. No improvement in renal function was observed in the long term.
In summary, when a patient presents with clinical symptoms of liver and kidney involvement, mushroom poisoning must be considered, including orellanus syndrome, especially in regional areas with a tradition of wild mushroom picking.3
