The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne
WILD-MUSHROOM INTOXICATION AS A CAUSE OF RHABDOMYOLYSIS
JEAN P. POMIES, M.D., PH.D., JEAN M. RAGNAUD, M.D.,
CLAUDE GABINSKI, M.D., STEN DE WITTE, M.D.,
JEAN C. CHAPALAIN, M.D., AND PIERRE GODEAU, M.D.
HE growing popularity of eating wild mush-rooms has led to an increase in the incidence
Tof mushroom poisoning. Most fatalities are due
to amatoxin-containing species, which cause fulminanthepatocytolysis, and to cortinarius species, which leadto acute renal damage. A 1996 report described a pa-tient with hepatic failure, encephalopathy, and myop-
Figure 1.Tricholoma equestre.
athy related to the ingestion of Amanita phalloides.1
The cap of this species measures 6 to 8 cm, and the stem is 7 to
Since 1992, 12 cases of delayed rhabdomyolysis have
occurred in France after meals that included largequantities of the edible wild mushroom Tricholomaequestre.2 The circumstances of these 12 cases clearlyimplicate T. equestre as the cause. The mushroom was
positively identified, and no other cause, such as bac-terial, viral, fungal, or immune disease or exposure to
Seven women (age range, 22 to 60 years) and five men (age
range, 24 to 61 years) were hospitalized between 1992 and 2000
a toxin, was found. Three of the 12 patients died.
with severe rhabdomyolysis approximately one week after eating wild
The implicated mushrooms were harvested from be-
mushrooms. All 12 patients had eaten at least three consecutive
neath pine trees on the sandy coast of southwestern
meals that included T. equestre, and none had a history of trauma,
France, between late fall and midwinter. T. equestre is
other known underlying cause, or medication use that could explain
widely disseminated throughout the world and is also
the occurrence of rhabdomyolysis. All patients reported fatigue andmuscle weakness accompanied by myalgia, mainly in the upper part
known as T. flavovirens and colloquially as “bidaou”
of the legs, 24 to 72 hours after their last meal containing mush-
or “canari” in France, “riddarmusseron” in Sweden,
rooms. The weakness worsened over a period of three to four days,
“shimokoshi” in Japan, and “man on horseback” or
leading to stiffness of the legs and the production of dark urine.
“yellow-knight fungus” in the United States (Fig. 1).3,4
These signs were accompanied by facial erythema, mild nausea with-out vomiting, and profuse sweating in eight of the patients. No fe-
We investigated the rhabdomyolysis apparently in-
ver was noted, and five patients had hyperpnea. The findings on
duced in 12 humans by several consecutive meals of
physical examination, which included pulmonary auscultation and
T. equestre by administering equivalent doses of ex-
a neurologic examination, were unremarkable.
Initial screening tests showed evidence of rhabdomyolysis, with
a mean maximal serum creatine kinase activity of 226,067 U perliter in the women and 34,786 U per liter in the men (Fig. 2). No
From the Poison Center (R.B.) and the Department of Infectious Dis-
hepatic injury was evident. g-Glutamyltransferase values were nor-
eases (J.M.R., M.D., D.N.), University Hospital Pellegrin, Bordeaux; the
mal (range, 5 to 24 U per liter), and maximal average levels of as-
Departments of Toxicology (I.B., E.E.C.) and Mycology (G.D.), Faculty of
partate aminotransferase and alanine aminotransferase were 8104
Pharmacy, University Bordeaux 2, Bordeaux; Histotox, La Rochelle (J.P.P.);
and 1392 U per liter, respectively, in the women and 1173 and
the Departments of Intensive Care (C.G.) and Internal Medicine (S.D.),
325 U per liter, respectively, in the men. Despite the intensity of
University Hospital St. André, Bordeaux; the Department of Gastroenter-
the clinical rhabdomyolysis, electrolyte levels, including potassium
ology, Hospital of Montbrisson, Montbrisson (J.C.C.); and the Depart-
values, were normal, and no renal failure occurred. Coagulation
ment of Internal Medicine, University Hospital Pitié–Salpetrière, Paris
tests were normal. Additional studies were negative for parasites or
(P.G.) — all in France. Address reprint requests to Dr. Creppy at the De-partment of Toxicology, University Bordeaux 2, 146 rue Leo-Saignat, 33076
other microorganisms (coxsackievirus, toxoplasma, toxocara, trichi-
Bordeaux, France, or at [email protected]
nella, hepatitis B and C viruses, and human immunodeficiency vi-
Jacques Beylot, M.D., Department of Internal Medicine, University
rus), as well as for systemic diseases (as assessed by complement-
Hospital St. André, Bordeaux, France, was also an author.
fixation tests and tests for circulating nuclear antibodies). 798 · N Engl J Med, Vol. 345, No. 11 · September 13, 2001 · www.nejm.org B R I E F R E P O R T Figure 2. Serum Creatine Kinase Levels in the 12 Patients during Hospitalization.
Given the absence of evidence of deliberate intoxication, the
cium, 5.6 to 8.3 mg per deciliter [1.4 to 2.07 mmol per liter]) and
analyses focused on the hypothesis that mushroom intoxication
a normal total protein level. The three patients had creatine kinase
caused the rhabdomyolysis. Electromyography was performed in
values of 632,000, 138,900, and 295,700 U per liter, with isoen-
four patients and revealed muscle injury without peripheral-nerve
zyme MB making up 0.5 to 0.7 percent of the total. Despite inten-
involvement. The greatest changes were in the proximal thigh mus-
sive physiological care, including, in one case, continuous veno-
cles. Complex and generally myotonic activity was present, without
venous hemofiltration, all three patients died. Autopsy revealed
fibrillation, even at rest. On stimulation, muscle contractile activity
myocardial lesions identical to the muscular lesions in one patient,
was particularly prominent. All the motor and sensory potentials
renal lesions in one patient, and no hepatic lesions.
were normal. Electromyography of the diaphragm was performedin one patient and showed similar findings, suggesting the presence
of rhabdomyolysis of the diaphragm without phrenic involvement.
Additional studies were necessary to demonstrate that T. equestre
In six patients, samples of quadriceps muscle were obtained for
was the cause of the rhabdomyolysis in the 12 patients. Since it
histologic analysis. On light microscopy, the fascicular architecture
would have been unethical to administer T. equestre extracts to hu-
of the muscles was well preserved, the myofibrils had a “nibbled”
man subjects, we chose an established model of myonecrosis in
appearance, and in some cases the fibers were separated from each
mice.5-7 Extracts of T. equestre were prepared and then administered
other by edema in the absence of vacuoles or the accumulation of
by gavage (gastric intubation) in a dose equivalent to that ingested
glycogen or lipid — signs of a direct muscle injury. In the three
by the patients. The animals were then assessed for evidence of rhab-
patients who died, samples of the psoas and other muscles (from the
domyolysis. Two protocols were employed: a dose-response study
arms, myocardium, and diaphragm) also showed evidence of acute
with T. equestre alone and one in which mice received extracts of
either T. equestre or the nontoxic mushroom Pleurotus ostreatus.
Over the next 15 days, in all but three of the patients, the serum
enzyme values gradually normalized and most symptoms disap-
peared, although the muscular weakness persisted for several weeks. In the three patients who died, the increasing dyspnea at rest was
Specimens of T. equestre collected in southwestern France were
the first symptom of further deterioration and was followed by in-
identified by qualified mycologists.2-4 The taxonomic denomination
creasing rales at both lung bases, leading to admission to the inten-
of T. equestre is synonymous with that of T. flavovirens (Fries) Lun-
sive care unit. All three patients had hyperthermia (a temperature of
dell.3 Specimens of P. ostreatus obtained commercially were con-
up to 42°C); signs of acute myocarditis, including cardiac arrhyth-
firmed as such by qualified mycologists. Then 500 g of T. equestre
mia, cardiovascular collapse, and widening of the QRS complex
was frozen, ground, and mixed with 200 ml of ultrapure water. The
without severe acidosis (pH, 7.37, with a serum bicarbonate level
resulting mixture was lyophilized to yield 60 g of powder. Extracts
of 16 to 20 mmol per liter); and evidence of renal dysfunction, in-
were then obtained. A concentrate of 1.35 g of cold aqueous extract
cluding elevated levels of blood urea nitrogen (30 to 52 mg per
was obtained from 5 g of powdered T. equestre, and a concentrate of
deciliter [10.7 to 18.7 mmol per liter]) and serum creatinine (1.4 to
1.65 g of boiled aqueous extract was obtained from 5 g of powdered
2.5 mg per deciliter [126 to 224 µmol per liter]), with hyperkale-
T. equestre. A concentrate of 1.3 g was obtained from 10 g of pow-
mia (potassium, 6.0 to 7.2 mmol per liter) and hypocalcemia (cal-
dered T. equestre after chloroform–methanol (vol/vol) extraction,
N Engl J Med, Vol. 345, No. 11 · September 13, 2001 · www.nejm.org · 799
The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne
and a concentrate of 50 mg of chloroform–methanol lipid-free
tine kinase level (up to a mean of 380±25 U per liter).
extract was then obtained from 200 mg of the chloroform–meth-
At a total dose of 4 g and 6 g per kilogram, the in-
anol extract. We obtained a cold aqueous extract, a boiled aqueous
crease was significant when compared with the levels
extract, and a chloroform–methanol (vol/vol) extract of P. ostrea-tus in a similar manner.
in controls (mean, 145±40 U per liter; P=0.01 forboth comparisons), although there was variability be-
Adult male Swiss mice (mean [±SE] weight, 30±5 g) (Depre),
Mice treated with boiled T. equestre extracts, chloro-
were randomly divided into several groups. In each group, T. eques-
form–methanol lipid-free extract, and p-phenylenedi-
tre powder, T. equestre or P. ostreatus extract, or solvent alone was
amine had a significant increase in serum creatine ki-
administered to each animal in a standardized fashion.
Twenty-four or 48 hours after the final dose, the mice were anes-
nase activity (912±425, 883±500, and 1828±450 U
thetized with ether, and blood was collected from the retroorbital
per liter, respectively; P=0.01 for each comparison
sinus and centrifuged at 2000¬g for 15 minutes at 5°C to recover
with base-line levels) (Fig. 3). No such increase was
serum. The serum was frozen and stored at ¡20°C until analysis.
observed in mice treated with extracts of P. ostreatus.
Creatinine levels were determined by the Jaffé reaction (Merck kit
Serum levels of aspartate aminotransferase, alanine
3385). Aspartate aminotransferase and alanine aminotransferase ac-tivities were determined with the use of enzyme kits (Merckotest,
aminotransferase, and creatinine were not increased
Merck).8 Creatine kinase was measured with a commercial kit (En-
significantly in mice treated with extracts of T. eques-
zyline kit, Biomérieux). The mice were then killed, and samples of
tre or P. ostreatus (data not shown).
striated muscle, liver, and tissues were obtained.
All the treated mice had tachypnea, reduced motor
In the first protocol, three groups of three mice each were given
1 ml of powdered T. equestre suspension in water once a day by ga-
activity, and occasional diarrhea. Light microscopy of
vage for three days. The highest total dose was 6 g per kilogram of
muscle fibers showed evident disorganization.
the body weight of the mouse (0.18 g per mouse), corresponding
Two mice — one that received boiled aqueous ex-
to a hypothetical toxic dose in a 60-kg person of 3 kg of fresh mush-
tract and one that received chloroform–methanol lip-
rooms eaten over the course of six meals in a period of three days
id-free extract — died 72 hours after the last dose.
(72 hours). Creatine kinase activity was determined in serum col-lected 48 hours after the final dose.
These animals were not autopsied because by the time
In the second protocol, five groups of five mice each were given
the deaths were discovered autolysis had set in.
0.3 ml of tricholoma or pleurotus extract dissolved in water or di-methylsulfoxide once a day by gavage for three days. This dose cor-
responded to a total dose of 0.18 g of powdered T. equestre suspen-sion. The positive control consisted of p-phenylenediamine (dose,
Rhabdomyolysis is a rare but potentially fatal condi-
70 mg per kilogram per day for three days), which is a potent my-
tion. Muscle compression is the most common cause,
otoxic compound in mice.6 Levels of aspartate aminotransferase,
but neither muscle ischemia nor unconsciousness was
alanine aminotransferase, creatine kinase, and creatinine were de-
noted before the onset of symptoms in our patients.
termined in serum collected 96 hours after the final dose.
Deliberate intoxication with substances including co-
caine, amphetamines, alcohol, theophylline, phenothi-azines, p-phenylenediamine,9,10 antihistamines, and an-
Data are presented as means ±SE. The results were analyzed with
use of the Wilcoxon rank-sum test, a nonparametric statistical test
tihyperlipidemic drugs was ruled out.11,12 Medications
chosen because of the small number of animals.
that could cause dermatomyositis or polymyositis (pen-icillamine, phenytoin, levodopa, and quinidine) were
ruled out by screening tests. Finally, immunologic
Mice treated with T. equestre powder (Table 1) had
screening as well as muscle biopsies did not indicate
a concentration-dependent increase in the serum crea-
the presence of other systemic disorders or McArdle’sdisease.13
Toxic rhabdomyolysis has been described after the
ingestion of small wild birds that had eaten water hem-lock (Conium maculatum), a direct muscle toxin.14,15Our patients had not eaten such birds. Although
TABLE 1. SERUM CREATINE KINASE LEVELS IN
MICE GIVEN A SUSPENSION OF TRICHOLOMA
mushroom poisoning is not known to produce rhab-
EQUESTRE POWDER (BY GASTRIC INTUBATION)
domyolysis, this series of cases clearly associates rhab-
domyolysis with the ingestion of T. equestre.
Since 75 percent of the patients with large increases
TOTAL DOSE CREATINE KINASE
in creatine kinase survived, a genetic muscular suscep-tibility may be unmasked by the direct muscle toxicant
contained in T. equestre when the amount of mush-
rooms ingested exceeds a certain threshold. Therefore,
physicians should be aware of the possibility of severe
rhabdomyolysis after repeated consumption of T. eques-tre. At this time treatment is supportive, and hospi-
*Plus–minus values are means ±SE.
talization is recommended for patients with dyspnea,
†P=0.01 for the comparison with the control.
signs of acute myocarditis, or even mild renal failure. 800 · N Engl J Med, Vol. 345, No. 11 · September 13, 2001 · www.nejm.org B R I E F R E P O R T
Chloroform–methanol Boiled aqueous extract
Figure 3. Mean (+SE) Serum Creatine Kinase Levels in Mice Treated by Gastric Intubation with Extracts of Tricholoma equestre and Pleurotus ostreatus Every Day for Three Days.
The total dose of T. equestre powder was 6 g per kilogram of body weight.
Our experiments in animals confirmed the involve-
2. Bon M. Les tricholomes de France et d’Europe occidentale. Paris:
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Lechevalier, 1984. 3. Miller OK Jr. Mushrooms of North America. New York: E.P. Dutton,
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Several metabolites have been isolated from vari-
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SEVENTH FRAMEWORK PROGRAMME ICT Call 2 FP7-ICT-2007-2 Grant agreement for: Small or medium-scale focused research project (STREP1) proposal Annex I - “Description of Work” Project acronym: GINSENG Project full title: Performance Control in Wireless Sensor Networks Grant agreement no.: 224282 Date of preparation of Annex I (latest version): 5.2.2008 Date of
Effects of childhood body size on breast cancer tumour characteristics Jingmei Li1,2, Keith Humphreys1, Louise Eriksson1, Kamila Czene1, Jianjun Liu2 and Per 1Karolinska Institutet, Department of Medical Epidemiology and Biostatistics, Box 281, 171 2Human Genetics, Genome Institute of Singapore, 60 Biopolis Street, Singapore, 138672, Corresponding author: Jingmei Li, [email protected] A