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(Redirected from Death Cap)
'''Amanita phalloides''', commonly known as the 'death cap', is a deadly poisonous basidiomycete fungus, one of many in the genus ''Amanita''. Widely distributed across Europe, ''A. phalloides'' associates with various deciduous and coniferous trees. An adaptable organism, its range is expanding in other countries after it was accidentally introduced alongside oak, chestnut, and pine. The large fruiting bodies (''i.e.'' the mushrooms), appearing in summer and autumn, are generally greenish in colour, with a white stipe and gills.
Unfortunately, these toxic mushrooms resemble several edible species commonly consumed by humans, increasing the risk of accidental ingestion. ''A. phalloides'' has an infamous reputation for being one of the most poisonous of all known toadstools. It has been involved in a majority of human deaths from mushroom poisoning, including several important historical figures such as the Roman Emperor Claudius and Holy Roman Emperor Charles VI. It has been the subject of much research and many biologically active agents have been isolated. The principal toxic constituent is α-amanitin, which damages the liver and kidneys, often fatally. No truly effective antidote is known.
The death cap was first described by French botanist Sébastien Vaillant in 1727, who gave a succinct phrase name "''Fungus phalloides, annulatus, sordide virescens, et patulus''," which is still recognizable as the fungus today.[1] Though the scientific name ''phalloides'' means "phallus-shaped", it is unclear whether it is named for its resemblance to a literal phallus or the Stinkhorn mushrooms ''Phallus''.
In 1821, Elias Magnus Fries described it as "''Agaricus phalloides''", but included all white Amanitas within its description.[2] Finally in 1833, Johann Heinrich Friedrich Link settled on the name ''Amanita phalloides'',[3] after Persoon had named it ''Amanita viridis'' thirty years earlier.[4][5] Although Louis Secretan's use of the name ''Amanita phalloides'' predates Link's, it has been rejected for nomenclatural purposes because Secretan's works did not use binomial nomenclature consistently,[6][7] however some taxonomists have disagreed with this opinion.[8][9]
''Amanita phalloides'' is the type species of ''Amanita'' section ''Phalloideae'', a group that contains all of the deadly poisonous ''Amanita'' species thus far identified. Most notable of these are the species known as destroying angels, namely ''Amanita virosa'' and ''A. bisporiga'' as well as the fool's mushroom ''(A. verna)''. The term "Destroying angel" has been applied to ''A. phalloides'' at times, but "death cap" is by far the most common vernacular name used in English. Other common names also listed include stinking amanita and deadly amanita.[10]
A rarely appearing all-white form was initially described ''A. phalloides'' f. ''alba'' by Max Britzelmayr,[11] though its status has been unclear. It is often found growing amid normal coloured death caps. It has been described in 2004 as a distinct variety and includes what was termed ''A. verna'' var. ''tarda''. The true ''Amanita verna'' fruits in spring and turns yellow with KOH solution, whereas ''A. phalloides'' never does.
Appearing after periods of rain from late summer through autumn,[12] the death cap has a large and imposing epigeous (above ground) fruiting body (basidiocarp), usually with a pileus (cap) from 5 to 15 cm (2–6 in) across, initially rounded and hemispherical, but flattening with age.[13] The colour of the cap can be pale-, yellowish- or olive-green, often paler toward the margins, and is often paler after rain. The cap surface is sticky when wet and easily peeled, a troublesome feature as it is allegedly a feature of edible fungi.[14] The remains of the partial veil is seen as a skirtlike, floppy annulus usually about 1 to 1.5 cm below the cap. The crowded white lamellae (gills) are free. The stipe is white with a scattering of grayish-olive scales and is 8 to 15 cm long and 1 to 2 cm-thick with a swollen ragged sac-like white volva (base). As the volva, which may be hidden by leaf litter, is a distinctive and diagnostic feature, it is important to remove some debris to check for one.[15]
The smell has been described as initially faint and honey-sweet but strengthening over time to become overpowering, sickly-sweet and objectionable. Young specimens first emerge from the ground resembling a white egg covered by a universal veil, which then breaks, leaving the volva as a remnant. The spore print is white, a common feature of ''Amanita''. The transparent spores are globular to egg-shaped, measure 8–10 μm long and stain blue with iodine. The gills on the other hand are seen to stain palid lilaceous or pink with concentrated sulfuric acid.[16][17]
The death cap is native to Europe, where it is widespread.[18] It is found from the southern coastal regions of Scandinavia in the north, to Ireland in the west, east to Poland and western Russia,[19] and south through the Balkans into Italy, Spain, and Morocco and Algeria in north Africa.[20] There are records from further east into Asia but these have yet to be confirmed as ''A. phalloides''.[21]
It is ectomycorrhizally associated with a number of tree species. In Europe, these include a large number of hardwood and, less frequently, conifer species. It appears most commonly under oaks, but also under beeches, chestnuts, horse-chestnuts, birches, filberts, hornbeams, pines, and spruces. In other areas, ''A. phalloides'' may also be associated with these trees, or only with some species, but not others. In coastal California, for example, ''A. phalloides'' is associated with coast live oak, but not the various coastal pine species, such as Monterey pine.[22] In countries where it has been introduced it has been restricted to those exotic trees it would associate with in its natural range. However there is evidence of ''A. phalloides'' associating with hemlock, and with genera of the Myrtaceae: ''Eucalyptus'' in Tanzania[23] and Algeria, and ''Leptospermum'' and ''Kunzea'' in New Zealand.[24] This suggests the species may have invasive potential.
By the end of the 19th century, Charles Horton Peck had reported ''A. phalloides'' in North America.[25] However, in 1918 samples from the Eastern United States were identified as being a distinct though similar species, ''A. brunnescens'', by G. F. Atkinson of Cornell University.[26] By the 1970s it had become clear that ''A. phalloides'' actually does occur in the United States, apparently having been introduced from Europe alongside chestnuts, with populations on the West and East Coasts.[27] A more recent historical review concluded that the East Coast populations were introduced, but that the origins of the west coast population remain unclear, due to the scantness of historical records.
''Amanita phalloides'' has been conveyed to new countries across the southern hemisphere with the importation of hardwoods and conifers. Introduced oaks appear to have been the vector to Australia and South America; populations under oaks have been recorded from Melbourne and Canberra,[28][29] as well as Uruguay,[30] It has been recorded under other introduced trees in Argentina[31] and Chile.[32]
Pine plantations are associated with the fungus in Tanzania and South Africa, where it is also found under oaks and poplars.[33]
As the common name suggests, the fungus is highly toxic, and is responsible for the majority of fatal mushroom poisonings worldwide.[34] In 2006, a family of three in Poland was poisoned, resulting in one death and the two survivors requiring liver transplants.[35] It is estimated that 30 grams (half a cap) of this mushroom is enough to kill a human.[36] Some authorities strongly advise against sharing a basket of fungi collected for the table with suspected death caps and to avoid touching them.[37] Furthermore, the toxicity is not reduced by cooking, freezing or drying. Not surprisingly, its biochemistry has been researched intensively for decades.
Recent cases highlight the issue of its similarity to the edible paddy straw mushroom ''Volvariella volvacea'', with southeast-Asian immigrants in Australia and the west coast of the United States falling victim, including an episode in Oregon where four members of a Korean family required liver transplants.[38] Of the seven people poisoned in the Canberra region between 1988 and 1998 three were from Laos.[39] This is a leading cause of mushroom poisoning in the United States.
Novices may also mistake juvenile death caps for edible puffballs[40] or mature specimens as other edible ''Amanita'' species such as ''Amanita lanei'', and for this reason, some authorities recommend avoiding the collection of ''Amanita'' species for the table altogether.[41] The white form of ''A. phalloides'' may be mistaken for edible species of ''Agaricus'', especially the young fruitbodies with unexpanded caps. All mature species of ''Agaricus'' have dark-coloured gills.[42]
In Europe, other similarly green-capped species collected by mushroom hunters include various green-hued brittlegills of the genus ''Russula'', and the formerly popular ''Tricholoma flavovirens''. However, the latter species is now regarded as hazardous after a series of restaurant poisonings in France. Brittlegills, such as ''Russula heterophylla'', ''R. aeruginea'', ''R. virescens'' and others, can be distinguished by their brittle flesh and the lack of both volva and ring.[43] Other similar species include ''A. subjunquillea'' in eastern Asia and ''A. arocheae'', which ranges from Andean Colombia to central Mexico (at least), both of which are also poisonous.
The species is now known to contain two main groups of toxins, both multicyclic (ring-shaped) peptides, spread throughout the mushroom tissue: the amatoxins and the phallotoxins. Another toxin is phallolysin, which has shown some hemolytic (red blood cell-destroying) activity ''in vitro''. An unrelated compound, antamanide has also been isolated.
'Amatoxins' consist of at least eight compounds with a similar structure, that of eight amino-acid rings; they were isolated in 1941 by Heinrich O. Wieland and Rudolf Hallermayer of the University of Munich. Of the amatoxins, α-amanitin is the chief component and along with β-amanitin is likely responsible for the toxic effects.[44][45] Their major toxic mechanism is the inhibition of RNA polymerase II, a vital enzyme in the synthesis of messenger RNA (mRNA), microRNA, and small nuclear RNA (snRNA). Without mRNA essential protein synthesis and hence cell metabolism grind to a halt and the cell dies.[46] The liver is the principal organ affected, as it is the organ which is first encountered after absorption in the gastrointestinal tract, though other organs, especially the kidneys, are susceptible.[47]
The 'phallotoxins' consist of at least seven compounds, all of which have seven similar peptide rings. Phalloidin had been isolated in 1937 by Feodor Lynen, Heinrich Wieland's student and son-in-law, and Ulrich Wieland of the University of Munich. Though phallotoxins are highly toxic to liver cells,[48] they have since been found to have little input into the death cap's toxicity as they are not absorbed through the gut. Furthermore, phalloidin is also found in the edible (and sought after) Blusher (''Amanita rubescens''). Another group of minor active peptides are the virotoxins, which consist of six similar monocyclic heptapeptides. Like the phallotoxins they do not exert any acute toxicity after ingestion in humans.
Death caps have been reported to taste pleasant.[49] This, coupled with the delay in symptoms appearing, during which time internal organs are being severely (sometimes irreparably) damaged — makes it particularly dangerous. Initially, symptoms are gastrointestinal in nature, and include colicky abdominal pain, watery diarrhea and vomiting, which may lead to dehydration, or in severe cases hypotension, tachycardia, hypoglycemia, and acid-base disturbances. These first symptoms resolve two to three days after the ingestion, before a more serious deterioration signifying liver involvement — jaundice, diarrhea, delirium, seizures and coma due to fulminant hepatic failure and hepatic encephalopathy (accumulation of normally liver-removed substance in the blood) may then occur. Poisonous plants and fungi in colour, , Pamela Mildred, North, Blandford Press, 1967, Renal failure, either occurring secondary to severe hepatitis[50] Toxins of ''Amanita phalloides'', , János, Vetter, Toxicon, 1998 or to direct toxic renal damage, and coagulopathy may appear during this stage. Life threatening complications include increased intracranial pressure, intracranial hemorrhage, sepsis, pancreatitis, acute renal failure and cardiac arrest. Death generally occurs six to sixteen days after the poisoning.[51]
Up to the mid-20th century, the mortality rate was around 60–70%, but this has greatly improved with advances in medical care. A review of death cap poisoning throughout Europe from 1971 to 1980, found the overall mortality rate to be 22.4% (51.3% in children under ten, and 16.5% in those older than ten).[52] This has further fallen in more recent studies to around 10–15%.[53]
Consumption of the death cap is a medical emergency requiring hospitalization. There are four main categories of therapy for poisoning, they include preliminary medical care, supportive measures, specific treatments, and liver transplantation.[54]
Preliminary care consists of gastric decontamination with either activated carbon or gastric lavage, however, due to the delay between ingestion and the first symptoms of poisoning, it is commonplace for patients to arrive for treatment many hours after ingestion, potentially reducing the efficacy of these interventions.[55] Supportive measures are directed towards treating the dehydration which results from fluid loss during the gastrointestinal phase of intoxication and correction of metabolic acidosis, hypoglycemia, electrolyte imbalances, and impaired coagulation.
No definitive antidote is available, but some specific treatments have been shown to improve survivability. High dose continuous intravenous penicillin G has been reported to be of benefit, though the exact mechanism is unknown, and trials with cephalosporins show promise.[56][57] There is some evidence that intravenous silibinin, an extract from the blessed milk thistle (''Silybum marianum''), may be beneficial in reducing the effects of death cap poisoning. Silibinin prevents the uptake of amatoxins by hepatocytes, thereby protecting undamaged hepatic tissue; it also stimulates DNA-dependent RNA polymerases, leading to an increase in RNA synthesis.[58][59][60] N-Acetylcysteine has shown promise in combination with other therapies.[61] Animal studies indicate the amatoxins deplete hepatic glutathione;[62] N-acetylcysteine serves as a glutathione precursor and may therefore prevent reduced glutathione levels and subsequent liver damage.[63] None of the antidotes used have undergone prospective, randomized clinical trials, and only anecdotal support is available. Silibinin and N-Acetylcysteine appear to be the therapies with the most potential benefit. Repeated doses of activated carbon may be helpful by absorbing any toxins that are returned to the gastrointestinal tract following enterohepatic circulation.[64] Other methods of enhancing the elimination of the toxins have been trialed; techniques such as hemodialysis,[65] hemoperfusion,[66] plasmapheresis,[67] and peritoneal dialysis[68] have occasionally yielded success but overall do not appear to improve outcome.
In patients developing liver failure, a liver transplant is often the only option to prevent death. Liver transplants have become a well established option in amatoxin poisoning,[69][70][71] however, this is a complicated issue as transplants themselves may have significant complications and mortality; patients require long term immunosuppression to maintain the transplant. As such, there has been work looking into criteria such as onset of symptoms, prothrombin time (PTT), serum bilirubin and presence of encephalopathy to determine at what point a transplant becomes necessary for survival.[72][73][74] Though survival rates have improved with modern medical treatment, evidence did suggest that in patients with moderate to severe poisoning up to half of those who did recover suffered permanent liver damage.[75] However, a follow up study has shown that most survivors recover completely without any sequelae if treated within 36 hours of mushroom ingestion.[76]
Several historical figures may have died from ''Amanita phalloides'' poisoning (or other similar, toxic ''Amanitas''). These were either accidental poisonings or assassination plots. Alleged victims of this kind of poisoning include Roman Emperor Claudius, Pope Clement VII, Tsaritsa Natalia Naryshkina, and Holy Roman Emperor Charles VI. The death of Claudius, or mushrooms for murderers, , Robert Gordon, Wasson, Botanical Museum Leaflets, Harvard University, 1972
R. Gordon Wasson recounted the details of these deaths, noting the likelihood of ''Amanita'' poisoning. In the case of Clement VII, the illness that led to his death lasted some five months, making the case clearly inconsistent with amatoxin poisoning. Natalia Naryshkina is said to have consumed a large quantity of pickled mushrooms prior to her death. However, it is unclear whether the mushrooms themselves were poisonous or whether she succumbed to food poisoning.
Charles VI experienced indigestion after eating a dish of sautéed mushrooms. This led to an illness from which he died ten days later — symptomology consistent with amatoxin poisoning. Charles' death led to the War of Austrian Succession. Noted Voltaire, "this dish of mushrooms changed the destiny of Europe."[77]
The case of the Claudius poisoning is more complex. It is known that Claudius was very fond of eating ''Caesar's mushroom''. Following his death, many sources have attributed it to him being fed a meal of death caps instead of Caesar's mushrooms. However, ancient authors such as Tacitus and Suetonius are unanimous about there being poison added to the mushroom dish, rather than the dish being prepared from poisonous mushrooms. Wasson speculates that the poison used to kill Claudius was derived from death caps, with a fatal dose of colocynth being administered later during his illness.[78]
1. Botanicon Parisiense, , Sébastien, Vaillant, J. H. Verbeek and B. Lakeman, 1727,
2. Systema Mycologicum I, , Elias Magnus, Fries, Ernesti
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3. Link JHF (1833) ''Grundriss der Kraeuterkunde IV''. Haude und Spenerschen Buchhandlung (S.J. Joseephy), Berlin
4. Tentamen Dispositionis Methodicae Fungorum, , Christian Hendrik, Persoon, P.P. Wolf,, 1797,
5. Synopsis Methodica Fungorum, , Christian Hendrik, Persoon, H. Dietrich, 1801,
6. On Secretan's Fungus Names, , M.A., Donk, Taxon, 1962
7. Invalidity of Names Published in Secretan's Mycographie Suisse and Some Remarks on the Problem of Publication by Reference, , V., Demoulin, Taxon, 1974
8. Are Secretan's Fungus Names Valid?, , Rolf, Singer, Taxon, 1962
9. Leave the Code Alone, , Robert E., Machol, Taxon, 1984
10. Benjamin.p203
11. Jordan & Wheeler. p109
12. Zeitlmayr. p61
13. A Colour Atlas of Poisonous Fungi, Bresinsky A, Besl H., , , Wolfe Publishing, 1990, ISBN 0-7234-1576-5
14. Jordan & Wheeler. p99
15. Jordan & Wheeler. p108
16. The Encyclopedia of Fungi of Britain and Europe, , Michael, Jordan, David & Charles, 1995, ISBN 0-7153-0129-2
17. California Fungi: Amanita phalloides
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21. Last chance to know? Using literature to explore the biogeography of and invasion biology of the death cap mushroom ''Amanita phalloides'' (Vaill. Ex Fr. :Fr) Link, , Anne, Pringle, Biological Invasions, 2006
22. Mushrooms demystified : a comprehensive guide to the fleshy fungi, , David, Arora, Ten Speed Press, 1986,
23. A preliminary agaric flora of East Africa, , , Pegler, Royal Botanic Gardens, Kew, 1977,
24. The New Zealand Species of ''Amanita'' (Fungi: Agaricales), , G.S., Ridley, Australian Systematic Botany, 1991
25. Annual report of the state botanist, , Charles H., Peck, University of the State of New York, 1897,
26. The most poisonous mushrooms, , W., Litten, Scientific American, 1975
27. Benjamin.p204
28. A monograph of the Australian species of ''Amanita'' Pers. ex Hook (Fungi), , D.A., Reid, Australian Journal of Botany Supplementary Series, 1980
29. ''Amanita phalloides'' in Victoria, , F.M., Cole, Medical Journal of Australia, 1993
30. La aparición del hongo venenoso ''Amanita phalloides'' en Sudamérica., , W.G., Herter, Revista Sudamericana de Botánica, 1934
31. ''Amanita phalloides'' en las Sierras de Córdoba, , A.T., Hunzinker, Kurtziana, 1983
32. ''Amanita phalloides'' en bosques de ''Pinus radiata'' de la IX Region de Chile: taxonomia, toxinas, metodos de dedection, intoxicacion faloidiana, , E., Valenzuella, Boletín Micológico, 1992
33. South African fungi: the genus ''Amanita'', , D.A., Reid, Mycological Research, 1991
34. Benjamin.p200
35. (''Amanita phalloides'' poisoning as an indication for liver transplantation in three family members.), , J., Pawlowska, Wiadomości Lekarskie, 2006
36. Benjamin.p211
37. The Complete Mushroom Book, Carluccio A, , , Quadrille, 2003, ISBN 1-84400-040-0
38. Benjamin.p198–199
39. Poisoning by ''Amanita phalloides'' ("deathcap") mushrooms in the Australian Capital Territory, Trim Geoffrey M. ''et al.'', , , Medical Journal of Australia, 1999
40. Edible and poisonous mushrooms of the world, Hall IR, Stephenson SE, Buchanan PK, Yn W, Cole AL., , , New Zealand Institute for Crop & Food Research Limited, 2003, ISBN 0-4781-0835-4
41. Mushrooms and Other Fungi of North America, , Roger, Phillips, Firefly books, 2005,
42. Deathcap Mushroom: Amanita phalloides
43. Zeitlmayr. p62
44. Clinical symptomatology and management of mushroom poisoning, Köppel C, , , Toxicon, 1993
45. Medical toxicology, , RC, Dart, Williams & Wilkins, 2004,
46. Cytotoxic fungi - an overview, Karlson-Stiber C, Persson H, , , Toxicon, 2003
47. Benjamin.p217
48. Phallotoxins bind to actins, Wieland T, Govindan VM, , , FEBS Lett., 1974
49. Toadstools and mushrooms and other larger fungi of South Australia, , John Burton, Cleland, South Australian Government Printer, 1976,
50. Death cap mushroom poisoning, Nicholls DW, Hyne BE, Buchanan P, , , The New Zealand Medical Journal, 1995
51. Histological criteria for diagnosis of amanita phalloides poisoning, Fineschi V, Di Paolo M, Centini F, , , J. Forensic Sci., 1996
52. Die klinische knollenblatterpilzvergiftung (''Amanita Phalloides''): prognostische faktoren und therapeutische massnahmen (Clinical death-cap (Amanita phalloides) poisoning: prognostic factors and therapeutic measures.), , G.L., Floerscheim, Schweizerische medizinische Wochenschrift, 1982
53. Benjamin.p215
54. Treatment of amatoxin poisoning: 20-year retrospective analysis, Enjalbert F, Rapior S, Nouguier-Soulé J, Guillon S, Amouroux N, Cabot C, , , Journal of Toxicology - Clinical Toxicology, 2002
55. Therapy of cytotoxic mushroom intoxication, Vesconi S, Langer M, Iapichino G, Costantino D, Busi C, Fiume L, , , Critical care medicine, 1985
56. Benjamin.p227
57. (Are cephalosporins more active than penicillin G in poisoning with the deadly ''Amanita''?), Neftel, K. ''et al.'', , , Schweizerische medizinische Wochenschrift, 1988
58. Chemotherapy of Amanita phalloides poisoning with intravenous silibinin, Hruby K, Csomos G, Fuhrmann M, Thaler H, , , Human toxicology, 1983
59. Silibinin and acute poisoning with ''Amanita phalloides'', Carducci, R. ''et al.'', , , Minerva Anestesiologica, 1996
60. {{cite book| last=Jahn| first=W.| coauthors=|year=1980|chapter=Pharmacokinetics of {3H}-methyl-dehydroxymethyl-amanitin in the isolated perfused rat liver, and the influence of several drugs| editor=Helmuth Faulstich, B. Kommerell & Theodore Wieland| title=Amanita toxins and poisoning|publisher=Witzstrock| location=Baden-Baden|pages=80–85|isbn=3-87921-132-9}}
61. Use of acetylcysteine as the life-saving antidote in Amanita phalloides (death cap) poisoning. Case report on 11 patients, Montanini S, Sinardi D, Praticò C, Sinardi A, Trimarchi G, , , Arzneimittel-Forschung, 1999
62. In vitro toxicity test of poisonous mushroom extracts with isolated rat hepatocytes, Kawaji A, Sone T, Natsuki R, Isobe M, Takabatake E, Yamaura Y, , , The Journal of toxicological sciences, 1990
63. Utility of acetylcysteine in treating poisonings and adverse drug reactions, Chyka P, Butler A, Holliman B, Herman M, , , Drug safety, 2000
64. Amanita toxins in gastroduodenal fluid of patients poisoned by the mushroom, Amanita phalloides, Busi C, Fiume L, Costantino D, Langer M, Vesconi F, , , New England Journal of Medicine, 1979
65. Intensive hemodialysis and hemoperfusion treatment of Amanita mushroom poisoning, Sabeel AI, Kurkus J, Lindholm T, , , Mycopathologia, 1995
66. Amanita phalloides poisoning treated by early charcoal haemoperfusion, Wauters JP, Rossel C, Farquet JJ, , , British medical journal, 1978
67. Plasmapheresis in the treatment of Amanita phalloides poisoning: II. A review and recommendations, Jander S, Bischoff J, Woodcock BG, , , Therapeutic apheresis, 2000
68. The early removal of amatoxins in the treatment of amanita phalloides poisoning, Langer M, Vesconi S, Iapichino G, Costantino D, Radrizzani D, , , Klinische Wochenschrift, 1980
69. ''Amanita'' poisoning: treatment and the role of liver transplantation, Klein AS, Hart J, Brems JJ, Goldstein L, Lewin K, Busuttil RW, , , American Journal of Medicine, 1989
70. Liver transplantation for severe ''Amanita phalloides'' mushroom poisoning, Pinson CW, Daya MR, Benner KG, Norton RL, Deveney KE, Ascher NL, Roberts JP, Lake JR, Kurkchubasche AG, Ragsdale JW, , , American Journal of Surgery, 1990
71. Indication of liver transplantation following amatoxin intoxication, Ganzert M, Felgenhauer N, Zilker T, , , Journal of Hepatology, 2005
72. Early indicators of prognosis in fulminant hepatic failure, , John G., O'grady, Gastroenterology, 1989
73. Letter to the editor: Liver transplantation represents the optimal treatment for fulminant hepatic failure from ''Amanita phalloides'' poisoning, , Fabrizio, Panaro, Transplant International, 2006
74. Amanita phalloides poisoning: reassessment of prognostic factors and indications for emergency liver transplantation, Escudié L, Francoz C, Vinel JP, Moucari R, Cournot M, Paradis V, Sauvanet A, Belghiti J, Valla D, Bernuau J, Durand F, , , J. Hepatol., 2007
75. Benjamin.p231–232
76. Amatoxin poisoning: A 15-year retrospective analysis and follow-up evaluation of 105 patients, Giannini L, Vannacci A, Missanelli A, Mastroianni R, Mannaioni PF, Moroni F, Masini E, , , Clinical toxicology (Philadelphia, Pa.), 2007
77. Benjamin.p35
78. Benjamin.p33–34
★ Mushrooms: poisons and panaceas — a handbook for naturalists, mycologists and physicians, , Denis R., Benjamin, WH Freeman and Company, 1995,
★ The Ultimate Mushroom Book, Jordan Peter, Wheeler Steven., , , Hermes House, 2001,
★ Wild Mushrooms:An Illustrated Handbook, , Linus, Zeitlmayr, Garden City Press, 1976,
★ ''Amanita phalloides'': the death cap
★ More on this species
★ Death cap in Australia - ANBG website
★ On the Trail of the Death Cap Mushroom from American National Public Radio
'''Amanita phalloides''', commonly known as the 'death cap', is a deadly poisonous basidiomycete fungus, one of many in the genus ''Amanita''. Widely distributed across Europe, ''A. phalloides'' associates with various deciduous and coniferous trees. An adaptable organism, its range is expanding in other countries after it was accidentally introduced alongside oak, chestnut, and pine. The large fruiting bodies (''i.e.'' the mushrooms), appearing in summer and autumn, are generally greenish in colour, with a white stipe and gills.
Unfortunately, these toxic mushrooms resemble several edible species commonly consumed by humans, increasing the risk of accidental ingestion. ''A. phalloides'' has an infamous reputation for being one of the most poisonous of all known toadstools. It has been involved in a majority of human deaths from mushroom poisoning, including several important historical figures such as the Roman Emperor Claudius and Holy Roman Emperor Charles VI. It has been the subject of much research and many biologically active agents have been isolated. The principal toxic constituent is α-amanitin, which damages the liver and kidneys, often fatally. No truly effective antidote is known.
| Contents |
| Taxonomy and naming |
| Description |
| Distribution and habitat |
| Toxicity |
| Similarity to edible species |
| Biochemistry |
| Symptoms |
| Treatment |
| Notable victims |
| Footnotes |
| Sources |
| External links |
Taxonomy and naming
The death cap was first described by French botanist Sébastien Vaillant in 1727, who gave a succinct phrase name "''Fungus phalloides, annulatus, sordide virescens, et patulus''," which is still recognizable as the fungus today.[1] Though the scientific name ''phalloides'' means "phallus-shaped", it is unclear whether it is named for its resemblance to a literal phallus or the Stinkhorn mushrooms ''Phallus''.
In 1821, Elias Magnus Fries described it as "''Agaricus phalloides''", but included all white Amanitas within its description.[2] Finally in 1833, Johann Heinrich Friedrich Link settled on the name ''Amanita phalloides'',[3] after Persoon had named it ''Amanita viridis'' thirty years earlier.[4][5] Although Louis Secretan's use of the name ''Amanita phalloides'' predates Link's, it has been rejected for nomenclatural purposes because Secretan's works did not use binomial nomenclature consistently,[6][7] however some taxonomists have disagreed with this opinion.[8][9]
''Amanita phalloides'' is the type species of ''Amanita'' section ''Phalloideae'', a group that contains all of the deadly poisonous ''Amanita'' species thus far identified. Most notable of these are the species known as destroying angels, namely ''Amanita virosa'' and ''A. bisporiga'' as well as the fool's mushroom ''(A. verna)''. The term "Destroying angel" has been applied to ''A. phalloides'' at times, but "death cap" is by far the most common vernacular name used in English. Other common names also listed include stinking amanita and deadly amanita.[10]
A rarely appearing all-white form was initially described ''A. phalloides'' f. ''alba'' by Max Britzelmayr,[11] though its status has been unclear. It is often found growing amid normal coloured death caps. It has been described in 2004 as a distinct variety and includes what was termed ''A. verna'' var. ''tarda''. The true ''Amanita verna'' fruits in spring and turns yellow with KOH solution, whereas ''A. phalloides'' never does.
Description
Appearing after periods of rain from late summer through autumn,[12] the death cap has a large and imposing epigeous (above ground) fruiting body (basidiocarp), usually with a pileus (cap) from 5 to 15 cm (2–6 in) across, initially rounded and hemispherical, but flattening with age.[13] The colour of the cap can be pale-, yellowish- or olive-green, often paler toward the margins, and is often paler after rain. The cap surface is sticky when wet and easily peeled, a troublesome feature as it is allegedly a feature of edible fungi.[14] The remains of the partial veil is seen as a skirtlike, floppy annulus usually about 1 to 1.5 cm below the cap. The crowded white lamellae (gills) are free. The stipe is white with a scattering of grayish-olive scales and is 8 to 15 cm long and 1 to 2 cm-thick with a swollen ragged sac-like white volva (base). As the volva, which may be hidden by leaf litter, is a distinctive and diagnostic feature, it is important to remove some debris to check for one.[15]
The smell has been described as initially faint and honey-sweet but strengthening over time to become overpowering, sickly-sweet and objectionable. Young specimens first emerge from the ground resembling a white egg covered by a universal veil, which then breaks, leaving the volva as a remnant. The spore print is white, a common feature of ''Amanita''. The transparent spores are globular to egg-shaped, measure 8–10 μm long and stain blue with iodine. The gills on the other hand are seen to stain palid lilaceous or pink with concentrated sulfuric acid.[16][17]
A young death cap emerging from universal veil (France).
Distribution and habitat
The death cap is native to Europe, where it is widespread.[18] It is found from the southern coastal regions of Scandinavia in the north, to Ireland in the west, east to Poland and western Russia,[19] and south through the Balkans into Italy, Spain, and Morocco and Algeria in north Africa.[20] There are records from further east into Asia but these have yet to be confirmed as ''A. phalloides''.[21]
It is ectomycorrhizally associated with a number of tree species. In Europe, these include a large number of hardwood and, less frequently, conifer species. It appears most commonly under oaks, but also under beeches, chestnuts, horse-chestnuts, birches, filberts, hornbeams, pines, and spruces. In other areas, ''A. phalloides'' may also be associated with these trees, or only with some species, but not others. In coastal California, for example, ''A. phalloides'' is associated with coast live oak, but not the various coastal pine species, such as Monterey pine.[22] In countries where it has been introduced it has been restricted to those exotic trees it would associate with in its natural range. However there is evidence of ''A. phalloides'' associating with hemlock, and with genera of the Myrtaceae: ''Eucalyptus'' in Tanzania[23] and Algeria, and ''Leptospermum'' and ''Kunzea'' in New Zealand.[24] This suggests the species may have invasive potential.
By the end of the 19th century, Charles Horton Peck had reported ''A. phalloides'' in North America.[25] However, in 1918 samples from the Eastern United States were identified as being a distinct though similar species, ''A. brunnescens'', by G. F. Atkinson of Cornell University.[26] By the 1970s it had become clear that ''A. phalloides'' actually does occur in the United States, apparently having been introduced from Europe alongside chestnuts, with populations on the West and East Coasts.[27] A more recent historical review concluded that the East Coast populations were introduced, but that the origins of the west coast population remain unclear, due to the scantness of historical records.
''Amanita phalloides'' has been conveyed to new countries across the southern hemisphere with the importation of hardwoods and conifers. Introduced oaks appear to have been the vector to Australia and South America; populations under oaks have been recorded from Melbourne and Canberra,[28][29] as well as Uruguay,[30] It has been recorded under other introduced trees in Argentina[31] and Chile.[32]
Pine plantations are associated with the fungus in Tanzania and South Africa, where it is also found under oaks and poplars.[33]
Toxicity
As the common name suggests, the fungus is highly toxic, and is responsible for the majority of fatal mushroom poisonings worldwide.[34] In 2006, a family of three in Poland was poisoned, resulting in one death and the two survivors requiring liver transplants.[35] It is estimated that 30 grams (half a cap) of this mushroom is enough to kill a human.[36] Some authorities strongly advise against sharing a basket of fungi collected for the table with suspected death caps and to avoid touching them.[37] Furthermore, the toxicity is not reduced by cooking, freezing or drying. Not surprisingly, its biochemistry has been researched intensively for decades.
Similarity to edible species
Recent cases highlight the issue of its similarity to the edible paddy straw mushroom ''Volvariella volvacea'', with southeast-Asian immigrants in Australia and the west coast of the United States falling victim, including an episode in Oregon where four members of a Korean family required liver transplants.[38] Of the seven people poisoned in the Canberra region between 1988 and 1998 three were from Laos.[39] This is a leading cause of mushroom poisoning in the United States.
Novices may also mistake juvenile death caps for edible puffballs[40] or mature specimens as other edible ''Amanita'' species such as ''Amanita lanei'', and for this reason, some authorities recommend avoiding the collection of ''Amanita'' species for the table altogether.[41] The white form of ''A. phalloides'' may be mistaken for edible species of ''Agaricus'', especially the young fruitbodies with unexpanded caps. All mature species of ''Agaricus'' have dark-coloured gills.[42]
In Europe, other similarly green-capped species collected by mushroom hunters include various green-hued brittlegills of the genus ''Russula'', and the formerly popular ''Tricholoma flavovirens''. However, the latter species is now regarded as hazardous after a series of restaurant poisonings in France. Brittlegills, such as ''Russula heterophylla'', ''R. aeruginea'', ''R. virescens'' and others, can be distinguished by their brittle flesh and the lack of both volva and ring.[43] Other similar species include ''A. subjunquillea'' in eastern Asia and ''A. arocheae'', which ranges from Andean Colombia to central Mexico (at least), both of which are also poisonous.
Biochemistry
The species is now known to contain two main groups of toxins, both multicyclic (ring-shaped) peptides, spread throughout the mushroom tissue: the amatoxins and the phallotoxins. Another toxin is phallolysin, which has shown some hemolytic (red blood cell-destroying) activity ''in vitro''. An unrelated compound, antamanide has also been isolated.
'Amatoxins' consist of at least eight compounds with a similar structure, that of eight amino-acid rings; they were isolated in 1941 by Heinrich O. Wieland and Rudolf Hallermayer of the University of Munich. Of the amatoxins, α-amanitin is the chief component and along with β-amanitin is likely responsible for the toxic effects.[44][45] Their major toxic mechanism is the inhibition of RNA polymerase II, a vital enzyme in the synthesis of messenger RNA (mRNA), microRNA, and small nuclear RNA (snRNA). Without mRNA essential protein synthesis and hence cell metabolism grind to a halt and the cell dies.[46] The liver is the principal organ affected, as it is the organ which is first encountered after absorption in the gastrointestinal tract, though other organs, especially the kidneys, are susceptible.[47]
The 'phallotoxins' consist of at least seven compounds, all of which have seven similar peptide rings. Phalloidin had been isolated in 1937 by Feodor Lynen, Heinrich Wieland's student and son-in-law, and Ulrich Wieland of the University of Munich. Though phallotoxins are highly toxic to liver cells,[48] they have since been found to have little input into the death cap's toxicity as they are not absorbed through the gut. Furthermore, phalloidin is also found in the edible (and sought after) Blusher (''Amanita rubescens''). Another group of minor active peptides are the virotoxins, which consist of six similar monocyclic heptapeptides. Like the phallotoxins they do not exert any acute toxicity after ingestion in humans.
Symptoms
Death caps have been reported to taste pleasant.[49] This, coupled with the delay in symptoms appearing, during which time internal organs are being severely (sometimes irreparably) damaged — makes it particularly dangerous. Initially, symptoms are gastrointestinal in nature, and include colicky abdominal pain, watery diarrhea and vomiting, which may lead to dehydration, or in severe cases hypotension, tachycardia, hypoglycemia, and acid-base disturbances. These first symptoms resolve two to three days after the ingestion, before a more serious deterioration signifying liver involvement — jaundice, diarrhea, delirium, seizures and coma due to fulminant hepatic failure and hepatic encephalopathy (accumulation of normally liver-removed substance in the blood) may then occur. Poisonous plants and fungi in colour, , Pamela Mildred, North, Blandford Press, 1967, Renal failure, either occurring secondary to severe hepatitis[50] Toxins of ''Amanita phalloides'', , János, Vetter, Toxicon, 1998 or to direct toxic renal damage, and coagulopathy may appear during this stage. Life threatening complications include increased intracranial pressure, intracranial hemorrhage, sepsis, pancreatitis, acute renal failure and cardiac arrest. Death generally occurs six to sixteen days after the poisoning.[51]
Up to the mid-20th century, the mortality rate was around 60–70%, but this has greatly improved with advances in medical care. A review of death cap poisoning throughout Europe from 1971 to 1980, found the overall mortality rate to be 22.4% (51.3% in children under ten, and 16.5% in those older than ten).[52] This has further fallen in more recent studies to around 10–15%.[53]
Treatment
Consumption of the death cap is a medical emergency requiring hospitalization. There are four main categories of therapy for poisoning, they include preliminary medical care, supportive measures, specific treatments, and liver transplantation.[54]
Preliminary care consists of gastric decontamination with either activated carbon or gastric lavage, however, due to the delay between ingestion and the first symptoms of poisoning, it is commonplace for patients to arrive for treatment many hours after ingestion, potentially reducing the efficacy of these interventions.[55] Supportive measures are directed towards treating the dehydration which results from fluid loss during the gastrointestinal phase of intoxication and correction of metabolic acidosis, hypoglycemia, electrolyte imbalances, and impaired coagulation.
No definitive antidote is available, but some specific treatments have been shown to improve survivability. High dose continuous intravenous penicillin G has been reported to be of benefit, though the exact mechanism is unknown, and trials with cephalosporins show promise.[56][57] There is some evidence that intravenous silibinin, an extract from the blessed milk thistle (''Silybum marianum''), may be beneficial in reducing the effects of death cap poisoning. Silibinin prevents the uptake of amatoxins by hepatocytes, thereby protecting undamaged hepatic tissue; it also stimulates DNA-dependent RNA polymerases, leading to an increase in RNA synthesis.[58][59][60] N-Acetylcysteine has shown promise in combination with other therapies.[61] Animal studies indicate the amatoxins deplete hepatic glutathione;[62] N-acetylcysteine serves as a glutathione precursor and may therefore prevent reduced glutathione levels and subsequent liver damage.[63] None of the antidotes used have undergone prospective, randomized clinical trials, and only anecdotal support is available. Silibinin and N-Acetylcysteine appear to be the therapies with the most potential benefit. Repeated doses of activated carbon may be helpful by absorbing any toxins that are returned to the gastrointestinal tract following enterohepatic circulation.[64] Other methods of enhancing the elimination of the toxins have been trialed; techniques such as hemodialysis,[65] hemoperfusion,[66] plasmapheresis,[67] and peritoneal dialysis[68] have occasionally yielded success but overall do not appear to improve outcome.
In patients developing liver failure, a liver transplant is often the only option to prevent death. Liver transplants have become a well established option in amatoxin poisoning,[69][70][71] however, this is a complicated issue as transplants themselves may have significant complications and mortality; patients require long term immunosuppression to maintain the transplant. As such, there has been work looking into criteria such as onset of symptoms, prothrombin time (PTT), serum bilirubin and presence of encephalopathy to determine at what point a transplant becomes necessary for survival.[72][73][74] Though survival rates have improved with modern medical treatment, evidence did suggest that in patients with moderate to severe poisoning up to half of those who did recover suffered permanent liver damage.[75] However, a follow up study has shown that most survivors recover completely without any sequelae if treated within 36 hours of mushroom ingestion.[76]
Notable victims
Several historical figures may have died from ''Amanita phalloides'' poisoning (or other similar, toxic ''Amanitas''). These were either accidental poisonings or assassination plots. Alleged victims of this kind of poisoning include Roman Emperor Claudius, Pope Clement VII, Tsaritsa Natalia Naryshkina, and Holy Roman Emperor Charles VI. The death of Claudius, or mushrooms for murderers, , Robert Gordon, Wasson, Botanical Museum Leaflets, Harvard University, 1972
R. Gordon Wasson recounted the details of these deaths, noting the likelihood of ''Amanita'' poisoning. In the case of Clement VII, the illness that led to his death lasted some five months, making the case clearly inconsistent with amatoxin poisoning. Natalia Naryshkina is said to have consumed a large quantity of pickled mushrooms prior to her death. However, it is unclear whether the mushrooms themselves were poisonous or whether she succumbed to food poisoning.
Charles VI experienced indigestion after eating a dish of sautéed mushrooms. This led to an illness from which he died ten days later — symptomology consistent with amatoxin poisoning. Charles' death led to the War of Austrian Succession. Noted Voltaire, "this dish of mushrooms changed the destiny of Europe."[77]
The case of the Claudius poisoning is more complex. It is known that Claudius was very fond of eating ''Caesar's mushroom''. Following his death, many sources have attributed it to him being fed a meal of death caps instead of Caesar's mushrooms. However, ancient authors such as Tacitus and Suetonius are unanimous about there being poison added to the mushroom dish, rather than the dish being prepared from poisonous mushrooms. Wasson speculates that the poison used to kill Claudius was derived from death caps, with a fatal dose of colocynth being administered later during his illness.[78]
Footnotes
1. Botanicon Parisiense, , Sébastien, Vaillant, J. H. Verbeek and B. Lakeman, 1727,
2. Systema Mycologicum I, , Elias Magnus, Fries, Ernesti
Mauritii, 1821,
3. Link JHF (1833) ''Grundriss der Kraeuterkunde IV''. Haude und Spenerschen Buchhandlung (S.J. Joseephy), Berlin
4. Tentamen Dispositionis Methodicae Fungorum, , Christian Hendrik, Persoon, P.P. Wolf,, 1797,
5. Synopsis Methodica Fungorum, , Christian Hendrik, Persoon, H. Dietrich, 1801,
6. On Secretan's Fungus Names, , M.A., Donk, Taxon, 1962
7. Invalidity of Names Published in Secretan's Mycographie Suisse and Some Remarks on the Problem of Publication by Reference, , V., Demoulin, Taxon, 1974
8. Are Secretan's Fungus Names Valid?, , Rolf, Singer, Taxon, 1962
9. Leave the Code Alone, , Robert E., Machol, Taxon, 1984
10. Benjamin.p203
11. Jordan & Wheeler. p109
12. Zeitlmayr. p61
13. A Colour Atlas of Poisonous Fungi, Bresinsky A, Besl H., , , Wolfe Publishing, 1990, ISBN 0-7234-1576-5
14. Jordan & Wheeler. p99
15. Jordan & Wheeler. p108
16. The Encyclopedia of Fungi of Britain and Europe, , Michael, Jordan, David & Charles, 1995, ISBN 0-7153-0129-2
17. California Fungi: Amanita phalloides
18.
19.
20.
21. Last chance to know? Using literature to explore the biogeography of and invasion biology of the death cap mushroom ''Amanita phalloides'' (Vaill. Ex Fr. :Fr) Link, , Anne, Pringle, Biological Invasions, 2006
22. Mushrooms demystified : a comprehensive guide to the fleshy fungi, , David, Arora, Ten Speed Press, 1986,
23. A preliminary agaric flora of East Africa, , , Pegler, Royal Botanic Gardens, Kew, 1977,
24. The New Zealand Species of ''Amanita'' (Fungi: Agaricales), , G.S., Ridley, Australian Systematic Botany, 1991
25. Annual report of the state botanist, , Charles H., Peck, University of the State of New York, 1897,
26. The most poisonous mushrooms, , W., Litten, Scientific American, 1975
27. Benjamin.p204
28. A monograph of the Australian species of ''Amanita'' Pers. ex Hook (Fungi), , D.A., Reid, Australian Journal of Botany Supplementary Series, 1980
29. ''Amanita phalloides'' in Victoria, , F.M., Cole, Medical Journal of Australia, 1993
30. La aparición del hongo venenoso ''Amanita phalloides'' en Sudamérica., , W.G., Herter, Revista Sudamericana de Botánica, 1934
31. ''Amanita phalloides'' en las Sierras de Córdoba, , A.T., Hunzinker, Kurtziana, 1983
32. ''Amanita phalloides'' en bosques de ''Pinus radiata'' de la IX Region de Chile: taxonomia, toxinas, metodos de dedection, intoxicacion faloidiana, , E., Valenzuella, Boletín Micológico, 1992
33. South African fungi: the genus ''Amanita'', , D.A., Reid, Mycological Research, 1991
34. Benjamin.p200
35. (''Amanita phalloides'' poisoning as an indication for liver transplantation in three family members.), , J., Pawlowska, Wiadomości Lekarskie, 2006
36. Benjamin.p211
37. The Complete Mushroom Book, Carluccio A, , , Quadrille, 2003, ISBN 1-84400-040-0
38. Benjamin.p198–199
39. Poisoning by ''Amanita phalloides'' ("deathcap") mushrooms in the Australian Capital Territory, Trim Geoffrey M. ''et al.'', , , Medical Journal of Australia, 1999
40. Edible and poisonous mushrooms of the world, Hall IR, Stephenson SE, Buchanan PK, Yn W, Cole AL., , , New Zealand Institute for Crop & Food Research Limited, 2003, ISBN 0-4781-0835-4
41. Mushrooms and Other Fungi of North America, , Roger, Phillips, Firefly books, 2005,
42. Deathcap Mushroom: Amanita phalloides
43. Zeitlmayr. p62
44. Clinical symptomatology and management of mushroom poisoning, Köppel C, , , Toxicon, 1993
45. Medical toxicology, , RC, Dart, Williams & Wilkins, 2004,
46. Cytotoxic fungi - an overview, Karlson-Stiber C, Persson H, , , Toxicon, 2003
47. Benjamin.p217
48. Phallotoxins bind to actins, Wieland T, Govindan VM, , , FEBS Lett., 1974
49. Toadstools and mushrooms and other larger fungi of South Australia, , John Burton, Cleland, South Australian Government Printer, 1976,
50. Death cap mushroom poisoning, Nicholls DW, Hyne BE, Buchanan P, , , The New Zealand Medical Journal, 1995
51. Histological criteria for diagnosis of amanita phalloides poisoning, Fineschi V, Di Paolo M, Centini F, , , J. Forensic Sci., 1996
52. Die klinische knollenblatterpilzvergiftung (''Amanita Phalloides''): prognostische faktoren und therapeutische massnahmen (Clinical death-cap (Amanita phalloides) poisoning: prognostic factors and therapeutic measures.), , G.L., Floerscheim, Schweizerische medizinische Wochenschrift, 1982
53. Benjamin.p215
54. Treatment of amatoxin poisoning: 20-year retrospective analysis, Enjalbert F, Rapior S, Nouguier-Soulé J, Guillon S, Amouroux N, Cabot C, , , Journal of Toxicology - Clinical Toxicology, 2002
55. Therapy of cytotoxic mushroom intoxication, Vesconi S, Langer M, Iapichino G, Costantino D, Busi C, Fiume L, , , Critical care medicine, 1985
56. Benjamin.p227
57. (Are cephalosporins more active than penicillin G in poisoning with the deadly ''Amanita''?), Neftel, K. ''et al.'', , , Schweizerische medizinische Wochenschrift, 1988
58. Chemotherapy of Amanita phalloides poisoning with intravenous silibinin, Hruby K, Csomos G, Fuhrmann M, Thaler H, , , Human toxicology, 1983
59. Silibinin and acute poisoning with ''Amanita phalloides'', Carducci, R. ''et al.'', , , Minerva Anestesiologica, 1996
60. {{cite book| last=Jahn| first=W.| coauthors=|year=1980|chapter=Pharmacokinetics of {3H}-methyl-dehydroxymethyl-amanitin in the isolated perfused rat liver, and the influence of several drugs| editor=Helmuth Faulstich, B. Kommerell & Theodore Wieland| title=Amanita toxins and poisoning|publisher=Witzstrock| location=Baden-Baden|pages=80–85|isbn=3-87921-132-9}}
61. Use of acetylcysteine as the life-saving antidote in Amanita phalloides (death cap) poisoning. Case report on 11 patients, Montanini S, Sinardi D, Praticò C, Sinardi A, Trimarchi G, , , Arzneimittel-Forschung, 1999
62. In vitro toxicity test of poisonous mushroom extracts with isolated rat hepatocytes, Kawaji A, Sone T, Natsuki R, Isobe M, Takabatake E, Yamaura Y, , , The Journal of toxicological sciences, 1990
63. Utility of acetylcysteine in treating poisonings and adverse drug reactions, Chyka P, Butler A, Holliman B, Herman M, , , Drug safety, 2000
64. Amanita toxins in gastroduodenal fluid of patients poisoned by the mushroom, Amanita phalloides, Busi C, Fiume L, Costantino D, Langer M, Vesconi F, , , New England Journal of Medicine, 1979
65. Intensive hemodialysis and hemoperfusion treatment of Amanita mushroom poisoning, Sabeel AI, Kurkus J, Lindholm T, , , Mycopathologia, 1995
66. Amanita phalloides poisoning treated by early charcoal haemoperfusion, Wauters JP, Rossel C, Farquet JJ, , , British medical journal, 1978
67. Plasmapheresis in the treatment of Amanita phalloides poisoning: II. A review and recommendations, Jander S, Bischoff J, Woodcock BG, , , Therapeutic apheresis, 2000
68. The early removal of amatoxins in the treatment of amanita phalloides poisoning, Langer M, Vesconi S, Iapichino G, Costantino D, Radrizzani D, , , Klinische Wochenschrift, 1980
69. ''Amanita'' poisoning: treatment and the role of liver transplantation, Klein AS, Hart J, Brems JJ, Goldstein L, Lewin K, Busuttil RW, , , American Journal of Medicine, 1989
70. Liver transplantation for severe ''Amanita phalloides'' mushroom poisoning, Pinson CW, Daya MR, Benner KG, Norton RL, Deveney KE, Ascher NL, Roberts JP, Lake JR, Kurkchubasche AG, Ragsdale JW, , , American Journal of Surgery, 1990
71. Indication of liver transplantation following amatoxin intoxication, Ganzert M, Felgenhauer N, Zilker T, , , Journal of Hepatology, 2005
72. Early indicators of prognosis in fulminant hepatic failure, , John G., O'grady, Gastroenterology, 1989
73. Letter to the editor: Liver transplantation represents the optimal treatment for fulminant hepatic failure from ''Amanita phalloides'' poisoning, , Fabrizio, Panaro, Transplant International, 2006
74. Amanita phalloides poisoning: reassessment of prognostic factors and indications for emergency liver transplantation, Escudié L, Francoz C, Vinel JP, Moucari R, Cournot M, Paradis V, Sauvanet A, Belghiti J, Valla D, Bernuau J, Durand F, , , J. Hepatol., 2007
75. Benjamin.p231–232
76. Amatoxin poisoning: A 15-year retrospective analysis and follow-up evaluation of 105 patients, Giannini L, Vannacci A, Missanelli A, Mastroianni R, Mannaioni PF, Moroni F, Masini E, , , Clinical toxicology (Philadelphia, Pa.), 2007
77. Benjamin.p35
78. Benjamin.p33–34
Sources
★ Mushrooms: poisons and panaceas — a handbook for naturalists, mycologists and physicians, , Denis R., Benjamin, WH Freeman and Company, 1995,
★ The Ultimate Mushroom Book, Jordan Peter, Wheeler Steven., , , Hermes House, 2001,
★ Wild Mushrooms:An Illustrated Handbook, , Linus, Zeitlmayr, Garden City Press, 1976,
External links
★ ''Amanita phalloides'': the death cap
★ Death cap in Australia - ANBG website
★ On the Trail of the Death Cap Mushroom from American National Public Radio
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