Acute liver failure caused by mushroom poisoning: a case report and review of the literature
A 63-year-old male patient was admitted to the emergency room with weakness, nausea, vomiting, and diarrhea. After specific query, he reported ingesting several wild mushrooms about 36 hours earlier. Severe nausea, vomiting, and diarrhea had set in 7–8 hours after ingestion. He had a medical history of hypertension and colon carcinoma. He had undergone surgery and had received chemotherapy two months earlier. Also, he had no metastasis in the liver, he did not consume alcohol, and he did not use any medication.\nOn admission, he was awake and fully oriented, and all vital signs were normal. His physical examination was unremarkable except for dehydration. Arterial blood gas analysis was normal. Hepatitis B surface antigen, hepatitis B core antibody, immunoglobulin M, and antihepatitis C antibody were found to be nonreactive. A hepatitis B virus DNA analysis was performed using the polymerase chain reaction and was determined to be negative. The patient was then admitted to the internal medicine intensive care unit. After performing a gastric lavage via a nasogastric tube, activated charcoal was initiated and continued at a dose of 50 grams every 6 hours. The patient was rehydrated via intravenous (iv) administration with 0.9% sodium chloride and 5% dextrose to guard against the risk of hypoglycemia. Simultaneously, silibinin, at a bolus dose of 5 mg/kg iv, was initiated and followed by a continuous iv infusion of 20 mg/kg/day. Acetylcysteine was given by continuous iv infusion for 21 hours, with a total dose of 300 mg/kg (150 mg/kg over 1 hour, followed by 50 mg/kg over 4 hours, followed by 150 mg/kg over 16 hours). Infusion of penicillin G in doses of 1,000,000 U/kg/day, multivitamin, and alpha lipoic acid were started. Treatments are summarized in . Complete blood count, biochemistry measurements, and blood gas monitoring were performed every 6 hours ( and ).\nAt 6 hours after his admission, aspartate aminotransferase (AST) was 880 U/L; alanine aminotransferase (ALT) 665 U/L; lactate dehydrogenase (LDH) 1,028 U/L; total bilirubin 4.9 mg/dL; direct bilirubin 1.9 mg/dL; prothrombine time (PT) 36.5 seconds; and international normalized ratio (INR) 3.11. His lactate level was normal. Vitamin K (menadion 20 mg/day, iv) and metilprednisolone in doses of 1 mg/kg/day were started.\nAt 12 hours from admission, AST was 1,836 U/L; ALT 1,232 U/L; LDH 1,471 U/L; total bilirubin 7.2 mg/dL; direct bilirubin 3.1 mg/dL; PT 73.1 seconds; and INR 6.86. Upon arterial blood gas analysis, the patient had metabolic acidosis with a normal anion gap (AG) and respiratory alkalosis (pH 7.38; partial pressure of carbon dioxide [pCO2] 26.5 mmHg; partial pressure of oxygen [pO2] 49.5 mmHg; bicarbonate [HCO3] 17.8 mmol/L; base excess [BE] −8.8 mmol/L). Fresh frozen plasma were administrated at a dose of 15 mL/kg, and hemodialysis was performed for 3 hours.\nAt 30 hours the patient’s general condition began to worsen. He was somnolent and mildly tachypneic. His AST level was 1,900 U/L; ALT 1,473 U/L; LDH 2,582 U/L; PT 76.5 seconds; INR 7.22; hemoglobin (Hb) 12.5 g/dL; and platelets (PLTs) 123,000/mm3. We consulted the committee for liver transplantation, but because of the patient’s colon carcinoma, our application was not accepted. Current therapies were continued. Hemodialysis was performed again for 4 hours, and fresh frozen plasma was given again. After dialysis and fresh frozen plasma replacement, AST was 1,843 U/L; ALT 984 U/L; LDH 3,826 U/L; PT 42.6 seconds; and INR 3.71.\nAt 48 hours from the time of admission, AST was 1,207 U/L; ALT 1,797 U/L; LDH 4,318 U/L; total bilirubin 9.8 mg/dL; direct bilirubin 3.3 mg/dL; PT 47.7 seconds; INR 4.21; Hb 11.8 g/dL; and PLTs 33,000/mm3. Arterial blood gas analysis revealed high AG metabolic acidosis with respiratory alkalosis (pH 7.36; pCO2 20.3 mmHg; pO2 52.3 mmHg; HCO3 14.7 mmol/L; BE −13 mmol/L; and AG 25.3 mmol/L). His fibrinogen level was in the normal range (200–400 mg/dL) and D-dimer concentration was elevated (>2000 μg/L). No schistocytes were apparent in a peripheral blood smear.\nThe patient had developed a flapping tremor. His blood ammonia level was 281 μg/dL. Hepatic encephalopathy treatment, including 500 mL of branched chain amino acid solution (HepatAmine®; B. Braun Medical Inc, Irvine, CA, USA) over a 12-hour period and infusion of ornithine-aspartate at a dose of 20 g/day and lactulose at a dose of 45 g/day, was started.\nAt 54 hours AST was 3,570 U/L; ALT 3,282 U/L; LDH 4,379 U/L; total bilirubin 12.4 mg/dL; PT 111 seconds; INR 11.05; and PLTs 29,000/mm3. Hemodialysis was performed for 4 hours and fresh frozen plasma was given again. At 60 hours, PT was 34.6 seconds; INR 2.92; Hb 8.6 g/dL; and PLTs 12,000/mm3. One unit of erythrocyte suspension was given.\nAt 72 hours after admission, the patient lost consciousness. His body temperature was 38.2°C, pulse rate 112 beats per minute, respiratory rate 32 breaths per minute, and blood pressure 89/57 mmHg. Meropenem was started at a dose of 500 mg every 12 hours for sepsis.\nAt 78 hours AST was 1,096 U/L; ALT 2,004 U/L; LDH 1,615 U/L; PT 100.6 seconds; INR 9.87; and PLTs 7,000/mm3. Hemodialysis was performed for 4 hours, and fresh frozen plasma and platelet infusion at a dose of 1 U/10 kg were given. Arterial blood gas analysis showed pure respiratory alkalosis (pH 7.54; pCO2 23.8 mmHg; HCO3 24.1 mmol/L; BE −1.6 mmol/L).\nAt 84 hours the patient’s serum lactate was 16.59 mg/dL, ammonia 415 μg/dL, and serum creatinine was 2.6 mg/dL, so he was considered to have developed hepatorenal syndrome. His arterial blood gas values were pH 7.39; pCO2 8.4 mmHg; pO2 86.8 mmHg; HCO3 10.4 mmol/L; BE: −20.2 mmol/L; and respiratory rate was 38 breaths per minute. The patient was sedated and intubated.\nAt 90 hours from his admission, the patient went into cardiac arrest and was revived after resuscitation. On arterial blood gas analysis; pH 7.07, pCO2 32.6 mmHg, pO2 94.7 mmHg, HCO3 9.9 mmol/L, BE −18.9 mmol/L and then intravenous sodium bicarbonate, was given.\nAt 96 hours, the patient’s AST was 329 U/L; ALT 855 U/L; PT 77.3 seconds; INR 7.31; PLTs 13,000/mm3; Hb 8.3 g/dL; serum creatinine 3.3 mg/dL; serum lactate 112 mg/dL; pH 7.36; pCO2 22.3 mmHg; HCO3 15.3 mmol/L; and BE −12 mmol/L. At 98 hours after his admission, the patient went into cardiac arrest again and died.