Accidental colourful mushroom poisoning – delirium, delusions and dreams

Clinical presentation

A 46-year-old woman, a Ukrainian emigrant, presented to the emergency department (ED) in the early hours of the morning in an acute confusional state. She had been found at home by her son at around 10pm acutely confused, complaining of ‘feeling cold’. She had been seen earlier in the evening by a family member and was then well in herself. On arrival to the ED, she had a temperature of 37.9°C but normal vital signs. She was extremely agitated with slurred speech and shouting. She had what appeared to be vivid visual and auditory hallucinations, in addition to involuntary twitching of her upper limbs.

On examination, Glasgow Coma Scale (GCS) was 10/15 (E2V3M5), with pupils equal and reactive to light. There were no signs of meningism. She was initially treated with IM lorazepam 2 mg, empirical IV ceftriaxone and acyclovir for presumptive central nervous system (CNS) infection.

Initial laboratory investigations revealed microcytic anaemia and mild lactic acidosis (Table 1). Her ECG showed normal sinus rhythm. Imaging studies, including chest X-ray and CT head, were normal.

As the patient became more awake and coherent, a more detailed history was obtained with her 16-year-old daughter acting as an interpreter. Her only past medical history included iron deficiency anaemia. There was no history of recent foreign travel, excessive alcohol intake or recreational drug use. She was not on any regular medications.

She reported a daily ingestion of 0.5 g of raw red-orange mushroom on a regular basis in the evenings for the past 2 weeks. These mushrooms are considered a common herbal remedy to help with sleep or relieve stress/anxiety in her country of origin. She had purchased 20 g of dried mushrooms via a social media website. On the night before admission, she had taken ∼1 g of dried mushroom before going to bed as she had been told by her mother, who was still in Ukraine, that their hometown was being heavily shelled. 2–3 hours later, she woke up feeling drunk with extremely vivid visual and auditory hallucinations, including beliefs that she was flying and her dead grandmother was talking to her, out-of-body experiences, and finally the sense that she had died before being reborn.

Her husband subsequently brought in the mushroom, which corresponds to dried Amanita muscaria mushroom in TOXBASE^®, the clinical toxicology database providing information on diagnosis and treatment of poisoning. A urine toxicology screen was sent. She was subsequently diagnosed with A muscaria mushroom poisoning and antimicrobial therapy was stopped. IV Hartmann's infusion was continued in view of hyperlactatemia. She regained full consciousness 8 hours after ingestion of the dried mushroom. She was monitored in the hospital for 24 hours before being discharged with safety netting.

Learning points

• Obtaining a comprehensive history is imperative to the diagnosis of accidental mushroom poisoning.

• The predominant features of A muscaria poisoning typically involve neuropsychiatric symptoms due to its psychoactive constituents.

• The rapid and correct identification of the mushroom is essential for early diagnosis, appropriate treatment and preventing unwarranted investigations.