About This Guide
This guide covers four African bioregions: Mediterranean North Africa and South African temperate fynbos (amatoxin — Death Cap); East and Southern African miombo wooded savannas and anthropogenic lawns (Chlorophyllum molybdites GI toxidrome); West African industrial corridors with heavy metal co-exposure risk; and Central African equatorial forests (native tropical Amanita species with variable amatoxin content). Species data are confirmed from peer-reviewed literature and herbarium voucher sources.
Data-only reference — no photographs. Species identification for clinical management must be confirmed by a toxicologist, mycologist, or poison control specialist, not from this text alone.
Pathophysiology
Classic triphasic amatoxin syndrome. Amatoxins inhibit RNA polymerase II, halting cellular protein synthesis, causing progressive, irreversible hepatocellular and renal tubular necrosis.
Clinical Timeline
- Phase 1 (6–24 hours): Delayed onset — severe cholera-like gastroenteritis (nausea, projectile vomiting, watery diarrhea, cramping)
- Phase 2 (24–48 hours): False recovery window — latent phase. Symptoms appear to resolve. Transaminases rising silently. DO NOT DISCHARGE.
- Phase 3 (48–96 hours): Fulminant hepatic necrosis, acute kidney injury, coagulopathy, hepatic encephalopathy, multi-organ failure
ICU Protocol — Adults
- Aggressive IV fluid resuscitation targeting urine output 100–200 mL/hour to enhance amatoxin renal clearance
- Multi-dose activated charcoal (MDAC) via NG tube: 1 g/kg every 4 hours — interrupts enterohepatic recirculation
- Meixner test: Apply mushroom juice to newspaper; blue-black color change = amatoxins present. CRITICAL WARNING: A negative Meixner test does NOT exclude amatoxin poisoning — do not use a negative result to rule out Amanita phalloides ingestion.
- Continuous IV Silibinin (Legalon SIL) 20–30 mg/kg/day — uninterrupted infusion. Do not hold for any reason.
- OR high-dose Benzylpenicillin (Penicillin G) 300,000–1,000,000 units/kg/day if Silibinin unavailable
- IV N-Acetylcysteine (NAC) — extended four-bag regimen:
- Bag 1: 150 mg/kg over 60 min
- Bag 2: 50 mg/kg over 4 hours
- Bag 3: 100 mg/kg over 16 hours
- Bag 4: Continue 150–300 mg/kg/day until clinical resolution
- Monitor PT/INR, AST/ALT, total bilirubin, creatinine every 6 hours
- King's College Criteria: Evaluate for liver transplantation eligibility early — do not wait for peak deterioration
Pediatric Dosing
- Activated charcoal: 0.5–1 g/kg (max 50 g) every 4 hours via NG tube
- Silibinin: 20 mg/kg/day IV continuous infusion
- NAC: Same weight-based four-bag regimen as adults
- Fluid resuscitation: 10–20 mL/kg boluses of normal saline, reassess every 30 minutes
Veterinary
Canine: Severe RNA polymerase II inhibition resulting in total liver failure. Mortality exceeds 85%. Emergency IV fluid support and referral to veterinary ICU.
Feline: Severe hepatocyte necrosis. Exposure frequently occurs via grooming spores or fungal debris from paws. Same hepatotoxic pathway.
Pathophysiology
Driven by the toxic metalloendopeptidase molybdophyllysin, which causes severe localized gastrointestinal cytotoxicity.
Clinical Timeline
- Onset: 30 minutes to 2.5 hours post-ingestion
- Symptoms: Immediate projectile vomiting, explosive watery green or bloody diarrhea, agonizing abdominal cramps, rapid hypovolemic shock
ICU Protocol
- Aggressive fluid resuscitation with IV balanced crystalloids
- IV antiemetics: Ondansetron 4–8 mg IV or Metoclopramide
- Monitor serum electrolytes — critical attention to hypokalemia
- DO NOT administer Loperamide or Diphenoxylate — contraindicated
- Condition is self-limiting, typically resolves within 24–48 hours with supportive care
Veterinary
Canine: Leading cause of suburban yard mushroom poisonings in domestic dogs across Africa. Triggers hypovolemic shock and severe dehydration — fatal without prompt veterinary IV fluid therapy.
Feline: Severe gastrointestinal distress and rapid dehydration. Requires immediate veterinary triage.
Clinical Implications of Heavy Metal Co-Exposure
- More severe and prolonged GI symptoms than typical Chlorophyllum molybdites cases
- Risk of acute heavy metal toxicity: renal tubular injury (cadmium), neurotoxicity (lead), hepatotoxicity (chromium)
- Order serum lead, cadmium, and chromium levels in West African cases alongside standard GI workup
- Consider chelation consultation if heavy metal levels are elevated
Pathophysiology
Amatoxin mechanism — RNA polymerase II inhibition. Variable amatoxin concentration across specimens; treat all suspected cases as high-risk.
Diagnostic Flowchart — Onset Timing Differentiation
Symptom Onset Timing Algorithm
Onset UNDER 3 Hours
- Suspect neurotoxic Amanita syndrome OR Chlorophyllum molybdites
- Immediate GI decontamination, supportive care, monitor neurological status
- If neurological symptoms (seizures, altered consciousness): rule out Amanita muscaria/pantherina group
Onset OVER 6 Hours
- Suspect hepatotoxic amatoxin syndrome — Amanita loosii / Amanita masasiensis / Amanita phalloides
- Initiate full amatoxin ICU protocol IMMEDIATELY — do NOT wait for laboratory confirmation
- Begin Silibinin infusion, MDAC, NAC four-bag regimen
- Serial liver and renal function monitoring every 6 hours
Pediatric Fluid Formulas
- Fluid resuscitation: 10–20 mL/kg normal saline bolus, reassess every 30 minutes
- Maintenance fluids: 4 mL/kg/hour for first 10 kg, 2 mL/kg/hour for next 10 kg, 1 mL/kg/hour thereafter
- Activated charcoal: 0.5–1 g/kg every 4 hours via NG tube
- Monitor glucose — hypoglycemia common in pediatric amatoxin cases; correct with D10W infusion
Edible vs Toxic Lookalike Reference
| Edible Species | Toxic Lookalike | Key Differentiator |
|---|---|---|
| Termitomyces spp. (Termite mushroom) | Chlorophyllum molybdites | Termitomyces lacks green gills and green spore print; grows from termite mounds |
| Volvariella spp. (Straw mushroom) | Amanita phalloides / Amanita loosii | Volvariella lacks a ring; Amanita has both ring AND volva |
Nursing ICU Flowsheet — Amatoxin Protocol
| Frequency | Monitoring / Intervention |
|---|---|
| Hourly | Urine output (target 100–200 mL/hr), vital signs, GCS |
| Every 4 hours | Activated charcoal via NG tube, fluid balance assessment |
| Every 6 hours | PT/INR, AST/ALT, total bilirubin, creatinine, electrolytes |
| Daily | Abdominal ultrasound (hepatomegaly, ascites), transplant eligibility reassessment |
| Continuous | IV Silibinin infusion — document any interruptions as clinical events |
Bilingual Community Warning
Do not eat wild mushrooms from the forest or ground without expert identification. Some mushrooms that look safe can cause severe liver failure and death. If someone eats a wild mushroom and feels sick, call emergency services immediately — do not wait.
Ne consommez pas de champignons sauvages de la forêt ou du sol sans identification par un expert. Certains champignons d'apparence inoffensive peuvent provoquer une insuffisance hépatique grave et la mort. Si quelqu'un mange un champignon sauvage et se sent mal, appelez immédiatement les services d'urgence — n'attendez pas.
Poisons Information Helpline (routes to Tygerberg Hospital or Red Cross War Memorial Children's Hospital):
📞 0861 555 777
Ambulance: 🚑 10177 Mobile Emergency: 112
Referral: Tygerberg Hospital Poisons Information Centre (Western Cape); Chris Hani Baragwanath Academic Hospital (Gauteng)
Protocol: Delayed presentation >6 hours — immediate stabilization and fast-track to tertiary ICU with renal replacement capability
Centre Anti Poison et de Pharmacovigilance du Maroc (CAPM):
📞 0801 000 180
Ambulance: 🚑 150
Referral: Hôpital Militaire d'Instruction Mohammed V / CHU Ibn Sina, Rabat
Protocol: Delayed symptom window >6 hours — fast-track to nearest provincial tertiary ICU hub
Kenyatta National Hospital Emergency Hotline:
📞 +254 20 2726300
Referral: Clinical Toxicology Unit, Kenyatta National Hospital, Nairobi
Protocol: Severe ingestions — stabilize with immediate fluid management, route directly to KNH Nairobi or nearest regional referral teaching hospital with ICU capability
Species Covered in Multiple Regional Guides
- Amanita phalloides is also covered in: Europe guide, Russia guide, Australia guide, Brazil guide, Africa guide (this guide)
- Chlorophyllum molybdites is also covered in: Mexico guide, Puerto Rico guide, Australia guide, Brazil guide, Africa guide (this guide)
Clinical Discharge Summary Template / Modèle de Résumé de Sortie Clinique
[1] Patient Administrative Registration / Enregistrement Administratif du Patient
Patient Name / Nom du Patient:
National ID or Passport / N° d'Identité National ou Passeport:
Date of Admission / Date d'Admission: ___/___/_____
Date of Discharge / Date de Sortie: ___/___/_____
Referring Clinic / Clinique d'Origine:
[2] Clinical Diagnostic Summary / Résumé Diagnostique Clinique
Primary Diagnosis / Diagnostic Principal:
Secondary Complications / Complications Secondaires:
Key Biomarker Trends / Tendances des Biomarqueurs Clés:
Baseline Values / Valeurs de Base:
Peak Values / Valeurs Maximales:
Discharge Values / Valeurs à la Sortie:
[3] Inpatient Therapeutic Summary / Résumé Thérapeutique Hospitalier
Interventions Deployed / Interventions Déployées:
[4] Mandated Outpatient Follow-Up / Suivi Ambulatoire Obligatoire
Initial Review / Premier Examen: Date ___/___/_____
Secondary Review / Deuxième Examen: Date ___/___/_____
Long-Term Follow-Up / Suivi à Long Terme: Date ___/___/_____
[5] Regional Health Notification / Notification Sanitaire Régionale
This clinical record should be shared with relevant regional health authorities or specialized monitoring services as per local regulations. / Ce dossier clinique doit être partagé avec les autorités sanitaires régionales compétentes selon les réglementations locales.
Discharging Physician Name / Nom du Médecin:
Professional Registry Number / Numéro d'Ordre:
Signature & Institutional Stamp / Signature et Cachet Institutionnel: ______________________ Date: ___/___/_____
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