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1Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 06351 Seoul, Republic of Korea
2Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, 06355 Seoul, Republic of Korea
*Corresponding Author(s):taerim.j.kim@gmail.com (Taerim Kim)
| History | Submitted: 10 November 2022 | Accepted: 02 February 2023 | Published: 08 September 2023 |
| Copyright: | ©2023 The Author(s). Published by MRE Press. |
This study aimed to investigate the association of characteristics and clinical outcomes of patients who presented with mushroom intoxication. We conducted a retrospective study of mushroom intoxication cases using national registry data (representative of the period 01 January 2011 to 31 December 2019). Specifically, we analyzed the demographics, vital signs, mental status, intoxication related factors, and clinical presentations of the patients. The outcomes were assessed based on general ward admission, intensive care unit (ICU) admission, length of hospitalization, and mortality. The t-test or chi-square test were used to compare the emergency department (ED) discharge group and admission group. Logistic regressions were used to predict patients that were high-risk with regards to being admitted. A total of 393 patients with mushroom intoxication were presented at the ED, and the highest number of visits occurred in the month of September. Overall, 277 (70.5%) patients were discharged from the ED and 116 (29.5%) patients were admitted. Of these, 25 (6.4%) patients were admitted to the ICU, and 3 (2.6%) patients died. Patients are more likely to be admitted to the general ward or ICU when symptoms presented after 6 h: 6 to 24 h (Odds ratio (OR) 2.158; 95% Confidence interval (CI), 1.218–3.816) or >24 h (OR: 3.382; 95% CI, 1.438–8.050). Additionally, when the patients presented with diarrhea, they were more likely to be discharged with favorable outcomes with a less likelihood for admission (OR: 0.237; 95% CI, 0.093–0.523). Most cases of mushroom intoxication presented with gastrointestinal symptoms and followed a benign course. The longer time to onset of symptoms increased the likelihood of hospitalization. Clinicians should evaluate more carefully, observe, or admit those with delayed symptom onset.
Cite this article
Sejin Heo, Se Uk Lee, Sung Yeon Hwang, Hee Yoon, Gun Tak Lee, Jong Eun Park, Hansol Chang, Tae Gun Shin, Min Seob Sim, Ik Joon Jo, Won Chul Cha, Taerim Kim. Mushroom intoxications presented to emergency departments in South Korea: a 2011‐2019 national registry study. Signa Vitae. 2023; 19(5): 196-205. doi: 10.22514/sv.2023.086
1. Introduction
Currently, over 2000 species of mushrooms have been reported; however, among these, only approximately 400 species are edible in South Korea [1]. Mushrooms are a popular food considered for the overall well-being and Koreans consume a significant amount of mushrooms. Recently, with the increasing interest in trekking or mountain climbing during the COVID-19 pandemic, intoxication due to wild mushrooms has been increasing [2]. It is difficult to distinguish edible mushrooms from poisonous mushrooms; therefore, the picking and consumption of wild mushrooms should be carefully done [3].
Mushroom intoxication accounts for a small percentage of all patients who are present to the ED. Patients may present with gastrointestinal symptoms, often severe, which in rare case progress from dehydration to multiorgan system failure and death [4, 5, 6]. From 2012 to 2017, seven South Koreans died due to mushroom intoxication [7]. In a previously published single-center research, 23 patients presented with acute liver injury due to mushroom intoxication during a 11-year period [8].
Some studies highlighted the importance of identifying non-toxic and toxic mushroom species [9]. However, at the ED, identification of mushrooms is not readily availed, if at all. Most patients do not bring the mushrooms and cooking of the mushrooms causes disfiguration which affects its identification. Analysis of the sample by the poison center is rarely performed [1]. Moreover, there are no poison centers, which can test for ‘amatoxin’ in South Korea, although amatoxin being the most common mushroom-related toxin in the country [10, 11].
Because the cases were rare and the incidence varied across the country, emergency physicians often lacked experience in screening for and treating severe mushroom intoxication [12]. There is limited data on the clinical presentation and outcomes of mushroom intoxication at the ED. As of now, there are only case reports or case series of adult cases in certain settings.
The aim of this multicenter observational study was to provide the clinician with epidemiological data and a description of the clinical features, predicting admission, and clinical outcomes of mushroom poisoning, which may serve as the early warning signs for addressing this disease and to optimize the available resources for its management.
2. Materials and methods
2.1 Study design
This retrospective observational study evaluated the characteristics and affecting factors of the clinical outcomes of mushroom intoxication patients presented to the emergency room. We studied nine years of the national registry.
2.2 National registry
The data were collected retrospectively from the Emergency Department-Based Injury In-Depth Surveillance (EDIIS) in South Korea. The EDIIS is a high-quality national injury registry which was initiated from 2006 that includes all injured patients admitted to the 25 EDs across South Korea. EDIIS had been developed and operated by Korea Centers for Disease Control and Prevention (KCDC). KCDC selected EDs based on the location of hospital (rural or urban), level of hospital, trauma centers, hospitals with toxicology centers, and so on. On an average, 200,000 patients with all kinds of injury visit ED and are enrolled in the registry annually. This registry includes basic demographics, prehospital data, clinical findings, diagnosis based on the International Classification of Disease 10th Revision (ICD-10), ED disposition, and patient outcomes after admission. The site coordinators collected data from the electronic medical records. Each ED has coordinators for collecting standard data, and the KCDC monitors the quality of the data on a monthly basis. The coordinators participating in the survey were expected to follow-up the outcome once more within 2 weeks of the entire missing or invalid survey target patients, and the date of diagnosis, detailed diagnosis according to ICD-10 code, surgery date, and types were listed [13, 14].
2.3 Participants
We included the records of patients who presented with mushroom poisoning from 01 January 2011 to 31 December 2019. Fig. 1 describes the patients’ selection. We selected patients who presented with intoxication. Subsequently, we extracted the cases in which the poisonous material was mushroom and excluded cases in which explicit documentation regarding edible mushroom cases was present.
Fig. 1.Patient selection diagram. ED, emergency department.
2.4 Measure
We investigated the patient demographics, initial vital signs, mental status, intoxication-related factors, date, and time-related information. The demographics included age and sex. Furthermore, 65 years of age was set as the cutoff point, as this age has been linked with high mortality with respect to acute poisoning [15, 16]. The vital signs included systolic and diastolic blood pressures, pulse rate, respiratory rate, and body temperature. The mental status data were described as “awake, verbal, pain, and unresponsive” on an AVPU scale. The intoxication related factors included alcohol-related factors, identity of the intoxicating mushroom, type of toxin, and symptoms. The time related factors included season, symptom onset time since ingestion, visit or discharge date, length of hospitalization. An investigation of the ICU admission cases was performed.
2.5 Outcomes
The intoxication outcomes were assessed based on the patient disposition at the ED, length of hospitalization, general ward admission, ICU admission, and mortality. Moreover, we investigated clinical outcomes based on time to symptom onset as a secondary outcome. We divided the interval from mushroom ingestion to the onset of the first symptoms of poisoning based on previous studies [9]. Thereafter, we investigated the clinical outcomes in terms of time to symptom onset as <6 h, 6 to 24 h, and over 24 h. Mortality is calculated by combining ED deaths and death after admission.
2.6 Statistical analysis
All continuous variables were described as the mean (standard deviation) and categorical variables as n (%). To test for normality, we performed the Shapiro-Wilk test. For continuous variables, we used the t-test or Wilcoxon rank sum test; for categorical values, we used the chi-square test or Fisher’s exact test, as appropriate. We used a proportion test, or Kruskal-Wallis test and a post-hoc analysis to compare clinical outcomes between three groups from the time of symptom onset. We conducted a univariable and multivariable logistic analysis to identify factors associated with admission. We included age, sex, and several types of clinical presentations to construct a logistic regression model. We selected variables for multivariable logistic regression using the forward stepwise selection method. Finally, we selected clinically-relevant variables such as age, sex, time until symptom onset, and variables that exhibited a p-value > 0.1 in univariable analysis. This was performed to apply the multivariable logistic regression model. The results were presented with an odds ratio (OR) and a 95% confidence interval (CI). For all statistical analyses, a p-value < 0.05 was considered as statistically significant. Statistical analyses were performed using R Software (version 4.1.2, the R Foundation for Statistical Computing, Vienna, Austria, https://www.R-project.org).
3. Results
3.1 General characteristics
During the study period, 393 patients with mushroom intoxication visited the ED. Table 1 presents the general characteristics and clinical outcomes of the study population. The mean (SD) age was 56.7 (14.1) years and 51.4% were men. A majority of mushroom intoxication events occurred during the summer and autumn, comprising 95.9% of the total patients. Intoxications frequently occurred in September, that is, 154 (39.2%) cases (Fig. 2).
| Characteristic | Overall (n = 393) | ED discharge (n = 277) | Admission (n = 116) | p value | |
| Age, n (%) | |||||
| <65-year-old | 288 (73.3) | 215 (77.6) | 73 (62.9) | 0.004 | |
| ≥65-year-old | 105 (26.7) | 62 (22.4) | 43 (37.1) | ||
| Sex, n (%) | |||||
| Male | 202 (51.4) | 136 (49.1) | 66 (56.9) | 0.099 | |
| Female | 191 (48.6) | 141 (50.9) | 50 (43.1) | ||
| Insurance, n (%) | |||||
| National health insurance | 374 (95.2) | 264 (95.3) | 110 (94.8) | 0.548 | |
| Medical care beneficiary | 11 (2.8) | 9 (3.3) | 2 (1.7) | ||
| Othersa | 8 (2.0) | 4 (1.4) | 4 (3.4) | ||
| Season (months) of ED visit, n (%) | |||||
| Spring (3, 4, 5) | 11 (2.8) | 8 (2.9) | 3 (2.5) | 0.005 | |
| Summer (6, 7, 8) | 155 (39.4) | 94 (33.9) | 61 (52.6) | ||
| Autumn (9, 10, 11) | 222 (56.5) | 171 (61.7) | 51 (44.0) | ||
| Winter (12, 1, 2) | 5 (1.3) | 4 (1.4) | 1 (0.9) | ||
| Mode of arrival, n (%) | |||||
| EMS (119) | 99 (25.2) | 65 (23.5) | 34 (29.3) | 0.007 | |
| hospital ambulance | 19 (4.8) | 9 (3.2) | 10 (8.6) | ||
| Private ambulance | 23 (5.9) | 12 (4.3) | 11 (9.5) | ||
| Walk-in | 11 (2.8) | 10 (3.6) | 1 (0.9) | ||
| Othersb and unknown | 241 (61.3) | 181 (65.3) | 60 (51.7) | ||
| Alcohol use, n (%) | |||||
| No evidence of alcohol use | 367 (93.4) | 259 (93.6) | 108 (93.1) | 0.809 | |
| No information available | 5 (1.3) | 4 (1.4) | 1 (0.9) | ||
| Alcohol use by the poisoned person | 19 (4.8) | 12 (4.3) | 7 (6.0) | ||
| Alcohol use by both poisoned person and other person(s) involved | 2 (0.5) | 2 (0.7) | 0 (0.0) | ||
| Initial vital sign, n (%) | |||||
| Systolic blood pressure <90 mmHg | 7 (1.8) | 1 (0.4) | 6 (5.2) | 0.004 | |
| Diastolic blood pressure <60 mmHg | 18 (4.6) | 6 (2.2) | 12 (10.3) | 0.001 | |
| Mean blood pressure <65 mmHg | 9 (2.3) | 1 (0.4) | 8 (6.9) | <0.001 | |
| Pulse rate >120 beats/min | 26 (6.6) | 14 (5.1) | 12 (10.3) | 0.090 | |
| Respiratory rate >20 breaths/min | 25 (6.4) | 12 (4.3) | 13 (11.2) | 0.021 | |
| Body temperature ≥38.0 °C | 2 (0.5) | 0 (0.0) | 2 (1/7) | 0.087 | |
| Initial mental status, n (%)** | |||||
| Awake | 326 (82.9) | 235 (84.8) | 91 (78.4) | 0.002 | |
| Verbal | 13 (3.3) | 7 (2.5) | 6 (5.2) | ||
| Pain | 7 (1.8) | 1 (0.4) | 6 (5.2) | ||
| Unresponsive | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
| Unknown | 47 (12.0) | 34 (12.3) | 13 (11.2) | ||
| Abbreviations: ED, emergency department; EMS, emergency medical service; LOS: length of stay. Othersa; self-pay, others, and unknown Othersb; different types of transportation (electric wheelchair, motorized vehicle, bicycle). |
Fig. 2.Emergency department visits for mushroom intoxication by month. ED: emergency department.
Most patients arrived to the ED in vehicles and only 11 (2.8%) patients arrived by walking. A total of 99 (25.2%) patients arrived through emergency medical services (EMS) and 43 patients (10.7%) used a private or hospital ambulance. Most patients presented with stable vital signs at the initial ED triage. The mean with SD of each vital sign was as follow: systolic blood pressure, 134.3 (26.2); diastolic blood pressure, 80.3 (15.6); pulse rate, 81.8 (13.8); respiratory rate, 18.9 (2.2); and body temperature, 36.5 (0.5). At ED triage, 326 (82.9 %) patients were alert (mental state), and no patients were unresponsive. Eleven (2.8%) patients presented psychiatric symptoms such as hallucination, aggressive behavior, and allergic symptoms such as skin rash (1.3%) and facial swelling (1.3%).
3.2 Clinical presentation and outcomes
Table 2 shows the clinical presentation and outcomes of the study population. Overall, 277 (70.5%) patients were discharged from the ED and 116 (29.5%) patients were admitted. Of these, 25 (6.4%) patients were admitted to the intensive care unit (ICU), and 3 (2.6%) patients died. The mean ED length of stay (LOS) was 6.4 (5.3) h. In the admission group, the mean in-hospital LOS was 3.1 (7.4) days.
Half of the patients presented with gastrointestinal symptoms. Notably, 192 (48.9%) patients presented with vomiting, over 15% patients reported nausea, abdominal pain, and diarrhea. The other symptoms that were common were neurologic symptoms (most common was dizziness or lethargy, 39 (9.9%)) and cardiology symptoms (most common was palpitation, 26 (6.6%)). Additionally, psychiatric symptoms and allergy symptoms were observed to be less frequent (under 2% of patients) and the frequency was similar between the groups.
| Characteristic | Overall (n = 393) | ED discharge (n = 277) | Admission (n = 116) | p value | |
| Time to symptom onset, n (%) | |||||
| <6 h | 278 (70.7) | 212 (76.5) | 60 (51.7) | <0.001 | |
| 6 to 24 h | 81 (20.6) | 51 (18.4) | 30 (25.9) | ||
| >24 h | 32 (8.2) | 13 (4.7) | 19 (16.5) | ||
| Unknown | 2 (0.5) | 1 (0.4) | 1 (0.9) | ||
| GI symptoms, n (%) | |||||
| Vomiting | 192 (48.9) | 142 (51.3) | 50 (43.1) | 0.261 | |
| Nausea | 74 (18.8) | 55 (19.9) | 19 (16.4) | 0.484 | |
| Abdominal pain | 60 (15.3) | 41 (14.8) | 19 (16.4) | 0.689 | |
| Diarrhea | 64 (16.3) | 55 (19.9) | 9 (7.8) | 0.007 | |
| None of symptoms | 158 (40.2) | 107 (38.6) | 51 (44.0) | 0.384 | |
| Neurologic symptoms, n (%) | |||||
| Dizziness or lethargy | 39 (9.9) | 28 (10.1) | 11 (9.5) | 0.997 | |
| General weakness | 11 (2.8) | 7 (2.5) | 4 (3.4) | 0.519 | |
| Dysarthria | 6 (1.5) | 5 (1.8) | 1 (0.9) | 0.030 | |
| Headache | 11 (2.8) | 7 (2.5) | 4 (3.4) | 0.519 | |
| Confused mentality | 11 (2.8) | 2 (0.7) | 9 (7.8) | <0.001 | |
| Othersa | 7 (1.8) | 3 (1.1) | 4 (3.4) | 0.878 | |
| None of symptoms | 325 (82.7) | 240 (86.6) | 85 (72.6) | 0.002 | |
| Cardiologic symptoms, n (%) | |||||
| Palpitation | 26 (6.6) | 14 (5.1) | 12 (10.3) | 0.127 | |
| Hypotension | 19 (4.8) | 6 (2.1) | 13 (11.2) | <0.001 | |
| Sweating | 2 (0.5) | 2 (0.7) | 0 (0.0) | NA | |
| Chest discomfort | 7 (1.8) | 6 (2.2) | 1 (0.9) | 0.678 | |
| Dyspnea | 8 (2.0) | 7 (2.5) | 1 (0.9) | 0.448 | |
| None of symptoms | 335 (85.2) | 246 (88.8) | 89 (76.7) | 0.003 | |
| Psychiatric symptoms, n (%) | |||||
| Hallucination | 5 (1.3) | 2 (0.7) | 3 (2.6) | 0.154 | |
| Othersb | 6 (1.5) | 0 (0.0) | 6 (5.2) | NA | |
| None of symptoms | 386 (98.2) | 275 (99.3) | 111 (95.7) | 0.030 | |
| Allergic symptoms, n (%) | |||||
| Skin rash | 5 (1.3) | 4 (1.4) | 1 (0.9) | 1.000 | |
| Facial swelling | 5 (1.3) | 2 (0.7) | 3 (2.6) | 0.154 | |
| Flushing | 1 (0.3) | 1 (0.4) | 0 (0.0) | NA | |
| None of symptoms | 9 (2.3) | 271 (97.8) | 113 (97.4) | 0.730 | |
| ED LOS, hour, Median (IQR) | 3.7 (4.9) | 3.7 (2.6) | 3.8 (5.9) | 0.510 | |
| Abbreviations: LOS, length of stay. ED, emergency department. GI, Gastrointestinal. IQR, Interquartile Range. Othersa; numbness, lateralizing sign, blurred vision, Othersb; euphoria, agitation, aggressive behavior, abnormal behavior. |
3.3 Predicting factors to admission
The patients were more likely to be admitted to the general ward or ICU when the symptoms presented after 6 h: 6 to 24 h (OR: 2.158; 95% CI, 1.218–3.816) or over 24 h (OR: 3.382; 95% CI, 1.438–8.050). Additionally, when patients presented with diarrhea, the patients were more likely to be discharged with favorable outcomes showing less likelihood to admission (OR: 0.237; 95% CI, 0.093–0.523) (Table 3).
| Univariate | Multivariate | ||||||
| OR | 95% CI | p value | OR | 95% CI | p value | ||
| Age | |||||||
| <65 y | (Reference) | 0.524 | (Reference) | 0.102 | |||
| ≥65 y | 1.188 | 0.624–2.220 | 0.984 | 0.966–1.003 | |||
| Sex | |||||||
| Female | (Reference) | 0.149 | (Reference) | 0.772 | |||
| Male | 0.651 | 0.371–1.130 | 0.722 | 0.416–1.242 | |||
| Time to symptom onset, n (%) | |||||||
| <6 h | (Reference) | (Reference) | |||||
| 6 to 24 h | 2.089 | 1.055–4.125 | 0.023 | 2.158 | 1.218–3.816 | 0.010 | |
| >24 h | 3.993 | 1.356–11.935 | 0.037 | 3.382 | 1.438–8.050 | 0.003 | |
| Unknown | 1.954 | 0.070–54.202 | 0.824 | 2.622 | 0.103–67.014 | 0.799 | |
| Initial mental status, n (%) | |||||||
| Awake | (Reference) | ||||||
| Verbal | 0.765 | 0.135–3.644 | 0.715 | ||||
| Pain | 7.398 | 0.858–170.035 | 0.115 | ||||
| Unresponsive | 0.104 | 0.002–1.188 | 0.148 | ||||
| GI symptoms | |||||||
| Vomiting | |||||||
| No | (Reference) | ||||||
| Yes | 0.673 | 0.250–1.881 | 0.422 | ||||
| Nausea | |||||||
| No | (Reference) | ||||||
| Yes | 1.030 | 0.463–2.229 | 0.855 | ||||
| Abdominal pain | |||||||
| No | (Reference) | ||||||
| Yes | 1.181 | 0.472–2.858 | 0.688 | ||||
| Diarrhea*** | |||||||
| No | (Reference) | (Reference) | |||||
| Yes | 0.210 | 0.072–0.532 | 0.003 | 0.237 | 0.093–0.523 | <0.001 | |
| Neurologic symptoms, n (%) | |||||||
| No | (Reference) | ||||||
| Yes | 1.587 | 0.686–3.639 | 0.280 | ||||
| Cardiologic symptoms, n (%) | |||||||
| No | (Reference) | ||||||
| Yes | 1.477 | 0.500–4.348 | 0.480 | ||||
| Psychiatric symptoms, n (%) | |||||||
| No | (Reference) | ||||||
| Yes | 3.118 | 0.455–32.500 | 0.259 | ||||
| Allergic symptoms, n (%) | |||||||
| No | (Reference) | ||||||
| Yes | 0.187 | 0.004–2.939 | 0.312 | ||||
| OR, odds ratio; CI, confidence interval; GI, Gastrointestinal. |
3.4 Clinical outcomes based on time to symptom onset
Table 4 shows the clinical outcomes according to the time to symptom onset. Notably, ≥70% patients with mushroom poisoning experienced symptoms within 6 h of ingestion. Eighty one (20.6%) patients presented with symptoms 6 to 24 h after consumption, whereas 32 (8.2%) patients reported symptoms over 24 h after ingestion. The rate of ICU admission was significantly different depending on the onset of symptoms. Eight of 31 (25.8%) patients who reported symptoms after 24 h were admitted to the ICU, compared to only 14 of 274 (5.1%) patients who presented with symptoms within 6 h (p < 0.001). Among hospitalized patients, the LOS was increased when the symptom onset was delayed. The mean (SD) LOS for patients who reported symptoms within 6 h was 1.4 (1.3) days. However, when symptoms appeared after 6 h, the hospital stays were longer, that is, 2.3 (4.0) days in the 6–24-h group and 9.7 (15.5) days in >24-h group. Two deaths occurred in the group whose symptoms appeared between 6 and 24 h, whereas one person died in the group whose symptoms appeared after 24 h.
| Clinical outcomes | Group I (n = 274) | Group II (n = 80) | Group III (n = 31) | p value | Post hoc analysis | ||
| I vs. II | I vs. III | II vs. III | |||||
| General ward admission, n (%) | 52 (19.0) | 25 (31.3) | 11 (35.5) | 0.015 | 0.086 | 0.165 | 1.000 |
| ICU admission, n (%) | 14 (5.1) | 6 (6.2) | 8 (25.8) | <0.001 | 1.000 | <0.001 | 0.070 |
| Hospital Length of stay, day, median (IQR) | 1.1 (1.1) | 2.3 (1.2) | 4.9 (7.1) | <0.001 | 0.030 | <0.001 | <0.001 |
| Death | 0 (0.0) | 2 (2.5) | 1 (3.2) | 0.5637 | - | - | - |
| IQR, Interquartile Range; ICU, Intensive Care Unit. Group I; <6 h, Group II; 6 to 24 h, Group III; >24 h. |
3.5 ICU admission cases
We conducted an in-depth investigation of 25 cases who were admitted to the ICU. Notably, 19 of the 25 (76.0%) patients were men. Only 10 cases were documented as mushroom poisoning of the following species: Podostroma cornu-damae (3), Amanita species (3), Macrolepiota neomastoidea (3), Ramaria species (1), Maegacollybia platyphylla (1). The hospital deaths included two cases due to Podostroma cornu-damae intoxication and one case from Ramaria species. Over 50% of the patients presented with vomiting as the most common symptom, followed by an altered mental status. Additional detailed data have been presented in online Supplementary material.
4. Discussion
We conducted 9 years of surveillance of mushroom intoxication in South Korea. To the best of our knowledge, this is the first study to address cases of mushroom intoxication presented to the EDs in South Korea. We identified 393 cases and most cases occurred during summer and autumn. Almost all the cases showed a benign course, only 25 (6.3%) cases required ICU care and 3 patients died.
Two death cases were identified as being due to Podostroma cornu-damae poisoning and one case was suspected with Ramaria species. Podostroma cornu-damae grow around tree stumps in summer and autumn. These mushrooms contain a toxin called trichothecene. Acute poisoning caused by trichothecene varies from gastrointestinal symptoms to epidermal exfoliation of the skin or mucous membranes at the site where the toxin has touched the skin to multiorgan failure [17, 18]. Podostroma cornu-damae intoxication was rare and only several reports in the literature. According to previous reports, the symptom onset was various from within 6 hours after eating mushroom to over a day. Most patients presented severe pancytopenia and desquamation on skins, multi-organ failure, and sepsis due to prolonged neutropenia over times. Only one patient was discharged on hospital day (HD) 27, other patients died on HD 6 and HD 13 due to severe pancytopenia and retractable multiorgan failure, respectively [19, 20].
All three cases due to Podostroma cornu-damae intoxication in this study presented with hypotension at the initial ED triage. One of them presented with allergic symptoms, such as facial swelling, dyspnea, and itching, and was discharged 5.7 days after admission. Similarly, in 2013, a case had been reported in South Korea that was confused with hypersensitivity at the initial stage and was finally diagnosed with Podostroma cornu-damae intoxication [21]. We suggest that physicians have to pay more attention when patients who consumed mushrooms showed allergic symptoms combined with hypotension and Podostroma cornu-damae intoxication should be suspected [22].
The other case of death was suspected to be due to the Ramaria species. Ramaria species are well-known edible mushrooms; however, R. formosa intoxication reportedly induced lethal gastrointestinal symptoms, such as diarrhea, vomiting, and abdominal pain in an animal study [23]. As the morphology is similar to that of the edible Ramaria species, even an expert would face difficulty in distinguishing these two species [24].
We found that some characteristics were statistically different between the ED discharge and admission groups. For example, in the ED discharge group, the most common season for ER visits was autumn, whereas summer was the most common season for the admission group. Additionally, in the admission group, more patients arrived at the ED via the EMS system or other ambulances than in the discharge group. Patients in the admission group had a more severely impacted mental status, blood pressure, and respiratory rate when they arrived at the ED than patients in the ED discharge group. Other factors, such as sex, insurance, pulse rate, and body temperature were not different between the two groups at the initial stage.
We identified that the time from ingestion to symptom onset and diarrhea were the associated factors ED disposition. Most patients who presented with diarrhea were discharged from the ED. We deduced that patients with benign progression of mushroom intoxication were more likely to present GI symptoms; overall, this pattern manifested itself in patients with diarrhea having more ED discharges. Some patients with dysarthria or hallucinations were discharged from the ED. This observation was impacted by factors such as ED treatment, an observation unit before hospitalization, etc. However, we could not investigate further to evaluate the suitability of ED treatment and admission due to the anonymous nature of the registry we used.
As with previous studies, a delayed symptom onset (>6 h after ingestion) was associated with serious and potentially lethal toxicity [25, 26, 27]. This study showed the same findings supporting the results of previous studies. When symptom onset was delayed, the admission to ICU was observed, and the hospital LOS was prolonged.
The classification of poisonings according to their clinical manifestations has been found to assist in the diagnosis and treatment of poisoning [1, 26, 28]. In this study, however, more than half of the patients reported GI symptoms; additionally, non-specific symptoms, such as general weakness, were prevalent, causing difficulty in the identification of cases according to the clinical symptoms. In some previous studies, diarrhea was found to cause dehydration and severe renal failure [10, 29]. In this study, diarrhea was not related to admission.
A few cases of mushroom poisoning resulted in life-threatening conditions, although it is uncommon [30, 31]. Mushroom intoxication varied by region and climate; therefore, a nationwide surveillance of mushroom intoxication would be useful in determining its overall characteristics and the population with the largest need for special attention.
This study has some limitations. Information of poisonous toxic mushrooms were unavailable in most cases. Only 30 cases were documented with the types of intoxicating mushrooms. This reflected the difficulty in distinguishing the mushroom type in the ED environment. Therefore, when patients arrived at the ED, physicians should have been attentive to the history of ingestion and the timing associated with the onset of symptoms that may indicate consumption of a more lethal variety of mushroom toxins. In addition, educating the public to bring in ingested fungal remains would improve diagnostic outcomes (i.e., in terms of increasing the frequency of accurate fungal identifications by emergency department referring mycologists).
Because of the observational nature of the study and the limitations of the registry, we did not have access to the lab findings or final diagnoses. Hence, we did not specify complications, such as acute kidney injury or acute liver failure. This limitation could bias the analysis of predictive factors linked to poor prognosis.
In this retrospective study, we did not include all the EDs of South Korea. Thus, it may not cover all instances of mushroom intoxication, as very mild or severe cases may not have visited the ED or have resulted in immediate death. In addition, mortality outside of the hospital could not be confirmed because the discharged patients were not followed up.
5. Conclusions
In the ED environment, the time from ingestion to symptom onset was a reliable predictor of admission, ICU admission, and prolonged hospitalization. Overall, clinicians should carefully evaluate, observe, or admit those with delayed symptom onset.
Availability of data and materials
Due to Korea Centers for Disease Control and Prevention regulations, the raw data for deep learning are not publicly available. Upon reasonable request, the corresponding author can provide simulation examples and data that support the findings of this study.
Author contributions
TK—Conceptualization. SH, SYH and HY—Data curation. SH, GTL and JEP—Formal analysis. HS and TGS—Investigation. SUL and MSS—Methodology. IJJ—Visualization. SH—Writing-original draft. SH, TK and WCC—Writing-review & editing.
Ethics approval and consent to participate
This study was approved by the Institutional Review Board (IRB) of Samsung Medical Center, IRB No. 2022-05-152. Informed consent was waived by the IRB due to the retrospective design.
Acknowledgment
Not applicable.
Funding
This work was supported by funding from the Korea Disease Control and Prevention Agency (KDCA), Republic of Korea.
Conflict of interest
The authors declare no conflict of interest. Won Chul Cha is serving as one of the Editorial Board members of this journal. We declare that Won Chul Cha had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to OK.
Supplementary material
Supplementary material associated with this article can be found, in the online version, at https://oss.signavitae.com/mre-signavitae/article/1699971693498253312/attachment/Supplementary%20material.docx.
