We describe a 49 year old male admitted with acute liver failure from likely Amanita phalloides poisoning, treated with NIH clinical trial protocol.

Case Presentation:

The patient is a 49 year old male with a history of chronic untreated hepatitis B and intraductal papillary mucinous neoplasm of the pancreas who initially presented to an outside hospital (OSH) with intractable nausea and non-bloody, non-bilious vomiting that began twelve hours after eating seven gray-white mushrooms from his backyard.

On initial presentation to the OSH, his hepatic function panel and coagulation markers were within normal limits. He was treated symptomatically with intravenous (IV) fluids and anti-emetics. Subsequently, he developed significantly elevated serum aminotransferases. On day 4 after ingestion, he was transferred to our hospital with concern for fulminant hepatitis and consideration for liver transplantation. On transfer, his aspartate aminotransferase (AST) was 4217 U/L, alanine aminotransferase (ALT) was 7385 U/L, alkaline phosphatase (ALP) was 105 U/L, total bilirubin (Tbili) was 5.0 mg/dL, and international normalized ratio (INR) was 5.91. N-acetylcysteine (NAC) was briefly started at the OSH, but discontinued due to insufficient evidence in the setting of presumed amatoxin poisoning. On admission to our institution, he was awake and oriented, with normal vital signs. He denied any abdominal pain, nausea, vomiting, or confusion. Ultrasound and MRI of the abdomen did not show evidence of intra- or extrahepatic biliary dilatation. He took no chronic medication, including acetaminophen. Alcohol and drug screen was negative. Hepatitis panel showed a Hepatitis B DNA viral load of 3100 IU/mL; reactive Hepatitis B surface antigen and Be antibody; and non-reactive Hepatitis Be antigen. Although it was unlikely that Hepatitis B was a contributing factor to the liver failure given the low viral load, he was started on tenofovir disoproxil on day 7 after ingestion. Based on his ingestion of home-grown mushrooms prior to symptom onset, amatoxin poisoning from Amanita phalloides was highest on the differential diagnosis.