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Psilocybe and others

1. NAME
   1.1 Scientific name
   1.2 Family
   1.3 Common name(s) and synonym(s)
2. SUMMARY
   2.1 Main risks and target organs
   2.2 Summary of clinical effects
   2.3 Diagnosis
   2.4 First aid measures and management principles
   2.5 Poisonous parts
   2.6 Main toxins
3. CHARACTERISTICS
   3.1 Description of the fungus
      3.1.1 Special identification features
      3.1.2 Habitat
      3.1.3 Distribution
   3.2 Poisonous parts of the fungus
   3.3 The toxin(s)
      3.3.1 Name(s)
      3.3.2 Description, chemical structure, stability
      3.3.3 Other physico-chemical characteristics
   3.4 Other chemical contents of the fungus
4. USES/CIRCUMSTANCES OF POISONING
   4.1 Uses
      4.1.1 Uses
      4.1.2 Description
   4.2 High risk circumstances
   4.3 High risk geographical areas
5. ROUTES OF EXPOSURE
   5.1 Oral
   5.2 Inhalation
   5.3 Dermal
   5.4 Eye
   5.5 Parenteral
   5.6 Others
6. KINETICS
   6.1 Absorption by route of exposure
   6.2 Distribution by route of exposure
   6.3 Biological halflife by route of exposure
   6.4 Metabolism
   6.5 Elimination and excretion
7. TOXINOLOGY
   7.1 Mode of action
   7.2 Toxicity
      7.2.1 Human data
         7.2.1.1 Adults
         7.2.1.2 Children
      7.2.2 Relevant Animal data
      7.2.3 Relevant in vitro data
   7.3 Carcinogenicity
   7.4 Teratogenicity
   7.5 Mutagenicity
   7.6 Interactions
8. TOXICOLOGICAL ANALYSES AND BIOMEDICAL INVESTIGATIONS
   8.1 Material sampling plan
      8.1.1 Sampling and specimen collection
         8.1.1.1 Toxicological analyses
         8.1.1.2 Biomedical analyses
         8.1.1.3 Arterial blood gas analysis
         8.1.1.4 Haematological analyses
         8.1.1.5 Other (unspecified) analyses
      8.1.2 Storage of laboratory samples and specimens
         8.1.2.1 Toxicological analyses
         8.1.2.2 Biomedical analyses
         8.1.2.3 Arterial blood gas analysis
         8.1.2.4 Haematological analyses
         8.1.2.5 Other (unspecified) analyses
      8.1.3 Transport of laboratory samples and specimens
         8.1.3.1 Toxicological analyses
         8.1.3.2 Biomedical analyses
         8.1.3.3 Arterial blood gas analysis
         8.1.3.4 Haematological analyses
         8.1.3.5 Other (unspecified) analyses
   8.2 Toxicological Analyses and Their Interpretation
      8.2.1 Tests on toxic ingredient(s) of material
         8.2.1.1 Simple Qualitative Test(s)
         8.2.1.2 Advanced Qualitative Confirmation Test(s)
         8.2.1.3 Simple Quantitative Method(s)
         8.2.1.4 Advanced Quantitative Method(s)
      8.2.2 Tests for biological specimens
         8.2.2.1 Simple Qualitative Test(s)
         8.2.2.2 Advanced Qualitative Confirmation Test(s)
         8.2.2.3 Simple Quantitative Method(s)
         8.2.2.4 Advanced Quantitative Method(s)
         8.2.2.5 Other Dedicated Method(s)
      8.2.3 Interpretation of toxicological analyses
   8.3 Biomedical investigations and their interpretation
      8.3.1 Biochemical analysis
         8.3.1.1 Blood, plasma or serum
         8.3.1.2 Urine
         8.3.1.3 Other fluids
      8.3.2 Arterial blood gas analyses
      8.3.3 Haematological analyse
      8.3.4 Interpretation of biomedical investigations
   8.4 Other biomedical (diagnostic) investigations and their interpretation
   8.5 Overall interpretation of all toxicological analyses and toxicological investigations
   8.6 References
9. CLINICAL EFFECTS
   9.1 Acute poisoning
      9.1.1 Ingestion
      9.1.2 Inhalation
      9.1.3 Skin exposure
      9.1.4 Eye contact
      9.1.5 Parenteral exposure
      9.1.6 Other
   9.2 Chronic poisoning
      9.2.1 Ingestion
      9.2.2 Inhalation
      9.2.3 Skin exposure
      9.2.4 Eye contact
      9.2.5 Parenteral exposure
      9.2.6 Other
   9.3 Course, prognosis, cause of death
   9.4 Systematic description of clinical effects
      9.4.1 Cardiovascular
      9.4.2 Respiratory
      9.4.3 Neurological
         9.4.3.1 Central nervous system (CNS)
         9.4.3.2 Peripheral nervous system
         9.4.3.3 Autonomic nervous system
         9.4.3.4 Skeletal and smooth muscle
      9.4.4 Gastrointestinal
      9.4.5 Hepatic
      9.4.6 Urinary
         9.4.6.1 Renal
         9.4.6.2 Other
      9.4.7 Endocrine and reproductive systems
      9.4.8 Dermatological
      9.4.9 Eye, ear, nose, throat: local effects
      9.4.10 Haematological
      9.4.11 Immunological
      9.4.12 Metabolic
         9.4.12.1 Acid-base disturbances
         9.4.12.2 Fluid and electrolyte disturbances
         9.4.12.3 Others
      9.4.13 Allergic reactions
      9.4.14 Other clinical effects
      9.4.15 Special risks
   9.5 Other
   9.6 Summary
10. MANAGEMENT
   10.1 General principles
   10.2 Life supportive procedures and symptomatic/specific treatment
   10.3 Decontamination
   10.4 Enhanced elimination
   10.5 Antidote/antitoxin treatment
      10.5.1 Adults
      10.5.2 Children
   10.6 Management discussion
11. ILLUSTRATIVE CASES
   11.1 Case reports from literature
12. Additional information
   12.1 Specific preventive measures
   12.2 Other
13. REFERENCES
14. AUTHOR(S), REVIEWER(S) DATA (INCLUDING EACH UPDATING), COMPLETE ADDRESSES
    PSILOCYBE AND OTHERS

    International Programme on Chemical Safety
    Poisons Information Monograph (Group monograph) G027
    Fungi

    Please note that further information on Sections 1, 3 and 8 is
    pending.

    1.  NAME

        1.1  Scientific name

             The psilocybin-containing species known to cause the
             majority of toxic exposures are:

             Psilocybe
             Panaeolus
             Copelandia
             Gymnopilus
             Pluteus
             Conocybe

             The main toxin is psilocybin.

        1.2  Family

             Families:  Genera:

             Strophariaceae            Psilocybe
             Coprinaeceae              Panaeolus,
                                            Copelandia
             Cortinariaceae            Gymnopilus
             Pluteaceae                Pluteus
             Bolbitiaceae              Conocybe

        1.3  Common name(s) and synonym(s)

    2.  SUMMARY

        2.1  Main risks and target organs

             The main toxins (psilocybin, psilocin, baeocystin,
             norbaeocystin) exert neurotoxic effects similar to those of
             LSD.  They all have a chemical structure closely related to
             serotonin and affect central and probably  also peripheral
             5-HT receptors, resulting in transient central nervous system
             symptoms, e.g. hallucinations, euphoria, anxiety and
             agitation. 
    

             Recently, the presence of phenylethylamine in Psilocybe
             semilanceata has been demonstrated and it is suggested that
             unwanted reactions may be ascribed to this substance. 

        2.2  Summary of clinical effects

             The onset of symptoms occur within 20 to 30 (to 60)
             minutes. The onset may even be more rapid if the mushrooms
             are prepared as a liquid (e.g. tea or soup).  A few cases of
             intravenous injection of mushroom juice are reported. The
             intoxication culminates 1.5 hours after the ingestion and
             subsides within 6 to 12 hours.
    
             Central nervous symptoms dominate with visual and auditory 
             hallucinations.  Also tactile hallucinations may occur. 
             Another common symptom is disturbed sensory perception like
             visual distorsions, e.g. heightened awareness of colours and
             a sensation of objects changing shape and/or somatic
             sensations such as numbness or tingling in the skin.  One
             case of prolonged (more than 24 hours) unilateral
             paraesthesiae affecting face and arm is described.  Body
             image distorsions, depersonalization, derealization and
             altered time and space sense are also frequent phenomena.
             
    
             Emotional alterations such as euphoria, anxiety, agitation
             and panic attacks often occur  and the latter reactions are
             the most common reasons for seeking medical attention. 
             Physical injury related to uncontrolled behaviour induced by
             agitation and panic poses the greatest risk for the patient.
             
    
             Somatic signs of intoxication are mydriasis, tachycardia,
             hypertension, hyperreflexia, nausea and vomiting. Flushing of
             the face may also be seen. Incontinence of urine occurs. One
             case of Psilocybe semilanceata intoxication resulting in
             seizures, cardiopulmonary arrest and myocardial infarction is
             reported.  Precordial ST-elevations have been observed in a
             young, earlier healthy patient.
    
             Chills, rigors, dyspnea, impaired oxygenation, headache,
             arthralgia, myalgia, fever, nausea, vomiting, diarrhoea and
             laboratory signs of hepatic and renal abnormalities have
             occurred after intravenous exposure.
    
             Delayed reactions (flash-backs) up to 4 months after
             ingestion of the mushroom have been reported by several
             authors.
    

             End-stage renal failure following confusing toxic fungi
             belonging to the genus Cortinarius with psilocybe mushrooms
             have occurred.

        2.3  Diagnosis

             In general the diagnosis can be made on the basis of 
             history and clinical signs and symptoms.
    
             Macroscopic and/or microscopic (spore identification)
             inspection of remaining mushrooms may be helpful in doubtful
             cases. Spores may also be found in gastric contents.
    
             Because of the presence of phenylethylamine in Psilocybe
             semilanceata, urine drug screening tests may show positive
             for amphetamine.

        2.4  First aid measures and management principles

             Gastric emptying and/or charcoal is rarely indicated and
             only in very recent ingestion while the patient is still
             asymptomatic.
    
             The patient should be put in a quiet room with dim lights and
             treated in a reassuring manner.
             Benzodiazepines are recommended as a sedative e.g. diazepam
             in a dose of  5 to 10 (-20) mg intravenous in adults and 0.1
             to 0.2 mg/kg intravenous in children.
    
             In case of seizures diazepam is the drug of choice.

        2.5  Poisonous parts

             All parts of the mushroom are toxic.

        2.6  Main toxins

             Psilocybin, psilocin, baeocystin, norbaeocystin.
             Phenylethylamine.

    3.  CHARACTERISTICS

        3.1  Description of the fungus

             3.1.1  Special identification features

             3.1.2  Habitat

             3.1.3  Distribution

        3.2  Poisonous parts of the fungus

        3.3  The toxin(s)

             3.3.1  Name(s)

                    The main toxins are psilocybin, psilocin,
                    baeocystin and norbaeocystin.

             3.3.2  Description, chemical structure, stability

             3.3.3  Other physico-chemical characteristics

        3.4  Other chemical contents of the fungus

    4.  USES/CIRCUMSTANCES OF POISONING

        4.1  Uses

             4.1.1  Uses

             4.1.2  Description

                    Used as a recreational drug.
    
                    The mushrooms are usually ingested raw in fresh or
                    dried condition.  Sometimes they are boiled in water
                    whereupon the water as well as the remaining mushrooms
                    are ingested.  They can also be stewed  or mixed in a
                    salad, soup or omelette. Occasionally, ethanol extract
                    is used. Intravenous injection of mushroom juice has
                    occurred.
    
                    These mushrooms have a bitter taste.

        4.2  High risk circumstances

        4.3  High risk geographical areas

             Not applicable.  Mushrooms containing psilocybe are
             often readily available on the illegal market or via the
             Internet.  They are also easy to cultivate at home and
             special "kits" for this purpose can be purchased.

    5.  ROUTES OF EXPOSURE

        5.1  Oral

             The most common route of exposure.

        5.2  Inhalation

             No data available.

        5.3  Dermal

             No data available.

        5.4  Eye

             No data available.

        5.5  Parenteral

             A few cases of intravenous injection of mushroom juice
             are reported (Sivyer & Dorrington, 1984; Curry & Rose,
             1985).

        5.6  Others

             No data available.

    6.  KINETICS

        6.1  Absorption by route of exposure

             In a controlled clinical study the pharmacokinetic
             properties of psilocybin were studied.  The metabolites
             psilocin and 4- hydroxyindole-3-acetic acid (4HIAA) were
             measured in plasma. 
    
             The average peak concentration of psilocin after oral
             administration of 10 to 20mg psilocybin was 8.2 ( 2.8 ng/ml
             plasma and were measured after 105 ± 37 min.
    
             4HIAA reached its maximum concentration of 150 ± 61 ng/ml
             plasma after 113 ± 41 min.
    
             After intravenous injection of 1mg psilocybin peak plasma
             concentration of psilocin was found 1.9 ± 1.0 min after
             injection.
    
             The bioavailability of psilocybin after oral administration
             of psilocybin were 52.7 ± 20% (Hasler et al., 1997).

        6.2  Distribution by route of exposure

             No human data.

        6.3  Biological halflife by route of exposure

             No data available.

        6.4  Metabolism

             The maximum plasma levels of psilocin appearing within 
             a very short period after systemic administration indicates a
             rapid dephosphorylation of psilocybin within the human body
             (Hasler et al., 1997).
    
             Psilocin is further metabolized by monoamine oxidase (MAO)
             leading to formation of 4- hydroxyindole-3-acetic acid (Beck
             et al., 1998). 

        6.5  Elimination and excretion

             The metabolite 4- hydroxyindole-3-acetic acid (4HIAA) is
             excreted in urine.

    7.  TOXINOLOGY

        7.1  Mode of action

             Psilocybin, psilocin, baeocystin and norbaeocystin are
             all indoles which are derivates from tryptamin.  They are
             thought to act by altering the concentration of indoles,
             including serotonin, in the central nervous system and thus
             interfering with the transmission and processing of external
             stimuli (Young et al., 1982).
    
             Phenylethylamine (PEA) recently found in Psilocybe
             semilanceata has been associated with psychosis and
             implicated in the etiology of mental disease (Wolf and
             Mosnaim, 1983, O'Reilly and Davis 1994).  PEA has been
             reported to exert amphetamine-like activity and to have
             peripheral sympathomimetic effects (Mantegazza & Riva, 1963;
             Sabelli & Giardina, 1972;  Ortman & Steen, 1973). 

        7.2  Toxicity

             7.2.1 Human data

                    7.2.1.1  Adults

                             10 to 40g of raw or 1 to 4g of dried
                             mushrooms are considered as an average dose
                             in recreational use.  However, the
                             concentration of indoles as well as
                             phenylethylamine in Psilocybe semilenceata

                             may vary considerably, and there is no
                             correlation between number of mushrooms
                             ingested and symptoms ( Peden et al., 1982; 
                             Francis and Murray, 1983; Beck et al.,
                             1998).

                    7.2.1.2  Children

                             No data available.

             7.2.2  Relevant Animal data

                    Not relevant.

             7.2.3  Relevant in vitro data

                    Not relevant.

        7.3  Carcinogenicity

             No data available.

        7.4  Teratogenicity

             No data available.

        7.5  Mutagenicity

             No data available.

        7.6  Interactions

             No data available.

    8.  TOXICOLOGICAL ANALYSES AND BIOMEDICAL INVESTIGATIONS

        8.1  Material sampling plan

             8.1.1  Sampling and specimen collection

                    8.1.1.1  Toxicological analyses

                             To be completed.

                    8.1.1.2  Biomedical analyses

                             Not indicated.

                    8.1.1.3  Arterial blood gas analysis

                             Not indicated.

                    8.1.1.4  Haematological analyses

                             Not indicated.

                    8.1.1.5  Other (unspecified) analyses

                             Not indicated.

             8.1.2  Storage of laboratory samples and specimens

                    8.1.2.1  Toxicological analyses

                             To be completed.

                    8.1.2.2  Biomedical analyses

                             Not indicated.

                    8.1.2.3  Arterial blood gas analysis

                             Not indicated.

                    8.1.2.4  Haematological analyses

                             Not indicated.

                    8.1.2.5  Other (unspecified) analyses

                             Not indicated.

             8.1.3  Transport of laboratory samples and specimens

                    8.1.3.1  Toxicological analyses

                             To be completed.

                    8.1.3.2  Biomedical analyses

                             Not indicated.

                    8.1.3.3  Arterial blood gas analysis

                             Not indicated.

                    8.1.3.4  Haematological analyses

                             Not indicated.

                    8.1.3.5  Other (unspecified) analyses

                             Not indicated.

        8.2  Toxicological Analyses and Their Interpretation

             8.2.1  Tests on toxic ingredient(s) of material

                    8.2.1.1  Simple Qualitative Test(s)

                    8.2.1.2  Advanced Qualitative Confirmation Test(s)

                    8.2.1.3  Simple Quantitative Method(s)

                    8.2.1.4  Advanced Quantitative Method(s)

             8.2.2  Tests for biological specimens

                    8.2.2.1  Simple Qualitative Test(s)

                    8.2.2.2  Advanced Qualitative Confirmation Test(s)

                    8.2.2.3  Simple Quantitative Method(s)

                    8.2.2.4  Advanced Quantitative Method(s)

                    8.2.2.5  Other Dedicated Method(s)

             8.2.3  Interpretation of toxicological analyses

                    Analyses of psilocybe mushroom toxins in
                    biological specimens may confirm the diagnosis. 
                    However, toxicological analyses are of no importance
                    for the treatment of the poisoned patient.  It could
                    be useful in the differential diagnosis between
                    drug-induced psychosis and psychosis from other
                    etiology.

        8.3  Biomedical investigations and their interpretation

             8.3.1  Biochemical analysis

                    8.3.1.1 Blood, plasma or serum

                             There is seldom any need for
                             biomedical investigations in psilocybe
                             mushroom poisoning.

                    8.3.1.2  Urine

                    8.3.1.3  Other fluids

             8.3.2  Arterial blood gas analyses

             8.3.3  Haematological analyse

             8.3.4  Interpretation of biomedical investigations

        8.4  Other biomedical (diagnostic) investigations and their
             interpretation

        8.5  Overall interpretation of all toxicological analyses and
             toxicological investigations

        8.6  References

    9.  CLINICAL EFFECTS

        9.1  Acute poisoning

             9.1.1  Ingestion

                    Symptoms appear within 20 to 30 ( to 60)
                    minutes after ingestion.  The intoxication culminates
                    after about 1.5 hours and subsides within 6 to 12
                    hours.  Central nervous symptoms dominate with
                    hallucinations and disturbed sensory perception. 
                    Euphoria or anxiety, agitation and panic attacks
                    leading to violent uncontrolled behaviour pose a risk
                    for physical trauma, also for other persons.  Somatic
                    signs of intoxication include mydriasis, tachycardia,
                    hypertension, hyperreflexia, nausea and vomiting.  One
                    case of seizures, cardiopulmonary arrest and
                    myocardial infarction is reported.  Delayed reactions
                    (flash-backs) may occur.

             9.1.2  Inhalation

                    No data available.

             9.1.3  Skin exposure

                    No data available.

             9.1.4  Eye contact

                    No data available.

             9.1.5  Parenteral exposure

                    Intravenous injection of mushroom juice
                    resulted in chills, rigors, dyspnea, headache,
                    arthralgia, myalgia, fever, nausea, vomiting,
                    diarrhoea and laboratory signs of hepatic and renal
                    abnormalities.

             9.1.6  Other

                    No data available.

        9.2  Chronic poisoning

             9.2.1  Ingestion

                    No data available.

             9.2.2  Inhalation

                    No data available.

             9.2.3  Skin exposure

                    No data available.

             9.2.4  Eye contact

                    No data available.

             9.2.5  Parenteral exposure

                    No data available.

             9.2.6  Other

                    No data available.

        9.3  Course, prognosis, cause of death

             The majority of poisonings by psilocybe mushrooms has a
             short and uncomplicated course. Trauma due to violent and
             uncontrolled behaviour poses the greatest threat to the
             patient.

        9.4  Systematic description of clinical effects

             9.4.1  Cardiovascular

                    Tachycardia and/or moderate hypertension are
                    rather frequent cardiovascular symptoms. 
                    ST-elevations on the ECG have been observed in a
                    young, earlier healthy patient.  One case of
                    myocardial infarction in connection with seizures and
                    cardiopulmonary arrest is reported.

             9.4.2  Respiratory

                    Dyspnea and impaired oxygenation has occurred
                    after intravenous exposure.

             9.4.3  Neurological

                    9.4.3.1  Central nervous system (CNS)

                             Visual, auditory and tactile
                             hallucinations together with disturbed
                             sensory perception like visual distorsions,
                             e.g. heightened awareness of colours and a
                             sensation of objects changing shape are the
                             most common symptoms of neurotoxicity. 
    
                             Body image distorsions, depersonalization,
                             derealization and altered time and space
                             sense are also frequent phenomenona.
    
                             Seizures may rarely occur. 

                    9.4.3.2  Peripheral nervous system

                             Numbness or tingling in the skin are
                             frequent symptoms.
                             One case of unilateral paraesthesiae
                             affecting face and arm lasting more than 24
                             hours is described.

                    9.4.3.3  Autonomic nervous system

                             Mydriasis is almost regular. 
                             Flushing of the face is sometimes
                             observed.

                    9.4.3.4  Skeletal and smooth muscle

                             Hyperreflexia is a common finding.

             9.4.4  Gastrointestinal

                    Nausea and vomiting may occur. Diarrhoea has
                    been observed after intravenous exposure.

             9.4.5  Hepatic

                    Laboratory signs of hepatic abnormalities have
                    been noted after intravenous exposure.

             9.4.6  Urinary

                    9.4.6.1  Renal

                             Laboratory signs of renal
                             abnormalities have been noted after
                             intravenous exposure.

                    9.4.6.2  Other

                             Involuntary passage of urine has
                             been observed
                             (Peden et al., 1982; Westberg and
                             Karlson-Stiber, 1999).

             9.4.7  Endocrine and reproductive systems

                    No data available.

             9.4.8  Dermatological

                    No data available

             9.4.9  Eye, ear, nose, throat: local effects

                    No data available.

             9.4.10 Haematological

                    No data available.

             9.4.11 Immunological

                    No data available.

             9.4.12 Metabolic

                    9.4.12.1 Acid-base disturbances

                             No data available.

                    9.4.12.2 Fluid and electrolyte disturbances

                             No data available.

                    9.4.12.3 Others

                             No data available.

             9.4.13 Allergic reactions

                    No data available.

             9.4.14 Other clinical effects

             9.4.15 Special risks

        9.5  Other

        9.6  Summary

             Most poisonings by psilocybin containing mushrooms have
             a short and uncomplicated course. Hallucinations, disturbed
             sensory perception, euphoria or anxiety, agitation and panic
             attacks are common in patients seeking medical attention.
             Mydriasis, tachycardia, hypertension, hyperreflexia, nausea
             and vomiting are symptoms often observed.  Delayed reactions
             (flash-backs) may occur.

    10. MANAGEMENT

        10.1 General principles

             The patient should be treated in a reassuring manner
             and placed in a quiet room with dim lights.  Sedatives are
             given as required.

        10.2 Life supportive procedures and symptomatic/specific treatment

             Diazepam is recommended as a sedative and given as
             required. Dose: 5 to 10 (to 20)mg intravenous in adults and
             0.1 to 0.2mg/kg intravenous in children. 
    

             In case if seizures diazepam is the drug of choice and given
             as required.

        10.3 Decontamination

             Gastric emptying and/or charcoal is rarely indicated
             and only in very recent ingestion while the patient is still
             asymptomatic.

        10.4 Enhanced elimination

             No data available.  Not indicated because of the short
             course of psilocybe mushroom poisoning.

        10.5 Antidote/antitoxin treatment

             10.5.1 Adults

                    Not available.

             10.5.2 Children

                    Not available.

        10.6 Management discussion

             Precautionary measures to protect the patient and other
             people from physical trauma due to uncontrolled behaviour
             during the hallucinatory phase should be taken.  If a mix-up
             with other mushrooms is suspected repeated laboratory tests
             of hepatic and renal function may be appropriate.

    11. ILLUSTRATIVE CASES

        11.1 Case reports from literature

             a)     Peden et al. 1982 reported data from 44
                    patients presenting to hospital within a 5 week
                    period.  The patients presented to hospital usually
                    because of dysphoric effects.  Mydriasis was observed
                    in 40 patients.  Other sympathomimetic features such
                    as tachycardia, hypertension or hyperreflexia were
                    seen in less than half of the patients.  Nausea and
                    vomiting prior to appearing at hospital had occurred
                    in 12 cases.  Four patients had been incontinent of
                    urine.
    

             The following are cases reported from the Swedish Poisons
             Centre:
    
             a)     A 21-year-old man was escorted to the hospital by two
                    police officers.  He was unable to give a complete
                    account of recent events but did admit ingestion of 3
                    grams dried Psilocybe cubensis which he had purchased
                    over the Internet.  On admission, he was agitated and
                    violent.  After ripping out his intravenous catheter),
                    he kicked and shoved one doctor, threw a
                    fire-extinguisher at another and attacked his girl
                    friend - among other things trying to strangle her.  A
                    few hours later he was filled with remorse and
                    indicated his actions were precipitated by fear.  He
                    recalled vivid hallucinations of his intestines
                    spilling out of his body and the delusion of being
                    castrated by a stranger.  This patient recovered
                    quickly with bed rest and was discharged the following
                    morning.
    
             b)     A 24-year-old man presented to the hospital after
                    drinking heavily and ingesting an unknown quantity of 
                    magic mushrooms at a party. On admission, the patient
                    was agitated and aggressive.  On examination he had
                    mydriasis, tachycardia and non-specific
                    electrocardiogram-changes.  He later admitted that his
                    aggressive behaviour was prompted by fear.  About one
                    hour after eating the mushrooms, he recalled having
                    frightening hallucinations such as electric cables
                    coming out of the walls and winding around him.  He
                    was discharged after one night of bed rest.
    
             c)     After drinking several beers with friends after work,
                    a 33-year-old man ingested 6 grams dried Psilocybe
                    cubensis and a short while later developed severe
                    anxiety and hallucinations.  Thinking he was going to
                    die, he panicked and called an ambulance.  On arrival
                    at the hospital he was restless, had hesitating
                    speech, amnesia, mydriasis and tachycardia.  Four
                    hours later, he still had chills, a dry mouth and
                    musculoskeletal cramps and pain.  He was admitted for
                    observation and bed rest and discharged the following
                    morning after complete recovery.

    12. Additional information

        12.1 Specific preventive measures

        12.2 Other

    13. REFERENCES

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        Benjamin C (1979) Persistent psychiatric symptoms after eating
        psilocybin mushrooms. BMJ19 May:1319-20
    
        Borowiak KS, Ciechanowski K & Waloszczyk P (1998) Psilocybin
        mushroom ( Psilocybe semilanceata) intoxication with myocardial
        infarction. J Toxicol Clin Toxicol 36:47-49
    
        Curry SC et al. (1985) Intravenous mushroom poisoning Ann Emerg
        Med 14(9):900-902
    
        Dewhurst K (1980) Psilocybin intoxication. Br J Psychiat 137:303-4
        Francis J & Murray VSG (1983) Review of enquiries made to the
        NIPIS concerning psilocybe mushroom ingestion, 1978-1981. Hum
        Toxicol 2: 349-52 
    
        Franz M et al. (1996) Magic mushrooms: hope for a "cheap high"
        resulting in end-stage renal failure. Nephrol Dial Transplant
        11:2324-47
    
        Harries A & Evans V (1981) Sequelae of a 'magic mushroom banquet' 
        Postgrad Med J 57:571-2 
    
        Hasler F, Bourquin D, Brenneisen R, Bär T & Vollenweider FX (1997)
        Determination of psilocin and 4-hydroxyindole-3-acetic acid in
        plasma by HPLC-ECD and pharmacokinetic profiles of oral and
        intravenous psilocybin in man. Pharm Acta Helv 72:175-84
    
        Holmgaard Kristensen L &  Harding Serensen B (1988) Vedvarende
        symptomer efter indtagelse af hallucinogene svampe Ugeskr Laeger
        150:1224-5
    
        Kunz MW, Rauber-Lüthy Ch, Meier PJ, Kupferschmidt H. (2000) Acute
        poisoning with hallucinogenic psilocybe mushrooms in Switzerland.
        EAPCCT XX International Congress 2-5 May, 2000, Amsterdam,
        Netherlands. (Abstract nr 99). 
    
        Mantegazza P & Riva M (1963) Amphetamine-like activity of
        ß-phenylethylamine after a monoamine oxidase inhibitor in vivo J
        Pharmacol 15:472-78 
    
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        Prog Neuro-Psychopharmacol Biol Psychiatry 18:63-75
    

        Ortman E & Steen G. (1973) Phenylethylamine- a hazardous
        substitute for amphetamine in the narcotics market. Läkartidningen
        70:118-19
    
        Peden NR, Macaulay KEC, Bissett AF, Crooks J, & Pelosi AJ (1981)
        Clinical toxicology of 'magic mushroom' ingestion. Postgrad Med J
        57:543-5 
    
        Peden NR, Pringle SD & Crooks J (1982) The problem of psilocybin
        mushroom abuse. Hum Toxicol;1:417-24 
    
        Raff E, Halloran PF & Kjellstrand CM (1992) Renal failure after
        eating "magic" mushrooms. Can Med Assoc J;149(9):1339-1341
    
        Sabelli HC & Giardina WJ (1972) Amine modulation of affective
        behaviour. In Chemical Modulation of Brain Function; HC Sabelli,
        Ed, Raven, New York, NY, pp225-59 
    
        Schwartz RH & Smith DE (1988) Hallucinogenic mushrooms. Clin
        Pediatr 27:70-3
    
        Sivyer G & Dorrington L(1984) Intravenous injection of mushrooms.
        Med J Australia 4:182
    
        Westberg U & Karlson-Stiber C (1999) A successful introduction of
        "Magic mushrooms" on the Swedish market through the internet. J
        Toxicol Clin Toxicol  37:415-16
    
        Westberg U & Karlson-Stiber C (1999) Hallucinogena svampar åter i
        ropet - försäljs via Internet. Läkartidningen;96:746-7.
    
        Wolf Me &  Mosnaim AD (1983) Phenylethylamine in neuropsychiatric
        disorders. Gen Pharmacol 14:385-90
    
        Young RE, Hutchison S, Milroy R & Kesson CM (1982) The rising
        price of mushrooms. Lancet;January 23:213-4 

    14. AUTHOR(S), REVIEWER(S) DATA (INCLUDING EACH UPDATING), COMPLETE
        ADDRESSES

        Dr C. Karlson-Stiber
        Swedish Poison Information Centre
        S-171 76 Stockholm 
        Sweden
    
        Tel: +46 8 6100533
        Fax: +46 8 327584
        E-mail: christine.karlson-stiber@apoteket.se
    

        Date: 18 October 2000
    
        Reviewed by:
    
        *    Dr Heinz Faulstich, Dr Luc de Haro, Dr Jonas Höjer,
             Dr Christine Karlson-Stiber, Dr Hans Persson and Dr Thomas
             Zilker (Meeting on Mushroom Poisoning, 19-21 October 2000,
             Stockholm, Sweden). 
    
        *    Dr B. Groszek and Dr Hans Persson (INTOX-12,
             6-11 November 2000, Erfurt, Germany)
    




















    See Also:
       Toxicological Abbreviations