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Inocybe, clitocybe, omphalotus and others

1. NAME
   1.1 Scientific name
   1.2 Family
   1.3 Common name(s) and synomym(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 Names
      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 Eyes
   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 half life by route of exposure
   6.4 Metabolism
   6.5 Elimination by route of exposure:
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
   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 analyses
      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. CLINCAL 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
         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 Renal/Urinary
      9.4.7 Endocrine and reproductive systems
      9.4.8 Dermatological
      9.4.9 Eyes, ears, nose, throat, local effects
      9.4.10 Haematological
      9.4.11 Immunological
      9.4.12 Metabolic
      9.4.13 Allergic reaction
      9.4.14 Other clinical effects
      9.4.15 Special risks
      9.4.16 Local effects
   9.5 Other
   9.6 Summary
10. MANGEMENT
   10.1 General principles
   10.2 Life support procedures and symptomatic/specific treatment
   10.3 Decontamination
   10.4 Enhanced elimination
   10.5 Antidotes/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



    INOCYBE, CLITOCYBE, OMPHALOTUS AND OTHERS

    International Programme on Chemical Safety
    Poisons Information Monograph (Group monograph) G028
    Fungi

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

    1.  NAME

        1.1  Scientific name

             The muscarine-containing species known to cause the
             majority of toxic exposures are:
    
             Inocybe patouillardi
             Inocybe fastigiata
             Inocybe geophylla
             Inocybe fragans
             Inocybe cincinnata
             Inocybe maculata
             Inocybe corydalina
             Inocybe godey
             Clitocybe dealbata
             Clitocybe rivulosa
             Clitocybe candicans
             Clitocybe cerussata
             Clitocybe phyllophila
             Omphalotus olearius
             Omphalotus illudens
             Omphalotus subilludens
             Amanita echinocephala
             Entoloma rhodopolium
    
             The main toxin is muscarine.

        1.2  Family

             Inocybe
    
             Inocybe (English and French)
             Risspilz  (German)
    
             Clitocybe
    
             Clitocybe (English and French) 
             Trichtering (German)

    
             Omphalotus 
    
             "Jack O'lantern" (North America).

        1.3  Common name(s) and synomym(s)

    2.  SUMMARY

        2.1  Main risks and target organs

             Muscarine containing mushrooms are responsible for
             parasympathicomimetic poisoning with a number of symptoms, of
             which the most severe signs are: bradycardia, hypotension and
             respiratory distress.

        2.2  Summary of clinical effects

             The symptoms are similar to cholinergic poisoning:
             general hyper-secretion (sweating, lacrimation, salivation,
             rhinorrhea, bronchorrhea), bradycardia, miosis, blurred
             vision and digestive troubles (nausea, vomiting, diarrhoea,
             abdominal pain). 

        2.3  Diagnosis

             As the symptoms appear within 30 minutes to a few hours
             after ingestion of the mushrooms, the diagnosis is possible
             on the basis of the typical clinical syndrome.  The
             identification of the mushroom and the description of the
             meal could be helpful.

        2.4  First aid measures and management principles

             The management of the patients (it is often collective
             poisoning with several patients) should be performed in
             hospital in order to provide symptomatic treatments for the
             pronounced digestive troubles.  For the cases with important
             cholinergic symptoms,  atropine is injected (2 mg
             intravenously for adults, and if necessary, repeated doses as
             required, for children, 0.05 mg/kg of atropine).  In case of
             early admission, gastric emptying and/or Activated Charcoal
             are indicated. 

        2.5  Poisonous parts

             The muscarine is present in all the different parts of
             the fungi.  The toxic species contain between 0.1 and 0.3% of
             the dry weight of mucarine.  The species containing less are
             not responsible for cholinomimetic signs (example:  Amanita
              muscaria which contains less than 0.002% of the dry weight
             of muscarine is only occasionally  responsible for muscarine
             symptoms).

        2.6  Main toxins

             The main toxin in muscarine which is a
             parasympathomimetic alkaloid.  Its pharmacological activity
             is close to acetylcholine. 

    3.  CHARACTERISTICS

        3.1  Description of the fungus

             3.1.1  Special identification features

                    Must be completed by specialists.

             3.1.2  Habitat

                    Inocybe species are very common in European
                    forests of deciduous trees like oaks (for 
                    I. patouillardi) or conifers (other toxic Inocybe). 
                    Clitocybe species grow in grasslands or open woods. 
                    In North America, Omphalotus species grow on dead
                    wood in clusters.

             3.1.3  Distribution

                    In Europe, the small white mushrooms of the
                    genus Inocybe and Clitocybe are eaten after
                    misidentification concerning famous edible species
                    like Tricholoma terreum, Tricholoma georgii
                    and Marasme oreades (global common name for the
                    three species in French of "Grisets") (Lambert,
                    1988).
    
                    In North America, "Jack O'lantern" mushrooms (genus
                    Omphalotus) can be the origin of confusion with
                    sulfur shelves (Laetiporus sulphureus) (French,
                    1988). 
    

                    In Japan, cases with accidental ingestion of Entoloma
                    rhodopolium have been reported.

        3.2  Poisonous parts of the fungus

             All the different parts of the mushrooms contain
             muscarine, and are toxic.

        3.3  The toxin(s)

             3.3.1  Names

                    The main toxin is muscarine which is a
                    parasympathicomimetic alkaloid.

             3.3.2  Description, chemical structure, stability

                    The formula of the muscarine is 3 hydroxy - 2
                    methyl - 5 trimethyl ammonium  methyl
                    tetrahydrofurune.  Its pharmacological activity is
                    close to acetylcholine.  There is in toxic fungi four
                    isomers.  The most toxic molecule is L-muscarine. 
                    None of these molecules are destroyed by heating
                    during cooking (Lambert, 2000). 

             3.3.3  Other physico-chemical characteristics

                    No data available.

        3.4  Other chemical contents of the fungus

             Some muscarinic toxic mushrooms may contain in different
             proportions other molecules like acethylcholine, choline,
             histamine, muscimol, muscazone or ibotenic acid.

    4.  USES/CIRCUMSTANCES OF POISONING

        4.1  Uses

             4.1.1  Uses

             4.1.2  Description

                    In most cases, the mushrooms responsible for
                    muscarine poisonings are eaten because they are
                    mistaken for the following species:  Tricholoma
                     terreum, Tricholoma georgii and  Marasme oreades. 
                    Accidental poisonings also occur with children.
    

                    However, in some published case series, more than one
                    quarter of the poisonings are collected with patients
                    who ate unidentified mushrooms (de Haro, 1999).  Cases
                    are often observed after ingestion of fresh mushrooms,
                    but poisonings after ingestion of frozen or dried
                    mushrooms also occur. 

        4.2  High risk circumstances

             The high risks are eating small mushrooms growing on
             grass and in parks during spring and autumn.  But poisoning
             may occur during the whole year.

        4.3  High risk geographical areas

             Muscarine mushroom poisonings are common in some
             countries where wild mushrooms are frequently eaten, such as
             France, Italy or Switzerland (Lambert, 2000).   However, in
             other countries, muscarine mushroom poisoning may
             occur.

    5.  ROUTES OF EXPOSURE

        5.1  Oral

             The poisoning is possible after ingestion of a meal made
             with fresh, dried or frozen mushrooms.  The heating during
             cooking does not destroy the toxic molecules.

        5.2  Inhalation

             Not applicable.

        5.3  Dermal

             Not applicable.

        5.4  Eyes

             Not applicable.

        5.5  Parenteral

             Never reported.

        5.6  Others

             Never reported.

    6.  KINETICS

        6.1  Absorption by route of exposure

             A very low part of ingested Muscarine and derivatives is
             absorbed in the digestive tract (Lambert, 2000).

        6.2  Distribution by route of exposure

             Absorbed muscarine is quickly distributed in throughout
             the body and the symptoms may occur within 30 minutes to a
             few hours after the meal.  In several cases, the patients did
             not finish eating their dish when the first symptoms appeared
             (de Haro, 1999).

        6.3  Biological half life by route of exposure

             No data available.

        6.4  Metabolism

        6.5  Elimination by route of exposure:

             No data available.

    7.  TOXINOLOGY

        7.1  Mode of action

             Muscarine and related molecules bind to the
             acethylcholine receptor of the post-ganglionary nerves,
             leading to a permanent depolarisation responsible of smooth
             muscle contraction (iris, bronchia, digestive tract,...), of
             the exocrine glands.  There are muscarinic receptors in the
             cardiac atrium.

        7.2  Toxicity

             7.2.1  Human data

                    7.2.1.1  Adults

                             See case reports.

                    7.2.1.2  Children

                             See case reports.

             7.2.2  Relevant animal data

                    Case report: after ingestion of Inocybe
                    phaeocomis and other non toxic mushrooms,  a
                    14-year-old female springer spaniel developed
                    hyper-salivation, hypothermia and digestive troubles. 
                    The animal was better within 24 hours (Yam,
                    1993).

             7.2.3  Relevant in vitro data

                    No data available

        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

        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 analyses

             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.  CLINCAL EFFECTS

        9.1  Acute poisoning

             9.1.1  Ingestion

                    The ingestion of muscarine containing mushrooms
                    leads to symptoms similar to cholinergic poisoning:
                    general exocrine glands hyper-secretion (sweating,
                    lacrimation, salivation, rhinorrhea, bronchorrhea),
                    bradycardia, miosis, blurred vision and digestive
                    troubles like nausea, vomiting, dairrhoea and
                    abdominal pain (Young, 1994). 

             9.1.2  Inhalation

                    Not applicable.

             9.1.3  Skin exposure

                    Not applicable.

             9.1.4  Eye contact

                    Not applicable.

             9.1.5  Parenteral exposure

                    Never reported.

             9.1.6  Other

                    Never reported.

        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

             Onset is within 30 minutes to a few hours (average 2
             hours, in one reported case, less than 10 minutes).  As soon
             as they appear, the symptoms are at maximal level, and begin
             to decrease after a few hours.  All the signs disappear
             before 24 hours (average delay of recovery 13 hours) (de
             Haro, 1999).  In old literature, fatalities have been
             reported.  In modern times, no fatalities have been reported
             (Lambert, 2000).

        9.4  Systematic description of clinical effects

             9.4.1  Cardiovascular

                    Sinus bradycardia is often observed. 
                    Hypotension with or without peripheral vasodilation is
                    frequent.

             9.4.2  Respiratory

                    Bronchorrhea and bronchoconstriction leading to
                    hypoxemia may occur.

             9.4.3  Neurological

                    9.4.3.1  Central Nervous system

                             Headaches and behaviour disturbance
                             (anxiety, euphoria, fear of death) may
                             occur.

                    9.4.3.2  Peripheral Nervous system

                             Never reported.

                    9.4.3.3  Autonomic Nervous system

                             All symptoms are due to autonomic
                             nervous system stimulation.

                    9.4.3.4  Skeletal and smooth muscle

                             Never reported.

             9.4.4  Gastrointestinal

                    Excessive salivation is an important sign of
                    this intoxication.  Nausea, vomiting, increased
                    peristalsis with diarrhoea and abdominal pain are
                    frequent. A bitter taste in the mouth and dysphagia
                    have been reported.

             9.4.5  Hepatic

                    Never reported.

             9.4.6  Renal/Urinary

                    Bladder contraction, painful need for urination
                    and increased ureter peristalsis may occur (Young,
                    1995). 

             9.4.7  Endocrine and reproductive systems

                    Never reported.

             9.4.8  Dermatological

                    Excessive perspiration is a frequent sign of
                    this intoxication.  The sweating is so important that
                    the patient's clothes and bed are completely
                    wet.

             9.4.9  Eyes, ears, nose, throat, local effects

                    Miosis, blurred vision, excessive lacrimation,
                    nasal congestion and rhinorrhea are often observed. 
                    Diplopia has been reported.

             9.4.10 Haematological

                    Never reported.

             9.4.11 Immunological

                    Never reported.

             9.4.12 Metabolic

                    Never reported.

             9.4.13 Allergic reaction

                    Never reported.

             9.4.14 Other clinical effects

                    Never reported.

             9.4.15 Special risks

                    Severe poisonings have been reported with
                    patients who have gastrectomy or a history of cardiac
                    disease (de Haro, 1999). 

             9.4.16 Local effects

                    Not applicable.

        9.5  Other

             Never reported.

        9.6  Summary

             30 minutes to a few hours after the ingestion of the
             mushrooms, symptoms appear at the maximum level, and begin to
             decrease after few hours.  The symptoms are similar to
             cholinergic poisoning: general hyper-secretion (sweating,
             lacrimation, salivation, rhinorrhea, bronchorrhea),
             bradycardia, hypotension, bronchoconstriction, miosis,
             blurred vision and digestive disturbances (nausea, vomiting,
             diarrhoea, abdominal pain).

    10. MANGEMENT

        10.1 General principles

             As gastrointestinal symptoms are often present during
             muscarine mushroom poisonings, gastric emptying and/or
             Activated Charcoal is indicated in the early stage and before
             the onset of the symptoms.  Atropine should be administered
             when cholinergic symptoms are pronounced.

        10.2 Life support procedures and symptomatic/specific treatment

             Intravenous fluids and electolytes should be
             administrated in order to treat dehydration.  Spontaneous
             vomiting should not be treated.  Bradycardia, bronchorrhea
             and bronchoconstriction should be treated with atropine. 
             Diazepam may be used as the patients are often very anxious. 
             Diazepam should be administered after atropine
             treatment.

        10.3 Decontamination

             Gastric emptying and/or Activated Charcoal are most
             effective if initiated within 30 minutes of ingestion.  In
             published case series in France, gastric lavage has been done
             for 6% of the patients.

        10.4 Enhanced elimination

             Not indicated.

        10.5 Antidotes/Antitoxin treatment

             10.5.1 Adults

                    When cholinergic symptoms are pronounced,
                    atropine should be administered.  A first dose of 2
                    mg/IV is administrated.  If the cholinergic symptoms
                    do not decrease, this dose can be repeated as required
                    every 30 minutes (maximum dose 8mg).

             10.5.2 Children

                    When cholinergic symptoms are pronounced, the
                    atropine treatment protocol is the same, but with the
                    doses of 0.05mg/kg.

        10.6 Management discussion

             Atropine effectively counteracts the cholinergic
             symptoms but does not shorten the duration of the symptoms. 
             Administration of Activated Charcoal does not further shorten
             the duration of the symptoms (de Haro, 1999).

    11. ILLUSTRATIVE CASES

        11.1 Case reports from literature

             A series of 248 incidences of muscarine mushroom
             poisonings occurring in southern France between 1973 and 1998
             was published (de Haro, 1999).  The 248 incidences included
             483 patients (41 children between 1 to 14 years old).  The
             average onset of the symptoms was 2 hours.  The most frequent
             signs were perspiration (96% of the patients), vomiting
             (70%), diarrhoea (62%), hypotension (36%), abdominal pain
             (32%), miosis (25%), blurred vision (22%), bradycardia (20%),
             rhinorrhea (6%) and lacrimation (6%).  58% of the patients
             were treated at hospital, and the treatments were atropine
             (24% of the 483 patients), Activated Charcoal (21%), gastric
             lavage (6%).  The average time to recovery was 13 hours
             without modification  for patients treated with atropine or
             Activated Charcoal.
    

             Two cases of this paper were exceptional because of the
             severity of the clinical feature.
             *   A man, 58 years old, with previous history of gastrectomy
                 and alcoholic hepatic disease presented with a
                 cardio-respiratory arrest 1.5 hours after ingestion of
                  Inocybe patouillardi.  During the transportation to the
                 hospital, bradycardia, bronchorrhea and
                 bronchoconstriction were observed.  The patient was
                 treated in the intensive care unit (atropine, adrenaline,
                 broncho-suction, artificial ventilation), and recovered
                 on the third day.
    
             *   A woman, 70 years old, treated with digitalis for
                 supra-ventricular rhythm, presented 3 hours after
                 ingestion of  Inocybe sp.  Severe bradycardia and
                 hypotension leading to a shock, was treated in the
                 intensive care unit with atropine, and she recovered
                 within one day.

    12. ADDITIONAL INFORMATION

        12.1 Specific preventive measures

             In order to avoid all types of mushrooms poisonings,
             people have to ingest only clearly identified species. 
             Muscarine containing species like  Inocybe sp. and
              Clitocybe sp. are able to grow in edible mushrooms groups
             (Lambert, 2000).  These small white mushrooms can be eaten by
             error with edible mushrooms, but the most common circumstance
             is the misidentification with edible  Tricholoma 
             species.

        12.2 Other

    13. REFERENCES

        de Haro L, Prost N, David JM, Arditti J, & Valli M (1999)
        Syndrome sudorien ou muscarinien: expérience du Centre Antipoison
        de Marseille. Presse Méd 28 (20): 1069-70.
    
        French AL, Garrettson LK (1988) Poisoning with the north american
        Jack O'lantern mushroom Omphalotus illudens. J Toxicol Clin
        Toxicol 26 (1): 81 - 8.
    
        Lambert H & Larcan A (1988) Intoxications par champignons
         Encycl Méd Chir. Toxicologie - Pathologie professionnelle,
        16077A10: 14p.
    

        Lambert H, Zitoli JL, Pierrot M, & Manel J (2000) Intoxications
        par les champignons: syndromes mineurs. Encycl Méd Chir
        Toxicologie - Pathologie professionnelle, 16077B10: 10p.
    
        Saviuc P&  Moreau PA (1999) Intoxications par les champignons
        supérieurs. In: Danel V, Barriot P. Intoxications aiguës en
        réanimation. Second Ed. Arnette Ed. Rueil-Malmaison, France: 
        523 - 48.
    
        Yam P(1993) Mushroom poisoning in a dog. Vet Rec 133: 24.
    
        Young A (1994) Muscarine containing Mushrooms. In: Spoerke D,
        Rumack BH Handbook of mushroom poisoning. CRC Press, Boca raton,
        Fl.

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

        Author:
   
        Luc de HARO, MD.
        Centre Antipoison de Marseille
        Hôpital Salvator
        249 boulevard Sainte Marguerite
        3009 Marseille
        France
   
        Tel: +33 491 74 50 75
        Fax: +33 491 74 41 68
        E-mail: deharo.l@jean-roche.univ-mrs.fr
   
        Reviewed by:
   
        *    Dr Heinz Faulstich, Dr Luc de Haro, Dr Jonas Höjer, Dr
             Christine Karlson-Stiber, Dr Hans Persson and Thomas Zilker
             (Meeting on Mushroom Poisoning, 19-21 October 2000,   
             Stockholm, Sweden). 
   
        *    Dr B. Groszek and Dr H. Persson (INTOX-12, 6-11 November
             2000, Erfurt, Germany).