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more leisure time for hobbies , hiking , and trekking has led to more mushroom exposures . increased demands for uncultivated food or gastronomic delights have contributed to more mushroom poisoning .
although severe mushroom poisonings and fatalities remain infrequent , the proportions of fatal mushroom poisonings among confirmed mushroom ingestions seems to be increasing ( 1 ) .
in addition to increasing poisoning of known toxic mushroom , new mushroom syndromes have been described ( 23 ) .
the severe patient with r. subnigricans mushroom poisoning was reported to present with rhabdomyolysis , severe electrolyte disturbance ( hyperkalemia , hypocalcemia ) , acute renal failure , respiratory failure , pulmonary edema , ventricular tachycardia , and circulatory shock ( 45 ) . in this case report
, we present a patient poisoned by r. subnigricans mushroom complicated with rhabdomyolysis , acute kidney injury ( aki ) , severe hypocalcemia , respiratory failure , ventricular tachycardia , and cardiogenic shock , leading to death .
a 51-year old man had a breakfast cooked with wild mushrooms that he had gathered one day earlier during summer vacation in august , 2010 at the jujak mountain located on the province of jeollanam - do , the southern area of korea .
he had no particular past medical or social history other than the occasional ingestion of wild mushrooms during recreational hiking .
he did not have a history of trauma , infection , other known underlying cause , or medication use that could explain the occurrence of rhabdomyolysis .
he shared the meal with his wife and son who did not eat any more mushrooms due to nausea after ingesting a single piece of mushroom .
six hours later , he began to complain of vomiting , diarrhea , and myalgia .
he visited a local hospital where his general condition worsened and systolic bp fell to 60 mmhg requiring dopamine treatment and endotracheal intubation .
twenty - eight hours after ingestion of the mushrooms , he was transferred to the intensive care unit of our hospital . at the time of admission , he was alert , but acute ill - looking .
blood pressure was 80/56 mmhg , heart rate 121/min , respiratory rate 25/min , and body temperature 36.3c .
laboratory tests showed the following : hemoglobin 15.9 g / dl , hematocrit 45.9% , leukocyte count 20,740/l with neutrophil 89.6% , platelet 253,000/l , c - reactive protein ( crp ) 8.36 mg / dl , blood urea nitrogen ( bun ) 38.5 mg / dl , serum creatinine 2.84 mg / dl , serum osmolarity 314 mosm / kg , sodium 140 meq / l , potassium 4.7 meq / l , chloride 100 meq / l , ionized calcium 0.75 mmol / l , glucose 187 mg / dl , cholesterol 221 mg / dl , albumin 4.0 g / dl , aspartate aminotransferase ( ast ) 1,214 u / l , alanine aminotransferase ( alt ) 343 u / l , total bilirubin 0.51 mg / dl , alkaline phosphatase 92 iu / l , creatine kinase ( ck ) 69,121 u / l , ck - mb > 500 ng / ml , lactate dehydrogenase ( ldh ) 2,196 u / l , troponin i 1.86 ng / ml , n - terminal pro brain natriuretic peptide ( nt - pro bnp ) 7,414 pg / ml , amylase 1,930 u / l , lipase 18 u / l , prothrombin time ( pt ) 10.2 seconds .
( inr 0.86 ) , activated partial thromboplastin time ( aptt ) 28.2 seconds , urine osmolarity 341 mosm / kg , sodium 22 meq / l , potassium 59.2 meq / l , chloride 14 meq / l , creatinine 123.8 mg / dl , myoglobin 51.7 ng / ml , and fractional excretion of sodium 0.36% .
urine analysis showed ph 5.0 , specific gravity 1.020 , protein 2 + , ketone 2 + , blood 4 + , rbc 5 - 9/high - power field , and wbc 0 - 1/high - power field .
arterial blood gas analysis was ph 7.04 , paco2 69 mmhg , pao2 172 mmhg , and hco3 
  18.7 mmol / l .
the enlarged left ventricle ( lv ) , severe lv systolic dysfunction ( ejection fraction 30% ) , and akinesia of lv mid to apex wall suggesting stress induced cardiomyopathy were noted on echocardiography .
he received ventilator support , hemodynamic monitoring , continuous venovenous hemodiafiltration , and conservative care including intravenous fluid and electrolyte repletion .
seventy hours after ingestion of the mushrooms , bun 41.9 mg / dl , serum creatinine 3.46 mg / dl , ast 3,271 u / l , alt 1,254 u / l , total bilirubin 1.55 mg / dl , ck 121,397 u / l , ck - mb > 500 ng / ml , ldh 6,102 u / l , troponin i 11.77 ng / ml , amylase 2,779 u / l , lipase 601 u / l , pt 42.1 seconds .
ventricular tachycardia developed , and he died due to cardiogenic shock 72 hours after ingestion of the mushrooms .
the leftover samples of the mushrooms that he had ingested were sent to agricultural microbiology division , national academy of agricultural science , rural development administration , suwon , korea . those were identified as r. subnigricans by their gross morphology ( fig .
the worldwide incidence of mushroom poisoning appears to be increasing due to increased human demands for uncultivated food or hallucinogenic mushrooms .
the proportion of severe and fatal mushroom poisonings among confirmed mushroom ingestions has demonstrated statistically significant increases .
deaths , although rare , occurred most commonly from the ingestion of amanita species , primarily amanita phalloides , in adult amateur mushroom hunters ( 16 ) .
in addition to increasing poisons following ingestions of known species , formerly edible or new mushroom species are causing newly recognized syndromes from mushroom poisonings .
several new syndromes in mushroom poisoning have been described since the early 1990s ( 123 ) : accelerated nephrotoxicity ( non - orellanine - induced renal failure ) , erythromelalgia , rhabdomyolysis , and delayed neurotoxicity ( convulsive or non - convulsive encephalopathy ) .
rhabdomyolysis is a new type of mushroom poisoning caused by ingestion of tricholoma equestre ( 1347 ) .
some of these cases with rhabdomyolysis are associated not only with renal dysfunction and electrolyte disturbance ( hyperkalemia , hypocalcemia ) , but also with respiratory and cardiac complications ( arrhythmia , cardiovascular collapse ) leading to death ( 4 ) .
an outbreak of russula subnigricans poisoning with rhabdomyolysis occurred in taiwan ( 5 ) . the most severely ill patient presented with rhabdomyolysis , severe electrolyte disturbance ( hyperkalemia , hypocalcemia ) , respiratory failure , acute renal failure , pulmonary edema , ventricular tachycardia , and circulatory shock .
japan has also experienced several cases of fatal poisoning with rhabdomyolysis caused by ingestion of this mushroom ( 311 ) .
r. eccentrica , r. nigricans and r. subnigricans have been recorded in korea ( 12 ) .
poisonous r. subnigricans can be mistaken with non - poisonous , edible r. eccentrica and r. nigricans .
r. subnigricans can be found associated with broad - leaved evergreen tree habitat which is present and restricted to the southern area of korean peninsula .
this report of our case represents the first record of r. subnigricans poisoning with rhabdomyolysis in korea .
rhabdomyolysis , the dissolution of skeletal muscle , is a rare but potentially fatal condition .
the common causes of rhabdomyolysis are trauma , exertion , muscle hypoxia , infections , body temperature changes , metabolic and electrolyte disorders , drug and toxins , and genetic defects .
the incidence of rhabdomyolysis in acute poisonings was the highest in poisonings with opiates , pesticides , neuroleptics , anticonvulsants , and ethyl alcohol ( 1314 ) . in our case , severe rhabdomyolysis with aki ,
severe hypocalcemia , respiratory failure , ventricular tachycardia , and cardiogenic shock were noted throughout the clinical course .
there was no history of trauma , strenuous exercise , seizures , and loss of consciousness .
the possible cause of rhabdomyolysis after ingestion of the mushroom may be the mushroom toxin , such as cycloprop-2-ene carboxylic acid , isolated from r. subnigricans .
this compound may be responsible for fatal rhabdomyolysis as a toxic trigger for some biochemical reactions ( 1011 ) .
the mechanism involved in the pathogenesis of rhabdomyolysis is depletion of atp within the myocyte , leading to an unregulated increase in intracellular calcium , resulting in disintegration of the myocyte .
it usually results from calcium entering the damaged myocyte and from the precipitation of calcium phosphate in necrotic muscle .
intrarenal vasoconstriction , direct and ischemic tubular injury , and tubular obstruction all may play a role in myoglobin - induced aki ( 13 ) .
cardiogenic shock due to severe lv systolic dysfunction might be caused by the mushroom toxin ( 451516 ) .
general management of mushroom poisoning is fluid resuscitation , early gastric decontamination by both gastric lavage and multiple dose activated charcoal , and baseline laboratory assessment .
since mushroom - poisoned patients often experience vomiting and diarrhea , emetics and cathartics are rarely indicated .
treatment should be directed by the patient 's clinical manifestation ( 117 ) . the mushroom poisoning with rhabdomyolysis
is usually associated with volume depletion that is due to the sequestration of water in damaged muscles .
therefore , the early , aggressive repletion of fluids is the main step of management .
, early hypocalcemia should not be treated unless it is symptomatic or unless severe hyperkalemia is present , since the calcium load could increase the precipitation of calcium phosphate in necrotic muscle ( 13 ) .
continuous venovenous hemofiltration or hemodiafiltration has shown some efficacy in removing myoglobin ( 18 ) . however , the evidence is from case reports , and the effect on outcomes is unknown .
if renal or hepatic function is worsening , patients should be transferred to the hospital equipped for hemodialysis and kidney or liver transplantation ( 1 ) . intra
- aortic balloon counterpulsation can be considered as a final treatment option in the mushroom poisoning with cardiogenic shock ( 15 ) .
correct categorization and better understanding are essential for the safe and healthy consumption of mushrooms ( 19 ) .
since mushroom toxicity may be dose - related , overconsuming mushrooms should be avoided ( 1 ) .
furthermore , r. subnigricans should be considered in the mushroom poisoning with rhabdomyolysis . to confirm the exact diagnosis , leftover raw or cooked mushrooms should be collected and sent to a mycologist for gross and spore identification .
mushroom exposures are increasing worldwide . 
 the incidence and fatality of mushroom poisoning are reported to be increasing . 
 several new syndromes in mushroom poisoning have been described . 
 rhabdomyolytic mushroom poisoning is one of new syndromes . 
 russula subnigricans mushroom can cause delayed - onset rhabdomyolysis with acute kidney injury in the severely poisoned patient . 
 there are few reports on the toxicity of r. subnigricans . 
 this report represents the first record of r. subnigricans poisoning with rhabdomyolysis in korea , describing a 51-year - old man who suffered from rhabdomyolysis , acute kidney injury , severe hypocalcemia , respiratory failure , ventricular tachycardia , cardiogenic shock , and death . 
 mushroom poisoning should be considered in the evaluation of rhabdomyolysis of unknown cause . 
 furthermore , r. subnigricans should be considered in the mushroom poisoning with rhabdomyolysis .