Trends in Amanita phalloides intoxications in the Czech Republic: how many antidotes are needed?

OBJECTIVES: In Central Europe, mushroom poisoning is a public health problem as the Czech Republic belongs to the countries with the highest proportion of mushroom pickers. The trends in A. phalloides intoxications, their treatment and outcome were investigated in verified cases, as several antidotes are recommended and their effect is still under discussion. METHODS: Mushroom intoxications in 2010-2024 were searched in the database of the Czech Toxicological Information Centre (TIC) and the Institute of Health Information and Statistics. Intoxications with amatoxins in 2019-2024 were analysed. RESULTS: Mushroom-related consultations of TIC reached an average of 490 calls/year (SD = 130), and 190 subjects/year (SD = 36) were hospitalized. A total of 1,248 mycological identifications and laboratory analyses were performed in 2019-2024; in 45 proven intoxications with amatoxins, lethality was 4.4%. The amount of ingested mushrooms (0.3-8 pieces) was negatively correlated (r = -0.358, p = 0.041) with the latency to symptoms (10.4 ± 1.3 hours), and positively with the duration of hospital stay (7.8 ± 2.3 days, r = 0.356, p = 0.042), peak international normalized ratio (r = 0.445, p = 0.010), and use of elimination methods (r = 0.451, p = 0.008). Later admission correlated with alanine aminotransferase activity (r = 0.318, p = 0.033) and creatinine level (r = 0.447, p = 0.002). Patients with simultaneous amatoxin positivity of blood and urine had a longer hospital stay than those with only one positive sample (14.0 ± 6.6 vs. 7.4 ± 2.1 days, p = 0.018). Of 45 patients, 32 patients were treated with 2 or 3 antidotes; two patients died; an additional critical factor for lethal intoxications was preceding liver or psychic disorders. Eight patients received one antidote and recovered; there was no difference between N-acetylcysteine and silibinin (p > 0.05). Five patients with early admission were treated without antidotes and did not develop hepatotoxicity. CONCLUSIONS: Deaths from unintentional poisoning with amatoxins can be averted. Amount of mushrooms ingested, early treatment with N-acetylcysteine or silibinin, and evidence of amatoxins in blood and urine are key factors. Timely mycological consultations and information for safe mushroom collection, including for immigrants, are crucial.