Keywords
mushroom poisoning - poisoning - coronavirus disease 2019 - toxic
Introduction
More than 5,000 mushroom species have been classified in the world, and more than
100 species have been found to be poisonous. Among these species, ∼10 are known to
cause fatal poisoning.[1] Poisonous mushrooms contain different toxins that can cause different clinical manifestations.
It has been reported that ∼2.5 to 7% of all poisoning cases in the world are due to
the mushroom ingestion. This rate has been reported as 0.5 to 3% in studies conducted
in Turkey. In the last decade, the number of mushroom poisoning cases has decreased
due to the increase in the production of cultivated mushrooms, production of various
species in the culture environment, and increased public awareness.[2]
The World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) as
a pandemic on March 11, 2020, and the first case was seen in Turkey on the same day.[3] Since then, measures taken by governments and individuals have affected the behavioral
characteristics of societies. In the peak periods of the disease, the hospital admissions
of all non-COVID-19 elective cases were postponed.[4]
[5]
[6] However, there was no significant increase in the number of non-COVID-19 emergency
department admissions across the world.[7] In a study from China, Li et al reported an increase in mushroom poisoning cases
in 2020.[8] Similarly, in a study from Israel, Lurie et al reported an increased number of mushroom
poisoning cases compared with the fall/winter period in 2019 and noted an increase
in the median annual rate between 2015 and 2019.[9] In light of this literature, we aimed to investigate the effect of the COVID-19
pandemic on emergency department presentations with mushroom poisoning in a tertiary
hospital in Turkey.
Materials and Methods
Study Design
This study was conducted as a retrospective cohort study at Umraniye Training and
Research Hospital, University of Health Sciences, a 795-bed tertiary education hospital
with 1,110 daily emergency department presentations (annual average of the study period).
The data of patients who presented to the emergency department between January 1,
2018, and December 31, 2020, were retrospectively collected. To reveal the effect
of COVID-19 pandemic on emergency department presentations with mushroom poisoning,
the means of the pre-pandemic period (2018–2019) and the pandemic period (2020) were
compared.
Study Population
The population of the study consisted of adult patients who presented to the emergency
department with symptoms of mushroom poisoning during the study period. The patients
who were diagnosed with the International Classification of Diseases (ICD)-10 code
T62.0 of the WHO medical classification concerning the toxic effect of ingested mushrooms
were identified through the computerized medical and laboratory record system of the
hospital. Patients with missing data were excluded from the study. The flowchart of
the study is shown in [Fig. 1].
Fig. 1 Flowchart of the study.
Data Collection
The patients' demographic data, presentation seasons, laboratory findings, emergency
department outcomes, and mortality due to mushroom poisoning were obtained from the
computer-based hospital system. The patient's files with the ICD-10 code T62.0 toxic
effect of ingested mushrooms were obtained from the hospital computer-based data system
in the electronic environment. Data were organized by the researchers (S.Ö. and İ.A.).
The presentation season of the patients was recorded as winter (December, January,
and February), autumn (September, October, and November), spring (March, April, and
May), and summer (June, July, and August). The mean values for sodium, potassium,
γ-glutamyl transpeptidase, total bilirubin, alanine aminotransferase (ALT), aspartate
aminotransferase, indirect bilirubin, and direct bilirubin were calculated for 2 years
preceding the pandemic (2018 and 2019). Emergency department outcomes were noted as
discharge, hospitalization, and refusal of hospitalization or hemodialysis treatment.
Statistical Analysis
We used IBM SPSS Statistics for Mac, IBM Corp, Version 27.0, Armonk, New York, United
States to perform statistical analyses. To evaluate the conformance of variables to
the normal distribution, the Kolmogorov–Smirnov's test was conducted. The nonnormally
distributed data were expressed as median and 25th to 75th percentile values, and
the data that conformed to the normal distribution were presented with mean and standard
deviation values. Categorical data were presented as the number of cases and percentages.
Although the first case was seen in our country and the declaration of the pandemic
was March 11, 2020, the effects of the government's reactions and measures on the
social behavior began in January 2020.[3] For this reason, the first months of 2020 were also evaluated within the effects
of the pandemic. To understand the impact of the pandemic, the data for 2020 and the
average data for 2019 and 2018 were compared. For the comparison of qualitative and
quantitative data between the two groups, the chi-square and Mann–Whitney's U tests were used. The p-value of 0.05 was considered as a cutoff point for statistical significance.
Results
Of the 171 patients included in the final analysis, 69 (42.3%) were male. The median
age was 39 (25th–75th percentile: 28–53) years. The baseline characteristics of the
enrolled patients are shown in [Table 1], and the seasonal distribution of the mushroom poisoning cases presenting to the
emergency department from 2018 to 2020 is shown in [Fig. 2]. The number of patients hospitalized due to mushroom poisoning was 49 (51%) in 2018,
28 (45.9%) in 2019, and 8 (57.1%) in 2020. Nineteen (19.9%) patients were discharged
in 2018, 15 (24.5%) in 2019, and 1 (7.1%) in 2020. Twenty-eight (29.1%) patients in
2018, 18 (29.5%) in 2019, and 5 (35.7%) in 2020 refused hospitalization or hemodialysis
treatment. Hemodialysis was applied to 39 (39.5%) patients in 2018, 21 (34.4%) in
2019, and 6 (42.8%) in 2020.
Fig. 2 Seasonal distribution of mushroom poisoning cases presenting to the emergency department
from 2018 to 2020.
Table 1
Baseline characteristics of the enrolled patients according to years
|
Variables
|
2018 (n = 96)
|
2019 (n = 61)
|
2020 (n = 14)
|
|
Age (y), median (25th–75th quarters)
|
39 (28–53)
|
40 (33–54.5)
|
39 (27.75–28.25)
|
|
Gender, n (%)
|
|
Male
|
40 (41.7%)
|
25 (41%)
|
4 (28.6%)
|
|
Female
|
56 (58.3%)
|
36 (59%)
|
10 (71.4%)
|
|
Season, n (%)
|
|
Winter
|
12 (12.5%)
|
17 (27.9%)
|
5 (35.7%)
|
|
Spring
|
20 (20.8%)
|
17 (27.9%)
|
2 (14.3%)
|
|
Summer
|
12 (12.5%)
|
12 (19.7%)
|
3 (21.4%)
|
|
Autumn
|
52 (54.2%)
|
15 (24.6%)
|
4 (28.6%)
|
|
Laboratory findings, median (25th–75th quarters)
|
|
Aspartate aminotransferase (U/L)
|
23 (19–29.25)
|
19 (16–25)
|
20 (17.75–21.75)
|
|
Alanine aminotransferase (U/L)
|
19.5 (14–26)
|
19 (13.5–28.5)
|
14.5 (11–19)
|
|
γ-glutamyl transpeptidase (U/L)
|
18 (13–30)
|
20.5 (14–35.75)
|
16 (10–23)
|
|
Total bilirubin (mg/dL)
|
0.51 (0.33–0.79)
|
0.51 (0.34–0.82)
|
0.59 (0.43–1.49)
|
|
Direct bilirubin (mg/dL)
|
0.18 (0.13–0.26)
|
0.19 (0.13–0.29)
|
0.22 (0.15–0.45)
|
|
Indirect bilirubin (mg/dL)
|
0.35 (0.21–0.52)
|
0.31 (0.21–0.53)
|
0.37 (0.30–1.04)
|
|
Sodium (mEq/L)
|
138 (137–140)
|
139 (138–141)
|
139 (138–140)
|
|
Potassium (mEq/L)
|
4.4 (4.2–4.6)
|
4.3 (4.1–4.6)
|
4.3 (4.1–4.6)
|
|
Emergency department outcomes, n (%)
|
|
Hospitalization
|
49 (51%)
|
28 (46%)
|
8 (57.1%)
|
|
Refusal of treatment
|
28 (29.1%)
|
18 (29.5%)
|
5 (35.7%)
|
|
Discharge
|
19 (19.9%)
|
15 (24.5%)
|
1 (7.1%)
|
|
Hemodialysis, n (%)
|
39 (39.5%)
|
21 (34.4%)
|
6 (42.8%)
|
|
Mortality, n
|
1
|
0
|
0
|
Only one patient died due to the toxic effect of ingested mushrooms during hospitalization
(in 2018). Transaminase levels were elevated in the initial tests in two patients
in 2018 and in two patients in 2019. No elevation of transaminases was observed in
initial test of the patients in 2020. The comparisons of the baseline characteristics
between the pre-pandemic and pandemic periods are shown in [Table 2]. In the pre-pandemic period, the average number of patients presenting with mushroom
poisoning per year was 78.5. In the pandemic period, 14 patients presented with mushroom
poisoning annually. There was a 5.6-fold decrease in the number of patients presenting
with mushroom poisoning during the pandemic.
Table 2
Comparisons of baseline characteristics between the pre-pandemic and pandemic periods
|
Variables
|
2018 and 2019 (n = 157)
|
2020 (n = 14)
|
p-Value
|
|
Age (y), median (25th–75th quarters)
|
39 (31–53)
|
39 (27.75–28.25)
|
0.616
|
|
Gender, n (%)
|
|
Male
|
65 (41.4%)
|
4 (28.6%)
|
0.348
|
|
Female
|
92 (58.6%)
|
10 (71.4%)
|
|
Season, n (%)
|
|
Winter
|
29 (18.5%)
|
5 (35.7%)
|
0.343
|
|
Spring
|
37 (23.6%)
|
2 (14.3%)
|
|
Summer
|
24 (15.3%)
|
3 (21.4%)
|
|
Autumn
|
67 (42.7%)
|
4 (28.6%)
|
|
Laboratory findings, median (25th–75th quarters)
|
|
Aspartate aminotransferase (U/L)
|
21 (18–28)
|
20 (17.75–21.75)
|
0.283
|
|
Alanine aminotransferase (U/L)
|
19 (14–27)
|
14.5 (11–19)
|
0.038
|
|
γ-glutamyl transpeptidase (U/L)
|
19 (14–34)
|
16 (10–23)
|
0.179
|
|
Total bilirubin (mg/dL)
|
0.51 (0.33–0.80)
|
0.59 (0.43–1.49)
|
0.129
|
|
Direct bilirubin (mg/dL)
|
0.18 (0.13–0.26)
|
0.22 (0.15–0.45)
|
0.237
|
|
Indirect bilirubin (mg/dL)
|
0.33 (0.21–0.53)
|
0.37 (0.30–1.04)
|
0.124
|
|
Sodium (mEq/L)
|
139 (137–141)
|
139 (138–140)
|
0.776
|
|
Potassium (mEq/L)
|
4.4 (4.1–4.6)
|
4.3 (4.1–4.6)
|
0.555
|
Discussion
In this retrospective study, we evaluated the effect of the COVID-19 pandemic on emergency
department presentations with mushroom poisoning. To this end, we compared the average
number of presentations during the pre-pandemic and pandemic periods. According to
our results, there was a 5.6-fold decrease in the number of patients presenting with
mushroom poisoning. To the best of our knowledge, this was the first study to evaluate
the effect of the COVID-19 pandemic on mushroom poisoning in Turkey. Contrary to the
literature, we found a decrease in mushroom poisoning cases during the pandemic.
We think that one of the logical explanations for the results of our study may be
the change in people's hospital admission habits during the pandemic period. During
the pandemic, there have been changes in the patient characteristics of emergency
departments. While the number of patients presenting with COVID-19-like symptoms increased,
presentations involving non-COVID-19-like symptoms have decreased considerably.[10] Another possible logical explanation for our results might be the changes in people's
eating habits. The COVID-19 pandemic and its restrictive measures have also resulted
in the modification of the eating habits of individuals. It has drastically changed
food shopping behaviors, and the resulting economic recession has caused concerns
over food availability. During lockdowns implemented, people have started to consume
more pasta and canned goods than green vegetables, which has led to the increased
incidence of nutritional disorders.[11]
[12]
Changes have also been reported in cases of mushroom poisoning due to altered nutritional
habits and emergency patient characteristics. Li et al called mushroom poisoning cases
in China mushroom poisoning outbreaks. They reported 24 new species of mushroom causes
poisoning, a case of shiitake mushroom dermatitis, and mortality in one case due to
Paxillus involutus. Li et al recommended promoting awareness concerning the safe consumption of mushrooms
to reduce related poisoning, but they did not comment on the reasons for this change
in mushroom poisoning cases.[8] In another study, Lurie et al investigated the effect of the COVID-19 pandemic on
mushroom poisoning cases in Israel. They showed a 5-fold increase compared with the
same fall/winter period in 2019, as well as a 2.5-fold increase in the median annual
rate from 2015 to 2019. They suggested that this might be due to favorable increased
outdoor activities of the public and climate conditions in response to restrictions
on other relaxation activities obligatory during the pandemic as an explanation of
their results.[9] Contrary to these two studies, our sample indicated a 5.6-fold decrease in the median
annual rate of mushroom poisoning cases during the pandemic compared with the pre-pandemic
2-year period. An explanation for this discrepancy may be that we used emergency department
data in our study, while the other two studies evaluated data obtained from national
poisoning information centers. Lurie et al reported that most cases had minor or no
symptoms and signs.[9] We consider this particular patient group may not have presented to the emergency
department due to the fear of contracting COVID-19. Another possible explanation is
our study being conducted in a metropolitan city and not including national data and
individuals' changing dietary habits in favor of storable foods, such as pasta and
canned food.
Limitations
The main limitation of our study was its retrospective nature. First, there may have
been other risk factors that could not be measured due to the retrospective design.
Retrospective studies cannot determine causation; they only evaluate association.
Second, we only evaluated data obtained from an emergency department of a tertiary
hospital located in a metropolitan city and did not include national data. The situation
may be different in the countryside. Third, the poisonous mushroom species were not
evaluated in our study; therefore, we were not able to determine whether there was
a change in the poisoning characteristics similar to the previous study conducted
in China.[8] Fourth, in our country, clinicians are obliged to report mushroom poisoning cases
to law enforcement in accordance with local legal policies. The data of these cases
are considered forensic data. Therefore, clinicians are careful while recording the
data of mushroom poisoning cases. On the other hand, this legal obligation may have
encouraged patients to give incorrect information. Another limitation of our study
was the high number of patients who refused treatment. Due to the clinical practices
of our hospital, we follow up the patients by hospitalizing them more. Before hospitalization,
patients are told that applications such as hemodialysis will be performed. Patients
who have already become asymptomatic with symptomatic treatment in the emergency department
refuse hospitalization and hemodialysis. Another explanation for about one-third of
patients' refusal to receive treatment may be the low level of health literacy in
our country, as in the rest of the world.[13] Finally, our study had a single-center design, and therefore, our results cannot
be generalized to other health care institutions.
Conclusion
In conclusion, our results indicated a 5.6-fold decrease in the number of patients
presenting to the emergency department with mushroom poisoning. This may be due to
the changes in the eating habits of individuals during the pandemic and our study
being conducted in a metropolitan city. We recommend that multicenter studies be performed
to verify the data obtained from our study and increase their generalizability.
