Ulcerating Ileocolitis in Severe Amatoxin Poisoning

Abstract

Amatoxin poisoning is still associated with a great potential for complications and a high mortality. While the occurrence of acute gastroenteritis within the first 24 hours after amatoxin ingestion is well described, only very few descriptions of late gastrointestinal complications of amatoxin poisoning exist worldwide. We present the case of a 57-year-old female patient with severe amatoxin poisoning causing fulminant but reversible hepatic failure that on day 8 after mushroom ingestion developed severe abdominal pain and watery diarrhea. Ulcerating ileocolitis was identified by computed tomography identifying a thickening of the bowel wall of the entire ileum and biopsies taken from the ileum and large bowel revealing distinct ileitis and proximally accentuated colitis. The absence of discernible alternative etiologies such as infectious agents makes a causal relationship between the ulcerating ileocolitis and the amatoxin poisoning likely. Diarrhea and varying abdominal pain persisted over several weeks and clinical follow-up after six months showed a completely symptom-free patient. The case presented highlights the importance to consider the possibility of rare complications of Amanita intoxication in order to be able to respond to them early and adequately.

Figure 1

Biopsy of the ileum. (a) Biopsy of the ileum with acute ulcerating inflammation and fibrinoleukocytic exudate (∗). Enteric architecture is changed with only fragmented residual villi and loss of Paneth cells. Mucosal vessels are heavily dilated (→) (40x magnification). (b) The lamina propria is filled by a dense mixed inflammatory infiltrate. Some neutrophilic granulocytes invade the epithelium of the crypts (→). In the lower right corner of the picture a residual crypt with atrophic epithelium and intraluminal cell detritus can be seen (∗). The epithelial cells show regeneratory and reactive changes with enlargement of the nuclei and prominent nucleoli (200x magnification).

Figure 2

Biopsy of the cecum, showing rarefication and atrophy of the crypts, dilation of the lumina with intraluminal cell detritus (∗), and fibrosis of the lamina propria. Epithelial cells present reactive, respectively, regeneratory nuclear atypia in the context of inflammation (40x magnification); for details see the inset (200x magnification).