Q: 42 year old male, a day after his return from france is admitted to ICU with c/o severe dehydration due to gastroenteritis. The patient get diagnosed with a history of mushroom poisoning and is discharged to home after resolution of symptoms with supportive treatment. Patient is now back in ER  with c/o severe burning, redness and swelling of bilateral extremities?


Answer:  Erythromelalgia 

Erythromelalgia is the triad of

• severe burning pain in the extremities 
• severe redness (erythema) of the extremities 
• Edema of the extremities

Objective of above question is to highlight the point that:  Management, treatment, expectations and follow up in mushroom poisoning requires proper identification of specific mushroom type. Clinically it ranges from simple gastroenteritis to delayed liver toxicity. 

Erythromelalgia is used in mushroom poisoning to identify 2 species 

• Clitocybe acromelalga, found mostly in Japan and 
• Clitocybe amoenolens found mostly in France

It is also described as a side effect of calcium channel blockers. It may occur as an isolated disease or as a manifestation of other diseases particularly bone marrow diseases.  Interestingly, nicotine is said to improve symptoms.



References:

1.  Nakajima N, Ueda M, Higashi N, Katayama Y. Erythromelalgia associated with Clitocybe acromelalga intoxication. Clin Toxicol (Phila) 2013; 51:451.

2. Saviuc PF, Danel VC, Moreau PA, Guez DR, Claustre AM, Carpentier PH, Mallaret MP, Ducluzeau R. "Erythromelalgia and mushroom poisoning". J. Toxicol Clin Toxicol 39 (4): 403–07 (2001)

3. Diaz, James H.  "Syndromic diagnosis and management of confirmed mushroom poisonings". Critical Care Medicine 33 (2): 427–36.(February 2005).