Raw and cooked mushrooms and the cooking water are capable of producing toxicity through ALDH inhibition. Symptoms begin within minutes of ethanol ingestion. Patients may relate symptoms to ethanol, not mushrooms. It is important to ascertain if other species of wild mushrooms were ingested concomitantly and the approximate elapsed time since ingestion. Provide intravenous fluids if GI effects have not abated.
Hypotension generally responds to volume expansion with normal saline.
Patients with severe hypotension may require vasopressor agents, once volume restoration is insured. Recommendation is an extension of known pharmacology of disulfiram, which inhibits dopamine beta-hydroxylase, thereby depleting presynaptic catecholamines. Activated charcoal may be beneficial if mushrooms were ingested recently. Fomepizole is currently very expensive, and use is not established in this clinical setting. Consultation with regional Poison Control Center, toxicologist, or mycologist may be helpful.