only approximately 30 of the thousands of mushrooms worldwide are known to be fatally poisonous . the most famous toxic mushroom is the genus amanita , which contains the lethal toxin amatoxin . as this mushroom resembles antler ganoderma lucidum and cordyceps in the early stage , amateur mushroom hunters have mistaken podostroma cornu - damae for these mushrooms . in korea , however , no cases were reported before 2013 . nevertheless , since then , cases of accidental intoxication of this mushroom have been reported . here , a 62-year - old woman , previously diagnosed with hypertension , was admitted to the emergency department due to desquamation of the hands and feet ( fig . the symptoms had started 7 days previously , and she tried taking oral medication and applying lotions prescribed by her dermatologist without improvement . the symptoms worsened , and she developed general weakness and mild nausea . upon further questioning , she admitted that she had gathered wild mushrooms from a nearby mountain and had made tea from the mushrooms . she had been drinking 2 or 3 cups of mushroom tea for the previous 12 days . on admission , her blood pressure was 115/64 mmhg , heart rate was 97 beats / min , and temperature was 37.7c . she complained of general weakness , fever , and light abdominal discomfort , and she had desquamation of the hands and feet and alopecia . blood tests showed severe bicytopenia with a white blood cell ( wbc ) count of 6,200/l and an absolute neutrophil count < 10 , as well as a hemoglobin ( hb ) level of 11.5 g / dl and platelet count of 29,000/l . the patient s c - reactive protein ( crp ) level was 21.18 mg / dl , which was elevated above the normal range . other test results were within normal limits ( blood urea nitrogen 33.8 mg / dl , creatinine 0.94 mg / dl , aspartate aminotransferase 7 iu / l , creatine kinase - mb 0.51 ng / dl , and troponin t 0.019 ng / dl ) . a peripheral blood smear showed severe neutropenia , while a chest radiograph and electrocardiograms showed normal findings . although her history suggested mushroom intake to be the cause of her abnormal laboratory measurements , she was admitted and treated with prophylactic antibiotics and granulocyte colony - stimulating factor ( g - csf ) . we tested for hantaan virus , tsutsugamushi , leptospirosis , and malaria antibody to rule out other infections , and two sets of blood cultures were performed immediately . neutropenia persisted during her hospitalization , and on the third hospital day , her platelet count decreased to 10,000/l . after 4 pints of platelet infusion and continuous g - csf infusion , her blood cell count improved without any other infective , renal , or cardiovascular complications . on the thirteenth day of her hospitalization , the laboratory measurements showed a wbc count of 2,000/l , absolute neutrophil count ( anc ) of 710 , segmented neutrophil count of 42% , hb level of 7.9 g / dl , and platelet count of 144,000/l . one week later , at an outpatient follow - up visit , her blood cell count had recovered fully . however , he admitted to having drunk mushroom tea with case 1 . on admission , his blood pressure was 133/66 mmhg , heart rate was 66 beats / min , and body temperature was 37.5c . initial laboratory results showed a wbc count of 1.7510/l , anc of 820 , hb level of 14.3 g / dl , platelet count of 1210/l , crp level of 2.05 mg / dl , blood urea nitrogen level of 15.0 mg / dl , creatinine level of 0.99 mg / dl , aspartate aminotransferase level of 18 u / l , alanine aminotransferase level of 19 iu / l , and procalcitonin level of 0.07 ng / dl . he was admitted and treated with prophylactic antibiotics and g - csf . on the fourth day of his admission , his anc fell to < 10 , and his crp level was 13.33 mg / dl . his antibody tests and cultures all yielded negative results ( similar to case 1 ) . on the twelfth day of his admission , his bicytopenia started to improve . on the eighteenth day of his admission , his complete blood cell count normalized , with a wbc count of 7,380/l , hb level of 11.0 g / dl , and platelet count of 30,000 . a 62-year - old woman , previously diagnosed with hypertension , was admitted to the emergency department due to desquamation of the hands and feet ( fig . the symptoms had started 7 days previously , and she tried taking oral medication and applying lotions prescribed by her dermatologist without improvement . the symptoms worsened , and she developed general weakness and mild nausea . upon further questioning , she admitted that she had gathered wild mushrooms from a nearby mountain and had made tea from the mushrooms . she had been drinking 2 or 3 cups of mushroom tea for the previous 12 days . on admission , her blood pressure was 115/64 mmhg , heart rate was 97 beats / min , and temperature was 37.7c . she complained of general weakness , fever , and light abdominal discomfort , and she had desquamation of the hands and feet and alopecia . blood tests showed severe bicytopenia with a white blood cell ( wbc ) count of 6,200/l and an absolute neutrophil count < 10 , as well as a hemoglobin ( hb ) level of 11.5 g / dl and platelet count of 29,000/l . the patient s c - reactive protein ( crp ) level was 21.18 mg / dl , which was elevated above the normal range . other test results were within normal limits ( blood urea nitrogen 33.8 mg / dl , creatinine 0.94 mg / dl , aspartate aminotransferase 7 iu / l , creatine kinase - mb 0.51 ng / dl , and troponin t 0.019 ng / dl ) . a peripheral blood smear showed severe neutropenia , while a chest radiograph and electrocardiograms showed normal findings . although her history suggested mushroom intake to be the cause of her abnormal laboratory measurements , she was admitted and treated with prophylactic antibiotics and granulocyte colony - stimulating factor ( g - csf ) . we tested for hantaan virus , tsutsugamushi , leptospirosis , and malaria antibody to rule out other infections , and two sets of blood cultures were performed immediately . neutropenia persisted during her hospitalization , and on the third hospital day , her platelet count decreased to 10,000/l . after 4 pints of platelet infusion and continuous g - csf infusion , her blood cell count improved without any other infective , renal , or cardiovascular complications . on the thirteenth day of her hospitalization , the laboratory measurements showed a wbc count of 2,000/l , absolute neutrophil count ( anc ) of 710 , segmented neutrophil count of 42% , hb level of 7.9 g / dl , and platelet count of 144,000/l . one week later , at an outpatient follow - up visit , her blood cell count had recovered fully . however , he admitted to having drunk mushroom tea with case 1 . on admission , his blood pressure was 133/66 mmhg , heart rate was 66 beats / min , and body temperature was 37.5c . initial laboratory results showed a wbc count of 1.7510/l , anc of 820 , hb level of 14.3 g / dl , platelet count of 1210/l , crp level of 2.05 mg / dl , blood urea nitrogen level of 15.0 mg / dl , creatinine level of 0.99 mg / dl , aspartate aminotransferase level of 18 u / l , alanine aminotransferase level of 19 iu / l , and procalcitonin level of 0.07 ng / dl . he was admitted and treated with prophylactic antibiotics and g - csf . on the fourth day of his admission , his anc fell to < 10 , and his crp level was 13.33 mg / dl . under suspicion of concealed infection , prophylactic vancomycin was administered . his antibody tests and cultures all yielded negative results ( similar to case 1 ) . on the twelfth day of his admission , his bicytopenia started to improve . on the eighteenth day of his admission , his complete blood cell count normalized , with a wbc count of 7,380/l , hb level of 11.0 g / dl , and platelet count of 30,000 . podostroma cornu - damae is an ascomycete fungus and was originally described by patouillard as hypocrea cornu - damae ( 1895 ) and said to originate in tibet . it was then published in saccardo s famous sylloge fungorum ( 1905 ) and was named since . many accidental poisonings by podostroma cornu - damae can be attributed to its similarity to antler ganoderma lucidum and cordyceps ( figs . 1 , 2 ) . podostroma cornu - damae is known to inhabit the java islands , korea , japan , and china . in 1999 , five people in japan drank sake made from about 1 g of this toxic mushroom , resulting in a death 2 days later despite intensive treatment . in korea , 4 people have reportedly been intoxicated by this mushroom , of whom 3 drank tea made from its fruit body . one died of multi - organ failure , and the 2 others were discharged from the hospital without complications . his lungs showed hemorrhagic and necrotic changes , and he died within 12 days due to multi - organ failure . the case reported by ahn et al . , is similar to ours in many ways . the patient consumed the mushroom in tea form and showed similar symptoms such as fever , generalized weakness , alopecia , and desquamation of the palms and soles ( as in case 1 ) . our patient recovered gradually , while the patient described by ahn et al . , despite being intubated and treated with continuous renal replacement , experienced worsening bilateral lower lung field consolidation and died due to multi - organ failure . the most common complaints were abdominal pain , desquamation of the hands and feet , alopecia , perception changes , and speech impediment . further evaluation showed blood cell count anomalies , such as pancytopenia or bicytopenia , and cerebellar atrophy . autopsies showed that the patients died of multi - organ failure , including disseminated intravascular coagulation , kidney failure , and hepatic failure . in japan , researchers have identified macrocyclic trichothecene toxins , such as satratoxin h , satratoxin h 12 , 13-diacetate , satratoxin h 12-acetate , and satratoxin h 13-acetate . the mice died the next day after they were injected with 0.5 g of the toxin . no specific treatment has been found for poisoning with this lethal mushroom , but one patient who showed severe hemophagocytosis and bicytopenia was treated with abundant intravenous fluids ( 12 liters over 9 hours ) , plasmapheresis , and g - csf . other patients , like ours , were treated using g - csf and prophylactic antibiotics and recovered without complications . cases in which a person drank or ate the fruit body itself resulted in intake of large amounts of the toxin , thereby leading to symptoms within only a few hours or few days . when patients make tea and drink small amounts of the mushroom over a long period , it takes 2 to 4 weeks for symptoms to appear . in the current case , the patients complained of alopecia and desquamation of the hands , with no other symptoms . both were treated with g - csf , and their symptoms and abnormal laboratory measurements remitted without any complications . we hope these cases will help treat future patients who present with an unknown cause of neutropenic fever and pancytopenia as well as desquamation on their palms and soles . furthermore , as the number of cases of podostroma cornu - damae poisoning is increasing , physicians should be sure to ask patients about any history of ingesting wild mushrooms when such symptoms appear .
podostroma cornu - damae is a rare , deadly fungus . 
 however , it can be easily mistaken for antler ganoderma lucidum . in this case report , two patients made tea with the fungus and drank it over a 2-week period . 
 both patients presented with bicytopenia , and one patient had desquamation of the palms and soles . 
 both were treated with prophylactic antibiotics and granulocyte colony - stimulating factor . 
 one patient was admitted to the intensive care unit and received a platelet transfusion . 
 both patients were discharged without complications . 
 podostroma cornu - damae infections caused by intoxication were successfully treated using our treatment strategy , which consisted of prophylactic antibiotics , platelet transfusion , and granulocyte colony - stimulating factor . 
 we believe this report can guide future treatment .