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Background: Amanita Phalloides or “death cap” is one of the most dangerous variants of fungi found in Western Europe and North America. While hepatic and renal necrosis are widely reported following ingestion of this toxin, multifocal osteonecrosis is yet to be described. We present the simultaneous polyarticular functional decline and challenging management of our patient following such an occurrence. Additionally, we illustrate the rare occurrence of atraumatic patellar osteonecrosis as a component of her presentation. Methods: We present the case of a 44-year-old female who presented to our institution with fulminant hepatic failure and subsequent multi-organ failure following ingestion of Amanita Phalloides mushrooms. Following liver transplant and diffuse dermal necrosis requiring multiple skin grafts, she became bed-bound due to intractable lower limb pain. Plain film and MRI investigations revealed bilateral Ficat stage 4 avascular necrosis of both hips with associated florid myositis. The overlying skin on her left hip had ongoing serous ooze from the split thickness skin graft sites, exacerbated limited mobility. She underwent synchronous bilateral Corail Pinnacle (Warsaw, IN, USA) total hip replacements. Further radiological investigation revealed right patellar osteonecrosis. Results: Her left hip wound and overlying skin developed superficial soft tissue infection post-operatively. This was managed with intravenous antibiotics and resolved after 6 weeks. Her right knee pain contributed to a difficult postoperative rehabilitation. Conclusions: Amanita Phalloides ingestion is often fatal. We document a rare presentation of a simultaneous polyarticular atraumatic osteonecrosis of the hips and unilateral patella in the setting of ‘death cap’ toxin ingestion and subsequent liver transplant.

AB211. SOH21AS252. Multifocal osteonecrosis following ingestion of the “Death Cap” mushroom: a rare occurrence