Although very distinctive in appearance, the fly agaric has been mistaken for other yellow to red mushroom species in the Americas, such as Armillaria cf. mellea and the edible A. basii—a Mexican species similar to A. caesarea of Europe. Poison control centres in the U.S. and Canada have become aware that amarill (Spanish for 'yellow') is a common name for the A. caesarea-like species in Mexico. A. caesarea is distinguished by its entirely orange to red cap, which lacks the numerous white warty spots of the fly agaric (though these sometimes wash away during heavy rain). Furthermore, the stem, gills and ring of A. caesarea are bright yellow, not white. The volva is a distinct white bag, not broken into scales. In Australia, the introduced fly agaric may be confused with the native vermilion grisette (Amanita xanthocephala), which grows in association with eucalypts. The latter species generally lacks the white warts of A. muscaria and bears no ring. Additionally, immature button forms resemble puffballs.
However, a 2006 molecular phylogenetic study of different regional populations of A. muscaria by mycologist József Geml and colleagues found three distinct clades within this species representing, roughly, Eurasian, Eurasian "subalpine", and North American populations. Specimens belonging to all three clades have been found in Alaska; this has led to the hypothesis that this was the centre of diversification for this species. The study also looked at four named varieties of the species: var. alba, var. flavivolvata, var. formosa (including var. guessowii), and var. regalis from both areas. All four varieties were found within both the Eurasian and North American clades, evidence that these morphological forms are polymorphisms rather than distinct subspecies or varieties. Further molecular study by Geml and colleagues published in 2008 show that these three genetic groups, plus a fourth associated with oak–hickory–pine forest in the southeastern United States and two more on Santa Cruz Island in California, are delineated from each other enough genetically to be considered separate species. Thus A. muscaria as it stands currently is, evidently, a species complex. The complex also includes at least three other closely related taxa that are currently regarded as species: A. breckonii is a buff-capped mushroom associated with conifers from the Pacific Northwest, and the brown-capped A. gioiosa and A. heterochroma from the Mediterranean Basin and from Sardinia respectively. Both of these last two are found with Eucalyptus and Cistus trees, and it is unclear whether they are native or introduced from Australia.
The active constituents of this species are water-soluble, and boiling and then discarding the cooking water at least partly detoxifies A. muscaria. Drying may increase potency, as the process facilitates the conversion of ibotenic acid to the more potent muscimol. According to some sources, once detoxified, the mushroom becomes edible. Patrick Harding describes the Sami custom of processing the fly agaric through reindeer.
Ibotenic acid and muscimol are structurally related to each other and to two major neurotransmitters of the central nervous system: glutamic acid and GABA respectively. Ibotenic acid and muscimol act like these neurotransmitters, muscimol being a potent GABAA agonist, while ibotenic acid is an agonist of NMDA glutamate receptors and certain metabotropic glutamate receptors which are involved in the control of neuronal activity. It is these interactions which are thought to cause the psychoactive effects found in intoxication.
Fly agarics are best known for the unpredictability of their effects. Depending on habitat and the amount ingested per body weight, effects can range from mild nausea and twitching to drowsiness, cholinergic crisis-like effects (low blood pressure, sweating and salivation), auditory and visual distortions, mood changes, euphoria, relaxation, ataxia, and loss of equilibrium (like with tetanus.)
Medical attention should be sought in cases of suspected poisoning. If the delay between ingestion and treatment is less than four hours, activated charcoal is given. Gastric lavage can be considered if the patient presents within one hour of ingestion. Inducing vomiting with syrup of ipecac is no longer recommended in any poisoning situation.
There is no antidote, and supportive care is the mainstay of further treatment for intoxication. Though sometimes referred to as a deliriant and while muscarine was first isolated from A. muscaria and as such is its namesake, muscimol does not have action, either as an agonist or antagonist, at the muscarinic acetylcholine receptor site, and therefore atropine or physostigmine as an antidote is not recommended. If a patient is delirious or agitated, this can usually be treated by reassurance and, if necessary, physical restraints. A benzodiazepine such as diazepam or lorazepam can be used to control combativeness, agitation, muscular overactivity, and seizures. Only small doses should be used, as they may worsen the respiratory depressant effects of muscimol. Recurrent vomiting is rare, but if present may lead to fluid and electrolyte imbalances; intravenous rehydration or electrolyte replacement may be required. Serious cases may develop loss of consciousness or coma, and may need intubation and artificial ventilation. Hemodialysis can remove the toxins, although this intervention is generally considered unnecessary. With modern medical treatment the prognosis is typically good following supportive treatment.
While Amanita mushrooms are unscheduled in the United States, they are listed as a poison by the FDA. Amanita mushrooms and muscimol are not approved as an ingredient in food, with some drawing comparisons to the controversial legal status of hemp-derived cannabinoids. The FDA is currently evaluating the use of Amanita muscaria and its constituents in dietary supplements, reminding manufacturers to ensure their ingredients meet safety standards and encouraging them to consult the Office of Dietary Supplement Programs with any questions.
A recent outbreak of poisonings and at least one death associated with products containing Amanita muscaria extracts has sparked debates regarding the regulatory status of Amanita mushrooms and their psychoactive constituents, prompting an FDA ban of their use in food products in December 2024. These products often use misleading advertising, such as erroneous comparisons to Psilocybin mushrooms or simply not disclosing the inclusion of Amanita mushrooms on the packaging.
Mycophilosopher Martijn Benders has proposed a novel evolutionary theory involving Amanita muscaria. In his book Amanita Muscaria – the Book of the Empress, Benders argues that a precursor of ibotenic acid, a compound found in the mushroom, was present in ancient seaweed and played a significant role in the evolution of life. According to this hypothesis, the compound influenced the twitching movements of early aquatic organisms, leading to the development of behaviors such as jumping onto land—a crucial step in the evolution of terrestrial species.
Use of this mushroom as a food source also seems to have existed in North America. A classic description of this use of A. muscaria by an African-American mushroom seller in Washington, D.C., in the late 19th century is described by American botanist Frederick Vernon Coville. In this case, the mushroom, after parboiling, and soaking in vinegar, is made into a mushroom sauce for steak. It is also consumed as a food in parts of Japan. The most well-known current use as an edible mushroom is in Nagano Prefecture, Japan. There, it is primarily salted and pickled.
A 2008 paper by food historian William Rubel and mycologist David Arora gives a history of consumption of A. muscaria as a food and describes detoxification methods. They advocate that Amanita muscaria be described in field guides as an edible mushroom, though accompanied by a description on how to detoxify it. The authors state that the widespread descriptions in field guides of this mushroom as poisonous is a reflection of cultural bias, as several other popular edible species, notably morels, are also toxic unless properly cooked.
The red-and-white spotted toadstool is a common image in many aspects of popular culture. Garden ornaments and children's picture books depicting gnomes and fairies, such as the Smurfs, often show fly agarics used as seats, or homes. Fly agarics have been featured in paintings since the Renaissance, albeit in a subtle manner. For instance, in Hieronymus Bosch's painting, The Garden of Earthly Delights, the mushroom can be seen on the left-hand panel of the work. In the Victorian era they became more visible, becoming the main topic of some fairy paintings. Two of the most famous uses of the mushroom are in the Mario franchise (specifically two of the Super Mushroom power-up items and the platforms in several stages which are based on a fly agaric), and the dancing mushroom sequence in the 1940 Disney film Fantasia.
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