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On August 29, 2022, twelve diners at a Markham, Ontario restaurant fell critically ill with vomiting, numbness, and life-threatening arrhythmias. The culprit? A deadly plant toxin: aconite.

In this episode—the first of a new Poison Lab Outbreak series—we go inside the Markham mass poisoning case. Join host Ryan Feldman, clinical toxicologist and emergency medicine pharmacist, as he investigates how a rare and lethal toxin ended up in a restaurant spice jar and nearly cost lives.

You’ll hear firsthand from the experts who responded to the outbreak:

• Dr. Jessica Kent, toxicology fellow at the time at the University of Toronto
• Dr. Abinhay Sathya, intensivist at Markham Stouffville Hospital
• Dr. Margaret Thompson, toxicologist and on-call consultant for the Ontario Poison Centre
• Dr. Randy Purves, research scientist at the Canadian Food Inspection Agency (CFIA)
• Bryn Shurmer, MS- analytical chemist at the Canadian Food Inspection Agency (CFIA)

Together, they walk us through the outbreak timeline—from the first patients in VT to the public health investigation that uncovered a mislabeled spice bag full of pure aconite root.

Looking for timestamps?

A fully timestamped version of the episode—so you can jump to any topic—is available to our supporting members.

💡 Key topics:

• Clinical presentation and toxic effects of aconite
• Challenges in mass poisoning recognition and coordination
• The crucial role of poison centers in outbreak response
• Public health trace-back to contaminated galangal powder
• Lessons for emergency departments and toxicologists

📍 Resources & Mentions:

• Twitter/X post by Dr. David Juurlink that helped disseminate early info
• The Poison Lab previous aconite episode: Open and shut (Mystery Case #31)
• Paper written by Ryan, Dan McCabe, and Crissy Lawson

🎧 Listen now at: www.ThePoisonLab.com

💬 Have thoughts or questions? Connect on Instagram...

In this episode of The Poison Lab, host Ryan Feldman is joined by Dr. Amy Zosel, a medical toxicologist, emergency physician, and educator. Together, they use real poisoning cases to practice identifying toxins and flexing their toxic differential The conversation dives into intriguing and challenging toxicology cases, with a focus on educating listeners about real-world poisoning scenarios, myth-busting internet misinformation, and providing practical clinical insights.

Mini episode with Dr. Robert Bassett on Remembering Poisonous Mushrooms

Dr. Zosel and Ryan discuss:

14:15 Case 1

33:04 Case 2

• News story

37:00 Case 3

• New story

48:00 Case 4

• News story
• US outbreak

"Robocough"

Study about Naloxone in Clonidine overdose

Below this will be key takeaways regarding managing the poisonings discussed, it may ruin your experience if you are guessing the poisons

Key Takeaways:

• Amatoxin Mushroom Poisoning: The classic delayed onset of severe GI symptoms, followed by a latent phase, can mask progressive liver damage. Early recognition and treatment with hydration, silibinin, and possible liver transplant are critical.
• Tetramine Toxicity: Known for causing refractory seizures, tetramine is a rare but serious poisoning often requiring aggressive supportive care and anticonvulsants.

A Lethal mushroom hiding in edible mushrooms

Mushroom foraging danger

Resources Mentioned:

• National Poison Control Hotline: 1-800-222-1222
• National Suicide Prevention Lifeline: 1-800-273-8255
• SAMHSA Free Helpline: 1-800-662-HELP (4357)

Follow The Poison Lab:

• Twitter: @LabPoison
• Instagram: @tox_talk
• Website: www.ThePoisonLab.com

Subscribe and Review:

Love what you're hearing? Help us reach more toxicology enthusiasts by leaving a review on Apple Podcasts, Spotify, or wherever you listen. Don’t forget to share this episode with...

Review the show where ever your listening

Join as a supporting member

• Ad free episodes
• Bonus content and early access
• Discounts and give aways on GOTA PICCEM Mushroom card game

The GOTTA PICCEM Poisonous Mushroom Game Landing Page!

Tox trinkets (Rep the show at home!)

• Email: Toxtalk1@gmail.com

More Show Resources

• Get Messages from Toxo (Newsletter)
• Ryan's Medical Games and Resources
• Show Website

If you are looking for links to Dr. Basset's initiatives check back later, they are not fully launched yet!

Check it out on Dr. Hamilton's website as well

Poison Mushrooms! Got’a Pic’em (GOTAAPPICEM) A mnemonic device to sort through mushroom ingestions – The Hot Stove League of EM/Tox

The GOTAA PPICCEM Mnemonic

Late-Onset (Severe) Toxic Mushrooms ("GOTA")

These mushrooms have delayed symptoms (>6 hours) and are associated with significant toxicity:

G – Gyromitrin (Gyromitra esculenta) – False morels; inhibits GABA, leading to seizures.

O – Orellanine (Cortinarius spp.) – Causes renal failure; famously poisoned The Horse Whisperer author.

T – Tricholoma equestre (Man on Horseback) – Leads to rhabdomyolysis.

A – Amatoxin (Amanita phalloides, Galerina spp.) – Causes liver failure; the most lethal mushroom toxicity.

Early Onset Nausea, Late Toxicity Mushrooms ("A²P²")

A² – Allenic norleucine (Amanita smithiana) – Found in the Pacific Northwest; early GI symptoms followed by renal failure.

These may present early but still cause significant toxicity.

P² – Paxillus spp. – Can cause hemolytic anemia and multi-organ injury.

Early-Onset Nausea Mushrooms ("PICCEM")

P– Psilocybin (Psilocybe spp.) – Hallucinogenic, similar to LSD, typically low toxicity but may cause hyperthermia or seizures.

Symptoms appear within 6 hours and are usually self-limited.

I – Ibotenic Acid & Muscimol (Amanita muscaria, Amanita pantherina) – Acts like a “mushroom speedball”, causing both stimulant and sedative effects.

C – Coprine (Coprinus spp., Inky Caps) – Induces disulfiram-like reaction with alcohol.

E – Emetic Mushrooms (LBMs: Little Brown Mushrooms) – Various species that cause self-limited vomiting and diarrhea.

M – Muscarine...