A 71-year-old man presented with progressive nausea, vomiting, diarrhea, and weakness 48 h after having ingested wild mushrooms while camping in northwestern Iowa. The following day, nausea, vomiting, and profuse, watery diarrhea led him to seek medical attention. Vital signs and physical examination results were normal. Abnormal chemistry levels included elevated aspartate aminotransferase, 2,313 IU/L (normal range, 15-37 IU/L); alanine aminotransferase, 2,730 IU/L (normal range, 12-78 IU/L); total bilirubin, 1.5 mg/dL (normal range, 0.0-1.0 mg/dL); international normalized ratio, 1.3 (normal range, 0.8-1.2); and creatinine, 2.7 mg/dL (normal range, 0.51-1.2 mg/dL) (Fig 1). The regional Poison Control recommended treatment with IV N-acetylcysteine for 48 h and penicillin G, 24 million units daily continuous infusion for 48 h. The following morning the patient became encephalopathic. Given the combination of acute kidney injury, encephalopathy, coagulopathy, and worsening transaminase elevations, he was classified as having stage 4 amatoxin poisoning and was transferred to our liver transplant center.