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before admission. He noticed the strange feeling of extraordinary spiritual ability to soul summoning. Following the fantasy, theosophical ceremony, and visual hallucination of the soul summoned, suddenly he suffered a severe thunderclap headache accompanied by nausea and vomiting leading to his referral to our emergency department.
On examination, he was conscious and oriented; however, he had disorganized thought and delusion of considerable mystical ability. The vital sign evaluation revealed a blood pressure of 185/110 mmHg, pulse rate of 90, the temperature of 37°C, and respiratory rate of 16. No evidence of meningeal signs was obtained, and other systemic and neurologic assessments were unremarkable.
The patient underwent brain computed tomography (CT) without contrast, which revealed subarachnoid hemorrhage along the parietal, temporal, occipital convexities without evidence of intraventricular hemorrhage or hydrocephalus (Figure 1).
The patient was admitted to the intensive care unit and subjected to standard medical treatment. Intravenous labetalol was used to control blood pressure. The laboratory findings were all within normal limits. Subsequently, the patient underwent CT angiography which was unrevealing. Brain magnetic resonance imaging did not show a more considerable finding than the brain CT.
The neurosurgery and clinical toxicology consult were requested, which all suggested conservative treatment. In the next days, the patient improved gradually with no complaint of headache and disorganized thought. The controlled brain imaging revealed the resolution of the hemorrhage. Taking into account all considerations, the patient was diagnosed with SAH associated with magic mushroom abuse. The patient was transferred to the neurology ward and discharged with a good general condition and normal physical examination.
 
Discussion
Psilocybin mushroom is a potentially illegal substance belonging to a subclass of hallucinogens. Historical evidence suggests the consumption of psilocybin mushrooms in ancient religious rites and ceremonies over 7,000 to 9,000 years ago, which is still one of the most recreational psychedelics in the United States and Europe (6). Brande reported the hallucinogenic effect of mushrooms for the first time in 1799 and described a family who served Psilocybe semilanceata mushrooms for breakfast leading to an uncontrollable laugh in one of the members of the family (7).
In the 1960s, psilocybin mushroom was adopted in the counterculture and soon was listed as an illegal drug in 1971. Currently, they are the most commonly used psychedelics among the youth. Based on the results of a survey conducted by Hallock et al. (2012), 30 % of the participants had tried mushrooms at least once (8).
A typical trip on a moderate dose of magic mushroom (1-2.5 g) comprises a dreamy state accompanied by perceptual, emotional change, and distorted sense of time. Furthermore, such side effects as vital sign instability, nausea and vomiting, tremor, and increased tendon reflexes have been reported (3-6).
The correlation between headache and magic mushroom administration is controversial. There are reports of psilocybin-induced migraine-like headache, as the double-blind study conducted by Johnson et al, which disclosed headache as an adverse event of non-medical exposure with psilocybin. On the other hand, a few preclinical trials are suggesting a promising role of psilocybin in the treatment of cluster headache (9-11). Psilocybin increases the expression of several genes, including Iκβ-α, the main inhibitor of NFκβ. Expression of inducible nitric oxide synthase enhancing NO release is dependent on NFκβ, which is directly suppressed by psilocybin. Nonetheless, there is no convincing evidence to confirm this hypothesis as the main mechanism of headache induced by psilocybin. In addition, psilocybin might trigger headache through an increase in brainstem serotonergic activities via influence on 5-HT1A, D, 5-HT2A, C, 5-HT5, 5-HT6, and 5-HT7 receptor (12, 13).
On the other hand, SAH is a rare type
of cerebrovascular accident, which is mainly aneurysmal and accounts for 5% of strokes occurring at a relatively young age. Compared to other cerebrovascular accidents, SAH has a poorer outcome. The overall mortality rate ranges from 32%-67% with 10%–20% of patients with long-term dependence due to brain damage. Regarding the increasing rate of stroke-related deaths and disability-adjusted life years, compared to all diseases, the early diagnosis and consequent appropriate treatment are of paramount importance and special attention should be dedicated toward SAH associated with drug abuse (14-16).
To the best of our knowledge, there is no report of subarachnoid hemorrhage as a consequence of psilocybin in the literature. Our research is the first report of subarachnoid hemorrhage induced by psilocybin products.
 
Conclusion
Our report is unique as it highlights the diversity of neurologic side effects of this common substance. This research focused on subarachnoid hemorrhage as a rare manifestation of psilocybin.
 
Conflict of interest
The authors declare that they have no conflict of interests.