Amanita phalloides, responsible for most mushroom poisoning deaths, is seen in areas where the mushroom is prevalent – the Pacific Northwest and Appalachian Mountain regions. The amantinin toxin is dose-dependent and disrupts hepatocyte mRNA synthesis. Mortality approaches 10–30%.  Other substances are associated with dose-related toxicity, including Amanita phalloides mushroom toxin, Bacillus cereus toxin, Cyanobacteria toxin, Organic solvents (eg, carbon tetrachloride), and yellow phosphorus.

Direct hepatotoxins usually are recognized quickly and removed from use (i.e., carbon tetrachloride, chloroform, and tannic acid). Certain direct hepatotoxins have been allowed to remain in clinical use because the toxicity is known and occurs only at high doses [i.e., APAP, iron sulfate, intravenous (i.v.) tetracycline, ethanol, and phosphorus]. Environmental toxins may also lead to ALF, including yellow phosphorus, used in rat poison and fireworks, Bacillus cereus toxin, and aflatoxin.  Aflatoxins can be commonly found in peanut butter, but usually in doses that are far too low to be of problem.