1
|
Li A, Chen B, Jin X, Bai Y, Zhang J, Zhang C, Cheng M, Guo C, Zhang Y, Zhou J. Antiepileptic therapy in a patient with star fruit intoxication: A case report. Medicine (Baltimore) 2023; 102:e32969. [PMID: 36862861 PMCID: PMC9981371 DOI: 10.1097/md.0000000000032969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
RATIONALE It is rare for uremia patients to have epileptic seizures after eating star fruit, only a dozen cases are reported worldwide. Such patients usually have poor prognoses. Few patients had good prognoses, all of them were treated with expensive renal replacement therapy. At present, there is no report on the addition of drug therapy to these patients based on the initial renal replacement therapy. PATIENT CONCERNS A 67-year-old male patient with star fruit intoxication who had a history of diabetic nephropathy, hypertension, polycystic kidney, and chronic kidney disease in the uremic phase, and regular hemodialysis 3 times a week for 2 years. Initial clinical manifestations include hiccups, vomiting, speech disturbances, delayed reactions, and dizziness, which gradually progress to hearing and visual impairment, seizures, confusion, and coma. DIAGNOSES This patient was diagnosed with seizures caused by star fruit intoxication. The experience of eating star fruit and the electroencephalograms can prove our diagnosis. INTERVENTIONS We performed intensive renal replacement therapy according to the recommendations in the literature. However, his symptoms did not improve significantly until he received an extra dose of levetiracetam and resumed his previous dialysis schedule. OUTCOMES The patient was discharged after 21 days without neurologic sequelae. Five months after discharge, he was readmitted due to poor seizure control. LESSONS To improve the prognosis of these patients and to reduce their financial burden, the use of antiepileptic drugs should be emphasized.
Collapse
Affiliation(s)
- Aixun Li
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Baoxin Chen
- Department of Neurology, Dong Fang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Xianglan Jin
- Department of Neurology, Dong Fang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yu Bai
- Department of Nephrology, Dong Fang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jingfeng Zhang
- Department of Nephrology, Dong Fang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chengcheng Zhang
- Department of Nephrology, Dong Fang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Miaomiao Cheng
- Department of Neurology, Dong Fang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chunyan Guo
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Yu Zhang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Zhou
- Department of Neurology, Dong Fang Hospital, Beijing University of Chinese Medicine, Beijing, China
- * Correspondence: Jing Zhou, Staff Physician, Department of Neurology, Dong Fang Hospital, Beijing University of Chinese Medicine, No. 6, Zone 1, Fangxingyuan, Fengtai District, Beijing 100078, China (e-mail: )
| |
Collapse
|
2
|
Asadi‐Pooya AA, Zeraatpisheh Z, Rostaminejad M, Damabi N. Caffeinated drinks, fruit juices, and epilepsy: A systematic review. Acta Neurol Scand 2022; 145:127-138. [PMID: 34694642 DOI: 10.1111/ane.13544] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/28/2021] [Accepted: 10/12/2021] [Indexed: 12/01/2022]
Abstract
The aim of this systematic review was to provide the required information regarding different aspects of the relationship between epilepsy/antiseizure medications and non-alcoholic drinks. The recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement were followed. MEDLINE and Scopus from the inception until 7 August 2021 were systematically searched. These key words were used: "epilepsy" OR "seizure" OR "antiepileptic" OR "antiseizure" OR "anticonvulsant" AND "coffee" OR "tea" OR "soda" OR "juice" OR "drink" OR "cola" OR "diet" (35 key word combinations). The primary search yielded 21 458 publications (PubMed, n = 4778; Scopus, n = 16 680). Only 50 studies met all the inclusion criteria and were included in the current systematic review. In total, 17 articles investigated various non-alcoholic drinks in human studies, 11 studies were case reports/series, and 22 articles were animal/in vitro studies. None of the studies provided a class 1 of evidence. There is limited evidence suggesting that certain drinks (eg, caffeinated energy drinks) might trigger seizures. Patients with epilepsy should avoid excessive consumption of certain fruit juices (eg, grapefruit, lime, pomegranate, kinnow, and star fruit) and caffeinated drinks. However, daily coffee and tea intake can be part of a healthy balanced diet, and their consumption does not need to be stopped in patients with epilepsy. Coffee/tea consumption is not harmful if consumed at levels of 200 mg (caffeine) in one sitting (about 2½ cups of coffee) or 400 mg daily (about five cups of coffee).
Collapse
Affiliation(s)
- Ali A. Asadi‐Pooya
- Epilepsy Research Center Shiraz University of Medical Sciences Shiraz Iran
- Jefferson Comprehensive Epilepsy Centre Department of Neurology Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Zahra Zeraatpisheh
- Epilepsy Research Center Shiraz University of Medical Sciences Shiraz Iran
| | | | | |
Collapse
|
3
|
Ishizaki Y, Nishizono R, Kikuchi M, Inagaki H, Sato Y, Fujimoto S. Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient. F1000Res 2021; 9:969. [PMID: 34868569 PMCID: PMC8602957 DOI: 10.12688/f1000research.25597.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/20/2022] Open
Abstract
Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.
Collapse
Affiliation(s)
- Yuri Ishizaki
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Ryuzoh Nishizono
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masao Kikuchi
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroko Inagaki
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuji Sato
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shouichi Fujimoto
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| |
Collapse
|
4
|
Yasawardene P, Jayarajah U, De Zoysa I, Seneviratne SL. Nephrotoxicity and neurotoxicity following star fruit (Averrhoa carambola) ingestion: a narrative review. Trans R Soc Trop Med Hyg 2021; 115:947-955. [PMID: 33693950 DOI: 10.1093/trstmh/trab026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 01/19/2021] [Accepted: 02/09/2021] [Indexed: 01/06/2023] Open
Abstract
In recent times, star fruit (Averrhoa carambola) nephrotoxicity and neurotoxicity have been increasingly reported, both in individuals with pre-existing renal disease and those with previously normal renal function. We summarise the clinical findings of star fruit toxicity in humans and outline the important pathogenetic insights provided by animal studies. Google Scholar, EMBASE, Scopus and PubMed were searched from 1995 through July 2020 for case reports/series on renal or neurological manifestations of star fruit toxicity in humans and mechanisms of star fruit toxicity in animal studies. Ten case series and 28 case reports in humans (total number of individuals=136) were included and 8 animal studies were analysed. Ninety-four (69.1%) patients had prior renal impairment. Renal histology showed acute oxalate nephropathy with tubulointerstitial nephritis or tubular necrosis. Neurotoxicity manifestations ranged from hiccups to status epilepticus. Oxalate and caramboxin are considered the main substances causing nephrotoxicity and neurotoxicity. Caramboxin inhibits GABA binding and activates the glutamatergic receptors. Haemodialysis improved outcomes in neurotoxicity. Nephrotoxicity and neurotoxicity need to be looked for with star fruit toxicity, both in individuals with abnormal or normal renal function. Once star fruit intoxication is identified, early renal replacement therapy should be considered. Further studies on the mechanisms of star fruit toxicity are needed.
Collapse
Affiliation(s)
- Pamodh Yasawardene
- Faculty of Medicine, University of Colombo, P.O. Box 271, Kynsey Road, Colombo 08, Sri Lanka
| | - Umesh Jayarajah
- Postgraduate Institute of Medicine, University of Colombo, 160, Prof. Nandadasa Kodagoda Mawatha, Colombo 07, Sri Lanka
| | - Ishan De Zoysa
- Department of Surgery, Faculty of Medicine, University of Colombo, P.O. Box 271, Kynsey Road, Colombo 08, Sri Lanka
| | - Suranjith L Seneviratne
- Nawaloka Hospital Research and Education Foundation, Nawaloka Hospitals, Colombo 02, Sri Lanka
| |
Collapse
|
5
|
Lakmal K, Yasawardene P, Jayarajah U, Seneviratne SL. Nutritional and medicinal properties of Star fruit ( Averrhoa carambola): A review. Food Sci Nutr 2021; 9:1810-1823. [PMID: 33747490 PMCID: PMC7958541 DOI: 10.1002/fsn3.2135] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/31/2020] [Accepted: 01/06/2021] [Indexed: 12/18/2022] Open
Abstract
Star fruit (Averrhoa carambola), a popular fruit in many parts of the world, is considered to have many beneficial nutritional and medicinal effects. However, harmful nephrotoxic and neurotoxic effects have also been described. In this review, we have discussed the reported beneficial effects of star fruit, explored the potential mechanisms for such beneficial effects, and outline factors that may affect the safe level of consumption. The beneficial effects include the following: antioxidant (mediated via L-ascorbic acid, epicatechin, and gallic acid), hypoglycemic (mediated via high fiber levels and 2-dodecyl-6-methoxycyclohexa-2,5-diene-1,4-dione), hypotensive (mediated via apigenin), hypocholesterolemic (mediated via micronized fiber), anti-inflammatory, anti-infective, antitumor effects, and immune-boosting effects. The presence of chronic kidney disease, gastroenteropathies, chronic pancreatitis, dehydration, consumption on an empty stomach, and higher concentration of oxalate in fruit/juice consumed predisposes to toxicity. The level of ingestion at which the beneficial effects transition to nephrotoxicity and neurotoxicity is still to be accurately ascertained. Furthermore, the relationship between the amount of star fruit ingested and the severity of toxicity is not certain and warrants further study.
Collapse
Affiliation(s)
- Kasun Lakmal
- Department of SurgeryFaculty of MedicineUniversity of ColomboColomboSri Lanka
| | - Pamodh Yasawardene
- Department of SurgeryFaculty of MedicineUniversity of ColomboColomboSri Lanka
| | - Umesh Jayarajah
- Department of SurgeryFaculty of MedicineUniversity of ColomboColomboSri Lanka
| | | |
Collapse
|
6
|
Ishizaki Y, Nishizono R, Kikuchi M, Inagaki H, Sato Y, Fujimoto S. Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient. F1000Res 2020; 9:969. [PMID: 34868569 PMCID: PMC8602957 DOI: 10.12688/f1000research.25597.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 12/01/2023] Open
Abstract
Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.
Collapse
Affiliation(s)
- Yuri Ishizaki
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Ryuzoh Nishizono
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masao Kikuchi
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroko Inagaki
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuji Sato
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shouichi Fujimoto
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| |
Collapse
|
7
|
Wijayaratne DR, Bavanthan V, de Silva MVC, Nazar ALM, Wijewickrama ES. Star fruit nephrotoxicity: a case series and literature review. BMC Nephrol 2018; 19:288. [PMID: 30348106 PMCID: PMC6198447 DOI: 10.1186/s12882-018-1084-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 10/08/2018] [Indexed: 01/30/2023] Open
Abstract
Background Star fruit is a popular medicinal fruit in the tropics. Its hypoglycaemic properties are considered useful in achieving glycaemic control in diabetes. Star fruit induced nephrotoxicity is a rare cause of acute kidney injury in individuals with both normal and reduced baseline renal function. We present three cases of acute kidney injury due to star fruit nephrotoxicity from Sri Lanka, and discuss the published literature on this topic. Case presentation Three Sri Lankan patients, all with a background of diabetes, presented to us with acute nausea and anorexia following recent consumption of star fruit. Two patients complained of diarrhoea and one patient complained of intractable hiccoughs. They all had elevated serum creatinine on admission. Two were known to have normal baseline serum creatinine levels. On renal biopsy two had evidence of oxalate crystal deposition. One did not show crystal deposition but had acute interstitial nephritis for which no alternate cause could be identified. Two were treated with short courses of prednisolone and two required acute haemodialysis. All recovered renal function, with both patients with known baselines approaching their premorbid serum creatinine levels. Conclusion Consumption of star fruit, especially on an empty stomach or in a state of dehydration may precipitate acute kidney injury. A history of star fruit ingestion must be actively looked for in patients presenting with unexplained acute kidney injury. The use of star fruit as a therapy for diabetes should be discouraged.
Collapse
Affiliation(s)
| | - V Bavanthan
- Nephrology, Dialysis and Transplant Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - M V C de Silva
- Department of Pathology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - A L M Nazar
- Nephrology, Dialysis and Transplant Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Eranga S Wijewickrama
- Univeristy Medical Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka.,Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| |
Collapse
|
8
|
Brown AC. Kidney toxicity related to herbs and dietary supplements: Online table of case reports. Part 3 of 5 series. Food Chem Toxicol 2018; 107:502-519. [PMID: 28755953 DOI: 10.1016/j.fct.2016.07.024] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 06/30/2016] [Accepted: 07/22/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND No tabular summary of potentially life-threatening, kidney-toxic dietary supplements (DS; includes herbs) based on PubMed case reports is currently available online and continually updated to forewarn United States consumers, clinicians, and companies manufacturing DS. The purpose of this review was to create an online research summary table of kidney toxicity case reports related to DS. METHODS Documented PubMed case reports (1966 to May 2016, and cross-referencing) of DS appearing to contribute to kidney toxicity were listed in "DS Toxic Tables." Keywords included "herb" or "dietary supplement" combined with "kidney" to generate an overview list, and possibly "toxicity" to narrow the selection. Case reports were excluded if they involved herb combinations (some exceptions), Chinese herb mixtures, teas of mixed herb contents, mushrooms, poisonous plants, self-harm, excessive doses (except vitamins/minerals), legal or illegal drugs, drug-herbal interactions, and confounders of drugs or diseases. Since commercial DS often include a combination of ingredients, they were treated separately; so were foods. A few foods with kidney-toxic effects were listed in a fourth table. The spectrum of herbal or DS-induced kidney injuries included kidney stones, nephritis, nephrotic syndrome, necrosis, acute kidney injury (AKI; previously known as acute renal failure [ARF]), chronic kidney disease, kidney transplant, and death. RESULTS Approximately 7 herbs (minus 4 no longer for sale) and 10 dietary supplements (minus 3 excluded due to excessive doses + germanium that is no longer sold) have been related to kidney injury case reports published in PubMed (+crosslisting) in the last 50 + years (1966 to May 2016). The implicated herbs include Chinese yew (Taxus celbica) extract, impila (Callilepis laureola), morning cypress (Cupressus funebris Endl), St. John's wort (Hypericum perforatum), thundergod vine (Tripterygium wilfordii hook F), tribulus (Tribulus terrestris) and wormwood (Artemisia herba-alba). No longer sold in the United States are chocolate vine or mu tong (Caulis aristolochiae), guang fang ji (Aristolochia fangchi), ma huang (Ephedra sinica), and Tenshin Tokishigyaku-ka-goshuyu-shokyo-to. The DS include bile (sheep), chlorella, chromium (Cr), CKLS, creatine, gallbladder (fish), glucosamine, hydrazine, N.O.-Xplode, Spanish fly, and excess intakes of vitamins A, C, and D. Germanium (Ge) is not available for sale. The top two DS with the largest number of reported publications, but not always case reports, in descending order, were the aristolochic acid-containing herbs guang fang ji (mistaken identity) and chocolate vine or mu tong. The remaining DS featured one to three publications over a 50+ year period. Numerous case reports were reported for kidney-toxic foods: djenkol bean, gallbladders (carp fish, pufferfish, & snake), and star fruit (only in chronic kidney disease patients), and uncooked yam powder or juice. CONCLUSION This online "DS Toxic Table" provides clinicians, consumers, and manufacturers with a list of herbs that could potentially contribute to kidney injuries.
Collapse
Affiliation(s)
- Amy Christine Brown
- Department of Complementary and Alternative Medicine, John A. Burns School of Medicine, 651 Ilalo Street, MEB 223, Honolulu, HI, USA; University of Hawaii at Manoa, Honolulu, HI, USA.
| |
Collapse
|
9
|
Chua CB, Sun CK, Tsui HW, Yang PJ, Lee KH, Hsu CW, Tsai IT. Association of renal function and symptoms with mortality in star fruit (Averrhoa carambola) intoxication. Clin Toxicol (Phila) 2017; 55:624-628. [PMID: 28443386 DOI: 10.1080/15563650.2017.1314490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Star fruit (SF) is a commonly available fruit produced and eaten in tropical and subtropical countries. Since 1993, various reports have described neurotoxicity after eating SF, but this clinical condition remains unfamiliar. We aimed to describe this clinical entity, the role of renal dysfunction in this disorder, treatment strategies, and prognosis of patients with SF intoxication. METHODS We conducted a search of PubMed and Google Scholar databases from 1993 to 2016. We included reports describing patients with a clear history of SF ingestion with acute symptoms. We described the demographic characteristics, reported SF intake, treatments used, and outcomes. RESULTS We reviewed totally 126 patients (male:female = 1.5:1) from 33 articles with mean age 54.4 ± 11 (range: 30-84). The most common symptom was hiccups (65%), whereas confusion and seizure were the most common symptoms associated with mortality (42% and 61%, respectively). Pre-intoxication renal function also affected mortality. While there was no mortality in patients with normal renal function (NRF), the mortality of patients among reported cases with chronic renal insufficiency and end-stage renal disease undergoing dialysis were 36% and 27%, respectively. With the inclusion of patients reported to have NRF, the overall mortality was 24%. Consistently, the number of SF consumed was substantially higher in the patients with NRF than those with renal functional impairment. The most common treatment strategy was hemodialysis (59%). CONCLUSIONS Patients with impaired renal function were at higher risks of SF intoxication. Severe neurologic symptoms mandate immediate medical intervention because of the association between their occurrence and high mortalities. Toxin removal through dialysis, rather than symptomatic relief, seems to be beneficial to patient survival. Early and continuous dialysis appears to alleviate severe symptoms and prevent symptom rebounds.
Collapse
Affiliation(s)
- Choon-Bing Chua
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Cheuk-Kwan Sun
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Huan-Wen Tsui
- b Department of Neurology , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Po-Jen Yang
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Kuo-Hsin Lee
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - Chih-Wei Hsu
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| | - I-Ting Tsai
- a Department of Emergency Medicine , E-Da Hospital, I-Shou University , Kaohsiung City , Taiwan
| |
Collapse
|
10
|
Shimizu MHM, Gois PHF, Volpini RA, Canale D, Luchi WM, Froeder L, Heilberg IP, Seguro AC. N-acetylcysteine protects against star fruit-induced acute kidney injury. Ren Fail 2016; 39:193-202. [PMID: 27845599 PMCID: PMC6014349 DOI: 10.1080/0886022x.2016.1256315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: Star fruit (SF) is a popular fruit, commonly cultivated in many tropical countries, that contains large amount of oxalate. Acute oxalate nephropathy and direct renal tubular damage through release of free radicals are the main mechanisms involved in SF-induced acute kidney injury (AKI). The aim of this study was to evaluate the protective effect of N-acetylcysteine (NAC) on SF-induced nephrotoxicity due to its potent antioxidant effect. Materials and methods: Male Wistar rats received SF juice (4 mL/100 g body weight) by gavage after a 12 h fasting and water deprivation. Fasting and water deprivation continued for 6 h thereafter to warrant juice absorption. Thereafter, animals were allocated to three experimental groups: SF (n = 6): received tap water; SF + NAC (n = 6): received NAC (4.8 g/L) in drinking water for 48 h after gavage; and Sham (n = 6): no interventions. After 48 h, inulin clearance studies were performed to determine glomerular filtration rate. In a second series of experiment, rats were housed in metabolic cages for additional assessments. Results: SF rats showed markedly reduced inulin clearance associated with hyperoxaluria, renal tubular damage, increased oxidative stress and inflammation. NAC treatment ameliorated all these alterations. Under polarized light microscopy, SF rats exhibited intense calcium oxalate birefringence crystals deposition, dilation of renal tubules and tubular epithelial degeneration, which were attenuate by NAC therapy. Conclusions: Our data show that therapeutic NAC attenuates renal dysfunction in a model of acute oxalate nephropathy following SF ingestion by reducing oxidative stress, oxaluria, and inflammation. This might represent a novel indication of NAC for the treatment of SF-induced AKI.
Collapse
Affiliation(s)
| | | | - Rildo Aparecido Volpini
- a Department of Nephrology, School of Medicine , University of São Paulo , São Paulo , Brazil
| | - Daniele Canale
- a Department of Nephrology, School of Medicine , University of São Paulo , São Paulo , Brazil
| | - Weverton Machado Luchi
- a Department of Nephrology, School of Medicine , University of São Paulo , São Paulo , Brazil
| | - Leila Froeder
- b Nephrology Division , Federal University of São Paulo , São Paulo , Brazil
| | | | - Antonio Carlos Seguro
- a Department of Nephrology, School of Medicine , University of São Paulo , São Paulo , Brazil
| |
Collapse
|
11
|
Numata T, Ito T, Egusa C, Kobayashi Y, Maeda T, Tsuboi R. A case of oral allergy syndrome due to star fruit sensitized from atopic hands. Allergol Int 2015; 64:393-5. [PMID: 26433542 DOI: 10.1016/j.alit.2015.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 06/04/2015] [Accepted: 06/30/2015] [Indexed: 10/23/2022] Open
|
12
|
Pichierri F. Molecular structure and conformations of caramboxin, a natural neurotoxin from the star fruit: A computational study. J Mol Struct 2015. [DOI: 10.1016/j.molstruc.2014.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
13
|
Glew RH, Sun Y, Horowitz BL, Konstantinov KN, Barry M, Fair JR, Massie L, Tzamaloukas AH. Nephropathy in dietary hyperoxaluria: A potentially preventable acute or chronic kidney disease. World J Nephrol 2014; 3:122-142. [PMID: 25374807 PMCID: PMC4220346 DOI: 10.5527/wjn.v3.i4.122] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 06/12/2014] [Accepted: 08/29/2014] [Indexed: 02/06/2023] Open
Abstract
Hyperoxaluria can cause not only nephrolithiasis and nephrocalcinosis, but also renal parenchymal disease histologically characterized by deposition of calcium oxalate crystals throughout the renal parenchyma, profound tubular damage and interstitial inflammation and fibrosis. Hyperoxaluric nephropathy presents clinically as acute or chronic renal failure that may progress to end-stage renal disease (ESRD). This sequence of events, well recognized in the past in primary and enteric hyperoxalurias, has also been documented in a few cases of dietary hyperoxaluria. Estimates of oxalate intake in patients with chronic dietary hyperoxaluria who developed chronic kidney disease or ESRD were comparable to the reported average oxalate content of the diets of certain populations worldwide, thus raising the question whether dietary hyperoxaluria is a primary cause of ESRD in these regions. Studies addressing this question have the potential of improving population health and should be undertaken, alongside ongoing studies which are yielding fresh insights into the mechanisms of intestinal absorption and renal excretion of oxalate, and into the mechanisms of development of oxalate-induced renal parenchymal disease. Novel preventive and therapeutic strategies for treating all types of hyperoxaluria are expected to develop from these studies.
Collapse
|
14
|
Wu CL, Chiu PF, Yang Y, Wen YK, Chiu CC, Chang CC. Sustained low-efficiency daily diafiltration with hemoperfusion as a therapy for severe star fruit intoxication: a report of two cases. Ren Fail 2011; 33:837-41. [PMID: 21770853 DOI: 10.3109/0886022x.2011.599048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Over the past decade, star fruit (Averrhoa carambola) intoxication decreased in the Taiwanese society due to improved public education on chronic kidney disease (CKD). Various complications including hiccups, altered levels of consciousness, coma, and seizures have been reported in individuals with renal failure who ingested fresh star fruit or star fruit juice. A high mortality rate (from 33 to 80%) was observed in patients with altered levels of consciousness, despite prompt dialysis and supportive care. According to previous case reports, the proposed treatment of choice for severe star fruit intoxication may be continuous renal replacement therapy with or without hemoperfusion. We report two cases of star fruit intoxication with stage V CKD (one case is predialysis) presenting with coma and generalized tonic-clonic seizures. The two patients were treated with sustained low-efficiency daily diafiltration (SLEDD-f) and charcoal hemoperfusion. Status epilepticus was controlled fairly quickly after treatment with SLEDD-f and hemoperfusion. However, the outcomes in this report are still poor (both remained comatose; one of two patients died). Currently, there are no data for the use of SLEDD-f with hemoperfusion for severe star fruit intoxication. SLEDD-f with charcoal hemoperfusion may play a role in managing refractory status epilepticus in patients with severe star fruit poisoning.
Collapse
Affiliation(s)
- Chia-Lin Wu
- Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | | | | | | | | | | |
Collapse
|