Non-convulsive status epilepticus and consciousness disturbance after star fruit (Averrhoa carambola) ingestion in a dialysis patient

Non-convulsive status epilepticus possibly induced by a rapid correction of severe hyperkalemia: a case report and literature review

BACKGROUND

Patients with chronic kidney disease frequently develop neurological complications including confusion and altered consciousness. Non-convulsive status epilepticus, which is characterized by a change in behavior and/or mental process accompanied by epileptiform discharges on electroencephalogram in the absence of convulsive seizures, is one of the overlooked causes of altered consciousness. The incidence and precise pathophysiological mechanism of non-convulsive status epilepticus in patients with kidney disease, and especially in patients with electrolyte disturbances, remains unknown. We recently treated an older patient with chronic kidney disease and severe hyperkalemia in whom non-convulsive status epilepticus developed following a correction of severe hyperkalemia.

CASE PRESENTATION

An 82-year-old male was admitted to our hospital at midnight because of weakness of all four limbs (Day 1). He underwent urgent hemodialysis for severe hyperkalemia (9.84 mEq/L) and his serum potassium concentration decreased to 4.97 mEq/L. He regained full consciousness and his limb weakness improved on the morning of Day 2, but he became confused in the evening. Electroencephalogram revealed repeated low-voltage ictal discharges in the right occipital region and a diagnosis of non-convulsive status epilepticus was made. Following medication with fosphenytoin and phenytoin, the patient became fully alert and orientated on Day 8.

CONCLUSION

We speculate that a rapid correction of hyperkalemia was the possible cause of non-convulsive status epilepticus development. To our knowledge, this is the first report of non-convulsive status epilepticus from a potassium abnormality. We described a case of this condition in detail and summarized 78 previous case reports of non-convulsive status epilepticus with kidney disease or electrolyte disturbances.

Nephrotoxicity and neurotoxicity following star fruit (Averrhoa carambola) ingestion: a narrative review

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.

Star fruit nephrotoxicity: a case series and literature review

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.

Association of renal function and symptoms with mortality in star fruit (Averrhoa carambola) intoxication

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.

Evaluation of the toxic effect of star fruit on serum biochemical parameters in rats

The objective of the present study was to evaluate the toxic effect of Averrhoa carambola (star fruit) juice at different storage conditions in Sprague Dawley (SD) rats. Twenty female rats weighing 180 +/- 20 g were randomly assigned into four groups with five rats per group (n = 5). First group served as the control group, fed with distilled water (vehicle). Second, third and fourth groups were orally treated with juice of A. carambola stored for 0, 1 and 3 h respectively for 14 days. Cage-side observations were done daily after each treatment. Body weight, food consumption and water intake were recorded on day-0, day-3, day-7 and day-14. All rats were fasted overnight prior to blood collection through cardiac puncture on day-15. The levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), urea and creatinine in blood serum were measured. Data were analyzed using Dunnett's test. From the results obtained, there was no lethality found and LD(50) could not be determined. Increment of ALT levels (P<0.05) was reported in those rats treated with A. carambola juice stored for 3 h. On the basis of these results, we can conclude that A. carambola juice stored for 0 hand 1 h are safe to be consumed. However, juice stored for 3 h exerts toxic effect on rat liver at hepatocellular level.

Severe encephalopathy after ingestion of star fruit juice in a patient with chronic renal failure admitted to the intensive care unit

Star fruit (Averrhoa carambola) is a popular tropical fruit that is usually consumed as fresh fruit or fruit juice. Consumption of star fruit by patients with chronic renal failure can lead to neurologic symptoms. The present report describes the clinical course, management, and outcome of a patient with chronic renal failure admitted to an intensive care unit after ingestion of star fruit juice 2 days before hospital admission. A case of nausea, vomiting, intractable hiccups, and severe encephalopathy along with mental confusion, disorientation, agitation, and seizures in a 53-year-old woman is presented. The patient's ventilatory pattern worsened, with development of dyspnea and tachypnea, which resulted in her transfer to an intensive care unit. Although hemodialysis was performed and the septic shock was adequately treated, the patient died on the fifth day after hospital admission. The susceptibility of patients with chronic renal failure to star fruit and the severity of intoxication are poorly known by intensivists. This case demonstrates that star fruit consumption should be considered as a cause of rapid deterioration in the renal function of patients with underlying chronic renal failure, potentially resulting in a fatal outcome.

Nonconvulsive status epilepticus: high incidence in dialysis-dependent patients

Nonconvulsive status epilepticus is defined as a mental status change from baseline of at least a 30-min duration associated with constant or near-continuous ictal discharges on an electroencephalogram (EEG). Nonconvulsive status epilepticus is an often-overlooked diagnosis as a cause of acute confusional state. There are few case reports in dialysis patients. We are reporting 5 patients on chronic dialysis treatment who presented with an acute confusional state. Nonconvulsive status epilepticus was diagnosed by EEG and response to intravenous benzodiazepines. We recommend early EEG to be considered in the evaluation of dialysis patients with an acute confusional state.

Herbal medicine and epilepsy: proconvulsive effects and interactions with antiepileptic drugs

The use of complementary and alternative medicine is on the rise, including among patients with epilepsy. Herbal medicine, one of the most popular forms of CAM, is considered to be both safe and effective by most consumers. Yet many herbs may increase the risk for seizures, through intrinsic proconvulsant properties or contamination by heavy metals, as well as via effects on the cytochrome P450 enzymes and P-glycoproteins, altering antiepileptic drug (AED) disposition. Herb-drug interactions may be difficult to predict, especially since the quality and quantity of active ingredients are often unknown. Since most patients do not inform their physicians that they are taking herbal medicines, health care professionals must initiate a dialogue in order to prevent complications with the combined regimen. At the same time, further research is required regarding the effect of herbs on seizure activity and interactions with AED treatment.

Hemoperfusion as an Effective Alternative Therapy for Star Fruit Intoxication: A Report of 2 Cases

This report describes 2 cases of star fruit intoxication successfully treated with charcoal hemoperfusion (CHP). Common clinical characteristics of the reported cases included persistent hiccup, consciousness disturbance, coma, need for ventilator support, and admission to an intensive care unit. The optimum treatment for star fruit intoxication has been controversial, with modality, dose, and appropriate timing of extracorporeal therapy debated. Analysis of the 2 reported cases shows several advantages of CHP, including increased extraction efficiency, rapid recovery of consciousness, decreased time of intensive care unit admission, and good clinical tolerance. CHP may provide an alternative treatment modality in cases with life-threatening star fruit intoxication with poor response to intensified hemodialysis.

Status epilepticus induced by star fruit intoxication in patients with chronic renal disease

Star fruit has been reported as containing neurotoxins that often cause severe neurological complications in patients with chronic renal disease. We report two patients with chronic renal failure at a pre-dialyzed stage who developed refractory status epilepticus after ingestion of star fruit. In addition, we review 51 cases in the literature. Among 53 patients, 16 patients presented with epileptic seizures (30%). The mortality rate was as high as 75% in patients with seizures. On the other hand, in patients without seizures, the mortality rate was only 0.03%. There is a poor correlation with the degree of underlying renal function and mortality due to intoxication. We propose that epileptic seizure is significantly associated with poor prognosis, and that status epilepticus is an unpredictable and potentially fatal complication in star fruit intoxication. We advise consultant neurologists that star fruit intoxication must be considered when patients with chronic renal disease present with seizures or other unexplained neurological or psychiatric symptoms. Since no effective treatment has been established, star fruit consumption should be avoided in patients with chronic renal disease, especially in the elderly.