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Siang LH, Arulsamy A, Yoon YK, Shaikh MF. Fruits for Seizures? A Systematic Review on the Potential Anti-Convulsant Effects of Fruits and their Phytochemicals. Curr Neuropharmacol 2022; 20:1925-1940. [PMID: 34517803 PMCID: PMC9886799 DOI: 10.2174/1570159x19666210913120637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/04/2021] [Accepted: 09/10/2021] [Indexed: 11/22/2022] Open
Abstract
Epilepsy is a devastating neurological disorder. Current anti-convulsant drugs are only effective in about 70% of patients, while the rest remain drug-resistant. Thus, alternative methods have been explored to control seizures in these drug-resistant patients. One such method may be through the utilization of fruit phytochemicals. These phytochemicals have been reported to have beneficial properties such as anti-convulsant, anti-oxidant, and anti-inflammatory activities. However, some fruits may also elicit harmful effects. This review aims to summarize and elucidate the anti- or pro-convulsant effects of fruits used in relation to seizures in hopes of providing a good therapeutic reference to epileptic patients and their carers. Three databases, SCOPUS, ScienceDirect, and PubMed, were utilized for the literature search. Based on the PRISMA guidelines, a total of 40 articles were selected for critical appraisal in this review. Overall, the extracts and phytochemicals of fruits managed to effectively reduce seizure activities in various preclinical seizure models, acting mainly through the activation of the inhibitory neurotransmission and blocking the excitatory neurotransmission. Only star fruit has been identified as a pro-convulsant fruit due to its caramboxin and oxalate compounds. Future studies should focus more on utilizing these fruits as possible treatment strategies for epilepsy.
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Affiliation(s)
| | | | | | - Mohd. Farooq Shaikh
- Address correspondence to this author at the Neuropharmacology Research Laboratory, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor, Malaysia; Tel/Fax: +60 3 5514 4483; E-mail:
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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.
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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
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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.
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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
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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.
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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.
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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.
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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
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Chen HY, Albertson TE, Olson KR. Treatment of drug-induced seizures. Br J Clin Pharmacol 2015; 81:412-9. [PMID: 26174744 DOI: 10.1111/bcp.12720] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/03/2015] [Accepted: 07/07/2015] [Indexed: 01/01/2023] Open
Abstract
Seizures are a common complication of drug intoxication, and up to 9% of status epilepticus cases are caused by a drug or poison. While the specific drugs associated with drug-induced seizures may vary by geography and change over time, common reported causes include antidepressants, stimulants and antihistamines. Seizures occur generally as a result of inadequate inhibitory influences (e.g., gamma aminobutyric acid, GABA) or excessive excitatory stimulation (e.g. glutamate) although many other neurotransmitters play a role. Most drug-induced seizures are self-limited. However, status epilepticus occurs in up to 10% of cases. Prolonged or recurrent seizures can lead to serious complications and require vigorous supportive care and anticonvulsant drugs. Benzodiazepines are generally accepted as the first line anticonvulsant therapy for drug-induced seizures. If benzodiazepines fail to halt seizures promptly, second line drugs include barbiturates and propofol. If isoniazid poisoning is a possibility, pyridoxine is given. Continuous infusion of one or more anticonvulsants may be required in refractory status epilepticus. There is no role for phenytoin in the treatment of drug-induced seizures. The potential role of ketamine and levetiracetam is promising but not established.
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Affiliation(s)
- Hsien-Yi Chen
- California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.,Department of Emergency Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Clinical Pharmacology & Toxicology, San Francisco General Hospital, San Francisco, USA
| | - Timothy E Albertson
- California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.,Department of Internal Medicine, University of California Davis School of Medicine and Veterans Administration Northern California Health Care System, California
| | - Kent R Olson
- California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.,Division of Clinical Pharmacology & Toxicology, San Francisco General Hospital, San Francisco, USA
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Alessio-Alves FF, de Souza CP, da Silva LK, Moyses-Neto M, Pontes-Neto OM. Starfruit neurotoxicity mimicking an acute brainstem stroke. Clin Neurol Neurosurg 2012; 114:684-5. [PMID: 22410650 DOI: 10.1016/j.clineuro.2011.10.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 10/25/2011] [Accepted: 10/30/2011] [Indexed: 12/01/2022]
Affiliation(s)
- Frederico Fernandes Alessio-Alves
- Department of Neurosciences and Behavioural Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, Brazil
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Auxiliadora-Martins M, Alkmin Teixeira GC, da Silva GS, Viana JM, Nicolini EA, Martins-Filho OA, Basile-Filho A. Severe encephalopathy after ingestion of star fruit juice in a patient with chronic renal failure admitted to the intensive care unit. Heart Lung 2009; 39:448-52. [PMID: 20561840 DOI: 10.1016/j.hrtlng.2009.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 09/03/2009] [Accepted: 09/09/2009] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Maria Auxiliadora-Martins
- Centro de Terapia Intensiva (Campus), Departamento de Cirurgia e Anatomia, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo-HCFMRP-USP, Bairro Monte Alegre, Ribeirão Preto, SP, Brasil
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Herbland A, El Zein I, Valentino R, Cassinotto C, Meunier C, Rieux D, Mehdaoui H. Star fruit poisoning is potentially life-threatening in patients with moderate chronic renal failure. Intensive Care Med 2009; 35:1459-63. [DOI: 10.1007/s00134-009-1490-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 03/27/2009] [Indexed: 12/01/2022]
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Abstract
Food poisoning is encountered throughout the world. Many of the toxins responsible for specific food poisoning syndromes are no longer limited to isolated geographic locations. With increased travel and the ease of transporting food products, it is likely that a patient may present to any emergency department with the clinical effects of food poisoning. Recognizing specific food poisoning syndromes allows emergency health care providers not only to initiate appropriate treatment rapidly but also to notify health departments early and thereby prevent further poisoning cases. This article reviews several potential food-borne poisons and describes each agent's mechanism of toxicity, expected clinical presentation, and currently accepted treatment.
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Affiliation(s)
- David T Lawrence
- Blue Ridge Poison Center, Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia, Charlottesville, VA 22908-0774, USA
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Wu MY, Wu IW, Wu SS, Lin JL. Hemoperfusion as an Effective Alternative Therapy for Star Fruit Intoxication: A Report of 2 Cases. Am J Kidney Dis 2007; 49:e1-5. [PMID: 17185136 DOI: 10.1053/j.ajkd.2006.09.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Accepted: 09/20/2006] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Mei-Yi Wu
- Division of Nephrology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Medical College of Chang Gung University, Taipei, Taiwan
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