024 STARFRUIT - THE FORBIDDEN FRUIT FOR RENAL FAILURE PATIENT. REMINDER FROM A FATAL CASE OF NEUROTOXICITY

Abstract

Category: Other Presenter: Dr KWEK FOONG CHEW Keywords: Starfruit toxicity, neurotoxicity, Hemodialysis, CVVHDF, charcoal hemoperfusion, status epilepticus, seizure Starfruit (SF), also known as Carambola, is common in South East Asia, usually consumed raw or taken as a juice. It is known to cause neurotoxicity due to neurotoxin called Caramboxin. This toxin has a glutamatergic ionotropic molecular action, with potent excitatory, convulsant, and neurodegenerative properties. Here we described a case of fatal starfruit intoxication in an end stage renal failure (ESRF) patient. A 67 years old lady with ESRF whom recently commenced on regular haemodialysis (HD). She presented with hiccups, insomnia, lethargy and episodes of blank stares one day after ingesting two SF. She became unconscious and developed generalized tonic-clonic seizures which progressed to status epilepticus. She was put on mechanical ventilation and required multiple anti-epileptics and propofol infusion. She was treated with HD initially and then was put on continuous veno-venous hemodiafiltration (CVVHDF) and charcoal heamoperfusion treatment. However, she did not obtain any significant neurological recovery. Electroencephalography (EEG) showed an encephalopathic picture. Magnetic resonance imaging (MRI) showed bilateral gyriform hyperintense signal changes and multiple microhemorrhages changes. Eventually she succumbed to nosocomial infection. High index of suspicion and active enquiry regarding SF ingestion is required for ESRF patients presenting with hiccups and seizure. Early diagnosis and treatment is important as immediate haemodialysis is potentially beneficial in starfruit neurotoxicity. Poor conscious level and seizures development in SF neurotoxicity are poor prognosis factors. Patients with renal failure should be advised to avoid starfruit ingestion.