Star fruit: A neglected but serious fruit intoxicant in chronic renal failure

Star fruit originated in Southeast Asia and is readily available in Taiwan. Star fruit causes several symptoms in patients with chronic renal failure or end-stage renal disease. The symptoms vary and include insomnia, intractable hiccups, agitation, muscle weakness, confusion, consciousness disturbances of various degrees, seizures, and cardiorespiratory arrest. The various star fruit subspecies contain different toxins, including a powerful neurotoxin that is suspected to accumulate in blood, cross the blood-brain barrier in chronic renal failure patients, and eventually cause irreversible damage. This investigation reports on three patients who suffered from star fruit intoxication, each of whom had different renal function status, clinical presentations and outcomes, and responses to different management. To our knowledge, this was the first case series study of star fruit intoxication that utilized electroencephalography and that treated the patients with plasma exchange. Nonetheless, star fruit intoxication cannot be treated effectively. Our case series study suggests that plasma exchange is an effective treatment for status seizure, but not for consciousness disturbances. This finding with regard to seizures, however, requires further study of the effectiveness, timing, frequency, and dosage of plasma exchange in star fruit intoxication in order to confirm this conclusion. Star fruit intoxication is a neglected but serious fruit intoxication frequently observed in patients with chronic renal failure. Because no effective treatment is currently available, patients-especially those who are newly diagnosed with chronic renal failure or end-stage renal disease-must be warned not to ingest star fruit, even in small amounts.