To the editor:

Patientsfrequently believed that natural products are harmless and that they have many curative and regenerative functions. The star fruit (scientific name Averrhoa carambola; See figure) is a widespread fruit in several regions of Central America, South America and above all, in Asia, where it is thought that the star fruit comes from. For some years the fruit is also in the markets of Europe and the United States, where it is considered an exotic fruit. Renal insufficiency is an increasingly prevalent medical condition. In patients with renal insufficiency star fruit intake has been causally related with severe neurotoxicity, that was the cause of death in a few patients. We present a case seen at our center.

A 67 year-old male came to the Emergency Room of a hospital in Cali, Colombia, because of hiccups for 2 days. He had a history of type 2 diabetes mellitus with secondary renal failure and was on hemodialysis three times per week for 19 months. Twelve hours before his first visit, he had taken star fruit juice in a quantity equivalent to 4 pieces of fruit. In the Emergency Room no apparent cause for the hiccups was found and the patient was referred to our center for the scheduled hemodialysis, after which the hiccups disappeared. He went home and drank a similar quantity of juice. Almost immediately the hiccups recurred followed by vomiting and the patient was admitted to the hospital. During the two following days the patient presented progressive neurological deterioration leading to stupor.

The patient was again referred to our center. On admission he was stuporous, with no neurological focalization and irregular respiratory pattern. The physical exam was otherwise unremarkable. Laboratory investigations showed mild anemia, glycemia 315 mg/dL (17.5 mmol/L), and creatinine 3.93 mg/dL (347.4 mmol/L). Cranial images were normal. The association between the clinical picture and the star fruit intake was evident. The patient remained for the following six days at the intensive care unit, and daily hemodialysis with 4 hours sessions was performed. The symptoms disappeared progressively with no consequences, except for a complete amnesia of the facts that happened around the intoxication episode. Since then he hasd never again taken the fruit. At the Emergency Room, a presentation with hiccups should arise the suspicion of this potentially fatal intoxication in patients with chronic renal disease.