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

We read with interest the paper from Tsai and colleagues describing two uraemic patients with neurologic symptoms following ingestion of star fruit (Averrhoa carambola), a popular fruit among Orientals, belonging to the Oxalidaceae family. Star fruit’s neurotoxic effect was first reported by Muir and Lam who showed that its intraperitoneally or intracerebroventricularly injection could induce persistent convulsions in rats. Since then, there have been many reports of uraemic subjects developing neurological symptoms after ingestion of star fruit. Most patients manifest intractable hiccups, vomiting, impaired consciousness and seizures or status epilepticus. Outcome is quite variable and while some patients recover without sequelae within some days, others may progress to death. Haemodialysis is the best treatment, whereas peritoneal dialysis seems to be ineffective. Posterior Reversible Encephalopathy Syndrome (PRES) is a condition occurring in patients hospitalised for acute illness and characterized by a combination of neurological symptoms including altered mental status, persistent epileptic seizures and blurred vision. In these patients, MRI study typically shows oedema involving the cerebral posterior regions. PRES may be related to a variety of conditions, but hypertensive encephalopathy, preeclampsia and treatment with immunosuppressive drugs are more frequently associated with this syndrome. Less common causes are uraemia, drugs