Carambola

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Code: f295
Latin name: Averrhoa carambola
Source material: Fresh fruit
Family: Oxalidaceae
Common names: Carambola, Star fruit, Starfruit

Related species: Bilimbi (Averrhoa bilimbi L.)

Food

A food, which may result in allergy symptoms in sensitised individuals.

Allergen Exposure

The fruit comes from a tree, which grows up to 12 metres. This tree has been cultivated in Southeast Asia and Malaysia for hundreds of years, and now is also found in many places in the New World, in appropriate climates. The fruit, ovate to ellipsoid and 6 to 13cm in length, has a yellowish or greenish, waxy, translucent skin. Slices cut in cross-section are star-shaped, with five corners. The flesh is yellow, translucent, crisp and very juicy. There may be up to 12 flat, thin, brown seeds. There are 2 distinct classes of carambola: the smaller, very sour type, richly flavoured, with more oxalic acid; and the larger, ‘sweet’ type, mild-flavoured, with less oxalic acid.

Ripe carambolas are eaten out of hand, sliced and served in salads, or used as garnish. Their juice is very popular in the East. They are also cooked in puddings, tarts, stews and curries. The sweeter type may be cooked green as a vegetable. They can serve as the main ingredient of sherbet, seasoning, jelly, or relish. The fruits may be stewed, dried, canned, pickled or candied.

Medicinally, the fruit is used against haemorrhages, fevers, diarrhoea, eye afflictions, eczema, and kidney, liver and bladder complaints. However, there are health risks from the oxalic acid in fully ripe carambolas: see under Other reactions below.

The acidic types of carambola are used to clean and polish metal, especially brass, as they dissolve tarnish and rust. The juice is also used as a stain remover. Unripe fruits serve as a mordant in dyeing.

Allergen Description 

No allergens from this food have yet been characterised.

Potential Cross-Reactivity

No cross-reactivity has been reported to date.

Clinical Experience

IgE-mediated reactions

Anecdotal evidence suggests that carambola may induce symptoms of food allergy in sensitised individuals; however, no studies have been reported to date.

Other reactions

Six patients in a dialysis programme were apparently intoxicated by ingestion of 2-3 fruits or 150-200ml of the juice, and developed a variety of symptoms –  ranging from insomnia and hiccups, to agitation and mental confusion – which in one case resulted in death. The effects were believed to come from an excitatory neurotoxin in the fruit. (1) A recent study concluded that oxalate is a main contributor to carambola neurotoxicity, rather than an excitatory neurotoxin. Carambola contains a large quantity of oxalate, which can induce depression of cerebral function and cause seizures. (2, 3)

There have been other reports of nausea, vomiting, intractable hiccups, severe encephalopathy along with mental confusion, disorientation, agitation, and seizures, and occasional fatal outcomes in uraemic patients after ingestion of star fruit. (4, 5, 6, 7, 8, 9, 10, 11)

A group of 7 patients is described, who developed symptoms including hiccup, confusion, vomiting, impaired consciousness, muscle twitching and hyperkalaemia shortly after ingestion of star fruit. Symptoms of most patients resolved after intensified dialysis or spontaneously, and no mortality was observed. (4)

Further support for oxalate as the cause of the adverse effects seen is reported in 2 other cases, where patients developed nausea, vomiting, abdominal pain, and backache within hours of ingesting large quantities of sour carambola juice; followed by acute renal failure. Both patients needed haemodialysis for oliguric acute renal failure, and pathologic examinations showed typical changes of acute oxalate nephropathy. Renal function recovered 4 weeks later without specific treatment. Sour carambola juice is a popular beverage in Taiwan, but commercial juice is usually prepared by pickling and dilution processes that reduce oxalate content markedly, whereas pure fresh or semi-fresh juice for traditional remedies (as had been used in the above cases) contains high quantities of oxalate. An empty stomach and a dehydrated state may pose additional risks for development of renal injury. (12)

In patients on dialysis, consumption of carambola can lead to alterations of consciousness, as described in a patient with underlying chronic kidney disease who developed a rapid increase in serum creatinine and oxalate nephropathy after chronic ingestion of carambola juice; there was no overt neurotoxicity. The decline in renal function was not fully reversible after stoppage. (13) However, toxicity may occur after a very short duration of ingestion, and may also result in epilepsy: an 84-year-old Asian woman with hypertension and chronic renal failure developed incoherent speech, followed by intermittent interruptions of consciousness, and then status epilepticus, after ingesting a single carambola fruit each day for 3 days. (14) Non-convulsive status epilepticus has also been reported in chronic renal failure patients on maintenance dialysis therapy after they have eaten star fruit. (15)

Carambola contains agents that inhibit cytochrome P450 3A4 (CYP3A4), which is the most important enzyme in drug metabolism. Carambola interacts with drugs. (16)

Compiled by Dr Harris Steinman, harris@allergyadvisor.com

References

  1. Neto MM, Robl F, Netto JC. Intoxication by star fruit (Averrhoa carambola) in six dialysis patients? Nephrol Dial Transplant 1998;13(3):570-2.
  2. Chen CL, Chou KJ, Wang JS, Yeh JH, Fang HC, Chung HM. Neurotoxic effects of carambola in rats: the role of oxalate. J Formos Med Assoc 2002;101(5):337-41.
  3. Su YJ, Lee CH, Huang SC, Chuang FR. Quiz page April 2011. A woman with oliguria. Acute oxalate nephropathy caused by excess intake of pure carambola juice. Am J Kidney Dis 2011;57(4):A23-5.
  4. Tse KC, Yip PS, Lam MF, Choy BY, Li FK, Lui SL, Lo WK, Chan TM, Lai KN. Star fruit intoxication in uraemic patients: case series and review of the literature. Intern Med J 2003;33(7):314-6.
  5. 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 2010;39(5):448-52.
  6. Signaté A, Olindo S, Chausson N, Cassinoto C, Edimo Nana M, Saint Vil M, Cabre P, Smadja D. Star fruit (Averrhoa carambola) toxic encephalopathy. [French] Rev Neurol (Paris) 2009;165(3):268-72.
  7. Wang YC, Liu BM, Supernaw RB, Lu YH, Lee PY. Management of star fruit-induced neurotoxicity and seizures in a patient with chronic renal failure. Pharmacotherapy 2006;26(1):143-6.
  8. Chen LL, Fang JT, Lin JL. Chronic renal disease patients with severe star fruit poisoning: hemoperfusion may be an effective alternative therapy. Clin Toxicol (Phila) 2005;43(3):197-9.
  9. Neto MM, da Costa JA, Garcia-Cairasco N, Netto JC, Nakagawa B, Dantas M. Intoxication by star fruit (Averrhoa carambola) in 32 uraemic patients: treatment and outcome. Nephrol Dial Transplant 2003;18(1):120-5.
  10. Chang CT, Chen YC, Fang JT, Huang CC. Star fruit (Averrhoa carambola) intoxication: an important cause of consciousness disturbance in patients with renal failure. Ren Fail 2002;24(3):379-82.
  11. Chang JM, Hwang SJ, Kuo HT, Tsai JC, Guh JY, Chen HC, Tsai JH, Lai YH. Fatal outcome after ingestion of star fruit (Averrhoa carambola) in uremic patients. Am J Kidney Dis 2000;35(2):189-93.
  12. Chen CL, Fang HC, Chou KJ, Wang JS, Chung HM. Acute oxalate nephropathy after ingestion of star fruit. Am J Kidney Dis 2001;37(2):418-22.
  13. Niticharoenpong K, Chalermsanyakorn P, Panvichian R, Kitiyakara C. Acute deterioration of renal function induced by star fruit ingestion in a patient with chronic kidney disease. J Nephrol 2006;19(5):682-6.
  14. Wang YC, Liu BM, Supernaw RB, Lu YH, Lee PY. Management of star fruit-induced neurotoxicity and seizures in a patient with chronic renal failure. Pharmacotherapy 2006;26(1):143-6.
  15. Chang CH, Yeh JH. Non-convulsive status epilepticus and consciousness disturbance after star fruit (Averrhoa carambola) ingestion in a dialysis patient. Nephrology (Carlton) 2004;9(6):362-5.
  16. Molden E, Spigset O. Fruit and berries--interactions with drugs. [Norwegian] Tidsskr Nor Laegeforen 2007;127(24):3218-20.

 

As in all diagnostic testing, the diagnosis is made by the physican based on both test results and the patient history.