First reported survival of anthrax meningoencephalitis in a low-incidence region: successful management with mNGS-guided combination therapy.

Starfruit () is a tropical fruit characterized by nutritional and medicinal benefits; however, it has also been linked to neurologic and nephrotic toxicity, due to breakdown of caramboxin (CBX), a potent neurotoxin, which can induce a severe and often fatal encephalopathy in patients with impaired renal function [-]. While individuals with normal kidney function efficiently clear this toxin, patients with end-stage renal disease (ESRD) are highly susceptible to its accumulation, even after consuming small quantities []. The clinical presentation of starfruit intoxication in uremic patients is characterized by a spectrum of neurological symptoms, mediated by an excitatory response, ranging from intractable hiccups and vomiting to more severe manifestations such as confusion, seizures, status epilepticus, and coma [-]. The diagnosis of starfruit intoxication is frequently delayed due to the nonspecific nature of the initial symptoms, which can mimic other common complications in the ESRD population, including uremic encephalopathy, electrolyte disturbances, or medication side effects. A high index of suspicion and a detailed dietary history are therefore paramount for timely diagnosis []. Management is centered on the prompt and efficient removal of CBX through intensive renal replacement therapy, as standard hemodialysis sessions may be insufficient []. Despite treatment, mortality rates remain high, underscoring the critical importance of patient education and prevention []. We present the case of a 63-year-old female patient on maintenance hemodialysis who developed severe, fluctuating encephalopathy after ingesting starfruit. The clinical picture was significantly complicated by multiple confounding factors, including a hypertensive emergency, suspected meningitis, and adverse effects from antiepileptic medications, which obscured the underlying diagnosis and posed considerable management challenges.