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Allegretti AS, Czawlytko CL, Stathatos N, Sadow PM. Case 13-2024: A 27-Year-Old Man with Leg Weakness. N Engl J Med 2024; 390:1514-1522. [PMID: 38657248 DOI: 10.1056/nejmcpc2312728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Andrew S Allegretti
- From the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Harvard Medical School - both in Boston
| | - Cynthia L Czawlytko
- From the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Harvard Medical School - both in Boston
| | - Nikolaos Stathatos
- From the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Harvard Medical School - both in Boston
| | - Peter M Sadow
- From the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Harvard Medical School - both in Boston
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Ye Z, Okamoto R, Ito H, Ito R, Moriwaki K, Ichikawa M, Kimena L, Ali Y, Ito M, Gomez‐Sanchez CE, Dohi K. Myosin Light Chain Phosphatase Plays an Important Role in Cardiac Fibrosis in a Model of Mineralocorticoid Receptor-Associated Hypertension. J Am Heart Assoc 2024; 13:e032828. [PMID: 38420846 PMCID: PMC10944028 DOI: 10.1161/jaha.123.032828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Myosin phosphatase targeting subunit 2 (MYPT2) is an important subunit of cardiac MLC (myosin light chain) phosphatase, which plays a crucial role in regulating the phosphorylation of MLC to phospho-MLC (p-MLC). A recent study demonstrated mineralocorticoid receptor-related hypertension is associated with RhoA/Rho-associated kinase/MYPT1 signaling upregulation in smooth muscle cells. Our purpose is to investigate the effect of MYPT2 on cardiac function and fibrosis in mineralocorticoid receptor-related hypertension. METHODS AND RESULTS HL-1 murine cardiomyocytes were incubated with different concentrations or durations of aldosterone. After 24-hour stimulation, aldosterone increased CTGF (connective tissue growth factor) and MYPT2 and decreased p-MLC in a dose-dependent manner. MYPT2 knockdown decreased CTGF. Cardiac-specific MYPT2-knockout (c-MYPT2-/-) mice exhibited decreased type 1 phosphatase catalytic subunit β and increased p-MLC. A disease model of mouse was induced by subcutaneous aldosterone and 8% NaCl food for 4 weeks after uninephrectomy. Blood pressure elevation and left ventricular hypertrophy were observed in both c-MYPT2-/- and MYPT2+/+ mice, with no difference in heart weights or nuclear localization of mineralocorticoid receptor in cardiomyocytes. However, c-MYPT2-/- mice had higher ejection fraction and fractional shortening on echocardiography after aldosterone treatment. Histopathology revealed less fibrosis, reduced CTGF, and increased p-MLC in c-MYPT2-/- mice. Basal global radial strain and global longitudinal strain were higher in c-MYPT2-/- than in MYPT2+/+ mice. After aldosterone treatment, both global radial strain and global longitudinal strain remained higher in c-MYPT2-/- mice compared with MYPT2+/+ mice. CONCLUSIONS Cardiac-specific MYPT2 knockout leads to decreased myosin light chain phosphatase and increased p-MLC. MYPT2 deletion prevented cardiac fibrosis and dysfunction in a model of mineralocorticoid receptor-associated hypertension.
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Affiliation(s)
- Zhe Ye
- Department of Cardiology and NephrologyMie University Graduate School of MedicineTsuMieJapan
| | - Ryuji Okamoto
- Department of Cardiology and NephrologyMie University Graduate School of MedicineTsuMieJapan
- Regional Medical Support CenterMie University HospitalTsuMieJapan
- Department of Clinical Training and Career Support CenterMie University HospitalTsuMieJapan
| | - Hiromasa Ito
- Department of Cardiology and NephrologyMie University Graduate School of MedicineTsuMieJapan
| | - Rie Ito
- Department of Cardiology and NephrologyMie University Graduate School of MedicineTsuMieJapan
| | - Keishi Moriwaki
- Department of Cardiology and NephrologyMie University Graduate School of MedicineTsuMieJapan
| | - Mizuki Ichikawa
- Department of Cardiology and NephrologyMie University Graduate School of MedicineTsuMieJapan
| | - Lupiya Kimena
- Department of Cardiology and NephrologyMie University Graduate School of MedicineTsuMieJapan
| | - Yusuf Ali
- Department of Pharmacology and ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Masaaki Ito
- Department of Cardiology and NephrologyMie University Graduate School of MedicineTsuMieJapan
| | - Celso E. Gomez‐Sanchez
- Department of Pharmacology and ToxicologyUniversity of Mississippi Medical CenterJacksonMS
| | - Kaoru Dohi
- Department of Cardiology and NephrologyMie University Graduate School of MedicineTsuMieJapan
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Ceccuzzi G, Rapino A, Perna B, Costanzini A, Farinelli A, Fiorica I, Marziani B, Cianci A, Rossin F, Cesaro AE, Spampinato MD, De Giorgio R, Guarino M. Liquorice Toxicity: A Comprehensive Narrative Review. Nutrients 2023; 15:3866. [PMID: 37764649 PMCID: PMC10537237 DOI: 10.3390/nu15183866] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/26/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Renowned since ancient times for its medical properties, liquorice is nowadays mainly used for flavoring candies or soft drinks. Continuous intake of large amounts of liquorice is a widely known cause of pseudo-hyperaldosteronism leading to hypertension and hypokalemia. These manifestations are usually mild, although in some cases may generate life-threatening complications, i.e., arrhythmias, muscle paralysis, rhabdomyolysis, and coma. In addition, liquorice has an important estrogenic-like activity. METHODS We summarized the current knowledge about liquorice and reviewed 104 case reports in both the English and Italian languages from inception to June 2023 concerning complications due to an excess of liquorice intake. RESULTS In contrast to most published data, female sex and old age do not appear to be risk factors. However, hypertension and electrolyte imbalance (mainly hypokalemia) are prevalent features. The detection of glycyrrhetinic acid in blood is very uncommon, and the diagnosis is essentially based on an accurate history taking. CONCLUSIONS Although there is not a significant mortality rate, liquorice toxicity often requires hospitalization and therefore represents a significant health concern. Major pharmaceutical drug regulatory authorities should solicit public awareness about the potentially dangerous effects caused by excessive use of liquorice.
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Affiliation(s)
- Giovanna Ceccuzzi
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Alessandro Rapino
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Benedetta Perna
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Anna Costanzini
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Andrea Farinelli
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Ilaria Fiorica
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Beatrice Marziani
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Antonella Cianci
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Federica Rossin
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Alice Eleonora Cesaro
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Michele Domenico Spampinato
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
- Department of Emergency, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
| | - Matteo Guarino
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy; (G.C.); (A.R.); (B.P.); (A.C.); (A.F.); (I.F.); (B.M.); (A.C.); (F.R.); (A.E.C.); (M.D.S.); (M.G.)
- Department of Emergency, St. Anna University Hospital of Ferrara, University of Ferrara, 44124 Ferrara, Italy
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Johnston JG, Welch AK, Cain BD, Sayeski PP, Gumz ML, Wingo CS. Aldosterone: Renal Action and Physiological Effects. Compr Physiol 2023; 13:4409-4491. [PMID: 36994769 DOI: 10.1002/cphy.c190043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Aldosterone exerts profound effects on renal and cardiovascular physiology. In the kidney, aldosterone acts to preserve electrolyte and acid-base balance in response to changes in dietary sodium (Na+ ) or potassium (K+ ) intake. These physiological actions, principally through activation of mineralocorticoid receptors (MRs), have important effects particularly in patients with renal and cardiovascular disease as demonstrated by multiple clinical trials. Multiple factors, be they genetic, humoral, dietary, or otherwise, can play a role in influencing the rate of aldosterone synthesis and secretion from the adrenal cortex. Normally, aldosterone secretion and action respond to dietary Na+ intake. In the kidney, the distal nephron and collecting duct are the main targets of aldosterone and MR action, which stimulates Na+ absorption in part via the epithelial Na+ channel (ENaC), the principal channel responsible for the fine-tuning of Na+ balance. Our understanding of the regulatory factors that allow aldosterone, via multiple signaling pathways, to function properly clearly implicates this hormone as central to many pathophysiological effects that become dysfunctional in disease states. Numerous pathologies that affect blood pressure (BP), electrolyte balance, and overall cardiovascular health are due to abnormal secretion of aldosterone, mutations in MR, ENaC, or effectors and modulators of their action. Study of the mechanisms of these pathologies has allowed researchers and clinicians to create novel dietary and pharmacological targets to improve human health. This article covers the regulation of aldosterone synthesis and secretion, receptors, effector molecules, and signaling pathways that modulate its action in the kidney. We also consider the role of aldosterone in disease and the benefit of mineralocorticoid antagonists. © 2023 American Physiological Society. Compr Physiol 13:4409-4491, 2023.
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Affiliation(s)
- Jermaine G Johnston
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Amanda K Welch
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Brian D Cain
- Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, Florida, USA
| | - Peter P Sayeski
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
| | - Michelle L Gumz
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
| | - Charles S Wingo
- Division of Nephrology, Hypertension and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida, USA
- Nephrology Section, Veteran Administration Medical Center, North Florida/South Georgia Malcom Randall Department of Veterans Affairs Medical Center, Gainesville, Florida, USA
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Ballin NZ, Larsen DM, Jensen ST, Andersen LB, Olesen PT. Glycyrrhizinic acid in licorice products on the Danish market. Food Control 2023. [DOI: 10.1016/j.foodcont.2022.109322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Hypertension and Severe Hypokalemia Associated With Oral Ingestion of Topical Hydrocortisone Cream. AACE Clin Case Rep 2022; 9:2-4. [PMID: 36654996 PMCID: PMC9837079 DOI: 10.1016/j.aace.2022.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022] Open
Abstract
Background Topical use of corticosteroids causes systemic effects, but systemic toxicity by ingesting topical corticosteroid cream has not been reported. We describe a patient admitted with ingestion of over-the-counter (OTC) hydrocortisone cream. Case Report A 64-year-old woman presented with 2-weeks of generalized weakness. She had a history of hypertension, anxiety, depression, and chronic fatigue syndrome, but medical records were unavailable and she was not on any medications. She reported taking prednisone 7.5 mg daily for several years, which was discontinued 5 months ago. Due to worsening symptoms, she started ingesting OTC topical hydrocortisone as replacement and admitted to consuming 2 squirts of 1% hydrocortisone cream twice daily over the previous month leading up to hospitalization. Her pulse rate was 77/min, blood pressure was 232/110 mmHg. There was no pedal edema, elevated jugular venous pressure, hirsutism, muscle wasting, or purplish skin striae. Labs revealed potassium 1.5 mg/dL (3.6-5.4), serum cortisol 61.5 μg/dL (2.3-19.4), Creatine Kinase 1864 IU/L (24-173), undetectable adrenocorticotropic hormone. She received potassium, labetalol, and intravenous fluids. Her serum cortisol level decreased to 11 μg/dL and potassium to 4.1 mg/dL within 24 hours. She left the hospital against medical advice on Day 2. Discussion Although both prednisone and hydrocortisone have glucocorticoid properties, only hydrocortisone has mineralocorticoid properties. Hydrocortisone 20 mg provides a mineralocorticoid effect equivalent to 0.1 mg fludrocortisone. Conclusion Hydrocortisone cream was confirmed as the source of exogenous corticosteroid by an undetectable adrenocorticotropic hormone and rapid decrease in cortisol following discontinuation. Incorrect use of OTC medications can lead to life-threatening side effects.
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Yoshino T, Shimada S, Homma M, Makino T, Mimura M, Watanabe K. Clinical Risk Factors of Licorice-Induced Pseudoaldosteronism Based on Glycyrrhizin-Metabolite Concentrations: A Narrative Review. Front Nutr 2021; 8:719197. [PMID: 34604277 PMCID: PMC8484325 DOI: 10.3389/fnut.2021.719197] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/16/2021] [Indexed: 11/23/2022] Open
Abstract
Licorice, the dried root or stolon of Glycyrrhiza glabra or G. ularensis, is commonly used worldwide as a food sweetener or crude drug. Its major ingredient is glycyrrhizin. Hypokalemia or pseudoaldosteronism (PsA) is one of the most frequent side effects of licorice intake. Glycyrrhizin metabolites inhibit type 2 11β-hydroxysteroid dehydrogenase (11βHSD2), which decomposes cortisol into inactive cortisone in the distal nephron, thereby inducing mineralocorticoid receptor activity. Among the several reported glycyrrhizin-metabolites, 18β-glycyrrhetyl-3-O-sulfate is the major compound found in humans after licorice consumption, followed by glycyrrhetinic acid. These metabolites are highly bound to albumin in blood circulation and are predominantly excreted into bile via multidrug resistance-associated protein 2 (Mrp2). High dosage and long-term use of licorice are constitutional risk factors for PsA. Orally administered glycyrrhizin is effectively hydrolyzed to glycyrrhetinic acid by the intestinal bacteria in constipated patients, which enhances the bioavailability of glycyrrhizin metabolites. Under hypoalbuminemic conditions, the unbound metabolite fractions can reach 11βHSD2 at the distal nephron. Hyper direct-bilirubin could be a surrogate marker of Mrp2 dysfunction, which results in metabolite accumulation. Older age is associated with reduced 11βHSD2 function, and several concomitant medications, such as diuretics, have been reported to affect the phenotype. This review summarizes several factors related to licorice-induced PsA, including daily dosage, long-term use, constipation, hypoalbuminemia, hyper direct-bilirubin, older age, and concomitant medications.
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Affiliation(s)
- Tetsuhiro Yoshino
- Center for Kampo Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Saori Shimada
- Department of Pharmaceutical Sciences, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masato Homma
- Department of Pharmaceutical Sciences, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Toshiaki Makino
- Department of Pharmacognosy, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Masaru Mimura
- Center for Kampo Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Psychiatry and Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Kenji Watanabe
- Center for Kampo Medicine, Keio University School of Medicine, Tokyo, Japan
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McHugh J, Nagabathula R, Kyithar MP. A life-threatening case of pseudo-aldosteronism secondary to excessive liquorice ingestion. BMC Endocr Disord 2021; 21:158. [PMID: 34362360 PMCID: PMC8349066 DOI: 10.1186/s12902-021-00816-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/30/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Liquorice is found in many food products, soft drinks, and herbal medicines. Liquorice ingestion is an uncommon cause of apparent mineralocorticoid excess or pseudo-aldosteronism. The mechanism involves the inhibition of 11-beta-hydroxysteroid dehydrogenase type-2 by the active ingredient called glycyrrhizin. This leads to the uninhibited activation of mineralocorticoid receptors by cortisol. Confectionary products that contain liquorice are readily available in many countries around the world. CASE PRESENTATION We report a case of severe refractory hypokalaemia with hypertensive crisis and acute pulmonary oedema due to excessive liquorice consumption. A 79-year-old female presented to the emergency department following a road traffic accident. She described feeling weak and dizzy while driving before the collision. She attended her general practitioner (GP) several weeks earlier for fatigue and was being managed for hypokalaemia on oral potassium supplements. Investigations revealed hypertension (BP 180/69 mmHg), severe hypokalaemia (K 2.2 mmol/l), normal renal function, normal serum magnesium with metabolic alkalosis. Spot urinary potassium was 22 mmol/l. The patient denied taking medications including over-the-counter or herbal medication that can cause hypokalaemia. Hypokalaemia persisted despite aggressive intravenous (i.v.) and oral potassium replacement. She later developed a hypertensive crisis (BP 239/114 mmHg) with pulmonary oedema. She required admission to the intensive care unit and was managed with intravenous furosemide infusion and isosorbide dinitrate infusion. On further discussion, our patient admitted to struggling with nicotine cravings since quitting smoking two months earlier. She began eating an excessive amount of liquorice sweets to manage her cravings. Suppression of plasma renin and aldosterone supported the diagnosis of apparent mineralocorticoid excess secondary to excessive liquorice consumption. Her symptoms and hypokalaemia resolved after stopping liquorice intake. CONCLUSIONS This case highlights the life-threatening and refractory nature of hypokalaemia secondary to excessive liquorice consumption. This case also emphasizes the importance of comprehensive history taking including dietary habits. Increased awareness among the public is required regarding the potential health hazards of excessive liquorice consumption.
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Affiliation(s)
- Joseph McHugh
- Endocrinology Department, Midlands Regional Hospital Portlaoise, Co. Laois, Republic of Ireland.
| | - Ramesh Nagabathula
- Radiology Department, Midlands Regional Hospital Portlaoise, Co. Laois, Republic of Ireland
| | - Ma Pyeh Kyithar
- Endocrinology Department, Midlands Regional Hospital Portlaoise, Co. Laois, Republic of Ireland
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Hussain H, Ali I, Wang D, Hakkim FL, Westermann B, Ahmed I, Ashour AM, Khan A, Hussain A, Green IR, Shah STA. Glycyrrhetinic acid: a promising scaffold for the discovery of anticancer agents. Expert Opin Drug Discov 2021; 16:1497-1516. [PMID: 34294017 DOI: 10.1080/17460441.2021.1956901] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Oleanane-type pentacyclic triterpenes named glycyrrhetinic acids (GAs) featuring a C-30 carboxylic acid group, are extracted from the licorice (Glycyrrhiza uralensis). Numerous biological properties of GA have been reported and have attracted researchers from all over the world in recent years due to the peculiar GA scaffold-based semisynthetic cytotoxic effects. AREAS COVERED This review represents the applications of semisynthetic derivatives of GA for the development of future cancer treatments. Included in the review are important structural features of the semisynthetic GAs crucial for cytotoxic effects. EXPERT OPINION Numerous semisynthetic GA derivatives illustrated excellent cytotoxic effects toward various cancer cells. Notably the C-3(OH) at ring A along with C30-CO2H at ring E as vital structural features, make GA very appealing as a lead scaffold for medicinal chemistry, since these two groups permit the creation of further chemical diversity geared toward improved cytotoxic effects. Furthermore, numerous GA derivatives have been synthesized and indicate that compounds featuring cyanoenone moieties in ring A, or compounds having the amino group or nitrogen comprising heterocycles and hybrids thereof, illustrate more potent cytotoxicity. Furthermore, GA has a great capability to be conjugated with other anticancer molecules to synergistically enhance their combined cytotoxicity.
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Affiliation(s)
- Hidayat Hussain
- Department of Bioorganic Chemistry, Leibniz Institute of Plant Biochemistry, Halle (Saale), Germany
| | - Iftikhar Ali
- School of Pharmaceutical Sciences and Key Laboratory for Applied Technology of Sophisticated Analytical Instruments of Shandong Province, Shandong Analysis and Test Center, Qilu University of Technology (Shandong Academy of Sciences), Jinan, China.,Department of Chemistry, Karakoram International University, Gilgit, Pakistan
| | - Daijie Wang
- School of Pharmaceutical Sciences and Key Laboratory for Applied Technology of Sophisticated Analytical Instruments of Shandong Province, Shandong Analysis and Test Center, Qilu University of Technology (Shandong Academy of Sciences), Jinan, China
| | | | - Bernhard Westermann
- Department of Bioorganic Chemistry, Leibniz Institute of Plant Biochemistry, Halle (Saale), Germany
| | - Ishtiaq Ahmed
- Department of Chemical Engineering and Biotechnology, University of Cambridge, Cambridge, UK
| | - Ahmed M Ashour
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Amjad Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Amjad Hussain
- Department of Chemistry, University of Okara, Okara, Pakistan
| | - Ivan R Green
- Department of Chemistry and Polymer Science, University of Stellenbosch, Matieland, South Africa
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Glycyrrhizin Effectively Inhibits SARS-CoV-2 Replication by Inhibiting the Viral Main Protease. Viruses 2021; 13:v13040609. [PMID: 33918301 PMCID: PMC8066091 DOI: 10.3390/v13040609] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/23/2021] [Accepted: 03/31/2021] [Indexed: 12/29/2022] Open
Abstract
The outbreak of SARS-CoV-2 developed into a global pandemic affecting millions of people worldwide. Despite one year of intensive research, the current treatment options for SARS-CoV-2 infected people are still limited. Clearly, novel antiviral compounds for the treatment of SARS-CoV-2 infected patients are still urgently needed. Complementary medicine is used along with standard medical treatment and accessible to a vast majority of people worldwide. Natural products with antiviral activity may contribute to improve the overall condition of SARS-CoV-2 infected individuals. In the present study, we investigated the antiviral activity of glycyrrhizin, the primary active ingredient of the licorice root, against SARS-CoV-2. We demonstrated that glycyrrhizin potently inhibits SARS-CoV-2 replication in vitro. Furthermore, we uncovered the underlying mechanism and showed that glycyrrhizin blocks the viral replication by inhibiting the viral main protease Mpro that is essential for viral replication. Our data indicate that the consumption of glycyrrhizin-containing products such as licorice root tea of black licorice may be of great benefit for SARS-CoV-2 infected people. Furthermore, glycyrrhizin is a good candidate for further investigation for clinical use to treat COVID-19 patients.
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Bell RF, Moreira VM, Kalso EA, Yli-Kauhaluoma J. Liquorice for pain? Ther Adv Psychopharmacol 2021; 11:20451253211024873. [PMID: 34349979 PMCID: PMC8287643 DOI: 10.1177/20451253211024873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/25/2021] [Indexed: 12/24/2022] Open
Abstract
Liquorice has a long history of use in traditional Chinese, Ayurvedic and herbal medicine. The liquorice plant contains numerous bioactive compounds, including triterpenes, flavonoids and secondary metabolites, with glycyrrhizin being the main active compound. Liquorice constituents have been found to have anti-inflammatory, antioxidant, antiviral, anticancer, hepatoprotective and neuroprotective properties. In addition, they appear to have antidepressant actions and effects on morphine tolerance. Glycyrrhizin, its metabolite glycyrrhetic (glycyrrhetinic) acid and other liquorice-derived compounds such as isoflavonoids and trans-chalcones, exert potent anti-inflammatory effects via a wide range of mechanisms including high mobility group box 1 protein (HMGB1) inhibition, gap junction blockade and α2A-adrenoceptor antagonism. These properties, together with an increasing body of preclinical studies and a long history of use in herbal medicine, suggest that liquorice constituents may be useful for pain management. Glycyrrhizin is used widely in the confectionary, food and tobacco industries, but has documented adverse effects that may limit clinical use. Whether liquorice plant-derived compounds represent a novel class of analgesics is yet to be established. Having a host of bioactive compounds with a broad range of mechanisms of effect, liquorice is a plant that, in the future, may give rise to new therapies for pain.
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Affiliation(s)
- Rae F Bell
- (Emerita) Regional Centre of Excellence in Palliative Care, Haukeland University Hospital, Jonas Lies vei 65, Bergen 5021, Norway
| | - Vânia M Moreira
- Laboratory of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - Eija A Kalso
- Department of Pharmacology and SleepWell Research Programme, Faculty of Medicine, University of Helsinki and Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Jari Yli-Kauhaluoma
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
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Brendler T, Al‐Harrasi A, Bauer R, Gafner S, Hardy ML, Heinrich M, Hosseinzadeh H, Izzo AA, Michaelis M, Nassiri‐Asl M, Panossian A, Wasser SP, Williamson EM. Botanical drugs and supplements affecting the immune response in the time of
COVID
‐19: Implications for research and clinical practice. Phytother Res 2020; 35:3013-3031. [DOI: 10.1002/ptr.7008] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/16/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Thomas Brendler
- Department of Botany and Plant Biotechnology University of Johannesburg Johannesburg South Africa
- Plantaphile Collingswood New Jersey USA
| | - Ahmed Al‐Harrasi
- Natural and Medical Sciences Research Centre University of Nizwa Nizwa Oman
| | - Rudolf Bauer
- Institute of Pharmaceutical Sciences, Department of Pharmacognosy University of Graz Graz Austria
| | | | - Mary L. Hardy
- Association of Integrative and Holistic Medicine San Diego California USA
| | - Michael Heinrich
- Research Group ‘Pharmacognosy and Phytotherapy’, UCL School of Pharmacy University of London London UK
- Graduate Institute of Integrated Medicine, College of Chinese Medicine China Medical University Taichung Taiwan
| | - Hossein Hosseinzadeh
- Pharmaceutical Research Center, Pharmaceutical Technology Institute Mashhad University of Medical Sciences Mashhad Iran
- Department of Pharmacodynamics and Toxicology, School of Pharmacy Mashhad University of Medical Sciences Mashhad Iran
| | - Angelo A. Izzo
- Department of Pharmacy, School of Medicine University of Naples Federico II Naples Italy
| | - Martin Michaelis
- Industrial Biotechnology Centre and School of Biosciences University of Kent Canterbury UK
| | - Marjan Nassiri‐Asl
- Department of Pharmacology, School of Medicine Shahid Beheshti University of Medical Sciences Tehran Iran
- Neurobiology Research Center Shahid Beheshti University of Medical Sciences Tehran Iran
| | | | - Solomon P. Wasser
- Institute of Evolution and Department of Evolutionary and Environmental Biology University of Haifa Haifa Israel
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Dangerous sweets: severe hypokalemia with rhabdomyolysis and tetraparesis from chronic consumption of licorice. J Neurol 2020; 268:707-708. [PMID: 33340333 PMCID: PMC7880938 DOI: 10.1007/s00415-020-10347-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/27/2020] [Accepted: 12/04/2020] [Indexed: 11/02/2022]
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