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Sabbadin C, Graziani A, Bavaresco A, Mazzeo P, Tizianel I, Ceccato F, Armanini D, Barbot M. Pseudohyperaldosteronism Due to Licorice: A Practice-Based Learning from a Case Series. Int J Mol Sci 2024; 25:7454. [PMID: 39000561 PMCID: PMC11242244 DOI: 10.3390/ijms25137454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/28/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024] Open
Abstract
Pseudohyperaldosteronism (PHA) is characterized by hypertension, hypokalemia, and a decrease in plasma renin and aldosterone levels. It can be caused by several causes, but the most frequent is due to excess intake of licorice. The effect is mediated by the active metabolite of licorice, glycyrrhetinic acid (GA), which acts by blocking the 11-hydroxysteroid dehydrogenase type 2 and binding to the mineralocorticoid receptor (MR) as an agonist. The management of licorice-induced PHA depends on several individual factors, such as age, gender, comorbidities, duration and amount of licorice intake, and metabolism. The clinical picture usually reverts upon licorice withdrawal, but sometimes mineralocorticoid-like effects can be critical and persist for several weeks, requiring treatment with MR blockers and potassium supplements. Through this case series of licorice-induced PHA, we aim to increase awareness about exogenous PHA, and the possible risk associated with excess intake of licorice. An accurate history is mandatory in patients with hypertension and hypokalemia to avoid unnecessary testing. GA is a component of several products, such as candies, breath fresheners, beverages, tobacco, cosmetics, and laxatives. In recent years, the mechanisms of action of licorice and its active compounds have been better elucidated, suggesting its benefits in several clinical settings. Nevertheless, licorice should still be consumed with caution, considering that licorice-induced PHA is still an underestimated condition, and its intake should be avoided in patients with increased risk of licorice toxicity due to concomitant comorbidities or interfering drugs.
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Affiliation(s)
- Chiara Sabbadin
- Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy
- Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy
| | - Andrea Graziani
- Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy
- Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy
| | - Alessandro Bavaresco
- Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy
- Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy
| | - Pierluigi Mazzeo
- Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy
- Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy
| | - Irene Tizianel
- Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy
- Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy
| | - Filippo Ceccato
- Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy
- Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy
| | - Decio Armanini
- Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy
| | - Mattia Barbot
- Unit of Endocrinology, University Hospital of Padua, 35128 Padua, Italy
- Department of Medicine (DIMED), University of Padua, 35128 Padua, Italy
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Latif A, Naqi M, McAnally JF. A Case of Liquorice-Infused Marijuana Causing Syndrome of Apparent Mineralocorticoid Excess. Eur J Case Rep Intern Med 2023; 10:003991. [PMID: 37680778 PMCID: PMC10482139 DOI: 10.12890/2023_003991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/05/2023] [Indexed: 09/09/2023] Open
Abstract
Marijuana has long been used both for recreational and medicinal purposes. Most of the available forms of marijuana contain additives such as liquorice to enhance its flavour. Liquorice increases the amounts of cortisol in the body and produces metabolic abnormalities seen in primary hyperaldosteronism[1]. Liquorice extracts are mixed with marijuana in the same way as for tobacco[2,3]. We describe a case of apparent mineralocorticoid excess due to excessive smoking of liquorice-laced marijuana. To our knowledge, this is the first reported case of apparent mineralocorticoid excess caused by marijuana use. LEARNING POINTS First report of liquorice-laced marijuana causing syndrome of apparent mineralocorticoid excess (SAME).Since its legalisation, marijuana is reported to be the most used substance second only to alcohol. With the increased availability of marijuana, the health care providers and consumers must be cognisant of its side effects.It is a dose-dependent phenomenon. The effects vary from minor clinical symptoms to fatal arrhythmias based on the amount consumed.
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Affiliation(s)
- Asnia Latif
- Department of Internal Medicine, Rutgers NJMS Trinitas Regional Medical Center, Elizabeth, New Jersey, USA
| | - Muniba Naqi
- Department of Internal Medicine, Rutgers NJMS Trinitas Regional Medical Center, Elizabeth, New Jersey, USA
| | - James F. McAnally
- Department of Nephrology, Rutgers NJMS Trinitas Regional Medical Center, Elizabeth, New Jersey, USA
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Arai M, Isono H, Isono M, Ihara K, Kondo K. A Case of Pseudohyperaldosteronism Induced by Yokukansan and Shakuyakukanzoto That Resulted in Severe Hypokalemia. Cureus 2023; 15:e38267. [PMID: 37261160 PMCID: PMC10228552 DOI: 10.7759/cureus.38267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 06/02/2023] Open
Abstract
Pseudohyperaldosteronism can be induced by the excessive use of Chinese herbal medicines (Kampo medicines), resulting in serious disorders. We report a case of pseudohyperaldosteronism induced by two Kampo medicines which resulted in severe hypokalemia. A 70-year-old woman was hospitalized for a left calcaneal fracture. She had no subjective symptoms other than trauma. On her admission, blood test results revealed a low serum potassium level of 2.4 mmol/L by chance, as well as low levels of both renin and aldosterone. The patient had been taking 5 g of Yokukansan per day for the past three months. In addition, she was on 5 g Shakuyakukanzoto per day for three months until a month prior to hospitalization. The daily licorice content from the aforementioned herbs was 1.0 g and 4.0 g, respectively. After hospitalization, the administration of the Kampo medicines was discontinued, and 610 mmol of potassium was administered over a period of 13 days, which resulted in the normalization of serum potassium levels. Pre-existing hypertension slowly improved as well. Patients consuming licorice at doses of 2.5 g per day or more, as in our case, are at a high risk of developing pseudohyperaldosteronism. Furthermore, the risk is particularly high with long-term licorice consumption as well as for women and elderly patients. To this end, high-dose potassium supplementation may be necessary for normalizing serum potassium levels. Therefore, awareness regarding the adverse effects of licorice is crucial, even in cases of low dosages of licorice.
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Affiliation(s)
- Mika Arai
- Department of General Medicine, HITO Medical Center, Ehime, JPN
| | - Hiroki Isono
- Department of General Medicine, HITO Medical Center, Ehime, JPN
| | - Momoko Isono
- Department of General Medicine, HITO Medical Center, Ehime, JPN
| | - Kousuke Ihara
- Department of General Medicine, HITO Medical Center, Ehime, JPN
| | - Keisuke Kondo
- Department of General Medicine, HITO Medical Center, Ehime, JPN
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Muacevic A, Adler JR, Escabi-Mendoza J. Close Call From a Sweet Twist: A Case of Licorice-Induced Torsades De Pointes. Cureus 2023; 15:e34126. [PMID: 36843745 PMCID: PMC9949741 DOI: 10.7759/cureus.34126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 01/25/2023] Open
Abstract
Torsades de pointes (TdP) is a life-threatening cardiac arrhythmia that can result from QT interval prolongation, sometimes secondary to medication adverse effects and electrolyte derangements. We present a 95-year-old Hispanic male with advanced chronic kidney disease (CKD) that was evaluated for dizziness and progressive weakness. The diagnosis of severe symptomatic hypokalemia and QT prolongation was made, and the patient was admitted for telemetry monitoring and aggressive intravenous electrolyte replacements. While under observation, the patient experienced syncope due to ventricular tachycardia (VT) with episodes of torsades de pointes. Due to refractory potassium depletion and hypertension, workup for hyperaldosteronism revealed renal potassium wasting, inappropriately normal plasma renin levels, and almost undetectable aldosterone levels. Careful analysis revealed the excessive chronic daily ingestion of licorice-containing candy twists and tea, which may cause pseudohyperaldosteronism. Licorice is a commonly used natural product that is available in many forms. It is sometimes used as a natural supplement and as a sweetener that can be widely found in many food products. Excessive ingestion can lead to apparent mineralocorticoid excess, reduced plasma potassium, sodium retention, hypertension, and metabolic alkalosis. Hypokalemia can be severe in some patients and lead to fatal cardiac arrhythmias such as ventricular tachycardia and torsades de pointes. Careful analysis is essential in cases of refractive hypokalemia and renal potassium wasting, especially in elderly patients with underlying renovascular disease.
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Shibata T, Yoshinuma H, Sugiyama D, Kobayashi O. Severe Hypokalemia and Metabolic Alkalosis Caused by Licorice Discovered During the Treatment of Intraoperative Hypoxemia. Cureus 2022; 14:e25432. [PMID: 35774714 PMCID: PMC9236722 DOI: 10.7759/cureus.25432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2022] [Indexed: 11/05/2022] Open
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