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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Blanpain JS, Adler JR. A Licorice-Flavored Edema: A Case Report of Glycyrrhizic Acid Toxicity From Chronic Licorice Root Consumption. Cureus 2023; 15:e34425. [PMID: 36874748 PMCID: PMC9981224 DOI: 10.7759/cureus.34425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/01/2023] Open
Abstract
This article presents a case study of a 49-year-old patient who was admitted to the emergency department with hypertension, edema, and intense fatigue caused by excessive consumption for three weeks of licorice herbal teas purchased on the internet. The patient was only taking antiaging hormonal treatment. The examination revealed bilateral edema of the face and lower limbs, and blood tests showed discrete hypokalemia (3.1 mmol/L) and low aldosterone levels. The patient revealed that she had been consuming large amounts of licorice herbal teas to compensate for the lack of sweetness in her low-sugar diet. This case study highlights that although licorice is widely used for its sweet taste and has medicinal properties, it can also have a mineralocorticoid-like activity that can lead to apparent mineralocorticoid excess (AME) when consumed in excess. The main component of licorice responsible for these symptoms is glycyrrhizic acid, which increases the availability of cortisol by decreasing its catabolism and has a mineralocorticoid effect through the inhibition of the enzyme 11-β-hydroxysteroid dehydrogenase (11-β-HSD) type 2. The case also discusses the clinical effects of licorice consumption, such as sodium retention and potassium excretion, leading to potential cardiovascular complications, as well as a differential diagnosis of similar clinical presentations mainly based on laboratory findings including aldosterone level and plasma renin activity (PRA). The potential dangers of consuming excessive amounts of licorice are well established, and we advocate stricter regulations and increased awareness and education for both the general public and the medical profession about these negative side effects and suggest that physicians should consider licorice consumption in their approach to patients' lifestyles and diets.
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Affiliation(s)
- Jean-Samuel Blanpain
- Emergency Medicine, Centre Hospitalier Régional Sambre et Meuse (CHRSM), Namur, BEL
| | - John R Adler
- Emergency Medicine, Centre Hospitalier Régional Sambre et Meuse (CHRSM), Namur, BEL
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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] [What about the content of this article? (0)] [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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Villar-Prados A, Chang JJ, Stevens DA, Schoolnik GK, Wang SXY. Severe Posaconazole-Induced Glucocorticoid Deficiency with Concurrent Pseudohyperaldosteronism: An Unfortunate Two-for-One Special. J Fungi (Basel) 2021; 7:jof7080620. [PMID: 34436160 PMCID: PMC8397024 DOI: 10.3390/jof7080620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022] Open
Abstract
A 56-year-old Hispanic man with a history of disseminated coccidioidomycosis was diagnosed with persistent glucocorticoid insufficiency and pseudohyperaldosteronism secondary to posaconazole toxicity. This case was notable for unexpected laboratory findings of both pseudohyperaldosteronism and severe glucocorticoid deficiency due to posaconazole’s mechanism of action on the adrenal steroid synthesis pathway. Transitioning to fluconazole and starting hydrocortisone resolved the hypokalemia but not his glucocorticoid deficiency. This case highlights the importance of recognizing iatrogenic glucocorticoid deficiency with azole antifungal agents and potential long term sequalae.
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Affiliation(s)
| | - Julia J. Chang
- Division of Endocrinology, Metabolism, and Gerontology, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - David A. Stevens
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (D.A.S.); (G.K.S.)
- California Institute of Medical Research, San Jose, CA 95128, USA
| | - Gary K. Schoolnik
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; (D.A.S.); (G.K.S.)
| | - Samantha X. Y. Wang
- Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
- Correspondence: ; Tel.: +1-650-721-8900
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Dandörfer A, Studhalter M. [An Unusual Case of Rhabdomyolysis]. Praxis (Bern 1994) 2021; 110:525-528. [PMID: 34231379 DOI: 10.1024/1661-8157/a003683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
An Unusual Case of Rhabdomyolysis Abstract. We present the case of a 52-year-old patient with accidental liquorice intoxication after consumption of liquorice tea. In the Arabic cultures the consumption of liquorice tea is very popular during Ramadan and is used to suppress thirst. In the described case this led to a severe case of pseudohyperaldosteronism. Because of the classic presentation of a hypertensive crisis, hypokalaemia and rhabdomyolysis, the patient needed intensive care. Typically, the symptoms last for up to seven days after discontinuation of liquorice and completely subside with time. The treatment consists only of supportive care.
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Affiliation(s)
- Artur Dandörfer
- Interdisziplinäre Intensivstation, Kantonsspital Olten, Olten
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Abstract
The by-products of black licorice metabolism are toxic in high concentrations. Patients who consume large quantities of black licorice are at risk of developing an acquired syndrome of apparent mineralocorticoid excess. This presents clinically as hypertension, hypernatremia, and hypokalemia. Here, we present the unique case of a 74-year-old woman with a past medical history of neurogenic orthostatic hypotension, on fludrocortisone, who presented to the emergency department with asymptomatic hypokalemia (2.4 mmol/L) as detected in outpatient laboratory studies. During her hospital stay, it was discovered that the patient was consuming excessive amounts of black licorice. With this information, the synergistic interaction of fludrocortisone and black licorice was recognized as the cause of the patient's severe hypokalemia. The patient's fludrocortisone was stopped and she was treated with multiple courses of potassium repletion. Upon discharge, her fludrocortisone was discontinued, and she was prescribed midodrine to treat her neurogenic orthostatic hypertension. While small amounts of black licorice are safe, excessive licorice consumption can cause severe disease. Our case presents an opportunity to appreciate the plethora of etiologies for severe hypokalemia and the importance of taking a thorough patient history to avoid potentially fatal clinical outcomes.
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Affiliation(s)
| | - Pinak Shah
- Internal Medicine, Mountainview Hospital, Las Vegas, USA
| | - Leo Yamaguchi
- Internal Medicine, Mountainview Hospital, Las Vegas, USA
| | - Vanessa Josef
- Internal Medicine, Mountainview Hospital, Las Vegas, USA
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Sabbadin C, Bordin L, Donà G, Manso J, Avruscio G, Armanini D. Licorice: From Pseudohyperaldosteronism to Therapeutic Uses. Front Endocrinol (Lausanne) 2019; 10:484. [PMID: 31379750 PMCID: PMC6657287 DOI: 10.3389/fendo.2019.00484] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/03/2019] [Indexed: 01/06/2023] Open
Abstract
Licorice has been used as a medicinal plant from 2.500 years. It shows a wide range of biological and pharmacological activities, including anti-inflammatory and immune regulatory actions. One of its most known effects is the induction of hypertension, and it can induce what appears to be pseudohyperaldosteronism, due to glycyrrhetinic acid, the main active component of the root. Glycyrrhetinic acid and metabolites block the 11 beta-hydroxysteroid dehydrogenase type 2 and also bind mineralocorticoid receptors directly, acting as agonists. However, other interesting therapeutic uses of licorice are linked to its anti-androgen and estrogen-like activity, especially in the treatment of polycystic ovary syndrome (PCOS) in conjunction with spironolactone therapy. In this brief review, we report the main features and possible therapeutic uses of this ancient plant.
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Affiliation(s)
- Chiara Sabbadin
- Endocrinology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Luciana Bordin
- Department of Molecular Medicine—Biological Chemistry, University of Padua, Padua, Italy
| | - Gabriella Donà
- Department of Molecular Medicine—Biological Chemistry, University of Padua, Padua, Italy
| | - Jacopo Manso
- Endocrinology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
| | - Giampiero Avruscio
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy
| | - Decio Armanini
- Endocrinology Unit, Department of Medicine, University Hospital of Padua, Padua, Italy
- *Correspondence: Decio Armanini
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Stavropoulos K, Sotiriadis A, Patoulias D, Imprialos K, Dampali R, Athyros V, Dinas K. Pseudohyperaldosteronism due to mumijo consumption during pregnancy: a licorice-like syndrome. Gynecol Endocrinol 2018; 34:1019-1021. [PMID: 29933704 DOI: 10.1080/09513590.2018.1480713] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Herbal supplements are widely used during pregnancy, although there are insufficient data regarding their efficacy and safety. Some of them have been associated with hypertension, including licorice, which induces the so called mineralocorticoid-excess syndrome, a clinical picture resembling to pseudohyperaldosteronism. This action is mediated via inhibition of 11-hydroxysteroid dehydrogenase type 2 (11-HSD2), leading to impaired inactivation of cortisol to cortisone, accumulation of cortisol, and finally to excessive mineralocorticoid activity, especially in the distal and cumulative tubule of kidneys. This syndrome is characterized by hypertension and hypokalemia. Herein, we report a case of a 37-year-old pregnant woman, who was referred from obstetrics department to our department due to persistent hypertension and hypokalemia. She consumed a herbal supplement called "mumijo" during the last 6 months. After a thorough diagnostic work-up, the diagnosis of a "licorice-like syndrome" due to mumijo consumption was made. Potassium supplementation at the acute phase and discontinuation of mumijo were the treatment of choice. This is the first report of pseudohyperaldosteronism due to mumijo consumption in literature. Clinicians should be aware of this side effect and this agent should be included in those causing pseudohyperaldosteronism. Besides all, our case highlights the undeniable value of a detailed medical history.
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Affiliation(s)
- Konstantinos Stavropoulos
- a 2nd Propedeutic Department of Internal Medicine , Aristotle University of Thessaloniki Hospital General Hippokration , Thessaloniki , Greece
| | - Alexandros Sotiriadis
- b 2nd Department of Obstetrics and Gynecology , Aristotle University of Thessaloniki, Hippokration General Hospital , Thessaloniki , Greece
| | - Dimitrios Patoulias
- a 2nd Propedeutic Department of Internal Medicine , Aristotle University of Thessaloniki Hospital General Hippokration , Thessaloniki , Greece
| | - Konstantinos Imprialos
- a 2nd Propedeutic Department of Internal Medicine , Aristotle University of Thessaloniki Hospital General Hippokration , Thessaloniki , Greece
| | - Roxani Dampali
- b 2nd Department of Obstetrics and Gynecology , Aristotle University of Thessaloniki, Hippokration General Hospital , Thessaloniki , Greece
| | - Vasileios Athyros
- a 2nd Propedeutic Department of Internal Medicine , Aristotle University of Thessaloniki Hospital General Hippokration , Thessaloniki , Greece
| | - Konstantinos Dinas
- b 2nd Department of Obstetrics and Gynecology , Aristotle University of Thessaloniki, Hippokration General Hospital , Thessaloniki , Greece
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Kuriakose K, Nesbitt WJ, Greene M, Harris B. Posaconazole-Induced Pseudohyperaldosteronism. Antimicrob Agents Chemother 2018; 62:e02130-17. [PMID: 29530850 PMCID: PMC5923153 DOI: 10.1128/aac.02130-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/02/2018] [Indexed: 12/27/2022] Open
Abstract
A woman in her late 60s with disseminated histoplasmosis was treated with posaconazole because first-line therapies were not tolerated. She subsequently presented with decompensated heart failure, hypertension, and hypokalemia. Laboratory tests revealed low renin and aldosterone levels. A potential mechanism is inhibition of the enzyme 11β-hydroxysteroid dehydrogenase 2, with resultant apparent mineralocorticoid excess.
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Affiliation(s)
- Kevin Kuriakose
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Whitney J Nesbitt
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew Greene
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Harris
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Abstract
We describe a patient presenting with hypertension and hypokalaemia who was ultimately diagnosed with liquorice- induced pseudohyperaldosteronism. This rare cause of secondary hypertension illustrates the importance of a methodical approach to the assessment of hypertension.
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Affiliation(s)
- Ravi Varma
- Department of Renal Medicine, Addenbrookes' Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Calum N Ross
- Department of Renal Medicine, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
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