Close Call From a Sweet Twist: A Case of Licorice-Induced Torsades De Pointes

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.

Liquorice Toxicity: A Comprehensive Narrative Review

“…Mild to severe AH with secondary organ impairment (i.e., hypertensive encephalopathy [ 19 , 26 , 51 , 72 , 73 , 83 ], hypertensive retinopathy [ 31 , 81 ], acute kidney injury [ 47 , 49 , 66 , 79 ], MACEs [ 11 , 24 , 25 , 42 , 43 , 45 , 54 , 59 , 88 , 97 , 99 , 100 ], pulmonary edema [ 22 , 94 ]) were commonly described. Sigurjònsdottir et al showed a linear dose-response relationship between liquorice intake and BP increase [ 130 ].…”

“…Severe K depletion is associated with typical ECG features (i.e., QT interval prolongation, U waves, and ST segment slight elevation in V1–V3). Few cases described hypokalemia-induced fatal arrhythmias leading to cardiac arrest in the absence of other established causes [ 25 , 42 , 45 , 59 , 86 , 88 , 97 , 99 , 100 , 134 ]. Liquorice was lethal in only two cases [ 88 , 97 ].…”

“…Among papers describing patients with altered mental status [ 19 , 37 , 72 , 101 ], Francini-Pesenti et al and Ceccuzzi et al reported an unconscious young woman with LT and daily oral contraceptive, confirming that this pharmacological combination is contraindicated, as previously described. In the other cases the unconsciousness was related to major adverse events, i.e., torsade de point [ 59 , 97 , 134 ], cardiac arrest [ 42 , 86 , 88 ], Brugada-like pattern [ 45 ], and ventricular tachycardia [ 99 , 100 ]. Neurological manifestations were quite frequently (27 out of 104) reported, such as flaccid paresis [ 29 , 33 , 40 , 45 , 77 , 84 , 87 , 96 , 101 ] and hypertensive encephalopathy microhemorrhages [ 51 , 83 ].…”