Licorice Ingestion; An Unusual Cause of Rhabdomyolysis and

Abstract

Licorice root has glycyrrhizic acid as the active ingredient and is responsible for a primary hyperaldosteronism-like syndrome with hypokalemia, metabolic alkalosis, and hypertension, typically accompanying low aldosterone. Herein, we present a rare complication of licorice consumption with acute renal failure.A 49-year-old male patient was admitted to emergency department with generalized muscle pain/ weakness, nausea, and dark urine. He was suffering from confusion and somnolence and the general condition was moderate. At laboratory assessment, potassium was 2.3 mEq/L, sodium 141 mEq/L, urea 146 mg/dl , creatinine 6.24 mg/dl, and total creatine kinase 4597 U/L. He had metabolic alkalosis (pH 7.59, HCO 3-37.2 mmol/L). Hemodialysis was performed because of uremic neurological symptoms. His detailed anamnesis revealed consumption of herbal medication for the last 1.5 years to treat gastric complaints. The herbal medication included 16 gr licorice root powder (~600-750 mg glycyrrhizic acid) per 100 gr. The plasma aldosterone concentration was significantly suppressed [1.6 pg/ml (normal; 38.1-300 pg/mL)]. Under these conditions, our final diagnosis was hypokalemic rhabdomyolysis and acute renal failure due to licorice ingestion. We present a rare life-threating effect of licorice ingestion in this report. Furthermore, we want to draw attention to the importance of a detailed medical history, including the use of herbal medications and regional traditional characteristics to confirm the diagnosis.Key wORdS: Licorice, Rhabdomyolysis, Acute renal failure Öz Meyan kökü; Güneydoğu Anadolu'da geleneksel bir içecek olmasının yanı sıra gıda/bitkisel ilaç endüstrisinde kullanılır. Aktif maddesi gliserizik asittir, primer hiperaldestronizim benzeri tablo ile hipokalemi, metabolik alkaloz ve hipertansiyona neden olabilir. Bu olgu sunumunda meyan köküne bağlı gelişen, literatürde nadir olan, bir rabdomiyoliz ve akut böbrek yetmezliği olgusu sunulmuştur. 49 yaşında erkek; kas güçsüzlüğü/ağrısı, bulantı, idrarda koyulaşma yakınmaları ile acil servise başvurdu. Fizik muayenesinde bilinç bulanıklığı ve uykuya meyil vardı. Hastanın laboratuvar bulguları; potasyum 2,3 mEq/L, sodyum141 mEq/L, üre 146 mg/dl, kreatin 6,24 mg/dl, total kreatin kinaz 4597 U/L idi, ayrıca metabolik alkalozu (pH 7,59, HCO 3-37.2 mmol/L) mevcuttu. Hasta üremik nörolojik bulguları nedeniyle hemodiyalize alındı. Bilinç durumu düzelince alınan detaylı anamnezde yaklaşık 1,5 yıldır mide yakınması nedeniyle bitkisel ilaçlar kullandığı ve bitkisel ilacın 100 gr'nın 16 gr meyan kökü (~600-750 mg gliserizik asit) içerdiği öğrenildi. Bu bulgular ışığında kesin tanımız; meyan kökü alımına bağlı hipokalemi, rabdomiyoliz ve akut böbrek yetmezliği oldu. Hastanın plazma aldosteron düzeylerindeki baskılanma da tanımızı destekler nitelikteydi [1,6 pg/ml (normal; 38,1-300 pg/ml)].Bitkisel ilaçlar ve gıda endüstrisinde yaygın olarak kullanılan meyan kökü yaşamı tehdit edici düzeyde akut böbrek yetmezliğine neden olabilir. Ayrıca bu olgu doğrultusunda hekimlere, bitki...

Atrial fibrillation due to licorice root syrup

“…[2] However, hypertension has not been observed in all cases similar to the present one. [6] Inhibition of renal 11-B-hydroxysteroid dehydrogenase type 2 activity by glycyrrhizic acid in licorice root syrup may yield enhanced cortisol effect on mineralocorticoid receptors of distal tubuli of the kidneys because this enzyme promotes the conversion of cortisol to cortisone. Ultimately, increased mineralocorticoid activity cause potassium excretion as well as sodium and water retention, thus leading to hypokalemia and edema.…”

Toxicological Effects of Glycyrrhiza glabra (Licorice): A Review

“…Besides, licorice‐induced hypokalemia evokes QT prolongation and torsade de pointes. This state totally is called pseudo‐hyperaldosteronism with low concentration of aldosterone and renin in serum (Luyckx, ; Schröder et al ., ; Bisogni et al ., ; Iida et al ., ; Panduranga and Al‐Rawahi, ; Eid et al ., ; Sontia et al ., ; Farese et al ., ; Ishiguchi et al ., ; Chubachi et al ., ; Velickovic‐Radovanovic et al ., ; Daniş et al ., ; Heidemann and Kreuzfelder, ; Saito et al ., ). In one case, carpal tunnel syndrome was reported that has been attributed to the salt and water retention and edema accompanied with licorice consumption (Tacconi et al ., ).…”

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 ].…”