Endocrine Abstracts

Liquorice is a sweetener found in many food products, soft drinks, snacks and herbal medicines. Liquorice ingestion is an uncommon cause of AME or pseudohyperaldosteronisim. The mechanism involves the inhibition of 11-beta-hydroxysteroid dehydrogenase type-2 by the active ingredient called glycyrrhizin, which leads to the uninhibited activation of mineralocorticoid receptors by cortisol. Confectionary products that contain liquorice are readily available in the European Union.

We report a case of severe refractory hypokalaemia due to excessive liquorice consumption. A 79-year-old female presented to the emergency department following a road traffic accident secondary to collapse. She described feeling weak in the preceding weeks and was managed by her GP for hypokalaemia. Investigations revealed hypertension (BP 180/69 mmHg), severe hypokalaemia (K 2.2 mmol/l), normal renal function (Na 143 mmol/l, urea 3.4 mmol/l, creatinine 54 umol/l), normal magnesium (0.79 mmol/l) and calcium (2.24 mmol/l) levels with metabolic alkalosis (pH 7.537, bicarbonate 33.5 mmol/l). Spot urinary potassium was 22 mmol/l. The patient denied taking medications including over-the-counter or herbal medicines that can cause hypokalaemia. Hypokalaemia persisted for six days despite aggressive IV and oral potassium replacement. She later developed hypertensive emergency (BP 239/114 mmHg) with pulmonary oedema and required admission to intensive care unit for emergency management of hypertension with intravenous furosemide infusion and isosorbide dinitrate infusion. Further discussion with the patient revealed that since she quitted smoking, she was taking liquorice sweets excessively for the past 3 months to manage her nicotine cravings. Suppression of plasma renin [4.4 pg/ml (reference range <20 pg/ml)] and aldosterone levels [<26 pg/ml (reference range 42–209 pg/ml)] also supported the diagnosis of AME. Her symptoms and hypokalaemia resolved since discontinuing liquorice. This case highlights the life-threatening and refractory nature of severe hypokalaemia and hypertensive emergency caused by pseudohyperaldosteronisim secondary to excessive liquorice consumption. This case also emphasizes the importance of comprehensive history taking including the dietary habits to identify the root cause. Increased awareness among the public is required regarding the potential health hazards of excessive liquorice consumption.