Originally posted by dalewick
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http://www.cmaj.ca/content/191/21/E581
Hypertensive emergency induced by licorice tea
Jean-Pierre Falet, Arielle Elkrief and Laurence Green
CMAJ May 27, 2019 191 (21) E581-E583; DOI: https://doi.org/10.1503/cmaj.180550
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KEY POINTS
Licorice-induced pseudohyperaldosteronism is an unusual but important cause of hypertensive emergency.
Common findings of licorice-induced pseudohyperaldosteronism include signs of sodium retention, such as hypertension, hypokalemia or metabolic alkalosis, with low serum aldosterone levels.
Given Canada’s multicultural population, physicians should consider screening for licorice root intake in patients with difficult-to-control hypertension.
An 84-year-old man presented to the emergency department with a hypertensive emergency. He reported a 1-week history of persistently elevated measurements, taken at home, of systolic blood pressure (between 180 and 210 mm Hg), along with symptoms of headache, photophobia, chest pain and fatigue. On presentation to the emergency department, his blood pressure was 196/66 mm Hg. He had signs of volume overload on physical examination, including pulmonary crackles on auscultation and pitting edema of the lower extremities up to the knees. Chest radiography was consistent with mild pulmonary edema.
The patient’s initial laboratory results in the emergency department showed a low potassium level of 2.5 (reference range 3.5–5.0) mmol/L, an elevated bicarbonate level of 31 (reference range 23–29) mmol/L and an increased troponin level of 0.14 (upper limit of normal 0.04) μg/L, with no signs of myocardial ischemia on the electrocardiogram.
The patient had long-standing hypertension. A blood pressure measurement taken 4 months earlier showed adequate control (125/60 mm Hg). He also had a history of coronary artery disease, type 2 diabetes and dyslipidemia. His medications included irbesartan, hydrochlorothiazide, acetylsalicylic acid, metformin, empagliflozin, insulin, ezetimibe and atorvastatin. He took furosemide on alternating days for mild venous insufficiency causing pitting edema of the feet.
On admission, the patient was started on a combination of amlodipine, metoprolol and hydralazine. Irbesartan was initially held to avoid altering tests of endocrine biochemistry and later resumed. Hydrochlorothiazide was held until the end of his hospital stay to avoid aggravating the hypokalemia. The patient’s presenting symptoms resolved over the next 24 hours, except for orthopnea and paroxysmal nocturnal dyspnea, which improved after several days of diuresis with intravenous furosemide.
On further questioning, the patient volunteered that he had been ingesting 1 to 2 glasses of homemade licorice root extract called “erk sous” daily for the 2 weeks leading up to his presentation. Although he knew of the potential association between licorice consumption and high blood pressure, he did not think of it when he noticed his blood pressure starting to rise.
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