Kidney Week

Abstract: PO1114

Licorice-Induced Syndrome of Mineralocorticoid Excess

Session Information

• Salt, Potassium, and Water Balance: Clinical
  November 04, 2021 | Location: On-Demand, Virtual Only
  Abstract Time: 10:00 AM - 12:00 PM

Category: Fluid, Electrolyte, and Acid-Base Disorders

• 902 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

• Gandhi, Nisarg, Houston Methodist Hospital, Houston, Texas, United States

Nisarg Gandhi, DO

• Ibrahim, Hassan N., Houston Methodist Hospital, Houston, Texas, United States

Hassan N. Ibrahim,

Introduction

Edema and volume overload are common complaints. Here, we present a case of a chronic licorice consumption resulting in edema and generalized weakness.

Case Description

A 34 y/o Caucasian women with history significant for hypothyroidism and recurrent episodes of bronchitis presented for evaluation of recurrent facial, arm, and lower extremity swelling over the past year. She has been evaluated extensively with no etiologies found in the past. She takes Bumex 0.5 mg at least once weekly when she has swelling. She does not have any evidence of kidney dysfunction, heart failure, liver failure, or evidence of proteinuria on laboratory findings. She has been evaluated by rheumatology and was only found to have a weakly positive ANA with no other associated findings (hematuria, arthralgias, or muscle pain). She denies any shortness of breath or orthopnea. Her vitals were within normal limits (BP: 115/70, Pulse: 55). She is very active and exercises daily. Despite limiting her sodium intake, she continues to have recurrent swelling. On further questioning, she mentioned drinking a tea high in licorice. Her basic metabolic panel shows Na⁺ at 140, K⁺ at 4.3, Cl^- at 100, and CO₂ at 26. Her urinalysis was bland with her urine Na⁺< 20. Measured plasma renin and aldosterone activity, shown in the table, were found to be low at baseline. Afternoon free cortisol level was measured to be 0.199. After discontinuation of licorice, they increased back to normal limits with complete resolution of symptoms.

Discussion

Chronic ingestion of licorice is a rare but a known cause of syndrome of mineralocorticoid excess (AME). Licorice contains a steroid, glycyrrhetinic acid, which inhibits the function of the enzyme 11-beta-HSD2. This same enzyme is deficient in AME. This can occur at even low amounts of licorice (50g per day). Typically, these cases present with hypertension, hypokalemia, metabolic alkalosis, low plasma renin activity, and low plasma aldosterone levels. The only treatment necessary is cessation of licorice and symptoms typically resolve in about 1 week. This case illustrates the importance of obtaining a complete medication history including supplement use.