A fistful of candies for hypertension

Excerpt

A 38 year-old woman was referred to the emergency department for psychomotor agitation preceded by abdominal pain. Her clinical history disclosed hypertension, hypothyroidism, endometriosis and anxiety treated with nebivolol, levothyroxine, benzodiazepines (BDZ) and estro-progestin. On admission, the patient had a GCS of 10 and showed trismus, myoclonus and muscle fasciculations with mydriatic and reactive pupils. The remaining physical examination was unremarkable except for mild hypertension (150/80 mmHg). The ECG revealed a sinus rhythm with prolonged QTc interval (560 ms), low-voltage T-waves and presence of U-waves (see Supplementary Information). Laboratory tests disclosed severe hypokalemia (2.1 mmol/L) (other results are reported in Supplementary Information). The urine test showed increased BDZ (212 ng/ml, n.v.: < 200). Arterial blood gas analysis showed a metabolic alkalosis (pH 7.6; PaCO₂ 37.9 mmHg; bicarbonates 38.5 mmol/L) with lactate elevation (12.2 mmol/L). Brain CT was unremarkable. After anti-poisoning centre consultation, a liquorice toxicity (LT) was suspected and then established by an anamnestic re-evaluation with patient’s relatives (confirming a daily assumption of about one pack of liquorice candies) and elevated circulating glycyrrhetinic acid (GA: 151 mcg/L, n.v.: < 15) levels. The patient was treated with intravenous hydro-electrolyte (1500 ml of 0.9% saline solution with 40 mEq of KCl) and potassium canreonate (50 mg/die) in intensive care unit and then transferred to Internal Medicine with persistent mild hypertension. After excluding other causes of secondary hypertension (including abdominal CT scan), she was discharged asymptomatic with a remodulation of antihypertensive therapy. After 3 months of liquorice discontinuation, the blood pressure normalized and the antihypertensive treatment was stopped. …