Poster Presentation ESA-SRB 2023 in conjunction with ENSA

Introduction

Pseudoaldosteronism is rare condition of apparent mineralocorticoid excess with hypokalaemia and hypertension, with low renin and aldosterone, attributable to excess liquorice consumption(1). We present a case of pseudoaldosteronism due to commercially available herbal supplement taken at recommended dose.

Case detail    

A 71-year-old man was referred to hospital for severe hypokalemia (2.7mmol/L), hypertensive urgency (189/94mmHg), associated with palpitations and tension headache. Medical history included restless legs syndrome, obstructive sleep apnea, benign prostate hyperplasia, without known hypertension. Regular medications included herbal supplements prescribed by his naturopathic practitioner for “adrenal fatigue”. This included Glycyrrhiza glabra (liquorice), equivalent to 100mg glycyrrhizic acid consumed daily. His herbal supplements were ceased and treated with oral and intravenous potassium supplementation. Antihypertensive medication was considered, but blood pressure improved without further intervention. Biochemistry revealed suppressed renin and aldosterone, which normalised when retested at 6 weeks (table 1). Hypokalaemia resolved without further potassium supplementation on discharge. Serum cortisol:cortisone ratio reduced from 16:1 to 7:1. No adrenal lesion was noted on computed tomography. 

Discussion

Pseudoaldosteronism is due to inhibition of 11-hydroxysteroid dehydrogenase type-2 by glycyrrhizic and glycyrrhetinic acid, the active ingredients of liquorice root(1).  Liquorice is regulated food additive in United States but not in Australia, with challenging risk prediction, given high number of products, variable content, and lack of routine surveillance for adverse effects(2,3). There is high variability in individual susceptibility, with no established safe dose(4,5). There are also 10-fold variability of glycyrrhizic acid content between plants cultivated in identical conditions(6). Additionally, “adrenal fatigue”, “adrenal burnout”, “tired adrenals” are terms not recognised by endocrinology societies, although some practitioners continue to advocate for recognition and treatment(7).

Conclusion

This case highlights potential dangers of liquorice-containing products and gaps remain in regulatory requirements. Clinicians should undertake careful medication reconciliation to identify undeclared liquorice consumption as potential cause of hypertension and hypokalaemia.