1. MEDICAL Registrar A.ABDULLAH
Case study
MEDICAL Registrar
A.ABDULLAH

2. A 54 years woman presented on 28th May to ED with 3/7 1-Numbness and cramps of legs, hands. 2-nausea ,anorexia and self resolving Diarrhoea (2days) Examination :mild dehydration Vitals were normal Neurology :normal Medical history: No significant disease Social Hx: Drink ETOH,usually OUZO 2-4 can which increased to 8-10 last several weeks due to stress Deny any use of OTC,DRUGS OR any medicine.

3. LAB NA 137 K 1.9 Mg 0.68 Phosphate 0.06 Cl 76 Urea 0.7 Creatinine 44
GFR 90
CK 3750
VBG
PH /HCO3 65 /Base Ex >30
FBC Normal
BSL Normal
ECG Prolong QTC
ST depression and U wave in many leads

4. Assessment : BY ED
Hypokalemic Metabolic Alkalosis likely 2 to Liquorice Toxicity
Rx: IV Fluid with replacement of Electrolytes
About mmol KCL given in hours
symptomatic Rx (nausea, cramps)
Despite Rx ,K was persistently low 2.1 /2.3
Patient symptoms partially improved.
Started to have phlebitis 2 to K therapy

5. Patient seen then by Med PHO /Discussed with Toxicologist on call who did not think that its consistent with Liquorice toxicity.
d/w Med Consultant on call a ,admitted to ICU with central line for K therapy and started on Aldosterone,
aldosterone/renin ratio was requested too.
patient stayed in ICU for hours, marked improvement in symptoms and biochemistry(all numbers all almost normalised )
Patient was advice to follow up with GP and not to drink in excess.

6. OUZO Beverages

9. ANISE
Pimpinella anisum, also called aniseed, is a flowering plant in the family Apiaceae native to the eastern Mediterranean region and Southwest Asia. Its flavor has similarities with some other spices, such as star anise, fennel, and liquorice.

11. Liquorice Toxicity

12. Liquorice Liquorice, or liquorice is a unique tasting herb
Derived from plant Glycyrrhiza Glabra
Used as a flavouring in many food products, alcohol beverages, herbal medicines and tobacco
Liquorice flavours are also found in the plants like Anise seeds, Fennel and other plants.
Often consumed by the public without much awareness of potential side effects
Its active chemical ingredient are glycyrrhizin acid and glycyrrhizin which are causing mineralocorticoid effects.

13. Mechanism of action

14. Inhibition of 11 B-HSD capable of inducing hypertension
Confectionary:licorice sticks,bricks,cakes,toffees,bars
Chewing gum(stimirol)
Liquorice flavoured cough mixtures and tea
Belgian beers
Alcohol beverages :Pasti/Raki/Ouzo,Pernid
Liquorice tea
Chewing tobacco
Herbal cough mixtures

16. Clinical presentation
Fatigue and muscle cramps
Weakness (hypokalaemia)
Dark urine(myoglobinuria)
Edema
Polyurea/nocturia
Headache(HTN)
Parasthesia/dysethesia
Impotence/decrease lipido
amenorhea
Edema (Pulmonary,peripheral)
Hyporeflexia,hypotonia
Hypertension
Spasm and tetany
Trousseau and Chevostk sign
Cardiac dysrhythmia ,arrest

17. Diagnosis History (type of food, drink , alcohol) Lab Hypokalaemia
Metabolic alkalosis
Raised CK(Rhabdomyolysis0
Low serum renin and aldosterone
Elevated cortisol/cortisone ratio
Increase urinary free cortisol

18. Factor increasing sensitivity
Hypokalaemia
Prolonged G.I transit time
Hypertension
Old age
Female sex
Decrease 11-B HSD2 activity

19. Complication HTN (Encephalopathy, stroke)
CVS
HTN (Encephalopathy, stroke)
Arrhythmia and death due to prolonged QT
Generalised Edema
Acute heart failure
Embolic Ischemia

20. CNS
Hypokalaemia myopathy
Carpal tunnel syndrome
Myoclonus

21. Renal and Electrolytes
Hypokalaemia metabolic alkalosis
Increased CK
Acute tubular necrosis due to myoglobinuria

22. Drug interactions Digoxin toxicity due to hypokalaemia
Enhancement of warfarin
Inhibition of CYP 3a4 and P450 systems.

23. Management Supplement potassium, as indicated
Consider potassium-sparing diuretics, as needed
Treat rhabdomyolysis if present (eg, hydration, alkalinization of urine, mannitol)
Monitor for and treat electrolyte-induced dysrhythmias.
Monitor for and treat pulmonary edema and respiratory muscle weakness

24. Resources Theraputic advances in Endocrineology and metabolism
Medscape
BMJ June ,2014 case report (licorice induced HTN) Turkish Pepper

26. A History Quiz??