[Adverse effects of licorice consumed as food: An update]

The word "licorice" refers to the plant, its root, and its aromatic extract. From a commercial point of view, Glycyrrhiza glabra is the most important species with a wide range of uses (herbal medicine, tobacco industry, cosmetics, food and pharmaceutical). Glycyrrhizin is one of the main constituents of licorice. Glycyrrhizin is hydrolyzed in the intestinal lumen by bacterial β-glucuronidases to 3β-monoglucuronyl-18β-glycyrrhetinic acid (3MGA) and 18β-glycyrrhetinic acid (GA), which are metabolized in the liver. Plasma clearance is slow due to enterohepatic cycling. 3MGA and GA can bind to mineralocorticoid receptors with very low affinity, and 3MGA induces apparent mineralocorticoid excess syndrome through dose-dependent inhibition of 11β-hydroxysteroid dehydrogenase type 2 in renal tissue. The cases of apparent mineralocorticoid excess syndrome reported in the literature are numerous and sometimes severe, even fatal, most often in cases of chronic high dose consumption. Glycyrrhizin poisonings are characterized by hypertension, fluid retention, and hypokalemia with metabolic alkalosis and increased kaliuresis. Toxicity depends on the dose, the type of product consumed, the mode of consumption (acute or chronic) and a very large inter-individual variability. The diagnosis of glycyrrhizin-induced apparent mineralocorticoid excess syndrome is based on the history, clinical examination, and biochemical analysis. Management is primarily based on symptomatic care and stopping licorice consumption.

[Hypokalemia with pseudo-hyperaldosteronism: Is it Lidl® syndrome?]

INTRODUCTION

Intoxication induced by glycyrrhizin is a common cause of hypokalaemia by pseudo-hyperaldosteronism.

OBSERVATION

We hereby present the observation of a 68-year old patient hospitalised following a full hip-prosthesis operation after a deep hypokalaemia at 2.5mM was observed, with ECG signs (flat T waves and appearance of U waves). The kaliuresis was not adapted at 8,4mmol/mmol of creatininuria. We noted a history of axonal and demyelinising polyneuropathy, of psoriasis and chronic ethylism.The evolution after intravenous potassic supplementation and then per os was favourable leading to a normalisation of the blood and urinary potassic concentrations. The blood concentrations of renin and of aldosterone upon admission were lower than the detection threshold and the tests carried out 7 days later were normal with a plasmatic renin of 35.2 pg/mL and a plasmatic aldosterone of 74 pg/mL, therefore indicating a toxic cause. It is the interview of the patient that allowed for the diagnosis, identifying a daily, prolonged and important consumption (around 1L every 2-3 days for several years) of a pastis produced by supermarket brand Lidl®. The composition of the drink mentions 'liquorice infusion' without giving any more information as regards to the real concentration; it was later estimated at 170 mg/L by the distributor.

DISCUSSION

The consumption of glycyrrhizin is a well-known aetiology for pseudo-hyperaldosteronism. It is commonly mentioned amongst excessive consumers of liquorice or of non-alcoholic anise drinks. Drinks that are derived from original pastis contain varying levels of glycyrrhizin, which is used as a flavour enhancer and can become toxic in cases of prolonged and important consumption.