A Man Ate 2 Pounds of Licorice Candy Everyday For 3 Weeks. This Is What Happened To His Organs. VP is a 46 year old man, presenting to the
emergency room, unconscious. Paramedics tell the admitting nurse that they
found him unresponsive, on the floor, with an abnormal heart rhythm. His heart stopped beating in the ambulance. You see, VP was a construction worker. When he was younger, there were some recreational
things he liked to put in to his veins with a needle. This habit was a major part of his early adult
life. Years ago, VP went in for a check up. He had been clean for a while, but a routine
test found he had hepatitis C, a viral infection that progressively damages the liver and is
transmitted by shared needles. VP vaguely remembered a time when he used
a needle that he thought was suspect, but he was still young enough at that time, that
the virus hadn’t permanently damaged his liver, yet. VP kicked his habits later in life, and most
of his life was going ok. He didn’t really have a healthy balanced
diet, though, and he did really like his candy. 3 weeks ago, VP switched from eating fruit-flavored
gummies to licorice. He was already eating several bags a day of
candy in general, and so he did the same with the licorice. A few days ago, VP had noticed some muscle
soreness in his right calf. He told his family about it, but no one really
thought anything of it. Must be from all that hard construction labor,
he thought. One day, during lunch, VP didn’t feel right. As he tries to eat his food, he gasps. Immediately his body starts shaking uncontrollably,
as he collapses to the floor. On the ground now, he's no longer shaking,
and hes not moving anymore, either. Someone close by realizes that something terrible
has happened because he’s blue in the face, as they call for 911, and VP’s brought to
the emergency room, where we are now. Doctors realize it’s been at least half
an hour since VP collapsed. Paramedics had to resuscitate him multiple
times, because his heart kept stopping. Those 30 minutes when his heart wasn’t beating,
were minutes where his brain wasn’t getting enough blood. Wasn’t getting enough oxygen— meaning,
parts of it, meaning parts of it could be permanently damaged. Neurology consult finds that VP’s pupils
were different sizes. When light is shined into someone’s eyes,
their pupils constrict. This is a reflex to adapt to the amount of
light going in to the eyes. When someone’s pupils are sluggishly reactive
to light, it could mean that something is wrong in the brain. And in VP, something was wrong in his brain. Doctors put a little pressure above his eyes
to see if he would react to the pain. They push against pain points on his fingernails. But there was no response. All of these together, after cardiac arrest,
suggest permanent brain damage, as he’s transferred in to the intensive care unit. A blood test reveals that VP has hypokalemia. Hypo meaning low. Kale referring to potassium, or more formally
kalium as shown by its symbol on the periodic table of elements And emia meaning presence in blood. Low potassium presence in blood. This was paired with a large number of white
blood cells that doubled in count, 4 hours after presenting to the emergency room. Both of these gives doctors some clues as
to what could be happening. VP ate 2 pounds of licorice everyday in the
weeks leading up to his hospitalization. But doctors didn’t know that, and even if
they did, it’s just candy, right? Further exam of the blood test reveals that
parts of VP’s liver have started shutting down. Liver cells are wasting away now, and they’re
leaking enzymes in to his blood. At 4 hours after presenting to the emergency
room, a second blood test shows that his liver shutdown was only getting worse. Is this hepatitis C, actually doing liver
damage now? Muscle proteins, are also found floating around
in his blood, because his muscles are melting away. This could affect the heart, but that wouldn’t
cause cardiac arrest because there’s no way for those proteins to collect in the heart. It wouldn’t be the reason why his liver’s
shutting down, because the liver processes proteins. But how about the kidneys? The kidneys act like a net to filter the blood. If muscle proteins are collecting and gunking
up the tubules, then they’ll start tearing apart the kidneys. Iron and oxygen from those muscle proteins
rip apart the kidneys as they do permanent damage. VP’s heart stopped beating while he was
eating lunch. It stopped oxygen from going in to his brain,
and his liver, shutting them down, causing permanent damage. So it doesn’t look like hepatitis C is making
the problems here. And then his muscles started melting away
in his body. Those proteins are now ripping apart and shutting
down his kidneys. All of this bringing us back to hypokalemia. Low potassium presence in blood. Potassium, like Sodium above it on the periodic
table, is important in telling tissues and organs to do things. When the muscles contract, they need a signal. Sodium is mostly outside cells. Potassium is mostly inside cells. When sodium rushes in, it signals to the muscle
cells to initiate a contraction. On the other hand, potassium promotes muscle
relaxation. A lot of potassium present means your muscles
relax for a long time. Too little potassium means your muscles won’t
stop contracting. The heart is a muscle. If it won’t stop contracting because there
isn’t enough potassium to give a relax signal, then it starts to shake in place, not actually
pumping blood, anymore. VP felt a cramp in his calf. Potassium wasn’t there to signal muscle
relaxation. But this also affected the blood vessels,
preventing them from dilating and relaxing because they’re muscles too. So parts of the muscle, starve of oxygen and
start to melt away in his body. If potassium is low in VP, then it means that
it must have been eliminated from his body. But where from? You could lose potassium from a stomach movement,
from either end. But VP didn’t have any movements up recently,
and if potassium concentrated in the stool that could mean laxative use, but it didn’t
look like VP had taken any. You couldn’t cry out potassium in large
amounts, and you don’t breathe it out either, meaning it must have been removed by his kidneys
in the urine over days before he presented to the emergency room. But how does this relate to the high white
blood cell count in his body? Just above the kidneys are the adrenal glands. Ad from Latin meaning towards or nearby, and
renal referring to the kidneys. Gland being an organ that releases hormones,
which are chemical messengers sent throughout the body. Adrenal glands produce adrenal-ine, adrenaline,
which is a fight or flight hormone in response to a stress stimulus. But in the setting of stress, those adrenal
glands, release other things too, one of which is cortisol. The interesting thing about cortisol, is that
it looks like another hormone, named aldosterone, also made in the adrenal glands. They’re actually all made from cholesterol,
just like testosterone and estrogen. Aldosterone helps regulate blood pressure
by binding in to the kidneys. Because it’s shaped so similarly, they both
interact with the same structure in the kidney. Actually, cortisol is 100 times more attracted
to those structures than aldosterone. Meaning when someone is stressed and cortisol
levels increase, then that cortisol is doing something to the kidneys. But what, exactly? Well, aldosterone increases blood pressure
by forcing you to hold on to water. When you are dehydrated, aldosterone binds
in to the structure, to tell the kidneys to take back sodium from the urine. The interesting thing about sodium is that
wherever it is, water will flow towards it. In this small science experiment, I take salty
water and place it into a semi-permeable tube, meaning only water can flow in and out of
it. I submerge the tube in a pool of distilled
water that has no salt in it. And you’ll see that water flows in to the
tube. That water follows sodium. So by telling the kidneys to take back sodium,
aldosterone actually causes water to follow back into the body too. But sodium has a plus one charge. If it’s pulled it out, then the remaining
urine becomes negatively charged. Urine can’t be electrically charged, so
something has to compensate for that. But what could that be? Well, potassium has a plus one charge. And so aldosterone forces a take back of sodium,
and a potassium is pushed in to the urine to balance everything out. But if cortisol has 100 times more affinity
for that kidney structure, and cortisol levels are high in VP’s body, then it means he's
pushing a lot of potassium in to his urine. And this isn’t cortisol’s only function. It also limits inflammation so that the immune
system isn’t overactive. This means it tells white blood cells to not
stick to lining of the blood vessels, causing them to float around in the blood, increasing
the white blood cell count. Both of these explaining all of VP’s problems,
but something’s wrong. Cortisol comes out in physiologic stress. And VP isn’t stressed. Hes eating several pounds of candy everyday. Meaning, there’s something in that candy,
that’s disrupting this balance in his body. As the hours pass in the hospital, doctors
confirm: whatever is left of VP’s urine has large amounts of potassium in it. But at 12 hours after presenting to the emergency
room, his kidneys no longer make any more urine, because they’ve completely shut down. If he has low potassium presence in blood,
then the first thing would be to replace potassium, intravenously. But that won’t reverse his brain damage. It won’t restart his liver and his kidneys. And it might not be enough to bring him back. How much potassium did VP lose, exactly? Well, to bring his levels back up to normal,
420 milliequivalents were needed. That is 10 and a half of these ultra-concentrated
vials worth of potassium. And these vials need to be diluted. Remember that potassium signals muscle relaxation. So if there’s too much of it, your muscles
like your heart, will relax, forever. If 1 milliequivalent of potassium chloride
is 75 milligrams, then VP needed 31 and a half grams of this potassium chloride to get
back to normal. Bananas and oranges are made of potassium
citrate and potassium phosphate, of which humans can only absorb 40% of the potassium
in those salts. If 1 banana has 420 milligrams of potassium
and only 40% of it can be absorbed, then VP needed to eat at least 100 bananas worth of
potassium in the first 12 hours. And that doesn’t count the fact that bananas
are sugary so they spike insulin levels, which shifts potassium in to cells and out of the
blood, so he probably would have needed much more than that. But he’s unconscious, and you don’t give
unconscious people things to eat by mouth, because they couldn’t chew on it, and they
cant swallow because they’re unconscious, so they would choke if it happened. In the licorice plant where VP’s candy was
from, the root has glycyrrhizic acid, which is 2 sugars chained to a larger ring. Doesn’t this look familiar? In humans, those 2 sugars are cleaved off,
and it leaves the body with glycyrrhetinic acid. The body doesn’t want cortisol hanging around
for too long, so it uses an enzyme to break it down to cortisone, which doesn’t bind
to any kidney structure. Cortisone doesn’t force sodium back in,
and potassium out. But because glycyrrhetinic acid is so similar
in shape, it binds in to that same enzyme, and blocks cortisol from getting broken down. And when it isn’t broken down, it hangs
around, it accumulates, and it causes all of these problems. If someone eats a little licorice candy, or
drinks 1 cup of licorice tea, they’re generally gonna be ok. But over several days, eating more and more
bags of candy, or drinking more and more of the tea, will confuse the kidneys, because
a signal 100 times stronger than normal, is telling it to reabsorb sodium in, in exchange
for potassium out. It’s not just a little potassium. It’s hundreds of bananas worth of potassium. The resulting hypokalemia is enough to prevent
muscle relaxation. Muscle starts to necrose, and proteins spill
into the blood. The heart can’t relax and it starts beating
in a way, that it just shakes in place, and doesn’t pump blood anymore. No more blood gets to the brain, causing VP
to lose consciousness. Causing him to collapse suddenly. And as the minutes pass without blood circulation,
his organs all start to shut down, and even if he’s resuscitated and his heart is back
up and beating again, the organ shut down is worsened still by his kidneys getting ripped
apart, by those floating muscle proteins. Actual licorice candy, is kind of hard to
get here in the United States. Most of what you can buy at the grocery is
licorice flavored, so you dont have glycyhhrizic acid in it, because they’re flavored and
not the actual thing. So it does make me wonder where exactly did
this patient get his candy from? The problem with licorice, is that the glycyrrhetinic
acid hangs around the body for weeks. It’s lipophilic. Lipo meaning fat and philic meaning affinity
for. So it hangs around fat tissue, distributing
widely in the body. Its half life in humans, that is the time
it takes for half of it to be eliminated from the body, is up to 30 hours. But it also recirculates in bile from the
liver, back into the small intestines. Then it traverses the intestines, only to
be reabsorbed up to the liver again, creeping around in the body, as it wrecks this havoc. VP’s potassium level was brought back up
with IV potassium chloride after 12 hours in the hospital. His blood pressure started to normalize after
more medicines were given. But the uneven pupils. The sluggish reactivity to light. The absent reflexes. VP didn’t have a good prognosis, as doctors
discussed goals of care with his family. Comfort measures were placed, and at 32 hours
after presenting to the emergency room, VP passed with family at his side. If you are eating actual licorice candy and
you know it, or are drinking licorice tea, be very careful with it. Licorice is still an herbal medicine and it’s
used as an anti inflammatory, because it increases cortisol, an anti-inflammatory hormone, in
your body. With any medicine, don’t treat it like it’s
candy. You wouldn’t eat gummy vitamins like gummy
candy so you shouldn’t eat licorice herbal medicine like regular candy either. It can all take a very terrible turn very
quickly, just like it did, for VP. Thanks for watching. Take care of yourself. And Be well.
I think the news flash here is don't eat two pounds of candy in a sitting.
Previous reddit thread on the actual news event 11 days ago here, and the NE Journal of Medicine article here.
When this news first came out, I knew this youtuber, chubbyemu, would see it and possibly make a video about it. Really like the youtuber, unfortunate that tragedy happened to the patient.
What construction worker has that glass lunch table at work? And all that fine art on the wall?