The Body After Eating Several Pounds Licorice Candy

a construction worker was eating lunch when suddenly his whole body started to shake he collapsed he lost consciousness a bystander thought something was wrong when they found the man unresponsive and blue in the face as they called for 9-1-1 paramedics arrived four minutes after the man collapsed and found he was still unresponsive he was in ventricular fibrillation they administered naloxone in the case of opioids they gave amiodarone bolus epinephrine followed by continuous infusion and observed a wide complex heart rhythm with a rate of 40 beats per minute and a regain of consciousness and then the man's heart stopped beating again as he was brought into the emergency room 30 minutes after the initial arrest ecg after spontaneous circulation returns showed very wide qrs complex with multifocal premature ventricular contractions blood pressure was 139 over 92 and heart rate was 108 beats per minute while receiving iv epinephrine and norepinephrine there were possible st segment elevations in avr avl and v1 with presence of u waves head ct without contrast was normal so no infarct intracranial hemorrhage or mass lesions bedside cardiac ultrasound showed left ventricular dysfunction neurology consult finds an isochoria so his pupils were different sizes and those pupils were sluggishly reactive to light corneal reflexes and response to noxious stimuli were absent all of this could mean poor prognosis as therapeutic hypothermia was not started typically after cardiac arrest the medical team could submerge the patient in ice bags this is called therapeutic hypothermia by cooling down the body data shows that neurologic outcomes can improve versus patients who don't get the cooling this could be because it lowers inflammation in the body to protect the brain but doing this depends on if the patient was resuscitated in time and in this patient he may not have been resuscitated in time a blood test finds hypokalemia lactatemia and acidemia creatine kinase was 2500 and became 9 500 4 hours after admission into the cardiac icu meaning rhabdomyolysis alt and ast elevation so liver failure all of this together is profound metabolic derangements with multi-organ failure that can all be linked together but where do we start the lactate and acid could come from tissue hypoperfusion following cardiac arrest so we could say that they're not the cause of a rest but a result of it the liver failure could be a result of some kind of substance ingestion but the patient does have a past medical history of untreated hepatitis c as he was documented to have been an intravenous substance user in the past although he was noted to have been clean for some time this could be from the arrest or not and we're going to have to put it on the side the blood test showed elevation in hematopoietic cell lines that increased four hours after presenting to the emergency room but alone this wouldn't cause left ventricular dysfunction but what could cause left ventricular dysfunction is hypokalemia the muscular dysfunction found in the heart muscle could be similar to the response in skeletal muscle 2 potentially explaining rhabdomyolysis where muscles break down and send proteins floating all throughout the body causing renal failure that resulting kidney damage could be the cause of liver failure and upstream the chain the hypokalemia could have caused cardiac arrest meaning the low potassium presence in blood is the starting point in understanding this patient's diagnosis potassium regulation in the body is a result of multiple factors potassium is the predominant intracellular cation so most of it's inside cells compared to sodium which is the predominant extracellular cation potassium can be ingested normally through diet famously known to the public is bananas and oranges but those are citrate and phosphate salts of potassium and only 40 percent of potassium is absorbed from them compared to potassium chloride so eating a banana isn't going to save someone from clinically relevant hypokalemia and if someone's knocked out cold on the ground good luck feeding them a banana by mouth but generally even if you somehow don't eat potassium from one day to another your body will compensate for it but in this case the doctors didn't know exactly what the patient had been eating in the days and the weeks leading up to this hospitalization so if someone is malnourished they could have hypokalemia because they wouldn't be eating it but people can also lose potassium from the gut these gastrointestinal losses come from movements out of either end it could come from taking too many laxatives but this patient didn't have those movements and gi losses are ruled out too potassium is recirculated throughout the body hormones like insulin can shift potassium intracellularly and many cell signals rely on a sodium potassium pump to exchange cations problems like acidosis can shift potassium one way or another due to its positive charge and in the context of acid-base balance the kidneys are a powerful regulator of potassium which is where this patient's problems begin the kidneys are very responsible for regulating blood pressure in fact most of the first line blood pressure medicines are diuretics that act directly on the kidneys flushing out water lowers blood pressure lowering the pressure in turn prevents long-term heart problems for example if the heart is beating really hard all the time the left ventricle which drives blood through the rest of the body can hypertrophy on a time scale of years and decades it's a muscle so increased workload causes it to adapt and become more muscular but the problem is if the muscle becomes too thick then that left ventricle doesn't eject out a lot of the blood that's in it you can't just cut out heart muscle there is an inefficient way to make it atrophy and if there's a lot of muscle there's a lot of oxygen demand doesn't matter if it's actually pumping out blood or not the muscle's there and it needs that oxygen and so this is why you want to prevent heart problems early in life because your heart's not going to stop beating you'll die if that happens there aren't quick and easy answers to problems that took 50 or 60 years to develop so we can conclude here that it's very possible that this patient's kidneys are removing potassium but how is that happening is it just doing it on its own or is there something telling it to remove potassium the latter could come from a tumor with a defect where it secretes a constant hormone signal telling the kidneys to get rid of potassium but that doesn't seem to be the case in this patient but if we look at the elevated hematopoietic stem cell count that increased while he was in the emergency room then it's very likely that this is hormone related centered on the kidneys just above the kidneys are the adrenal glands from them and in the context of potassium is the steroid hormone named aldosterone decreased renal perfusion leads to the kidneys releasing renin which converts angiotensinogen from the liver to angiotensin 1. angiotensin 1 gets broken down by angiotensin converting enzyme ace to angiotensin 2. ace being the drug target of blood pressure medicines ending in prill captopril lysinopril enalapril the former being derived from snake venom that was intended to incapacitate its victims by lowering blood pressure angiotensin ii is a stimulator of sympathetic activity arteriolar vasoconstriction and antidiuretic hormone secretion a diuretic is something that causes you to urinate so an antidiuretic is something that prevents you from urinating angiotensin ii also causes tubular reabsorption of sodium and we know that wherever sodium is water will flow towards it so if sodium is getting re-absorbed that is getting absorbed back into the body then water comes along with it and angiotensin ii stimulates the release of aldosterone from the adrenal glands in the kidneys are the mineralocorticoid receptors corticoid referring to corticosteroids and steroid referring to a hormone with the cholesterol backbone lots of times i'll see people on the internet comment about the word steroids thinking that it's referring to an athlete or a bodybuilder but in medicine steroids overwhelmingly refers to corticosteroids not anabolics aldosterone is the primary mineralocorticoid when it's secreted its action on the kidney is to reabsorb sodium when this happens water follows so sodium and water come back from what would have been the urine but some urine is still made and whatever's left is missing a positive charge now that sodium has been pumped back in to the body urine is not supposed to have any electrical charge at all and if the body can substitute another cation then it'll pump that in so what cat ion would that be well it could be a hydrogen an acid which is h plus but if you calculate the ph of the blood you'll find that there's 10 to the negative 7 molar of hydrogen so really not a whole lot floating around calcium is floating around in the blood too and it has a positive 2 charge so you'd only need half of it to replace that sodium but that wouldn't work because there really isn't too much calcium in the blood either and so that leaves us with potassium which by standard has a sodium potassium pump in the tubules meaning that presence of aldosterone means that potassium will get put into the urine and excreted from the body interestingly enough this process is exploited by bodybuilders right before their show they call this drying out which gives them that ultra defined look but it can only really happen if they're lean enough usually defined by them as less than two percent body fat what they do is they'll drink several gallons of water and make sure not to ingest any sodium they'll go so far as to boil raw chicken breast and eat that without seasoning to ensure that no sodium is consumed they do this for a couple days while drinking many gallons of water every day to the point where they're urinating every five to ten minutes and that evening about a day or two before their show they stop eating and drinking altogether but they keep urinating to the point where they drive themselves into a water deficit thus becoming dry by doing this they suppress any aldosterone that would be secreted normally that would be used to reabsorb water and sodium because the body knows that there's too much water and it wants to get rid of it and by pushing down those hormone levels they eventually run themselves into a sodium and water deficit and then they run their bodybuilding show as lean and as dry as possible before the body rebounds the hormones to hold on to as much water and sodium again so that would be aldosterone and antidiuretic hormone levels shooting up i can't imagine anyone feeling good while doing this or at any time immediately after but back to the average person think about those diuretic medicines for blood pressure there's spironolactone which sometimes gets called a potassium sparing diuretic but that's only describing one part of the result of what it does what's better is to say that spironolactone is an aldosterone antagonist therefore blocking aldosterone from reabsorbing water by exchanging sodium for a potassium this makes the body push water and sodium out while keeping potassium it has a similar shape to aldosterone but if we go further down the chain it could look similar to testosterone but we know that testosterone in large amounts gets broken down to estrogen and so one side effect of spironolactone in men is gynecomastia bringing us back to corticosteroids upstream the process aldosterone shares a biosynthetic precursor with cortisol in progesterone 17 alpha hydroxylase converts progesterone to it's in the name 17 alpha hydroxy progesterone that's the only differing step between aldosterone and cortisol in biosynthesis understanding these pathways and how they derive from cholesterol is pivotal in understanding these hormone pathways in the body that's why a nobel prize was one for discovering how cholesterol is biosynthesized if aldosterone and cortisol are so similar and have a shared precursor would they have cross reactivity i mean the medicine to block aldosterone has androgenic effects crossing into an entirely different class of hormones linked together by a shared precursor cortisol is a glucocorticoid meaning that its target should be to the glucocorticoid receptor this should be for things like anti-inflammatory and metabolic activities but glucocorticoids also increase white blood cell counts in people because it stops them from adhering to the endothelial surface mobilizing them into the blood and cortisol has a hundred times more affinity for the mineralocorticoid receptor than aldosterone and it has the same effect meaning if cortisol levels are high then it's a much stronger version of aldosterone binding into the kidneys and forcing sodium and water reabsorption at the expense of potassium secretion but also high cortisol levels would mean a high white blood cell count both of these put together explains this patient's hypokalemia so now we know that cortisol is high in this patient what's stimulating this excess there doesn't appear to be a disturbance in the hypothalamic pituitary adrenal access so this could be a case of acquired apparent mineralocorticoid excess meaning this stimulation could be a result of ingesting an exogenous compound the patient's family tells doctors in the cardiac icu that he had been eating bags of licorice candy over the past few weeks and he had changed candy brands from a fruit flavor to an actual licorice candy could this have been the reason for everything that's happened to this patient maybe but there's a few other factors to keep in mind licorice is an old herbal remedy chinese pharmacopia going back at least 2 000 years has documented its use in ailments like stomach ulcers assyrian clay tablets going back to even 2500 bc and egyptian papyrus have documented its medical use too it was known back then to be a remedy for things that we know today are caused by inflammation and how would it do that well licorice comes from the root of the glyceriza glabra plant in it is a compound named glycerizic acid which is sweeter than sucrose if you look at the compound do you notice something maybe a cholesterol ring on there these two glucoses are cleaved off in humans and were left with glycorytenic acid earlier in the 20th century cases were documented highlighting problems of sodium and water metabolism in patients who consumed licorice and because glycorytenic acid has that cholesterol backbone they thought that maybe it binds to the mineralocorticoid receptor just like aldosterone but the problem is glyceritinic acid only has 0.01 percent affinity to that receptor so if it doesn't directly stimulate the same action that aldosterone would why would licorice cause sodium reabsorption and hypokalemia several decades later scientists found that glycorytenic acid binds to 11 beta hydroxy steroid dehydrogenase type 2 that's the enzyme that's employed by the human body to break down cortisol to cortisone has no mineralocorticoid activity but if cortisol's never broken down to cortisone the body has trouble eliminating or inactivating it cortisol starts floating around in large amounts and because it has a hundred times the affinity for the same receptor as aldosterone then it'll force sodium reabsorption and potassium secretion both in large quantities all of this was happening with low plasma renin and low serum aldosterone consistent with a mineralocorticoid disorder involving something other than aldosterone and the 11 beta hydroxy steroid dehydrogenase inhibition from excessive licorice consumption is in line with this so how did hypokalemia cause rhabdomyolysis what does it have to do with cardiac arrest skeletal muscle is a very metabolically demanding tissue in order to meet this demand it needs to have appropriate perfusion when muscles contract they may need a signal that's initiated by sodium which shifts intracellularly as it reaches a threshold calcium enters to commit to a contraction and potassium is shifted out the local elevation in potassium usually causes vasodilation which enhances regional blood flow that's in normal function but if potassium is low in the blood then the muscle cells don't release so much potassium meaning that there isn't that vasodilation there isn't enough perfusion to meet the metabolic demands of the muscle tissue this causes ischemia as the muscle tissue starts to necros resulting in rhabdomyolysis cramps in the calf muscles commonly happen as an indicator of rhabdomyolysis just like in this patient and so with this aberrant signal conduction in muscle tissue the final part of it goes to the heart as potassium is supposed to signal relaxation hypokalemia means no relaxed signal is sent to the muscle and the longer the patient is pulseless without cpr the worse the outcome as was shown in the case of this patient because goals of care were discussed with his family they decided upon comfort measures given the poor prognosis and at 32 hours after presenting to the emergency room the patient passed with family present the final thing i want to bring up is that actual licorice candy containing glycorizin is kind of rare to find in the united states you typically won't find it at chain grocery stores so any big brand name candy in the united states isn't going to do this for you this is why i would like to know where this patient got his candy because it is really kind of rare here but you may be able to find real licorice in ethnic grocers if you have a chinatown in your city there's probably going to be a traditional chinese medicine doctor who may have some root extract because glycerizin does in fact elevate cortisol by inhibiting 11 beta hsd2 it is an anti-inflammatory herbal medicine that really only should be used sparingly corticosteroids as well as any steroid should never be messed with because they disturb equilibriums in the body for a very very long time and the changes that they make in the body could be permanent fun fact the video about a grandpa who set his clock forward one hour for daylight savings time published on chubby emu was originally shot as a grandpa who drank several liters of licorice tea someone who i had a personal connection with but i ended up changing it last minute i probably shouldn't have thanks so much for watching take care of yourself and be well

Channel: Heme Review

Views: 269,536

Keywords: candy, licorice

Id: 8lGmvFkAMOU

Length: 18min 36sec (1116 seconds)

Published: Mon Oct 05 2020