When Licorice Attacks

And from foods you least expect.

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By Marven Ewen, MD, ABFM
Medical Director


As an ER doctor, I often saw many patients that were inmates of the criminal justice system. One of the emergency departments I worked at was in the same town as the county jail. In some cases, those in custody were looking for a way to avoid incarceration. One of the methods was to find a way to be sent to the ER or be admitted to the hospital.

If the inmate was charged with a fairly low-level offense, the county might drop the charges rather than pay for a big ED workup. You can imagine that there were plenty of inmates presenting with fabricated or minor complaints; however, I tried to keep an open mind so as not to miss a legitimate medical problem.

With this in mind, I went into examine a young man that had reportedly collapsed when he attempted to get out of his bunk to go to the cafeteria at the correctional facility. He didn’t actually lose consciousness, he just didn’t have the strength to stand. He had been previously healthy. In fact, he had been working hard all day on a highway cleaning detail. The patient was taking no medications. He denied any pain and didn’t have any other complaints.

His vital signs were within normal limits and there was no sign of dehydration. I asked him to get off the cot and try to stand. He couldn’t stand. Odd. I gave him the benefit of doubt about the legitimacy of his complaint. He really seemed genuine. I ordered some basic lab work.

To my great surprise, his blood potassium level came back critically low for no apparent reason, a condition technically called hypokalemia. Low potassium can lead to muscle weakness and even heart arrhythmias. It can be caused by a variety of conditions, including taking certain drugs. Back to the drawing board.

“Are you sure you didn’t take anything?”

“Yes,” he replied. So I enquired about his diet. He said he ate a big bag of licorice for lunch and had some soda. Ah! I thought, licorice! He must be suffering from Licorice Toxicity. Licorice Toxicity is caused by an over-consumption of licorice, which contains a component called glycyrrhizin (GZA). This compound leads to the abundance of the hormone cortisol, which then ultimately leads to the kidneys excreting too much potassium.

Very happy with my brilliant detective skills, I wrote some orders to get him admitted and start some IV potassium. Then the patient asked if this happened because the licorice was red.

“Red!” I exclaimed, “There’s no licorice in red licorice.” There goes my eloquent theory. Now I had to consider some other possibilities in my differential diagnosis.

While I was writing admission orders, the patient’s wife showed up. She was very concerned about how much soda he had been drinking lately. She was worried about all the sugar and caffeine. I asked what kind of soda he drinks. She informed me it was root beer.

Ah-hah! Root beer is made with licorice! Since the concentration of licorice in root beer is pretty low, normally drinking root beer would not cause Licorice Toxicity. But it was hot outside, and he was drinking it in abundance, liters of the stuff everyday. He had a potentially life-threatening problem due to the over-indulgence of root beer.

He was admitted overnight for IV potassium administration and fully recovered to go back to jail the following day. He was told to stick with water to quench his thirst.