An Unusual Etiology Of Hypokalemic Paralysis Secondary To Mineralocorticoid Excess In A Patient With Addison Disease

Objective: To describe the effects of licorice consumption via smokeless tobacco products in combination with mineralocorticoids in a patient with Addison disease (AD) and increase awareness of this deadly combination. Methods: We present a case of hypokalemic paralysis caused by smokeless tobacco use in a patient with AD on replacement therapy and the literature describing this association. Results: A 43-year-old Caucasian male with known history of AD on replacement therapy, who presented to the emergency department with 5 days of progressive weakness and inability to ambulate. On examination he was hemodynamically stable. He had profound generalized weakness, most pronounced in lower extremities. Laboratory evaluation was notable for severe hypokalemia of 1.5 mEq/L. On further questioning, he disclosed use of daily smokeless tobacco, which ingredients included licorice. Once he discontinued chewing snuff in the hospital, potassium levels normalized and his symptoms resolved with potassium replacement. He was discharged on home dose of hydrocortisone, and fludrocortisone was discontinued given his potential use of snuff despite counseling. Licorice consumption via smokeless tobacco products is a rare cause of apparent mineralocorticoid excess in healthy subjects. To the best of our knowledge, this has not been reported in patients with AD on replacement therapy. Conclusion: Our case highlights possible life-threating complications of licorice use in combination with replacement therapy in patients with AD. An excessive licorice consumption can present clinically as primary hyperaldosteronism, which can cause confusion in patients with AD, therefore delaying both the diagnosis and treatment.