A 20 year old patient with no significant family history presents with hypertension. The last health care visit was two years ago and findings were all within normal limits. You're worried that this isn't essential hypertension (after all, how could that be a case of the day?). You draw some labs and find that the patient has hypokalemia and metabolic alkalosis. Both renin and aldosterone are low. Urinary free cortisone is modestly decreased and the ratio of cortisol to cortisone is only modestly elevated. Well, that's odd.
The only other remarkable finding on history and physical is that the patient is chewing tobacco. You counsel the patient on related health consequences and the patient replies, "Yeah, I know, I started chewing this stuff a year ago and I've been going through a ton of it. I only like this brand too."
Challenge: What's the cause of the hypertension?
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1 comment:
Secondary to What?
This is an apparent mineralcorticoid excess syndrome due to chronic licorice ingestion. Licorice contains a steroid glycyrrhetinic acid that inhibits 11-beta-hydroxysteroid dehydrogenase. Normal levels of cortisol can markedly increase net mineralcorticoid activity in patients chronically ingesting licorice. Ingested licorice can sometimes be found in chewing gum and tobacco.
Source: UpToDate.
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