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.