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Hypertensive Crisis with Neurological Impairment Mimicking a Guillain–Barrè Syndrome: Searching for a Link

  • Alberto Mazza
  • Marta Lucchetta
  • Gioia Torin
  • Laura Schiavon
  • Antonella Paola Sacco
  • Giorgio Villi
  • Michela Armigliato
  • Edoardo Casiglia
Case Report

Abstract

Guillain–Barré syndrome (GBS) may be complicated by severe hypertension (HT) and in turns severe HT can occur with neurological damage mimicking a GBS, so that underlying causes should be investigated. We describe a case of a 62-year-old woman presented to the emergency department for hypertensive crisis with symmetric flaccid paralysis, hypotonia and hyporeflexia of both upper and lower limbs. Brain computed tomography, magnetic resonance imaging and lumbar puncture were normal. Laboratory investigations revealed severe hypokalemia, renal failure, liver impairment, rabdomyolysis, metabolic alkalosis, and low plasma renin and aldosterone levels. Continuous potassium replacement led to complete clinical resolution. A detailed history revealed chronic intake of 250 g/day black liquorice. Hypokalaemic muscle weakness may simulate a GBS. When serum potassium level falls below 2.5 mmol/l, rhabdomyolysis may occur. In this clinical case, an apparent mineralocorticoid excess syndrome was induced by chronic ingestion of liquorice. This latter contains the glycyrrhetic acid that inhibits the enzyme 11-β-hydroxysteroid dehydrogenase enzyme type-2 leading an aldosterone-like effect and causing hypertension, hypokalemia, metabolic alkalosis and low renin values. The clinical presentation is similar to that observed in the primary aldosteronism, but in this syndrome plasma aldosterone levels are low rather than elevated as in primary aldosteronism. Liquorice-induced hypertension with severe hypokalemia and rhabdomyolysis is a rare condition and the initial presentation with acute muscle paralysis is still more unusual. Before performing instrumental examinations in middle-aged peoples with hypertension crisis and neurological impairment, a detailed clinical history is mandatory.

Keywords

Glycyrrhetic acid Guillain–Barrè syndrome Hypokalemia Rhabdomyolysis Secondary hypertension 

Notes

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Compliance with Ethical Standards

Conflict of interest

The authors report no conflict of interest.

Human rights statement

The research involved human participant.

Informed consent

The subject included in the reasearch provided her informed consent and is anonymized.

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Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Department of Internal Medicine, ESH Excellence Hypertension CenterSanta Maria della Misericordia General HospitalRovigoItaly
  2. 2.Unit of NeurologySanta Maria della Misericordia General HospitalRovigoItaly
  3. 3.Unit of Internal Medicine C, Department of MedicineUniversity of VeronaVeronaItaly
  4. 4.Department of Internal Medicine, Santa Maria della Misericordia General HospitalRovigoItaly
  5. 5.Unit of UrologySanta Maria della Misericordia General HospitalRovigoItaly
  6. 6.Unit of InternalGeneral Hospital Mater SalutisLegnagoItaly
  7. 7.Studium Patavium (Formerly Department of Medicine)University of PadovaPaduaItaly
  8. 8.Department of Internal Medicine‘Santa Maria della Misericordia’ HospitalRovigoItaly

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