We present a case of Epilepsia Partialis Continua (EPC) due to posterior reversible encephalopathy syndrome (PRES) in the setting of pseudo-hyperaldosteronism.

Case report.

A 55-year-old man with esophageal reflux being treated with the natural supplement “Hipep”, presented with 2 days of left hemiparesis, hemianesthesia and confusion. Vitals signs were remarkable for BP of 150/100mmHg. He was noted to have repetitive focal movements of the left upper extremity, eyelid and face, followed by worsening of his hemiparesis. He was then found to have severe fluctuations in his BP. An electroencephalogram (EEG) revealed lateralized periodic discharges and multiple seizures. A levetiracetam load was given with electroencephalographic improvement. However, he persisted having focal rhythmic movements suggestive of EPC. Therefore, he was loaded with fosphenytoin with resolution of his stereotypic movements.

A brain MRI showed diffuse parieto-occipital non-enhancing hyperintensities in both DWI and FLAIR. Laboratories revealed treatment refractory severe hypokalemia. After a detailed work up and anamnesis, it was noted that Hipep contains licorice (285mg). Licorice contains glycyrrhizinic acid (GRA) which inhibits 11-beta dehydrogenase, impeding the conversion of cortisol into cortisone. The excess cortisol attaches to aldosterone receptors in the kidney causing sodium retention leading to severe hypertension and hypokalemia. Additionally, renin and aldosterone levels were found undetectable. Successful treatment consisted on supportive therapy and discontinuation of Hipep.

Given the clinical presentation, MRI findings, EEG abnormalities and history of Hipep intake, the most compatible diagnosis was PRES secondary to pseudo-hyperaldosteronism. Many over-the-counter products contains the inactive version of GRA, however some natural supplements, like Hipep, contains the active version as well as more than the recommended FDA dose (100mg/daily). Neurologists should be aware of natural supplements ingredients.