LAUSR

Abstract Introduction St. John’s Wort (Hypericum perforatum) is a commonly available herbal supplement often used for depression and other mood disorders.1 Described below is the case of a young woman who presented with Hypertensive crisis in the setting of self-treatment of depression with St. John’s wort (SJW). Case A 39-year-old female with past history of migraines presented with blurry vision and frontal headache of 1 week duration. She was noted to have significant papilledema and blood pressure of 209/115mm hg and started on nitroprusside infusion. Physical exam was significant for relative afferent pupillary defect and also a right inferior nasal visual field cut. Work up for secondary causes of hypertension showed urine metanephrine level of 194 mcg/g/cr (32-134 mcg/g cr). Renin and aldosterone levels were not consistent with hyperaldosteronism. MRI showed Flattening of the pituitary gland and the posterior sclerae along with enlargement of the subarachnoid space around the optic nerves. Findings were suggestive of Idiopathic intracranial hypertension. Lumbar puncture showed an opening pressure of 42 cm and closing pressure of 21cm CSF. After management of hypertensive emergency in ICU, she was started on acetazolamide for intracranial hypertension and labetalol for hypertension. History of use of St John’s wort was elicited on follow up with endocrinology. Also, in the last 2 months prior to admission she could not recollect a history of excessive amounts of alcohol or cheese intake. She was asked to repeat work up after stopping SJW and labetalol being switched to amlodipine. Plasma metanephrine level repeated 2 weeks later was <25 pg/ml. Blood pressure checked 2 months after stopping SJW was noted to be 126/86 mm hg on amlodipine 10mg and Lisinopril 5mg daily. Discussion The temporal relation of SJW and hypertensive emergency and the normalization of blood pressure and plasma metanephrine levels after stopping SJW in our patient is compelling. SJW is described to act as a potent monoamine oxidase inhibitor and MAO inhibitors with excessive intake of tyramine containing foods like cheese and wine can cause hypertensive crisis. 1 The potential excess tyramine containing foods in the presence of SJW may have played a role. Also use of MAO inhibitors with other SSRI can cause Serotonin syndrome2, however our patient did not have features of serotonin syndrome. Further studies are required to elucidate the side effects of SJW and to educate the general population about such potential dangerous effects of this commonly used herbal remedy. References 1 Patel S et al. Hypertensive crisis associated with St. John’s Wort. The American Journal of Medicine, Volume 112, Issue 6, 507 - 508 2 Lawvere S. St. John’s Wort. American Family Physician. 2005 Dec 1;72(11):2249-2254.