Introduction: Kratom (Mitragyna speciosa) is an herb with opiate and stimulant like properties. It is marketed as an herbal supplement. It can be exploited as a recreational drug and is popular for self-treatment of opiate withdrawal and pain. It was previously unknown what pathological changes could occur with chronic Kratom use. New evidence suggests that Kratom can cause a drug induced liver injury (DILI). There is little published evidence of the toxic effects of Kratom, yet there is increasing self-treatment of opioid withdrawal and reports of adverse events and lethal overdoses. We describe a case where chronic use of Kratom caused severe DILI.
Case Description/Methods: A 39-year-old male with no significant medical history presented to the emergency department with sharp abdominal pain and diarrhea. Physical exam revealed jaundice, scleral icterus, and left lower quadrant tenderness. Initial labs were AST 791 units/L ALT 1841 units/L, total bilirubin 7.4 mg/dL, alkaline phosphatase 449 units/L and INR of 1.2. A CT demonstrated scattered porta hepatis lymph nodes. The patient reported no medication or recreational drug use. He underwent extensive testing including viral hepatitis panel, stool studies, toxicity screen, anti-smooth and anti-mitochondrial antibodies which all produced negative results. Magnetic resonance cholangiopancreatography and right upper quadrant ultrasound were unremarkable. A liver biopsy revealed grade-III inflammatory activity with significant eosinophilia, highly suspicious for drug interaction. On hospital day 5, the patient admitted to several months of kratom consumption. His AST level peaked at 1190 units/L, ALT peaked at 2261 units/L, total bilirubin peaked at 20.2 mg/dL and alkaline phosphatase continually declined. Given the strong correlation with his biopsy results, the likely etiology of this liver injury was determined to be hepatocellular toxicity due to chronic Kratom use. The patient symptomatically improved and in outpatient follow-up there was normalization of liver function after discontinuation of Kratom.
Discussion: Kratom’s mechanism and scope of toxicity is not well understood. It remains legal in our state, Georgia, but is banned in some other states and countries around the world. As it remains commercially available, policy regarding this substance should be reviewed closely and studies should be conducted to evaluate its toxicity. Fortunately, this case demonstrates reversible toxic effects to the liver.
