The Harm in Kratom.

We noted the most interesting blog by Don Dizon [1] regarding the potential pulmonary toxicity induced by one (or a combination of several) of the fifteen herbal supplements taken by his patient. To illustrate the real and serious toxicity of such supplements, which are commonly available and unregulated by federal agencies, we present a case of severe hepatic toxicity associated with kratom, a plant derivative of increasing use as an alternative psychostimulant. A 23‐year‐old male presented to the emergency department with 4 days of painless jaundice, light stools, and dark urine, 1 week after last consuming kratom, a legally available psychoactive extract from the Mitragyna speciosa plant. He began ingesting a powdered form of kratom 6 weeks prior, consuming an estimated 85 grams in total. He denied exposure to toxins or medications, other than moderate alcohol and marijuana consumption. Total bilirubin was 7.4 mg/dL, direct bilirubin 5.8 mg/dL, ALKP 225 U/L, ALT 210 U/L, and AST 129 U/L. His INR was 0.9 and albumin 4.6 g/dL. White blood cell count was 5.6 K/uL, with 8% eosinophils. Serologies and viral molecular tests for infectious and autoimmune hepatitis were negative. Liver biopsy was entirely consistent with cholestatic liver injury. His recovery over a 2‐week period was uneventful, with a return to normal liver function.

Mitragyna speciosa is a tree indigenous to Southeast Asia. Traditionally, its leaves have been chewed, smoked, or strained into tea for increased energy or medicinal purposes. Kratom contains the alkaloids mitragynine and 7‐hydroxymitragynine, which, in addition to having broad neurochemical activity, are known opioid agonists, perhaps explaining why kratom has been used in the community to mitigate symptoms of opioid withdrawal. Effects are dose‐dependent: small doses produce stimulatory effects, and larger doses produce sedation [2].

Reports of kratom's adverse effects in Asia focus on dependence and withdrawal. More alarming toxicities have been revealed in the Western literature, perhaps as the result of product adulteration or under‐reporting of side effects in Asia. These toxicities include hypertension, nephrotoxicity, seizures, and death from presumed overdose [2]. There have been two prior reports of cholestatic jaundice, in cases occuring within 2 and 8 weeks of onset of drug ingestion [3], [4].

In Thailand, a 2007 survey reported lifetime use prevalence of 2.32%, but similar data are not available from other countries [5]. In the U.S., kratom may be purchased on the Internet, in “head shops,” or in convenience stores. Federal data suggest rising use in the U.S., with increasing numbers of reports (one report in 2010, 81 reports in the first 6 months of 2012) from forensic laboratories involving kratom detection in human subjects [6].

A better understanding of the potential toxicities of kratom will enable physicians to identify this entity as a causative agent of unusual side effects and to warn patients of risks associated with its ingestion.