Kratom-induced cholestatic liver injury: A pandemic within a pandemic?

ABSTRACT

Objectives: Mitragyna speciosa (commonly known as kratom) has both opioid and stimulant-like effects. Recently, Thailand decriminalized the possession and sale of kratom, led to people in many areas earned income selling Kratom at a time of widespread unemployment due to COVID-19. Here, we report a patient with post-Covid syndrome who developed mixed cholestatic-hepatocellular liver injury secondary to kratom. Materials and Methods: A 23-year-old Thai man was seen for evaluation of fatigue and nausea, followed soon after with pruritus, dark urine and jaundice. The patient had no known underlying disease but had been treated with mild COVID-19 pneumonia in the past 2 months. He reported taking kratom recreationally for 2 weeks as a treatment for his post-COVID insomnia. Kratom was bought from his friend and used as a homemade iced cocktail called ''4 9 100'' that consists of Coca-Cola, tea made from boiled kratom leaves, and diphenhydramine-containing cough syrup which has been popular in Southernmost provinces of Thailand. On workup, his total bilirubin was noted to be 10.6 mg/dL, aspartate aminotransferase was 642 U/L, alanine aminotransferase 1,635 U/L. Extensive workups including viral etiologies was negative. Abdominal ultrasound revealed only fatty liver without cirrhosis. Results: The patient had been managed conservatively for 5 days in the hospital. Urine toxicology screening confirmed the presence of only mitragynine. At two weeks later, serum total bilirubin was decreased to 1.5 mg/dL, aspartate aminotransferase was 112 U/L, alanine aminotransferase 404 U/L. He was in a stable condition and normalized liver function tests at 3 months after discharge. Conclusion: There is growing evidence that kratom is safe if used as pure kratom products or brewed herbal decoction in small doses and for a limited period of time. However, the polydrug patterns of kratom use could lead to severe liver injury.