INTRODUCTION:Kratom is an unregulated herb with psychogenic properties that can be ingested as a tablet, powder, or brewed tea. Patients use it for relief against a variety of ailments such as pain, gastrointestinal discomfort, opiate withdrawal and mood disorders. It has been associated with detrimental consequences such as seizures, cardiac arrest, and coma. [1,2] We present a rare case of a young healthy male who suffered cardiac arrest likely secondary to excessive Kratom use. CASE PRESENTATION:A 32-year-old male arrived at the Emergency Department after suffering a cardiac arrest at home. The patient called EMS with complaints of abdominal pain and feeling unwell, and he went into cardiac arrest shortly after EMS arrival. Following ROSC, a bedside FAST exam was negative and an EKG revealed ST elevations in the inferior leads. Preliminary laboratory results indicated that CBC and BMP were within normal limits. Lactic acid, troponin and cortisol were elevated. Urine chemistry and toxicology was devoid of common toxins. Serum alcohol, acetaminophen and salicylate levels were undetectable. Pan-cultures showed no growth. CTA of the chest, abdomen and pelvis confirmed the absence of a pulmonary embolism and aortic dissection, and showed no other abnormalities. He was taken to the cardiac catheterization lab which did not reveal any coronary disease, and echocardiogram showed a normal ejection fraction and left ventricular function. Subsequently, he was transferred to the ICU for targeted temperature management (TTM) per ACLS protocol.We contacted the family, who reported that the patient has schizophrenia on no medications, and confirmed that he was in his usual state of health until his arrest. The family also mentioned that he drinks Kratom tea multiple times per day, and there were dozens of boxes of Kratom tea found in his apartment. CT of the head showed anoxic brain injury, which was later confirmed with a brain MRI. Despite TTM, the patient never regained any significant neurologic response, and the family made the decision to withdraw care. DISCUSSION:The psychoactive compound in Kratom is mitragynine, an alpha and mu opioid agonist. It has been used increasingly for its properties to alleviate opioid withdrawal symptoms. [1] Studies have shown that Kratom causes QT prolongation and Torsade de Pointes by inhibiting rapid delayed rectifier potassium currents in cardiomyocytes.[3] As with our patient, this can potentiate ventricular fibrillation and cardiac arrest. CONCLUSIONS:We highlight the importance of considering Kratom when toxins are suspected as the possible etiology of cardiac arrest. This clinical vignette emphasizes the need for public education of the lethal adverse effects of this seemingly harmless supplement. Additionally, increased awareness amongst the healthcare community and the need to regulate herbal supplements can help prevent events like the one reported here.

Table 1. (continued) Variables NASH* with Thromboembolism** N56,820(1.6%) NASH without Thromboembolism** N5429,025(98.4%) P-Value Peripheral vascular disease 5.6% 4.6% , 0.001 COPD*

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