Kratom-Associated Mixed Cholestatic-Hepatocellular Liver Injury in a Patient With Long COVID: A case Report

Abstract

Introduction: Mitragyna speciosa (commonly known as kratom) has both opioid and stimulant-like effects. Recently, Thailand decriminalized the possession and sale of kratom which led people in many areas to seek income from the sale of kratom at a time of widespread unemployment due to COVID-19. Here, we report a patient with post-COVID syndrome who developed a mixed cholestatic-hepatocellular liver injury secondary to kratom. Case presentation: A 23-year-old Thai man was seen for an evaluation of fatigue and nausea which was soon followed by 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 purchased from a friend and used in a homemade iced cocktail called “4 × 100” consisting of Coca-Cola, tea made from boiled kratom leaves, and diphenhydramine-containing cough syrup which has been popular in Southernmost provinces of Thailand. His lab workup showed his total bilirubin to be 10.6 mg/dL, aspartate aminotransferase was 642 U/L, and alanine aminotransferase was 1635 U/L. Extensive workups including viral etiologies was negative. Abdominal ultrasound revealed normal liver and no cirrhosis. The case was managed conservatively for 5 days in the hospital by giving intravenous fluid and stopping all medications. Urine toxicology screening confirmed the presence of mitragynine and diphenhydramine. He was in a stable condition with normalized liver function tests at 3 months after discharge. Conclusion: The COVID-19 pandemic has posed unprecedented challenges to health consequences and this case highlights the importance of kratom as potential cause of acute liver injury. Future studies should accumulate further case series and identify kratom-user subgroups or the polydrug patterns of kratom use that are at heightened risk of severe liver injury.

Clinical Implications of Kratom (Mitragyna speciosa) Use: a Literature Review

“…Other underlying motivations for kratom intake include the improvement of sexual performance [ 23 ], coping strategies for negative emotional states [ 24 ], ameliorating psychiatric symptoms (i.e., anxiety, depression, insomnia, attention deficit hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD) [e.g., 4 ••, 16 ••], and the enhancement of sociability, energy, and focus [ 14 ]. A recent case even reported its use in post-COVID insomnia [ 25 ].…”

“…While in Asia kratom has been used with a limited number of associated health hazards [ 25 , 108 ], most of the safety issues have been reported in the West, mainly among users ingesting kratom on a daily basis in combination with other drugs, such as prescription medicines (e.g., antipsychotic, antidepressant, and hypnotic drugs, among others) and psychoactive substances (e.g., amphetamine, methamphetamine, cyclopropyl fentanyl, opioids, ethanol) [ 76 , 88 , 108 ]. Unscheduled contaminants/adulterants in kratom products (e.g., propyl-hexedrine, phenyl-ethylamine, O-desmethyl-tramadol, hydrocodone, and morphine) [ 90 , 96 •, 97 •, 100 ], microbes (e.g., Salmonella, M. incognita), and toxic metals (lead and nickel) [ 109 ••, 110 ••, 111 ••] have also been found responsible for toxicities.…”

A murine model of post-acute neurological sequelae following SARS-CoV-2 variant infection

“…Viral loads in liver were nevertheless barely detectable at both acute and chronic stages. Liver injury has been reported to develop as a post-COVID sequela (54,55). The primary focus of this study is SARS-CoV-2 variant infection in the CNS tissues and its contribution to PASC pathogenesis.…”

Research and publication gaps on kratom and kratom products: a scoping review of current literature

“…Among the identified articles, there were 20 clinical case [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] and 7 case series reports [33][34][35][36][37][38][39] published between 2022 and 2023. A vast majority of articles in the case and case series reports category were from the United States (20 articles).…”