Pressure Necrosis Requiring Fasciotomy After Kratom Overdose

Abstract

Introduction: Kratom (Mitragyna speciosa) is a popular plantbased extract that has dose-dependent stimulatory and sedative effects. It has been used for self-treatment of opioid withdrawal and can result in seizures, hepatotoxicity, and infectious complications from bacterial contamination. Reports of morbidity and mortality associated with Kratom may be confounded by coingestants. We report a case of severe rhabdomyolysis and pressure necrosis leading to fasciotomy in a patient who was using Kratom. Case report: A 31-year-old male with substance use presented to the emergency department after loss of consciousness for 6 hours after smoking Kratom. He was found to have rhabdomyolysis, acute renal and hepatic injury, and electrolyte disturbances. No ethanol was detected, and urine drug screen was negative. Over the next 3 hours, the patient developed signs of compartment syndrome and he was transferred to the operating room for fasciotomy. He required continuous renal replacement therapy for 48 hours and his labs and clinical status improved. He was discharged 18 days later. A serum and urine sample from the first day of presentation were analyzed for mitragynine and 7-hydroxymitragynine using an Ultra Performance Liquid Chromatography-Tandem Mass Spectrometer (UPLC-MSMS) method. The serum mitragynine was 5 ng/mL and the urine mitragynine 6 ng/mL. Conclusions: Although there are numerous reports of opioids resulting in prolonged periods of immobilization and rhabdomyolysis, this is not commonly reported in Kratom overdoses. This case report highlights the profound sedative effect of Kratom and the potential of pressure necrosis injury resulting in rhabdomyolysis and compartment syndrome requiring fasciotomy.

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

“…However, in another study, kratom use has been associated with a dose-dependent prolonged QTc interval [ 49 ], highlighting the need for more investigation on the cardiological impact of kratom use. The serotonin syndrome, the autonomic nervous system dysfunction, an undifferentiated shock, conditions of multi-organ dysfunction [ 84 – 86 ], overdoses, and fatalities (e.g., [ 87 , 88 ] must also be considered (for a summary of the main kratom-related toxicities and their clinical presentations, see Table 3 ).…”

“…Evidence related to kratom-associated clinical negative consequences in the last 5 years (2018–2022) has been reported. PRES , posterior reversible leukoencephalopathy; ARDS , acute respiratory distress syndrome Reference(s) Main symptoms and clinical presentations Kratom-related neurological issues [ 77 , 89 , 90 ] Central nervous system depression and coma, (focal, bilateral, and generalized tonic–clonic) seizures, ataxia, PRES (headache, disorientation, aphasia, confusion), transient paralysis (lightheadedness, weakness, paralysis as catatonic state), intracerebral hemorrhage Kratom-related psychiatric issues [ 91 , 92 ] Altered mental status, agitation, psychotic symptoms (visual and auditory hallucinations, delusions of grandeur, paranoid thoughts), confusion, irritability, reduction in motivation, withdrawal symptoms with obsessive thoughts, and suicidal or homicidal ideation Kratom-related dependence/withdrawal syndrome [ 93 , 94 ] Craving, physical (runny nose, fatigue, dyspepsia, nausea, anorexia, diarrhea, diaphoresis, myalgia, rhinorrhea, lacrimation, arthralgia) and psychological symptoms (e.g., aggression, hostility/irritability, nervousness, restlessness, inability to work, sadness, emotional imbalance, insomnia, depression, anxiety, thoughts of self-harm, sedation, anhedonia, poor concentration, social isolation) Kratom-related neonatal abstinence syndrome, with or without maternal abstinence syndrome [ 78 , 95 ] Muscle hypertonicity, sneezing, jittery, crying, increased muscle tone, tachypnea, hyperthermia, excessive sucking, irritability, sleeplessness, facial excoriations, feeding intolerance Kratom-related acute intoxication, overdoses, and fatalities [ 87 , 88 , 96 , 97 ] Overdose symptoms (respiratory depression, neurological and psychiatric acute manifestations), dry mouth, dizziness, palpitations, tremors, and death (cardiorespiratory arrest, hypoxic brain damage, intramuscular hemorrhage of the tongue, pulmonary edema and congestion, brain edema, left ventricular hypertrophy, rhabdomyolysis, renal failure, transient non-ischemic reversible cardiomyopathy, pressure necrosis, hepatic injury, electrolytic distur...…”

Clinical Assessment of the Drug Interaction Potential of the Psychotropic Natural Product Kratom

“…Evaluating the effects of kratom on the pharmacodynamics of a therapeutic dose of midazolam or an alternate object drug is needed to assess the clinical significance of a pharmacokinetic kratom‐drug interaction. Third, although less common, kratom has been reported to be administered via nonoral routes, including intravenous and inhalation 39,40 . Our PBPK model could be refined to simulate potential drug interactions precipitated by kratom upon administration by nonoral routes.…”

Health Effects Associated With Kratom (Mitragyna speciosa) and Polysubstance Use: A Narrative Review

“…Clinicians should be mindful of emerging literature detailing beneficial and harmful health effects, such as dizziness or respiratory depression, associated with kratom use, dependency, overdose, or polysubstance use. 13 , 25 - 27 , 29 - 31 , 33 , 35 , 40 - 43 , 49 , 50 , 54 , 75 - 84 Relatively high rates of polysubstance use and/or co-occurring substance use disorders 10 , 15 , 23 , 55 may also contribute to difficulties in establishing evidence-based treatment guidelines for patients experiencing an adverse health effect associated with using kratom individually or for people interested in receiving best-practice medical guidelines for kratom reduction, cessation, or responsible use.…”