Kratom induced severe cholestatic liver injury histologically mimicking primary biliary cholangitis: A case report

Abstract

BACKGROUND Kratom is a psychoactive substance that is isolated from the plant Mitragyna speciosa . The leaves can be chewed fresh or dried, smoked, or infused similar to herbal teas. The plant leaves have been used by natives of Southeast Asia for centuries. The substance has been used for its stimulant activity at low doses, and as an opium substitute at higher doses due to a morphine like effect. CASE SUMMARY A 37-year-old female with a history of depression and obesity (body mass index: 32) presented to emergency room with a week-long history of nausea, decreased appetite, fatigue, and two days of jaundice. On admission bilirubin was markedly elevated. Her condition was thought to be due to consumption of Kratom 2 wk before onset of symptoms. Liver biopsy showed changes mimicking primary biliary cholangitis. Patient’s symptoms and jaundice improved quickly. CONCLUSION The use of Kratom has been on the rise in recent years across the United States and Europe. Several case reports have associated adverse health impact of Kratom-containing products including death due to its ability to alter levels of consciousness. Only a few case reports have highlighted the hepatotoxic effects of Kratom. Even fewer reports exist describing the detailed histopathological changes.

Kratom (Mitragyna speciosa)-Induced Hepatitis

“…Previously described clinical symptomatology and histology are mostly consistent with a cholestatic pattern in which canalicular cholestasis seems to be the most common histological finding. 11,12 Three of the 4 cases also described mixed portal inflammation; however, they identified mild bile duct injury, which was not seen in our case. [13][14][15] One case described an additional component of granulomatous inflammation of the bile ducts and lobular areas.…”

Case Report: Treatment of Kratom Use Disorder With a Classical Tricyclic Antidepressant

“…Kratom use has been often linked to liver toxicity. Kratom has been associated with biliary cholangitis and cholestasis in several cases (67,(103)(104)(105)(106)(107)(108)(109)(110) and with one case of hepatomegaly (111), but also with acute hepatitis (112). Mitragynine inhibits hepatic and intestinal cytochrome P450 3A activities (113) and hepatic microsomal CYP2D6 (114), thus increasing blood levels of other concomitantly administered drugs that are metabolized by these isoenzymes, that is, most psychiatric drugs.…”

“…In a US-Thailand comparison, for example, symptoms were more severe and mortality higher in the US sample, with drowsiness, irritability-agitation and tachycardia being the most common in order of increasing frequency (64). Kratom may be used according to users' taste and adjusted according to the desired effects, with low doses producing stimulant and activating effects and high doses sedative and tranquilizing effects (65)(66)(67), although these dose-related effects were not confirmed in a recent study and was unrelated to the amount and duration of kratom use (68). Many people, especially in South-East Asia, get to use kratom after being addicted to opioids and in the attempt to quit; others are prompted to use kratom due to its anxiolytic and mood enhancing effects (69)(70)(71).…”

Clinical Pharmacology of the Dietary Supplement Kratom (Mitragyna speciosa)

“…87,88 According to other case reports, kratom-induced hepatotoxicity may histologically mimic antimitochondrial antibody-negative primary biliary cirrhosis with variable biochemical and clinical abnormalities. 89,90 The mechanism of liver injury secondary to kratom use is unknown. Because kratom is often used in combination with other agents, including alcohol and drugs of abuse, its role as a causative agent in producing liver disease is often difficult to discern.…”

“…The dose of kratom that has been associated with hepatotoxicity was 14 to 21 g per day 87,88 . According to other case reports, kratom‐induced hepatotoxicity may histologically mimic antimitochondrial antibody–negative primary biliary cirrhosis with variable biochemical and clinical abnormalities 89,90 . The mechanism of liver injury secondary to kratom use is unknown.…”