Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Introduction: “Kratom” refers to both Mitragyna speciosa, a tree native to Southeast Asia, and to its products, derived from the tree’s leaves, which are marked as an herbal supplement. Kratom is an herbal supplement with both opioid and stimulant-like effects. While there are no approved uses for kratom by the U.S. Food and Drug Administration, it is frequently used by individuals to manage withdrawal symptoms and cravings (especially related to opioid use), pain, fatigue, and mental health disorders. Furthermore, because kratom is unregulated, it can contain contaminants, including heavy metals and harmful bacteria. This case details the development of parapneumonic effusion in an individual taking increasing concentrations of kratom. Case: Patient is a 37-year-old male with a past medical history of tobacco dependence and polysubstance use (current kratom use, history of marijuana use, and amphetamine use with last reported amphetamine use four months prior to admission) who presented to the hospital with a four-week history of right-sided chest pain, dyspnea, night sweats, and unintentional weight loss of approximately 10 pounds. Patient reported that prior to symptom onset he began taking higher concentration of Kratom. The patient was referred to the hospital after receiving a chest x-ray at an urgent care, which showed an extensive infiltrate involving the right lower lobe with right lateral perihilar upper lobe involvement, and a right-sided pleural effusion. Upon presentation patient was febrile to 38.4 C and tachycardic to the 100s. Laboratory studies were significant for leukocytosis 22. Urine drug screen was positive for mitragynine, a metabolite of kratom. CT imaging of the chest showed a heterogenous consolidation of the right middle lobe with rounded hypodensities measuring up to 1.3 x 1.2 cm as well as a moderate multi-loculated and septated right parapneumonic effusion, with concern for necrotizing pneumonia and mediastinitis. He was initiated on antibiotic therapy with metronidazole, azithromycin, and ceftriaxone. Pulmonology was consulted however due to loculation of the effusion, surgery was necessary. Thoracic surgery was consulted, and the patient underwent right-sided video-assisted thoracoscopic surgery (VATS) with total decortication. Pleural cultures were obtained and were ultimately negative. Infectious Disease was consulted, and antibiotics were escalated to ampicillin-sulbactam. Patient’s condition improved and he was discharged on amoxicillin-clavulanate for an additional 4 weeks. Discussion: Mitragynine, the major alkaloid metabolite of kratom, is a partial agonist at the mu-opioid receptor. In animal studies, mitragynine has shown a ceiling effect of respiratory depression due to metabolic saturation of the CYP3A enzyme. Other available evidence suggests that mitragynine has an improved side effect profile and reduced respiratory depression, when compared with traditional opioids such as morphine and codeine. Nevertheless, there is much that remains unknown regarding the physiologic effects and safety profile of kratom, particularly at higher doses. Patients should be counseled that kratom is largely unregulated, and that effects may vary between brands or doses of the supplement.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter Resident and Medical Student Day, May 2, 2025, Troy, MI

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