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World Journal of
Hepatology
ISSN 1948-5182 (online)
World J Hepatol 2020 October 27; 12(10): 693-882
Published by Baishideng Publishing Group Inc
WJH https://www.wjgnet.com IOctober 27, 2020 Volume 12 Issue 10
World Journal of
Hepatology
W J H
Contents Monthly Volume 12 Number 10 October 27, 2020
REVIEW
Neoadjuvant treatment strategies for intrahepatic cholangiocarcinoma
693
Akateh C, Ejaz AM, Pawlik TM, Cloyd JM
Metabolic syndrome and liver disease in the era of bariatric surgery: What you need to know!
709
Ziogas IA, Zapsalis K, Giannis D, Tsoulfas G
Combined liver-kidney transplantation for rare diseases
722
Knotek M, Novak R, Jaklin-Kelez A, Mrzljak A
MINIREVIEWS
Hepatocellular carcinoma Liver Imaging Reporting and Data Systems treatment response assessment:
Lessons learned and future directions
738
Aslam A, Do RKG, Kambadakone A, Spieler B, Miller FH, Gabr AM, Charalel RA, Kim CY, Madoff DC, Mendiratta-Lala M
Tumor necrosis family receptor superfamily member 9/tumor necrosis factor receptor-associated factor 1
pathway on hepatitis C viral persistence and natural history
754
Peña-Asensio J, Sanz-de-Villalobos E, Miquel J, Larrubia JR
Apatinib as an alternative therapy for advanced hepatocellular carcinoma
766
Zhang XH, Cao MQ, Li XX, Zhang T
ORIGINAL ARTICLE
Basic Study
Hepatitis B virus detected in paper currencies in a densely populated city of India: A plausible source of
horizontal transmission?
775
Das P, Supekar R, Chatterjee R, Roy S, Ghosh A, Biswas S
Case Control Study
PNPLA3 and TM6SF2 polymorphisms in Brazilian patients with nonalcoholic fatty liver disease
792
Lisboa QC, Nardelli MJ, Pereira PA, Miranda DM, Ribeiro SN, Costa RSN, Versiani CA, Vidigal PVT, Ferrari TCA, Couto
CA
Retrospective Cohort Study
Impact of sarcopenia on mortality in patients undergoing liver re-transplantation
807
Dhaliwal A, Larson D, Hiat M, Muinov LM, Harrison WL, Sayles H, Sempokuya T, Olivera MA, Rochling FA, McCashland
TM
WJH https://www.wjgnet.com II October 27, 2020 Volume 12 Issue 10
World Journal of Hepatology
Contents Monthly Volume 12 Number 10 October 27, 2020
Retrospective Study
Increased incidence of and microbiologic changes in pyogenic liver abscesses in the Mexican population
816
Pérez-Escobar J, Ramirez-Quesada W, Calle-Rodas DA, Chi-Cervera LA, Navarro-Alvarez N, Aquino-Matus J, Ramírez-
Hinojosa JP, Moctezuma-Velázquez C, Torre A
Observational Study
Malnutrition and non-compliance to nutritional recommendations in patients with cirrhosis are associated
with a lower survival
829
Crisan D, Procopet B, Epure A, Stefanescu H, Suciu A, Fodor A, Mois E, Craciun R, Crisan N
Effect of treating chronic hepatitis C with direct-acting antivirals on extrahepatic cutaneous manifestations
841
El Kassas M, Hegazy OM, Salah EM
Novel markers of endothelial dysfunction in hepatitis C virus-related cirrhosis: More than a mere
prediction of esophageal varices
850
Hanafy AS, Basha MAK, Wadea FM
CASE REPORT
Kratom induced severe cholestatic liver injury histologically mimicking primary biliary cholangitis: A case
report
863
Gandhi D, Ahuja K, Quade A, Batts KP, Patel L
Severe COVID-19 after liver transplantation, surviving the pitfalls of learning on-the-go: Three case reports
870
Alconchel F, Cascales-Campos PA, Pons JA, Martínez M, Valiente-Campos J, Gajownik U, Ortiz ML, Martínez-Alarcón L,
Parrilla P, Robles R, Sánchez-Bueno F, Moreno S, Ramírez P
LETTER TO THE EDITOR
Role of platelet-albumin-bilirubin score in predicting re-bleeding after band ligation for acute variceal
hemorrhage
880
Faisal MS, Singh T, Amin H, Modaresi Esfeh J
WJH https://www.wjgnet.com III October 27, 2020 Volume 12 Issue 10
World Journal of Hepatology
Contents Monthly Volume 12 Number 10 October 27, 2020
ABOUT COVER
Editorial board member of World Journal of Hepatology, Dr. Fernando Oscar Bessone is Professor of
Gastroenterology and Chief of the Gastroenterology and Hepatology Department at the Hospital Provincial del
Centenario, University of Rosario School of Medicine (Brazil). Dr. Bessone completed postgraduate training in
Clinical Hepatology, Liver Pathology (Hospital de Clinicas, San Pablo, Brazil), Pediatric Hepatology (Hospital da
Criança, San Pablo, Brazil), and Liver Transplantation and Clinical Hepatology (Hospital Clinic y Provincial de
Barcelona, Spain). He has served as Principal Investigator or Co-Investigator in more than 50 clinical trials, and is
currently the Coordinator of the Latin American Registry of Hepatotoxicity. He authored more than 70 articles, 30
book chapters, and more than 140 papers presented at scientific meetings. In addition, he serves as an editorial
board member for several international hepatology-related journals. (L-Editor: Filipodia)
AIMS AND SCOPE
The primary aim of World Journal of Hepatology (WJH, World J Hepatol) is to provide scholars and readers from
various fields of hepatology with a platform to publish high-quality basic and clinical research articles and
communicate their research findings online.
WJH mainly publishes articles reporting research results and findings obtained in the field of hepatology and
covering a wide range of topics including chronic cholestatic liver diseases, cirrhosis and its complications, clinical
alcoholic liver disease, drug induced liver disease autoimmune, fatty liver disease, genetic and pediatric liver
diseases, hepatocellular carcinoma, hepatic stellate cells and fibrosis, liver immunology, liver regeneration, hepatic
surgery, liver transplantation, biliary tract pathophysiology, non-invasive markers of liver fibrosis, viral hepatitis.
INDEXING/ABSTRACTING
The WJH is now abstracted and indexed in PubMed, PubMed Central, Emerging Sources Citation Index (Web of
Science), Scopus, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal
Database (CSTJ), and Superstar Journals Database.
RESPONSIBLE EDITORS FOR THIS ISSUE
Production Editor: Li-Li Wang; Production Department Director: Yun-Xiaojian Wu; Editorial Office Director: Jia-Ping Yan.
NAME OF JOURNAL INSTRUCTIONS TO AUTHORS
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LAUNCH DATE GUIDELINES FOR NON-NATIVE SPEAKERS OF ENGLISH
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FREQUENCY PUBLICATION ETHICS
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EDITORS-IN-CHIEF PUBLICATION MISCONDUCT
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Submit a Manuscript: https://www.f6publishing.com World J Hepatol 2020 October 27; 12(10): 863-869
DOI: 10.4254/wjh.v12.i10.863 ISSN 1948-5182 (online)
CASE REPORT
Kratom induced severe cholestatic liver injury histologically
mimicking primary biliary cholangitis: A case report
Darshan Gandhi, Kriti Ahuja, Alexis Quade, Kenneth P Batts, Love Patel
ORCID number: Darshan Gandhi
0000-0002-7079-450X; Kriti Ahuja
0000-0001-6878-919X; Alexis Quade
0000-0003-0394-8967; Kenneth P.
Batts 0000-0002-2963-3843; Love
Patel 0000-0002-6271-6376.
Author contributions: Gandhi D
acknowledged the idea of this
article and contributed to writing
the manuscript substantially;
Ahuja K contributed to the
discussion of the manuscript;
Quade A contributed to figure
formation of the manuscript and its
revision; Batts KP contributed to
reference numbering and revision
of the manuscript; Patel L
conceived the idea of this article
and contributed to design and
revision of the manuscript; all the
authors have read and approved
the final revised manuscript.
Informed consent statement:
Informed written consent was
obtained from the patient for
publication of this report and any
accompanying images.
Conflict-of-interest statement: The
authors declare that they have no
competing or conflicts of interests.
CARE Checklist (2016) statement:
The authors have read the CARE
Checklist (2016), and the
manuscript was prepared and
revised according to the CARE
Checklist (2016).
Darshan Gandhi, Department of Radiology, Northwestern Memorial Hospital, Northwestern
University Feinberg School of Medicine, Chicago, IL 60611, United States
Kriti Ahuja, Department of Internal Medicine, Maulana Azad Medical College, New Delhi
110002, Delhi, India
Alexis Quade, Internal Medicine-Pediatrics, University of California-San Diego and Rady
Children's Hospital San Diego, San Diego, CA 92103, United States
Kenneth P Batts, Department of Pathology, Abbott Northwestern Hospital, Allina Health,
Minneapolis, MN 55407, United States
Love Patel, Division of Hospital Medicine, Abbott Northwestern Hospital, Allina Health,
Minneapolis, MN 55407, United States
Corresponding author: Darshan Gandhi, MD, Academic Fellow, Doctor, Department of
Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of
Medicine, 676 N St. Clair St, Suite 800, Chicago, IL 60611, United States.
darshangandhi7@gmail.com
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
Gandhi D et al. Kratom induced severe cholestatic liver injury
WJH https://www.wjgnet.com 864 October 27, 2020 Volume 12 Issue 10
Open-Access: This article is an
open-access article that was
selected by an in-house editor and
fully peer-reviewed by external
reviewers. It is distributed in
accordance with the Creative
Commons Attribution
NonCommercial (CC BY-NC 4.0)
license, which permits others to
distribute, remix, adapt, build
upon this work non-commercially,
and license their derivative works
on different terms, provided the
original work is properly cited and
the use is non-commercial. See: htt
p://creativecommons.org/licenses
/by-nc/4.0/
Manuscript source: Unsolicited
manuscript
Received: May 21, 2020
Peer-review started: May 20, 2020
First decision: July 29, 2020
Revised: August 2, 2020
Accepted: August 26, 2020
Article in press: August 26, 2020
Published online: October 27, 2020
P-Reviewer: Jiang W, Liu J
S-Editor: Yan JP
L-Editor: A
P-Editor: Liu JH
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.
Key Words: Case report; Kratom; Cholestasis; Liver injury; Mitragyna speciosa;
Cholangitis; Substance induced injury
©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
Core Tip: Kratom induced liver injury is an important differential diagnosis for
physicians to consider in any patient presenting with acute liver injury. As observed in
our patient, this manifestation of Kratom consumption may occur even at low doses.
Further, this case report demonstrates that a thorough history is essential for an
accurate and timely diagnosis. Patients may consider dietary and herb supplements to
be natural and risk-free products, not realizing the potential for harm. In addition to
asking their patients about consumption of any supplements, it is imperative that
physicians update themselves so as to be able to discuss the benefits and risks, and
counsel their patients effectively. Identifying use of supplements helps in early
diagnosis and treatment, while also preventing future harm. From the pathology
perspective, biliary changes associated with Kratom injury can mimic primary biliary
cholangitis.
Citation: Gandhi D, Ahuja K, Quade A, Batts KP, Patel L. Kratom induced severe cholestatic
liver injury histologically mimicking primary biliary cholangitis: A case report. World J
Hepatol 2020; 12(10): 863-869
URL: https://www.wjgnet.com/1948-5182/full/v12/i10/863.htm
DOI: https://dx.doi.org/10.4254/wjh.v12.i10.863
INTRODUCTION
Acute liver failure is a severe condition which may rapidly become fatal[1]. In the
United States, a significant number of these cases occur due to drug-induced liver
injury[2]. Apart from prescribed medications, consumption of herbal and dietary
supplements also plays an important role in causing liver injury[2]. We present here a
case of a 37-year-old female, with drug induced liver injury mimicking as
antimitochondrial antibody (AMA) negative primary biliary cholangitis (PBC),
secondary to consumption of an herbal supplement, Kratom. Derived from the leaves
of Mitragyna speciosa, a plant found in Southeast Asia and Africa, this supplement is
used for its stimulant properties, as a substitute for opioids, and to help opioid
withdrawal symptoms[3]. People in the United States report using this supplement
predominantly for pain relief, and also report increased levels of energy and focus
with consumption[4]. Our patient learned of this herbal supplement from a friend and
reported consuming it in order to boost her energy levels. Although uncommon, this
herbal supplement is associated with the risk of hepatotoxicity, making it imperative
for physicians to be aware of its harmful effects and caution their patients against its
use[4].
CASE PRESENTATION
Chief complaints
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.
History of present illness
Four days prior to admission, she noticed that her stools were becoming tanner and
Gandhi D et al. Kratom induced severe cholestatic liver injury
WJH https://www.wjgnet.com 865 October 27, 2020 Volume 12 Issue 10
eventually turned white. She also reported that her urine was dark. Two days prior to
admission the patient noticed jaundice and scleral icterus which prompted her to seek
treatment. Her only home medication was venlafaxine, which she had been taking for
several years. She has no history of alcohol abuse.
On further questioning about new medications or supplement use, the patient
reported using an herbal supplement containing Kratom two weeks prior to the onset
of her symptoms. She used the supplement for the first time in her life. Encouraged by
a friend to use the supplement to “boost energy levels,” she believed it was safe
because it was “all natural”. She consumed approximately three grams in total over
the course of three days in the form of powder (which she dissolved in water) and
tablets. During her hospitalization, the patient’s liver enzymes continued to rise. On
day 3 of her hospitalization, a liver biopsy was performed.
History of past illness
History of depression and obesity.
Physical examination
Unremarkable except jaundice.
Laboratory examinations
On admission, the patient had markedly elevated liver enzymes (Table 1). Other basic
laboratory findings including blood count, basic metabolic panel, coagulation panel,
serum thyroid stimulating hormone and antinuclear antibody were within normal
range. Viral and autoimmune hepatitis studies were normal. Ceruloplasmin level was
also normal. AMA was negative.
Imaging examinations
An abdominal ultrasound showed diffuse increased echogenicity of the liver with
normal liver size and contour suggests diffuse hepatic steatosis (Figure 1). No
intrahepatic or common biliary duct dilation or gall stones seen. An abdominal
computed tomography scan showed similar findings. Magnetic resonance
cholangiopancreatography did not demonstrate any further abnormalities.
FINAL DIAGNOSIS
Kratom induced severe liver injury histologically mimicking PBC.
TREATMENT
The patient was started on prednisone 40 mg daily. Advised to avoid any new
medications or over the counter products with the potential risk of liver injury till her
liver enzymes normalized.
OUTCOME AND FOLLOW-UP
The patient was discharged on day 5 of hospitalization and follow up was arranged
with gastroenterology clinic. The patient had liver enzymes checked six days after
discharge; her symptoms and liver enzymes showed marked improvement. Steroids
were stopped. Patient was lost to further lab follow up with gastroenterology clinic but
reported feeling back to her normal on follow up phone call 2-wk post hospitalization.
DISCUSSION
The herbal supplement Kratom is a psychoactive substance derived from the leaves of
Mitragyna speciosa, a plant native to Southeast Asia[3]. Its leaves are used for a variety of
purposes, such as pain relief, enhancing energy levels, substituting opioids, managing
opioid withdrawal[3,4]. The psychoactive compounds of Kratom, mitragynine, and 7-
hydroxymitragynine may also result in altered consciousness, particularly at high
doses of consumption[3]. As a result, Kratom is a controlled drug in several countries
Gandhi D et al. Kratom induced severe cholestatic liver injury
WJH https://www.wjgnet.com 866 October 27, 2020 Volume 12 Issue 10
Table 1 Patient’s liver function labs from the day after admission until the day of hospital discharge
HD1 HD2 HD3 HD4 HD5 Six days post- discharge Normal values
Total bilirubin (mg/dL) 10.3 12.0 14.5 17.2 19.5 5.7 < 1.0
Alkaline phosphatase (U/L) 672 677 744 817 839 507 50-160
ALT (U/L) 578 585 600 608 591 323 0-30
AST (U/L) 455 461 437 401 385 101 0-40
HD: Hospital day; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase.
Figure 1 The abdominal ultrasound. A: Diffuse fatty infiltration of liver; B: Normal common bile duct and intrahepatic biliary ducts (orange arrows) in magnetic
resonance cholangiopancreatography 3D image.
and illegal in several others[5]. The Drug Enforcement Administration of the United
States considers it a Drug and Chemical of Concern[6]. While Kratom products are legal
in most parts of the United States, a few states and cities have banned them[4]. With
concerns regarding its safety, the Food and Drug Administration warns consumers
against the use of these products[4,7].
Further, studies have shown that patients reporting Kratom use may present with
confusion, lethargy, irritability, agitation, nausea and vomiting, tachycardia,
hypertension or in severe cases, bradycardia, seizures, increased bilirubin, renal failure
and even coma[4]. Further, Kratom is also reported to exert effects similar to opioids,
such as sedation, hypnosis, nausea, stupor and respiratory depression[3,4,8]. In addition
to this, the Food and Drug Administration has recalled Kratom supplements due to
contamination with Salmonella[9].
Although Kratom induced liver injury is described, reports with detailed
description of histopathological changes are rare which are mentioned below in
Table 2. Rapid clinical and liver enzyme improvement supports the diagnosis of
Kratom induced liver injury.
An interesting aspect of our case is the pathological features of liver injury
(Figure 2). The zone 3 cholestasis was felt to reflect drug effect; zone 3 cholestasis is a
common finding in cholestatic drug reactions but not a feature of early stage PBC. The
lymphocytic cholangitis, a typical feature of PBC and unusual medication-injury
finding, raised initial concern for underlying early stage PBC. This is of lesser concern
given her negative antinuclear antibody and AMA status, trend toward rapid
resolution of liver enzymes, and a case report by Aldyab et al[10] in 2019 that reported a
case of kratom toxicity with granulomatous cholangitis (another form of florid duct
lesion) that mimicked PBC. This was from a 40-year-old female presenting with liver
injury after Kratom use who initially perceived to have AMA-negative PBC but
diagnosed with Kratom induced liver injury after rapid normalization of liver
enzymes.
In the first published case report of intrahepatic cholestasis due to consumption of
Kratom, the patient’s laboratory results showed a peak bilirubin of 29.3 mg/dL with
prolonged elimination based on known half-life of the drug and analysis of urine
Gandhi D et al. Kratom induced severe cholestatic liver injury
WJH https://www.wjgnet.com 867 October 27, 2020 Volume 12 Issue 10
Table 2 Kratom-induced hepatotoxicity with review of literature in patients with liver biopsy
Ref. Age,
sex Clinical findings Form, amount, duration of Kratom
consumed
Peak bilirubin
(mg/dL) Disease pattern Radiological findings Histological findings
Kapp et al[11]25, M Abdominal pain, brown
urine, jaundice, pruritus
Powder, 1 to 2 teaspoon twice a day and
increased to 4-6 teaspoon over 2 wk (1
teaspoon approximately 2-3 g)
Direct bilirubin
29.3
Cholestatic (increased bilirubin,
AST, ALT, ALP)
USG, CT-hepatic steatosis Cholestatic injury, no hepatocellular
damage, canalicular cholestasis
Drago et al[14]23, M Jaundice, pale stool, brown
urine for 4 d
Powder, 85 g total over 6 wk Direct bilirubin
5.8
Cholestatic (increased bilirubin,
AST, ALT, ALP)
USG, CT-normal Cholestatic liver injury
Bernier et al[15]41, F Jaundice, diarrhea, pruritus Form not available, 1 teaspoon twice daily
for 1 wk
Direct bilirubin
15
Cholestatic (increased bilirubin,
AST, ALT, ALP)
- Intralobular bile duct destruction with
cholestatic overload
Shah et al[16]30, F Abdominal pain, jaundice,
dark urine, pruritus
Tea containing Kratom, dose not available Direct bilirubin
18
Cholestatic (increased bilirubin,
AST, ALT, ALP)
MRI-normal, ERCP–no bile duct
obstruction
Intrahepatic cholestasis
Riverso et al[13]38, M Dark urine, light stools,
fever
Not available Total bilirubin
5.6
Cholestatic (increased bilirubin,
AST, ALT, ALP)
USG-normal Acute cholestatic injury, mild bile duct
injury, portal inflammation
Mackenzie et al[17]
and De Francesco
et al[18]
27, M Vomiting, epigastric pain,
diarrhea with associated
heavy alcohol intake
Powder, 3-4 teaspoon multiple times
weekly for several wk
Total bilirubin
11.2
Cholestatic (increased bilirubin,
AST, ALT, ALP)
- Widespread hepatocellular necrosis with
extracellular cholestasis
Fernandes et al[12]52, M Mild fatigue, jaundice Crushed leaves with water, 1 teaspoon
(approximately 1.5 g) once or twice a day
for 2 mo
Total bilirubin
28.9
Cholestatic (increased bilirubin,
ALP; slightly increased AST,
ALT)
MRI - normal Canalicular cholestasis, bile duct injury,
hepatic lobule injury, mixed
inflammation in portal tracts
Aldyab et al[10]40, F Abdominal pain, fever Form not available, once a week for 1 mo Total bilirubin
5.1
Mixed cholestatic and
hepatocellular (increased
bilirubin, AST, ALT, ALP)
CT, MRCP–mild, nonspecific
periportal edema
Granulomatous duct injury
Pronesti et al[19]30, M Dark urine and pale stool for
1 wk, scleral icterus for 1 d
Powder with water, for 4-6 wk Total bilirubin
5.7, direct
bilirubin 4.5
Cholestatic (increased bilirubin,
AST, ALT, ALP)
USG–coarse hepatic echotexture Hepatocellular and canalicular cholestasis
with inflammation and focal prominent
eosinophils. No fibrosis
LiverTox case
6972[20]
25, M Abdominal pain, fever,
jaundice, dark urine,
pruritus
Powder, for 23 d Total bilirubin
22.4
Mixed Hepatocellular and
cholestatic (increased bilirubin,
AST, ALT, ALP)
USG, CT–gall bladder wall
thickening with increased
perihepatic lymph nodes
Cholestatic injury with mild necrosis and
inflammation
M: Male; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; USG: Ultrasonography; CT: Computed tomography; F: Female; MRI: Magnetic resonance imaging; ERCP: Endoscopic retrograde
cholangiopancreatography; MRCP: Magnetic resonance cholangiopancreatography.
samples[11]. It was speculated that this could be due to the patient’s underlying
steatohepatitis[11]. Similarly, our patient also had steatohepatitis observed on imaging
and pathology, which could explain why even the relatively low doses of Kratom used
by our patient compared to other cases discussed in the literature led to such profound
liver injury.
As Kratom use appears to be on the rise in the United States, physicians need to be
aware of its potential for adverse effects[4,9]. This case highlights how even small
Gandhi D et al. Kratom induced severe cholestatic liver injury
WJH https://www.wjgnet.com 868 October 27, 2020 Volume 12 Issue 10
Figure 2 Histopathological findings. A: Centrilobular areas showed well defined cholestasis; B and C: Portal tracts showed moderate chronic inflammation
and brisk lymphocytic-predominant bile duct injury; D: Background liver showed steatohepatitis which was felt to most likely be due to underlying obesity-related non-
alcoholic fatty liver disease.
amounts of the supplement can be hepatotoxic. Physicians need to be able to discuss
safety concerns of over-the-counter supplements with their patients. Moreover, the
rising use of supplements and recreational substances can pose diagnostic challenges
for clinicians when their use is not reported. Medical providers always need to
consider the use of supplements when patients present with possible drug-induced
liver injury.
CONCLUSION
Kratom induced liver injury is an important differential diagnosis for physicians to
consider in any patient presenting with acute liver injury. As observed in our patient,
this manifestation of Kratom consumption may occur even at low doses. Further, this
case report demonstrates that a thorough history is essential for an accurate and timely
diagnosis. Patients may consider dietary and herb supplements to be natural and risk-
free products, not realizing the potential for harm. In addition to asking their patients
about the consumption of any supplements, it is imperative that physicians update
themselves so as to be able to discuss the benefits and risks and counsel their patients
effectively. Identifying use of supplements helps in early diagnosis and treatment,
while also preventing future harm. From the pathology perspective, biliary changes
associated with Kratom injury can mimic PBC.
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