Case Presentation: A 46-year old Caucasian male with history of anxiety/depression-on citalopram, tobacco, alcohol use, bilateral chronic knee pain, presented to an outside facility with concerns of nausea, vomiting and epigastric abdominal pain. While undergoing evaluation, he was suddenly unresponsive, underwent CPR x3, found to have ventricular fibrillation rhythm and subsequently cardioverted with successful ROSC. Intubation and amiodarone drip were instituted and he was transferred to our facility. While in the ICU, the patient was put on a hypothermia protocol. Pertinent labs showed: normal electrolytes, troponins, and mild transaminitis. EKG showed prolonged QT at 500-530ms. Upon clinical improvement, he was transferred to the floors where he underwent further work up to determine etiology of Vfib. An echocardiogram and left heart catheterisation ruled out ischemic pathology but noted an anomalous left circumflex arising from the right coronary sinus. Preliminary urine and serum drug screens were negative. Historically, the patient was not known to consume caffeinated products, however, he was consuming kratom to offset chronic knee pain; had no personal or family history of heart disease. With appropriate counseling to avoid QT prolonging agents, the patient was discharged with a life vest and plans to follow up with cardiology.
Discussion: Kratom: an extract from Mitragyna speciosa is popular in the United States for its stimulatory activity in low doses and analgesic effects at higher amounts [1]. Easily available online or at gas stations, it is predominantly used to manage chronic pain [1,2]. Preliminary surveys show that the majority of consumers are males, Caucasian with a median age of 40, and about 20% of them carry a diagnosis of substance use disorder[2]. Interestingly, there have been reports of cardiotoxic effects of kratom use such as prolonged QT and associated arrhythmias due to kratom’s effects on cardiomyocyte potassium channel inhibition[1-3]. The incidence of ventricular fibrillation however, is novel and very rare.Few differentials for this case include coronary atherosclerosis, HOCM, familial arrhythmias, long QT syndrome, valvular pathologies, all of which were excluded in our patient. Additionally, although an anomalous coronary was noted, it was later deemed non malignant on imaging. While the extent to which kratom contributed to ventricular fibrillation is unclear, this report should certainly alert clinicians of its possibility.
Conclusions: Kratom is frequently abused for purposes of pain relief. It is not detected by standard toxicology tests, thereby necessitating thorough history collection regarding drug consumption habits.Kratom can cause fatal arrythmias and more studies are needed to understand its pharmacodynamics. One may even have to consider ICD placement if cardiotoxicity is proven.