A case report published in European Journal of Case Reports in Internal Medicine entitled “Kratom-Induced Acute Respitory Distress Syndrome (ARDS)” claimed kratom induced ARDS in a 36 year old man with a “a 7.5-pack year history”.
A “pack year” according to the National Cancer Institute, “is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked.” A 7.5 pack year may mean a pack of cigarettes per day for 7.5 years
Kratom alkaloids “pose a threat to society” and kratom is an “evolving threat” according Justine Chinnappan and others at Michigan State University at Hurley Medical Center, who wrote the report.
In addition to excessive tobacco use, the patient had a history of polysubstance use and “a 3-day history of progressive pleuritic chest pain and shortness of breath”. During his hospital stay, the patient’s “respiratory status progressively worsened requiring intubation and mechanical ventilator support.”
Extensive tests turned up negative for multiple infections, including COVID-19. Authors did not report the patient’s history of COVID-19, which is known to cause ARDS as well as post-infection complications. But chest radiography showed “extensive bilateral infiltrates” (foreign matter in the lungs, common causes are tuberculosis (Dontfraid & Ramphal, 1994) and pneumonia (Bernstein, 2022)) and “extensive bilateral multifocal consolidative changes” (lung consolidation is when air in the lungs is replaced by something else, like fluid (Healthline, 2018)). According to the Centers for Disease Control (CDC), “Pneumonia and respiratory problems are far more common in smokers” (2010).
Tests also determined the patient had a low “white blood cell count of 200/μl”.
Initially, doctors diagnosed the patient with “sepsis due to suspected multifocal pneumonia”, however further tests for this diagnoses “returned negative and the patient remained unresponsive to antibiotic treatment with worsening symptoms, ruling out infection.”
To determine that kratom caused ARDS in the patient, doctors ruled out other causes and simply asked the family, who “revealed that he used kratom to combat his opioid cravings.” Given “no other triggering events identified… a final diagnosis of kratom-induced acute respiratory distress syndrome (ARDS) was made.”
If a drug screen occurred, Chinnappan et al 2023 did not report it, therefore the presence of other drugs (like fentanyl or other opioids that have been proven to cause respiratory depression) cannot be ruled out. Why a patient with a history of opioid use was not screened for respiratory-depression-causing drugs, or why it was not included in this report, is anyone’s guess.
As in most case reports involving kratom, doctors did not attempt to obtain the kratom product itself to test for contaminents, other drugs, or alkaloid content. Authors do not report on the amount, type of kratom, or time frame in which it was consumed.
In a letter to the journal Substance Abuse, multiple scientists with kratom expertise called for the “Need for clarity and context in case reports on kratom use, assessment, and intervention” and pointed out that “such inconsistencies and generalizations can be observed throughout kratom-specific case reports” (Smith et al, 2022).
A recent review (Feldman et al, 2023) of kratom case reports, scientists at National Institute on Drug Abuse (NIDA) found the reports “tended to be inadequate in full assessment of the patient’s kratom use.” Out of 52 case reports/case series reviewed, and 67 patients examined, there were only five instances where kratom products were tested. Kratom was adulterated/contaminated in three cases.. The brand of kratom was not reported in nearly all cases. The dose of kratom ingested “was not reported or unclear for 31 patients”. Forty-two patients were screened for the presence of other drugs, and 24 were negative for non-kratom substances. In the remaining cases (over one third of patients), the presence of other substances could not be ruled out, and, as the authors note, many kratom consumers are polysubstance users. Liver injury was reported in 24 patients, seizure in 19, kidney injury in 9, rhabdomyolysis in 6, and “suspected overdose” in 6. However, according to the authors, given the variation in alkaloid profile and contamination/adulteration in kratom products, linking symptoms to a cause is difficult “when product information is absent or incomplete, as it was for nearly half of the patients described in the reports we reviewed.”
Chinnappan et al 2023 has no trouble declaring in its “Learing Points” section that “Acute respiratory distress syndrome (ARDS) is one of the adverse effects of kratom” but writes in the “Discussion” section, “An extensive literature search revealed only two abstracts describing patients who developed ARDS following kratom ingestion, and no published case reports”. The authors then go on to note pulmonary oedema has been frequently discovered in deaths declared to be caused by “mitragynine intoxication”, but notes one case report where other drugs, “venlafaxine, mirtazapine and diphenhydramine were detected at autopsy”.
Exposure to cigarette smoke has been found to induce or increase the risk of ARDS (de Oliveira Rodrigues, 2022) (Rounds et al, 2022) (White et al, 2022). Given that the subject of Chinnappan et al 2023 smoked heavily, it’s baffling why the paper was not titled “Tobacco-Induced ARDS”.
References
- Bernstein, S. (2022, December 2). Bilateral Interstitial Pneumonia. WedMD. https://www.webmd.com/covid/bilateral-interstitial-pneumonia
- Centers for Disease Control. (2010). A Report of the Surgeon General: How Tobacco Smoke Causes Disease…and What It Means to You (p. 11). https://www.cdc.gov/tobacco/data_statistics/sgr/2010/consumer_booklet/index.htm
- Chinnappan, J., Navari, Y., Casini, D., Palanisamy, N., Parikh, N., & Seedahmed, E. (2023). Kratom-Induced Acute Respiratory Distress Syndrome (ARDS). European journal of case reports in internal medicine, 10(4), 003835. https://doi.org/10.12890/2023_003835
- de Oliveira Rodrigues, S., Patricio de Almeida, M. A., Castro-Faria-Neto, H. C., Silva, A. R., & Felippe Gonçalves-de-Albuquerque, C. (2022). Mouse Model of Oleic Acid-Induced Acute Respiratory Distress Syndrome. Journal of visualized experiments : JoVE, (184), 10.3791/63566. https://doi.org/10.3791/63566
- Dontfraid, F., & Ramphal, R. (1994). Bilateral pulmonary infiltrates in association with disseminated actinomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 19(1), 143–145. https://doi.org/10.1093/clinids/19.1.143
- Feldman, J.D., Schriefer, D., Smith, K.E. et al. Omissions, Ambiguities, and Underuse of Causal Assessment Tools: a Systematic Review of Case Reports on Patients Who Use Kratom. Curr Addict Rep (2023). https://doi.org/10.1007/s40429-023-00466-7
- The Healthline Editorial Team. (2018, Septermber 16). Lung Consolidation: What It Is and How It’s Treated. healthline. https://www.healthline.com/health/lung-consolidation
- Rounds, S., Lu, Q., & Siamwala, J. (2022). CIGARETTE SMOKING INCREASES THE RISK OF ACUTE RESPIRATORY DISTRESS SYNDROME. Transactions of the American Clinical and Climatological Association, 132, 224–235.
- Smith, K. E., Dunn, K. E., Epstein, D. H., Feldman, J. D., Garcia-Romeu, A., Grundmann, O., Henningfield, J. E., McCurdy, C. R., Rogers, J. M., Schriefer, D., Singh, D., & Weiss, S. T. (2022). Need for clarity and context in case reports on kratom use, assessment, and intervention. Substance abuse, 43(1), 1221–1224. https://doi.org/10.1080/08897077.2022.2074608
- White, A., Wang, Z., Wang, X., King, M., Guo, C., Mantsounga, C., Ayala, A., Morrison, A. R., Choudhary, G., Sellke, F., Chambers, E., Ware, L. B., Rounds, S., & Lu, Q. (2022). NLRP3 inflammasome activation in cigarette smoke priming for Pseudomonas aeruginosa-induced acute lung injury. Redox biology, 57, 102467. https://doi.org/10.1016/j.redox.2022.102467