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

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.