Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Oct 27, 2020; 12(10): 863-869
Published online Oct 27, 2020. doi: 10.4254/wjh.v12.i10.863
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
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
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).
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:
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.
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

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.


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.


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 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.

Keywords: Case report, Kratom, Cholestasis, Liver injury, Mitragyna speciosa, Cholangitis, Substance induced injury

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.