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SAEM Clinical Image Series: Surfing Sting

sting

A 38-year-old male presents 8 days after being stung in the left foot while surfing. He reports the sudden onset of sharp pain while walking in the ocean. He was seen initially in the emergency department. The puncture wound on his left foot was anesthetized, explored, and irrigated. No X-ray was obtained, no foreign body was discovered, and he was discharged home.

Two days ago, he noticed worsening heat, itchiness, swelling, and skin changes (red bumps and patches extending from the foot up to the lower calf) in his left foot. His current pain is rated 3/10 and localized to the left foot. The patient is able to walk and bear weight. He has been taking ibuprofen for pain control and is not taking antibiotics. He denies fevers, but reports fatigue and feels more cold than usual.

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By |2020-11-29T21:29:33-08:00Nov 30, 2020|Academic, Emergency Medicine, SAEM Clinical Images, Tox & Medications|
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ACMT Toxicology Visual Pearls: Case of a Toxic Tea

teakratom

The plant pictured is used as a tea, powder, or capsule by individuals looking to self-treat pain or opioid use disorder.  Patients may develop nausea, vomiting, hallucinations, or other serious clinical effects after ingestion.  What compound is contained in this plant?

  1. Arecoline from Areca catechu
  2. Kava lactone from Piper methysticum
  3. Mitragynine from Mitragyna speciosa
  4. Salvinorin from Salvia divinorum

Answer

3 – Mitragynine from Mitragyna speciosa also known as Kratom

What is Kratom? [1-6]

  • Kratom is an herbal product that derives from the tree Mitragyna speciosa, native to Southeast Asia, where it has been historically used as a stimulant.
  • Recently it has grown in popularity in western countries for its opioid activity, primarily used to self-treat opioid withdrawal and chronic pain.
  • It is sold in several forms including leaves, powder, capsules, gum, and extract.
  • The active compound, mitragynine, may cause nausea, vomiting, hallucinations, and opioid-like Deaths have been reported.
  • There are currently no FDA-approved uses for kratom and its legal status is evolving, most recently classified by the DEA as a Drug and Chemical of Concern. The FDA continues to warn consumers not to use any products labeled as containing the botanical substance kratom or its psychoactive compounds, mitragynine, and 7-hydroxymitragynine.

What is the clinical presentation of kratom toxicity? [1,3,5,7]

  • Kratom contains over 40 alkaloids, including mitragynine. Mitragynine is primarily a mu-opioid receptor agonist but also has activity at postsynaptic α-2, serotonin, dopamine, adenosine, and additional opioid receptors.
  • Kratom’s neuropsychiatric effects occur rapidly after ingestion and may last 4-6 hours after the exposure.
  • At lower ingestions (approximately 2-6 grams) kratom acts as a stimulant, while larger ingestions predominantly result in sedation and other opioid effects.
  • The dose-dependent effects of kratom are thought to be due to the dual binding of α adrenergic receptors leading to stimulation and μ opioid receptors causing sedation.
  • Gastrointestinal symptoms including nausea, vomiting, and constipation
  • Cardiovascular symptoms such as tachycardia and hypertension
  • Neurologic symptoms including seizures, hallucinations, agitation, psychosis, and coma
  • Respiratory depression can occur
  • Substance use disorder and withdrawal are reported with symptoms similar to other opioids.

How do you manage kratom toxicity? [1, 3]

  • Minor symptoms generally require only supportive care
  • Naloxone can reverse opioid effects
  • Benzodiazepines can be used to treat patients with seizures, tachycardia, hypertension, and agitation.
  • Withdrawal and substance use disorder may be managed similarly to other opioids.

Bedside pearls

  • Kratom use is increasingly popular in the United States, often for self-treatment of chronic pain or opioid use disorder.
  • Kratom acts on many different receptors, including the μ, κ, and δ opioid receptors, which contributes to potential withdrawal symptoms and substance use disorders
  • Toxicity can lead to life-threatening symptoms such as respiratory depression, seizure, and coma
  • Withdrawal presents similarly to opioid withdrawal and should be managed similarly

This post has been peer-reviewed on behalf of ACMT by William Eggleston, Bryan Judge, and Louise Kao

The American College of Medical Toxicology hosts this Toxicology Visual Pearls series.

References

  1. Rech MA, Donahey E, Cappiello Dziedzic JM, Oh L, Greenhalgh E. New drugs of abuse. Pharmacotherapy. 2015;35(2):189-197. doi:10.1002/phar.1522 PMID: 25471045
  2. Stolt AC, Schröder H, Neurath H, et al. Behavioral and neurochemical characterization of kratom (Mitragyna speciosa) extract. Psychopharmacology (Berl). 2014;231(1):13-25. doi:10.1007/s00213-013-3201-y  PMID: 23846544
  3. Fox LM. Plant- and Animal-Derived Dietary Supplements. In: Goldfrank’s Toxicologic Emergencies. Nelson LW Howland MA Lewin NA eds; 11th edition 2019; McGraw Hill,
  4. Boyer EW, Babu KM, Adkins JE, McCurdy CR, Halpern JH. Self-treatment of opioid withdrawal using kratom (Mitragynia speciosa korth). Addiction. 2008;103(6):1048-1050. doi:10.1111/j.1360-0443.2008.02209.x PMID: 18482427
  5. Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Kratom Use and Toxicities in the United States. Pharmacotherapy. 2019;39(7):775-777. doi:10.1002/phar.2280 PMID: 31099038
  6. Department of Justice/Drug Enforcement Administration Drug Fact Sheet:  Kratom.  Available at: https://www.dea.gov/factsheets/kratom, accessed August 24, 2020
  7. Swogger MT, Walsh Z. Kratom use and mental health: A systematic review. Drug Alcohol Depend. 2018;183:134-140. doi:10.1016/j.drugalcdep.2017.10.012  PMID: 29248691
By |2020-11-11T13:55:15-08:00Nov 9, 2020|ACMT Visual Pearls, Emergency Medicine, Tox & Medications|
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SAEM Clinical Image Series: Red, White, & Blue

bite

A 29-year-old female presented to the emergency department for a rash on her right calf. 5 days prior, at her home in Alabama, the patient developed pain and swelling of her right calf following a spider bite while putting on her pants. The patient felt a “burning pain” and found a spider which she then killed. She went to a hospital and received cephalexin, trimethoprim/sulfamethoxazole, and oxycodone. Despite taking these medications she continued having aching pain rated 10/10 in her right calf along with generalized pruritus. The patient stated that the bite evolved from an initial generalized redness into a blue/black lesion with blistering and extensive redness along her leg and torso. She denied fever, chills, lightheadedness, abdominal pain, nausea, vomiting, and hematuria.

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By |2020-10-13T21:07:28-07:00Oct 12, 2020|Dermatology, Emergency Medicine, Environmental, SAEM Clinical Images, Tox & Medications|
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SAEM Clinical Image Series: The Cocaine Gut

pneumoperitoneum

A sixty-five-year-old male with a medical history of gastroesophageal reflux disease (GERD), hypertension, alcohol dependence, homelessness, and cocaine abuse presents to the emergency department with abdominal pain for three days. The patient describes his abdominal pain as knife-like, 9/10, located diffusely throughout his abdomen, with associated anorexia and nausea. He reports that he had one episode of coffee ground emesis this morning which provoked him to come to the ED. He reports frequent cocaine use with his last use three days ago. He endorses subjective fevers, chills, and no bowel movement for two days. He has had no sick contacts.

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By |2020-08-14T13:13:28-07:00Aug 17, 2020|Emergency Medicine, SAEM Clinical Images, Tox & Medications|
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