A 54-year-old man utilized the supplement kratom for symptom management of Crohn’s disease. After acquiring a new formulation of the supplement, he presented to the emergency department with nausea and lightheadedness after accidentally ingesting approximately 10 times his usual dose. His initial electrocardiogram (ECG) demonstrated coved ST elevation, as seen with a type I Brugada pattern (Fig. 1A). His presenting potassium level was 3.4 mmol/L, and his magnesium level was 0.66 mmol/L. His echocardiogram was normal. Supportive care was provided in the intensive care unit, with full resolution of the ST-segment elevation occurring within 24 hours. A procainamide challenge (1 mg/kg dose) was subsequently performed, which did not demonstrate any ST-segment changes in the usual and modified V1 and V2 lead positions (Fig. 1B). The temporal association of kratom ingestion and the negative procainamide challenge suggested a Brugada phenocopy due to kratom.
Figure 1.
Electrocardiogram obtained (A) on presentation to the hospital after Kratom ingestion and (B) 15 minutes after administration of 1 mg/kg of intravenous procainamide. Leads V1 and V2 are positioned in the conventional position (4th intercostal space), and leads V5 and V6 are positioned in a higher position (2nd intercostal space).
Brugada syndrome and Brugada phenocopies have similar ECG patterns, but they are clinically distinct entities, with the former being related to a cardiac channelopathy and the latter being a specific environmental insult.1 Kratom is an extract from the Mitragyna speciosa tree found in Southeast Asia. Although this herb is touted to boost energy and mood, and relieve pain, it is not approved by either Health Canada or the US Food and Drug Administration. Few case reports on the development of a Brugada ECG pattern with kratom overdose exist.2,3 Mitragynine, the primary alkaloid in kratom, inhibits delayed rectifier potassium currents leading to a prolongation of the action potential duration and QT interval.4 However, the mechanism of the Brugada phenocopy with kratom is not clear. The presence of a negative procainamide challenge suggests that the patient did not have an inherent abnormality of his sodium channels. One possibility is that hypokalemia at the time of his illness contributed to this ECG pattern.1
The patient was advised to avoid kratom and has not had any arrhythmic symptoms (palpitations, presyncope, or syncope) for over 1 year of follow-up evaluation. Clinicians should be aware of this ECG phenomenon, given the increasing use of this unregulated agent.
Novel Teaching Points.
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Kratom is an unregulated herb that may inhibit myocardial ion channels.
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Kratom may mimic a type 1 Brugada ECG pattern. The long-term implication of this pattern in the absence of kratom use is unclear.
Acknowledgments
Ethics Statement
Ethics approval was not required for this case report due to the deidentified nature of the report.
Patient Consent
Informed consent including the use of images was obtained from the patient.
Funding Sources
The authors have no funding sources to declare.
Disclosures
The authors have no conflicts of interest to disclose.
Footnotes
See page 325 for disclosure information.
References
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