DROOLING, STIFF, AND MUTE! S Liang MD, K Bhyravabhotla MD, R Hammer MD Department of Medicine, Tulane Health Sciences Center, New Orleans, LA
INTRODUCTION: Kratom is commonly used to abate the symptoms of opiate withdrawal. Due to its complex pharmacology, kratom can exhibit opioid, stimulant, and/or psychotic effects, and may contribute to atypical phenotypes of substance toxidromes. Standard urine drug screens cannot detect kratom.
CASE: A 36-year-old man with heroin and alprazolam use presented with stiffness, mutism, and hypersalivation. After using heroin daily for ten days, he quit and used kratom for three days to “detox”. On presentation, he reported having been without heroin for seven days, alprazolam for four days, and kratom for three days. Two days prior to presentation, he experienced typical opioid withdrawal symptoms: diarrhea, sweating, nausea, and gastrointestinal upset. The next day, he developed bizarre delusions of “breathing out of his gills” and pondered the “negative side of the universe.” Twelve hours prior to presentation, he became mute, withdrawn and developed rigid extremities, a clenched jaw, and sialorrhea. On initial assessment, he was mute with a flat affect, hypersalivating and shivering with his mouth clenched. He was febrile to 100.8o F, tachycardic to 106 bpm, and tachypneic to 36 bpm. Pupils and reflexes were normal; his extremities had mild rigidity. Labs showed a hyperchloremic non-gap acidosis and mild leukocytosis, which resolved the following day. Urine drug screen was positive for opiates and benzodiazepines, but the urine was obtained after he was given these medications to treat presumed withdrawal. Blood cultures and infectious workup were negative. The patient received intravenous fluids and diazepam 5 mg every eight hours with rapid improvement in his vitals, physical exam and mental status. After three days, he transitioned to oral diazepam, however, subsequently eloped from the hospital. DISCUSSION: Our patient’s pattern of use and cessation from heroin, kratom, and benzodiazepines resulted in autonomic instability, psychosis, hypertonia, and sialorrhea, making his initial differential quite broad as demonstrated here with an atypical presentation of opioid and benzodiazepine withdrawal. In addition to substance toxicity and withdrawal, life-threatening conditions such as sepsis, serotonin syndrome, neuroleptic malignant syndrome, catatonia, and cholinergic syndrome were also considered and warranted admission to the internal medicine service. Meanwhile, kratom remains poorly regulated and readily available nationwide.
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