Hyponatremia is defined as a serum sodium concentration of less than 135 mEq/L. Severe hyponatremia is defined as a serum sodium concentration of less than 125 mEq/L and is a life-threatening complication that must be managed promptly to avoid irreversible neurological damage. One particular cause of hyponatremia is the ingestion of recreational drugs, such as 3,4-Methylenedioxymethamphetamine (MDMA), also known as Ecstasy. Another drug with limited understanding of its adverse effects on specific individuals and is widely available to purchase legally is Kratom (Mitragyna speciosa). Here, we present the case of severe hyponatremia secondary to the ingestion of Kratom. Kratom is believed to act on various pain-modulating receptors and may explain its role in causing hyponatremia. Unfortunately, Kratom remains poorly understood and underreported. Our case illustrates the need for further in-depth studies to determine the complete toxic profile of Kratom, providing awareness to clinicians in anticipation of severe complications that may develop.
Serum sodium concentration is tightly regulated on a physiological level between 135-145 mEq/L. Hyponatremia is defined as a serum sodium concentration less than 135 mEq/L and is dependent on the ratio of total body water (TBW) to total body solutes (TBS), as first proposed by Edelman in 1958 [1,2].
The extracellular space determines volume status and can explain how an imbalance of TBW to TBS leads to hyponatremia. Causes of hypovolemic hyponatremia include gastrointestinal fluid loss, diuretic use and mineralocorticoid deficiency . Causes of euvolemic hyponatremia include the syndrome of inappropriate antidiuretic hormone (SIADH), Addison’s disease, and hypothyroidism . Causes of hypervolemic hyponatremia causes include chronic renal failure, congestive heart failure, and cirrhosis . Once the volume status has been determined, further steps to consider in the workup of hyponatremia are calculating the serum osmolality, urine osmolality, and urine sodium concentration. The main symptoms of hyponatremia are neurologic, which stem from electrolyte imbalances causing cerebral edema. Acute hyponatremia occurs in less than 48 hours and tends to present with more severe neurologic presentations, whereas patients with chronic hyponatremia tend to have an adaptive mechanism of generating idiogenic osmoles to maintain an asymptomatic state .
Many drugs can cause hyponatremia, both legal and illegal. Of particular interest are substances that have been used for many years yet remain poorly studied and lack understanding of acute or chronic adverse effects. Kratom has over 25 distinct metabolically active alkaloids with side effects that remain underreported and are yet to be extensively studied for their efficacy and safety . Kratom can be obtained legally and acts on receptors similar to those of opioids. A few reported adverse effects that have been demonstrated are hypothyroidism, hypogonadism, hepatitis, acute respiratory distress syndrome, posterior reversible encephalopathy syndrome, seizure, and coma . …….