The subject of this report is a 29 year old male, US citizen of Palestinian descent, who works full-time as a biomedical research technician. His health history is unremarkable, except for the fact that at age 16 he was diagnosed with ulcerative colitis and primary sclerosing cholangitis. Since then, he has been treated successfully with mesalamine (1.2 g, 2 times per day), azathioprine (50 mg, 3 times per day), and ursidiol (300 mg, 2 times per day). The subject has been able to live an active lifestyle and participate in a variety of sports including running, weightlifting, basketball, and baseball. The subject denies any history of smoking or use of alcohol, opioids, or illicit drugs. On April 22, 2020, the subject's father, who lives in the same house as the subject, and works for a major shipping company, was diagnosed with COVID-19. This was about 2 months after the first case of COVID had been confirmed in his state of residence, which was one of the early active zones of COVID-19 transmission in the US. On April 25, the patient began to experience general malaise and fatigue. Over the next 24 h, the symptoms worsened to include severe fatigue and weakness, loss of appetite, tiredness, slight dry cough, body aches, muscle pain, loss of taste and smell, sore throat and fever. The patient was then seen by his general practice physician. Vital signs at the time of examination were BP 110/72, pulse 97 BPM, respiration 14 per minute, oxygen saturation 98%, and body temperature 101.7 F. The patient was given a naso-pharyngeal swab, real-time RT-PCR test [COBAS (R) SARS-COV-@ test, Labcorp Laboratories, South Bend, IN] that confirmed a diagnosis of COVID-19. In compliance with standard medical practice standards, the patient was ordered to self-isolate and to start a 5-day course of azithromycin (250 mg, daily), and to also take 1 g of paracetamol (acetaminophen) every 6 h for treatment of pain and fever. Despite good adherence to the recommended treatment, the symptoms other than fever, did not improve, and he also started to feel depressed, demotivated, and spend long periods in bed. During this period, the patient experienced ongoing generalized myalgia and musculoskeletal pain. He described the pain as persistent and relatively severe (rated 7 on a scale of 1-10). Because of this discomfort, after 4 days the patient decided to consume kratom to relieve his symptoms. According to the patient, he had first used kratom 14 months earlier before his COVID-19 infection. He used kratom sporadically (no more than 4-5 times in total) as a cognitive enhancer and not to self-treat pain.
The patient decided to take 2.5 gms (or grams) of green kratom (as ground leaf powder suspended in water). The product was purchased at a local shop in April 2020 sold under the name "Green Bali." After 30 min, he noticed a significant improvement in the intensity of the physical symptoms (mainly pain and fatigue), and within 60 min he felt a sensation of mild euphoria and well-being that lasted for about 5 h. After 6 h following consumption the effects of kratom wore off, and the patient administered another dose. He used kratom three times a day continuously for 3 days (for a total of 9 doses of 2.75 g each) with significant benefit.
When asked to score from 0 to 100% the improvement that kratom had on COVID-19 symptoms: fatigue and weakness (80% improvement), tiredness (70% improvement), body aches (80% improvement), muscle pain (90% improvement, "much better than paracetamol/acetaminophen"). The kratom did not seem to have an impact on: fever, cough, or sore throat. The patient also stated: "I didn't have anxiety or any psychological symptoms. For me, kratom mainly gave improvement in physical reaction." "It also elevated my mood and made me feel less miserable, to the point where I was able to get out of bed, shower, look at work emails without feeling completely exhausted and drained"; "Kratom helped me more than antibiotic"; "I slept better, I essentially fell asleep immediately. Without kratom, sleep was not nice, with kratom less wake ups, about 6 h." Over the next 2 weeks the patient's symptoms gradually subsided and on May 13 he had a televisit with his physician and a follow-up swab test that was negative for COVID-19. The subject was able to end his quarantine and return to work in early June. In a follow-up interview with us, the patient reported that he did not experience any side effects from using kratom, except for a very bad taste when swallowing it. The patient was also able to discontinue kratom use immediately without any evidence of physical or psychological withdrawal symptoms. The patient also informed us that he still had some of the kratom product that he had taken and he agreed to provide us with a sample for chemical analysis.
An established quantitative liquid chromatography mass spectrometry method was conducted and found that the sample obtained from the patient is kratom due to the presence of mitragynine (102 mg/g kratom powder) and 7-hydroxymitragynine (0.8 mg/g kratom powder). The extracted kratom sample was analyzed for the presence of 13 opioids and 8 benzodiazepines by comparing the chromatograms to those of the reference mixtures Pain Management Multi-component Opiate Mixture-13 solution and Benzodiazepine Multi-component Mixture-8 solution. These data suggest the sample was not fortified with 7-hydroxymitragynine and there was also no evidence of adulteration with opioids or common benzodiazepines in the sample.