S5640 When Psoriasis Heals and the Liver Fails: A Unique Presentation of Kratom Toxicity

Introduction: Kratom is a popular, unregulated herbal supplement used for its psychotropic and opioid-like effects. It has emerged as a significant cause of drug-induced liver injury, including rare cases of acute liver failure (ALF). Little is known about its immunomodulatory effects. We present a unique case of spontaneous remission of plaque psoriasis from acute liver failure due to Kratom. Case Description/Methods: A 43-year-old woman with a past medical history of plaque psoriasis presented to the emergency room with confusion, nausea, and jaundice for the past week. She reported drinking multiple bottles of Kratom daily for chronic back pain for the past 5 months. She was not on any medication for psoriasis. One week before presentation to the hospital, she experienced near-complete resolution of her psoriatic plaques after years of persistent symptoms. Liver function tests were notable for bilirubin of 23 mg/dL, alkaline phosphatase 1,436 U/L, aspartate aminotransferase 644 U/L, alanine aminotransferase 115 U/L, and international normalized ratio 1.18. Physical exam showed no active psoriatic lesions. Liver serological workup was unremarkable for alternative etiologies of elevated liver enzymes. She was treated with empiric N-acetylcysteine for 3 days and Budesonide 9 mg daily for one week. At 2-month follow up, her liver function had vastly improved. Remarkably, her psoriasis remained in remission without any treatment. Discussion: Spontaneous resolution of chronic plaque psoriasis is rare and typically suggests a profound shift in immune regulation. This case presents an unusual instance where ALF was associated with the complete remission of psoriasis. Psoriasis is a chronic, Th1/Th17-mediated autoimmune condition, and spontaneous resolution is uncommon. The abrupt and complete remission of psoriasis immediately before Kratom-induced acute liver failure suggests a potential immune shift triggered by acute liver failure. ALF is associated with alterations in immune regulation, including impaired antigen presentation, lymphocyte dysfunction, and a shift in cytokine profiles. There is limited evidence that acute hepatitis can induce a shift from Th1/Th17 (pro-inflammatory) to a Th2 (anti-inflammatory) cytokine predominance. This inflammatory change may lead to the suppression of the inflammatory state associated with psoriasis. This case underscores the complex interplay between liver injury and systemic immune regulation. As the use of herbal supplements like Kratom grows, clinicians should remain vigilant for both their toxic and unexpected immunologic effects.