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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 57-60

Rapid normalization of thrombocytopenia following Ayurveda treatments in leptospirosis suspect: A case report


1 Regional Ayurveda Research Institute for Lifestyle Related Disorders, Poojappura, Trivandrum, Kerala, India
2 Regional Ayurveda Research Institute for Eye Disorders, Lucknow, Uttar Pradesh, India

Date of Submission08-Dec-2019
Date of Acceptance14-Jul-2020
Date of Web Publication16-Oct-2020

Correspondence Address:
Praveen Balakrishnan
Regional Ayurveda Research Institute for Lifestyle Related Disorders, Poojappura, Trivandrum- 695012, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JACR.JACR_45_20

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  Abstract 


Leptospirosis, a public health issue, is an infectious condition caused by bacteria of genus Leptospira. The disease comes under the category of acute febrile illness and manifests with fever (~Jvara), chills (~Jadyata), headache (~Shirahshula), myalgia (~Angamarda), vomiting (~Chardi), or diarrhea (~Atisara). The advanced form of the disease threatens life by causing either liver or kidney failure or meningitis or respiratory distress. Ayurveda classical literature provides an in-depth stage-wise description and treatment of Jvara (~febrile illness). This is an evidence-based case report of the rapid normalization of decreased platelet count by administering Amruthotharam kashayam and Punarnavadi kashayam in low frequent dose in a case of leptospirosis suspect.

Keywords: Ayurveda, leptospirosis, platelet count, thrombocytopenia


How to cite this article:
Balakrishnan P, Sudhakar D, Makhija P. Rapid normalization of thrombocytopenia following Ayurveda treatments in leptospirosis suspect: A case report. J Ayurveda Case Rep 2020;3:57-60

How to cite this URL:
Balakrishnan P, Sudhakar D, Makhija P. Rapid normalization of thrombocytopenia following Ayurveda treatments in leptospirosis suspect: A case report. J Ayurveda Case Rep [serial online] 2020 [cited 2020 Dec 2];3:57-60. Available from: http://www.ayucare.org/text.asp?2020/3/2/57/298294




  Introduction Top


Leptospirosis is a major neglected and highly under-reported public health issue in India.[1] A previous report in 2008 shows that Kerala is one of the five endemic states where leptospirosis is present.[2] It is an infectious disease caused by bacteria of genus Leptospira[3] where prompt treatment is required, else it may lead to kidney damage, meningitis, liver failure, respiratory distress, or even death.[4]

Management of Jvara (~fever) with associated complications is explained extensively in classical textbooks of Ayurveda. Hence, even leptospirosis may be managed successfully through Ayurveda. This is a case report of a rapid normalization of decreased platelet count (thrombocytopenia) in a case of leptospirosis suspect, who was treated through Ayurveda guidelines. Initial presentation of thrombocytopenia (platelets 89,000/μL) came to normal limits (platelets 3.06 lakhs/μL) within nine days of treatment. This case report can open doors for Ayurveda research in leptospirosis cases, and guidelines can be confirmed only after further evidence-based researches. This case has been reported confining to CARE guidelines.


  Case Report Top


A 69-year-old female had approached outpatient department with complaints of body pain (~Angmarda), headache (~Shirahshula), mild swelling all over the body (~Sopha), loss of appetite (~Agnimandya), and severe weakness (~Glani) associated with giddiness (~Bhrama) since about a week. Complaints started with Jvara associated with chills (~Jadyta), headache, and body pain since September 18, 2019, for which she was admitted elsewhere on September 19, 2019. Her previous reports showed decreased hemoglobin count (7.1%), leukocytosis, and mild lymphopenia (82% polymorphonucleocytes, 14% lymphocytes, and 2% eosinophils). Total white blood cell count (16,000 cells/mm 3) and erythrocyte sedimentation rate (50 mm/h) were elevated. Platelet (PLT) count was within normal limits (3.1 lakhs/μL) at that time. Serum sodium (137 mmol/L) and potassium (3.9 mmol/L) were within normal limits. To confirm the presence of leptospirosis, lepto IgM was suggested but was not performed as the patient refused it. She was given injection of ceftriaxone sulbactam, paracetamol, naproxen-domperidone, and pantoprazole. She was discharged on September 20, 2019, with an advice to continue the same medications for three more days and review on September 23, 2019, after investigating total and differential count, but she herself discontinued the medicines.

She then presented to hospital on September 24, 2019, with initially said complaints, for which she was admitted. She was afebrile, and her vitals were within normal limits. Her blood reports on September 25, 2019, showed elevated total count (TC = 12,300 cells/mm 3), leukopenia (21%), lymphocytosis (72%), and thrombocytopenia (PLT = 89,000 cells/μL).


  Timeline Top


The case was assessed as per Ayurveda guidelines and is described in [Table 1]. She was admitted, and Ayurvedic treatment was done after due consideration of the above details. Only internal medications and Pathya were prescribed [Table 2].
Table 1: Ayurveda parameters of the patient during the first visit at hospital

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Table 2: Timeline showing details of condition, medicines given along with dosage

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  Follow up and Outcome Top


The patient was discharged on October 03, 2019. Platelet count was checked on alternate days that showed an improvement, starting from 89,000 cells/μL on day one (September 25, 2019) to 3.06 lakhs/μL on day nine (October 03, 2019) [Figure 1]. Clinically, appetite became normal (~Samagni) with no myalgia, headache, swelling in the body, weakness, and giddiness.
Figure 1: Day-wise increase in platelet count following the administration of Ayurveda treatments

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  Discussion Top


Discussion on diagnosis as leptospirosis

Leptospirosis comes under the spectrum of acute febrile illness.[5] Laboratory confirmation of leptospirosis is based on the reference standard microscopic agglutination test, direct demonstration of the organism, and isolation by culture and DNA detection by polymerase chain reaction amplification.[6] Due to limited resources, these tests could not be performed. Clinical presentation of leptospirosis includes fever, chills, headache, muscle aches, vomiting, or diarrhea. The advanced disease presents with liver or kidney failure or meningitis.[4] Without treatment, recovery may take several months. Increased level of total white blood cells and neutrophils and decreased hemoglobin content are usually seen in a severe form of leptospirosis (which was quite evident from the previous report). Thrombocytopenia was nearly observed by 5th day, which may be the reason for the normalcy of platelet count in the previous report and its presence on the day of admission in this hospital.[7] Contemporary guidelines include early diagnosis and initiation of antibiotic treatment.[8] Ceftriaxone, a third-generation cephalosporin, is an efficient anti-leptospiral drug.[9],[10] Considering the clinical presentation, initial blood reports, and treatment given the disease could be diagnosed to be a case of leptospirosis, i.e., a leptospirosis suspect. Confirmation can be done only on the base of lepto IgM level but was not performed as the patient was not willing for it.

Discussion on Ayurveda diagnosis

Loss of appetite, myalgia, headache, weakness, and edema of body parts invariably indicate the presence of “Ama.”[11] Since the patient was febrile earlier, Jvara was diagnosed. Jvara had come down following the administration of paracetamol, but Ama was not resolved. Jvara is a Rasagata condition, and Ama can be said to be localized in Rasa, leading to loss of appetite, myalgia, headache, weakness, and giddiness (~Tandra).[12] Hence, it may be said that Sama rasa dhatu (Ama with Rasadhatu) without Jvara was the condition at the time of presentation in this hospital.

Discussion on treatment protocol

The basic treatment protocol of Ama and Jvara is Langhana initially. Hence, Langhana was performed by avoiding heavy, oily food and giving only rice gruel (~Kanji). Amruthotharam kashayam (AK) was taken as the drug of choice as it is Jvara shamana (~decrease fever) by Prabhava (~special effect), Ama hara due to the presence of Shunthi (~dry ginger), and Vata anulomana due to the presence of Haritaki (Terminalia chebula Retz.). Vettumaran gulika was added to it to remove Ama and for bringing margavishodhana (~clearing the pathways). Punarnavadi kashayam (PK) was taken as the other drug owing to the presence of whole-body edema. PK is basically selected as it is a drug which acts on inflammatory edema (Sopha [~edema – tumor]) associated with Jvara (~fever – calor) and Shoola (~pain – dolor). Leptospirosis may become life-threatening if not properly managed, i.e., it may lead to Prana nasha. Medicine was administered Muhurmuhu (~frequent low doses) considering the critical stage of the patient; Muhurmuhu is indicated in critical situations such as Visha badha (~toxic state).[13]

The medicine was prepared by taking 4 g each of AK and PK and was boiled in a liter of water and then reduced to 1/4th (250 ml). It was then administered in divided dose of 30 ml for every 2 h eight times a day. The total dose per day was 240 ml. This is an alteration to normal 120 ml of Kwatha per day. Here, the strength of the medicine was made weak by taking only 16 g (total) medicine per day instead of 30 g as per the normal dosage. Amruthotharam paneeyam was prepared like a Phanta kashaya, wherein 10 g of medicine was put in one litre of rolling boiling water, then closed with a lid and kept aside for self-cooling and then given for drinking as and when required.

Pathya always provides a conducive environment for reversing the disease pathology. Hence, light diet with abstinence from oily food was given to ensure the fast correction of Agni. Draksharishta was finally given to remove the weakness of the body.


  Conclusion Top


As the case was a leptospirosis suspect, this management protocol opens the door for possibility of Ayurveda treatment guidelines in definitive cases of leptospirosis and other infectious disease. Ayurveda classical literature has concretely described step-wise, stage-wise treatment protocol for Jvara. Even though effective Ayurveda treatments are given for leptospirosis in many places, there is a severe lack of evidences in the health database. More objective evidence is required to project the effectiveness of Ayurveda management strategy in leptospirosis.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/ caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rathinam S, Vedhanayaki R, Anjana S. Leptospirosis. In: Yu H, editors. Inflammatory and Infectious Ocular Disorders. Retina Atlas. 1st ed. Singapore: Springer; 2020. p. 159-62.  Back to cited text no. 1
    
2.
Shivakumar S. Medicine Update 2008. Leptospirosis Current Scenario in India. Ch. 106. 18th ed. Mumbai: APIIndia; 2008.p799-809.  Back to cited text no. 2
    
3.
National Health Portal. Leptospirosis. Available from: https://www.nhp.gov.in/disease/leptospirosis. [Last accessed on 2019 Dec 12].  Back to cited text no. 3
    
4.
Centres for Disease Control and Prevention. Leptospirosis. Available from: https://www.cdc.gov/leptospirosis/symptoms/index.html. [Last accessed on 2019 Dec 12].  Back to cited text no. 4
    
5.
Adiga DSA, Mittal S, Venugopal H, Mittal S. Serial changes in complete blood counts in patients with leptospirosis: Our experience. J Clin Diagn Res 2017;11:EC21-4.  Back to cited text no. 5
    
6.
Rajapakse S, Weeratunga P, Niloofa R, Fernando N, de Silva NL, Rodrigo C, et al. A diagnostic scoring model for leptospirosis in resource limited settings. PLoS Negl Trop Dis 2016;10:e0004513.  Back to cited text no. 6
    
7.
De Silva NL, Niloofa M, Fernando N, Karunanayake L, Rodrigo C, De Silva HJ, et al. Changes in full blood count parameters in leptospirosis: A prospective study. Int Arch Med 2014;7:31.  Back to cited text no. 7
    
8.
Patil H, Agrawal V, and Patil V. Clinical profile and outcome of leptospirosis at tertiary care centre in Western Maharashtra. J Academy Med Sci 2012;2:30.  Back to cited text no. 8
    
9.
Panaphut T, Domrongkitchaiporn S, Vibhagool A, Thinkamrop B, Susaengrat W. Ceftriaxone compared with sodium penicillin g for treatment of severe leptospirosis. Clin Infect Dis 2003;36:1507-13.  Back to cited text no. 9
    
10.
Raptis L, Pappas G, Akritidis N. Use of ceftriaxone in patients with severe leptospirosis. Int J Antimicrob Agents 2006;28:259-61.  Back to cited text no. 10
    
11.
Tripathi B, editor. Commentary Madhukosha of Vijayarakshita and Srikantadutta on Madhava Nidana of Sri Madhavakara, Panchanidana Lakshanam. Ch. 1., Ver. 3., 1st ed. Varanasi: Chowkhambha Sanskrit Series; 2010. p. 20.  Back to cited text no. 11
    
12.
Trikamji J, editor. Charaka Samhita of Agnivesa with Ayurveda Dipika Commentary by Sri Cakrapanidutta, Sootra Sthana; Vividha Ashita Peeteeyam Adhyaayam. Ch. 28., Ver. 9-10., 1st ed. Varanasi: Chowkhambha Sanskrit Sansthan; 2010. p. 179.  Back to cited text no. 12
    
13.
Shivaprasad S, editor. Astanga Samgraha of Vruddha Vagbhata with Sashilekha Commentary by Sri Indu, Sutra Sthana; Bheshajavachareenyam Adhyaayam. Ch. 23., Ver. 21., 3rd ed. Varanasi: Chowkhambha Sanskrit Sansthan; 2012. p. 180.  Back to cited text no. 13
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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