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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 25-29

Management of dimorphic anemia through Ayurveda


1 Department of Kayachikitsa, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya, India
2 Department of Rasa Shastra & Bhaishajya Kalpana, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya, India

Date of Submission28-Sep-2019
Date of Acceptance08-May-2020
Date of Web Publication14-Jul-2020

Correspondence Address:
Dr. Rehana Parveen
Department of Kayachikitsa, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JACR.JACR_3_20

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  Abstract 


Dimorphic anemia is one of the common forms of anemia in India, but there is a paucity of literature regarding this entity. It has a complex pathogenesis with involvement of more than one deficiency state, usually due to deficiency of both iron and Vitamin B12or folic acid, characterized by two different cell populations, comprising of microcytic hypochromic with macrocytic normochromic red blood cells. Conventional treatment of such condition is supplementation of iron and Vitamin B12, but the long-term treatment with iron salts is associated with several side effects. An alternative approach of therapy is to enhance the absorption of dietary iron and Vitamin B12, rather than increasing them in the diet. This is a case study of a 33-year-old female patient from Shillong, Meghalaya, presented with dimorphic anemia to Kayachikitsa outpatient department at Ayurveda Hospital, North Eastern Institute of Ayurveda and Homoeopathy, Shillong. Ayurvedic treatment regimen comprising of herbo-mineral and metallic preparations was administered for a period of 70 days, which resulted in marked rise in hemoglobin level, hematocrit, mean corpuscular volume, and reticulocyte count along with changes in the peripheral blood smear. Ayurvedic principles and drugs with its multidimensional approach can prove to be immensely effective in the management of this condition as evident in this case study.

Keywords: Dhatri lauha, dimorphic anemia, iron, Kasisa bhasma, Vitamin B12


How to cite this article:
Parveen R, Baruah H. Management of dimorphic anemia through Ayurveda. J Ayurveda Case Rep 2020;3:25-9

How to cite this URL:
Parveen R, Baruah H. Management of dimorphic anemia through Ayurveda. J Ayurveda Case Rep [serial online] 2020 [cited 2020 Aug 6];3:25-9. Available from: http://www.ayucare.org/text.asp?2020/3/1/25/289374



[TAG:2]Introduction[/TAG:2]

Anemia, the most common hematological disorder in all age groups, globally affects 1.62 billion people, which corresponds to 24.8% of the population.[1] It is estimated that more than half of all Indian women and three-fourth of Indian children suffers from anemia.[2] Dimorphic Anemia (DA) is a specific form of anemia, which has a complex pathogenesis with involvement of more than one deficiency state, usually due to deficiency of both iron and Vitamin B12 or folic acid.[3] This condition may be reflected by increased red cell distribution width in the presence of normal mean corpuscular volume, with dimorphic blood picture showing two Red Blood Cell (RBC) populations, that is combination of microcytic hypochromic and macrocytic normochromic cells.[4] DA is one of the common forms of anemia in India, but there is a paucity of literature regarding this entity. One study conducted in India showed the incidence of DA to be 12.5%.[5] Other causes of dimorphic anemia include Iron Deficiency Anemia (IDA) responding to iron therapy, after transfusion of normal blood to a patient with a hypochromic anemia, sideroblastic anemia, macrocytic anemia, the unmasking of iron deficiency following treatment of megaloblastic anemia, and delayed transfusion reactions. Nutritional anemia, which is an important cause of dimorphic anemia, is a significant problem worldwide. The role of complete hemogram and Peripheral Blood Smear (PBS) examination is much emphasized.[3] In spite of significant developments in the diagnostic modalities, PBS examination remains an invaluable component of hematology,[5] and it may also guide further testing and patient management.[6],[7] Serum iron studies and serum ferritin assay are sufficient in arriving at the diagnosis of IDA. For macrocytic anemia, smear examination and reticulocyte count form the first line of investigation. Based on these results, further laboratory tests are ordered namely serum Vitamin B12, folic acid, hemolytic profile, or marrow examination, if required.[8] Concomitant Vitamin B12 or folate deficiency with iron deficiency results in masked megaloblastosis, where the vitamin deficiencies are not associated with the classic findings of megaloblastic anemia. If treated with iron alone, megaloblastosis will be unmasked.[9]

In Ayurveda, Panduroga (~anemia) has been described in almost all classical texts in detail, but the spectrum of Panduroga is not just limited to anemia. The etiology, pathogenesis, clinical features, prognosis, complications, and management of Pandu in relation to anemia hold grounds till date. Dimorphic anemia can be interpreted as Vata-kaphaja pandu in Ayurveda, and the possible explanation for the same may be that Ranjakapitta can be considered as hemoglobin as the function of the both is to color the RBCs. Vata causes Kshaya[10] (~decrease) in the size and color of the RBCs, therefore microcytic and hypochromic state of hemoglobin indicates toward Vataja pandu. Kapha is responsible for Guruta[11] (~heaviness) and enlargement of the cells as well as diminishes the Agni (~digestive capacity), hence macrocytic and hyperchromic state of RBC indicates to Kaphaja pandu. Increase in Erythrocyte Sedimentation Rate (ESR) may be due to Agnimandya (~diminished digestive capacity), which produces Ama (~metabolic toxins), and increase in ESR may be taken as indicative of Ama, which occurs due to Guruta of RBC caused by attachment of antigen–antibody product on RBC.[12]

Conventional treatment of such condition is supplementation of iron and Vitamin B12, but the long-term treatment with iron salts is associated with several side effects, such as heartburn, nausea, upper gastric discomfort, constipation, and diarrhea.[13] Recently, it has been shown to generate damaging free radicals in the intestine.[14] An alternative approach of therapy is to enhance the absorption of dietary iron, rather than increase iron in the diet. A variety of such substances have been marketed, namely, surface acting agents, carbohydrates, inorganic salts, amino acids, and ascorbic acid. None of these have become popular, although ascorbic acid seems to be promising.[15] Ayurvedic principles and medications can be put to use very effectively in these scenario, many of which have been scientifically validated.[16] The aim of the present case report is to highlight the presentation and treatment of this aspect of anemia with a brief review of the existing literature and create awareness among practicing Ayurvedic physicians about a treatable condition.

[TAG:2]Case Report[/TAG:2]

A 33-year-old, female, non-vegetarian, residing at Jaiaw, Shillong, presented to Kayachikitsa outpatient department at Ayurveda Hospital, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, with the chief complaints of generalized weakness, giddiness, exertional dyspnea, and decreased appetite for two months along with mild ankle edema for 12 days. The ankle edema was bilateral, was pitting in character, and was not associated with pain. The patient was non-diabetic and non-hypertensive. There was no history of fever, chest pain, vomiting, diarrhea, jaundice, bleeding diathesis, etc.

Examination of the patient revealed a pulse rate of 92/min, a blood pressure of 114/70 mmHg (supine), and an axillary temperature of 98°F. She had moderate conjunctival pallor and no icterus. There was no lymphadenopathy, clubbing, skin rashes, or pigmentation. Cardiovascular examination revealed a normal S1 and S2 with no murmur. Upon examining the chest, vesicular breath sound was heard with no added sound, and nervous system examinations were within normal limits. Gastrointestinal Tract (GIT) examination showed aphthous ulcers in the oral mucosa, and abdominal examination was normal. No specific etiological factor was found in the history and physical examination.

Peripheral smear showed dimorphic picture with moderate degree of anisopoikilocytosis; hypochromic cells are predominant and normocytic cells are seen with a good number of macrocytes with hypochromatosis, macro-ovalocytes, and hypersegmented neutrophils. Vitamin B12 deficiency was confirmed biochemically by low levels of serum Vitamin B12(113.4 pg/mL) and normal folic acid (4.9 ng/mL). Iron deficiency state was further confirmed by markedly elevated serum total iron-binding capacity (521 μg/dl) and moderately low serum ferritin levels (23 ng/ml). The patient's routine liver and renal function tests were within normal limits. Her chest X-ray and ultrasound-whole abdomen revealed no significant abnormalities except for mild hepatomegaly. Her upper GIT endoscopy showed antral gastritis. On examining, Prakr.uti (~body constitution) was Vata-kaphaja; Agnibala (~digestive power) and Sharirbala (~physical strength) were Madhyama (~average) and Satva and Avara (~poor).

[TAG:2]Treatment Protocol[/TAG:2]

Considering the history, clinical examination, and investigations, treatment was given for a period of 70 days with three follow-ups on day 20th, 50th, and 70th [Table 1].
Table 1: Treatment protocol

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[TAG:2]Followup and Outcome[/TAG:2]

A total of three follow-ups were done and during each visit, the patient was asked to repeat Complete Blood Count (CBC) while serum ferritin, Total Iron Binding Capacity (TIBC), vitamin B12 and folic acid were done only before and after completion of treatment, the results of which are presented in [Table 2].
Table 2: Results of lab investigations

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PBS on the 50th day of treatment showed dimorphic picture and predominant hypochromic cells and normocytic cells. White Blood Cells (WBCs) were normal in number with relative lymphocytosis and a few hyper-segmented neutrophils. Platelets were adequate in number. No malignant cells and haemoparasites were seen. On the 70th day, PBS confirmed the absence of dimorphic picture, while mild aniso-poikilocytosis was still existing, there was predominant normocytosis with hypo-chromatosis, and WBCs were normal in number with relative lymphocytosis with a few hyper-segmented neutrophils. Platelets were adequate in number. No malignant cells and haemoparasites were seen.

[TAG:2]Discussion[/TAG:2]

The line of treatment was decided for Vata kaphaja pandu. Drugs were selected with the intention to achieve Deepana (~carminative), Pachana (~digestive), Mala shuddhi (~laxative), and Dhatuposhana (~nutritional). The efficacy and safety profile of Dhatri lauha in IDA has been established through various studies and also through cluster analysis.[17]Dhatri lauha[18] comprises of Amalaki (Emblica officinalis Gaertn.), Lauha bhasma (~incinerated iron), root of Yastimadhu (Glycyrrhiza glabra Linn.) , and stem of Guduchi (Tinospora cordifolia [Willd.] Miers). Amalaki possesses antioxidant activity and is an important dietary source of Vitamin C, which is a powerful water soluble antioxidant[19] and aids in increasing iron absorption from the gut.[20]Avipattikara churna[21] was given for Mala shuddhi (~laxative).

According to Ayurvedic literature, most of the drugs in Punarnava mandoora[22] such as Triphala[23] [combination of Amalaki (Emblica officinalis Gaertn.), Haritaki (Terminalia chebula Retz.) and Bibhitaki (Terminalia bellirica Roxb.)], Trikatu[24] [combination of Sunthi (Zingiber officinalis Rosc.), Maricha (Piper nigrum Linn.) and Pippali (Piper longum Linn.)], Chitraka[25] (Plumbago zeylanica Linn.), Vidanga[26] (Embelia ribes Burm.), and Pippalimula[26] (root of Piper longum Linn.) are having appetizing, digestive, and carminative properties. Hence, it improves digestive power and ultimately absorption of nutrition as well as drug. One study on Pippali suggests that, piperine gets absorbed very quickly across the intestinal barrier through the intracellular pathway. It may modulate membrane dynamics due to its easy partitioning, thus helping in efficient permeability across the barriers.[27] In addition, Pippali is said to be bio-availability enhancer of the drug,[28] which further helps in easy assimilation of the drug components. Hence, it counteracts poor digestion and absorption usually reported in patients with dimorphic anemia.[29]Mandura bhasma (~incinerate form of iron – Fe2O3) is the main component and is the chief responsible component for the pharmacodynamics of Punarnava mandoora. It pacifies aggravated Pitta by virtue of its Rasa (~taste) and Guna (~properties). The ferric and ferrous fractions of Mandura provide sufficient amount of iron to the living matter, which is needed for normal erythropoiesis.[30]

Presumably, Ayurvedic medicines contain trace elements in a bioavailable form, and their impact on the overall pharmacological action cannot be ruled out. The cobalt (Co) and iron (Fe) content was observed to be high in roots of Ashwagandha (3.91 μg/g), suggesting their use in medicinal preparation for the treatment of anemia.[31] This plant was also found to be rich in copper (Cu), nickel (Ni), manganese (Mn), and Zinc (Zn),[32] which are important hemopoetic factors. In addition to this, Ashwagandharishta is also considered to be Balya (~strengthening) and Brimhaniya (~anabolic).[33]

Current lifestyle, food choices, and injudicious use of medications have contributed immensely to Vitamin B12 deficiency and deficiencies of minerals such as chromium, copper, iron, magnesium, manganese, selenium, and zinc.[34],[35]Takra (~butter milk), which has been used as an Anupana (~adjuvant) for Punarnava mandoora , detoxifies body and cleanses the intestines, relieves constipation, and helps to replenish intestinal flora. It has less fat compared to milk and is rich in calcium, potassium, and Vitamin B12. In Ayurveda, it has been suggested as a medicine either singly or in combinations, especially in the diseases of the colon where homeostasis of digestion and absorption is inevitable.[36]Kasisa bhasma[37] (~ incinerated green vitriol) is said to be Vata-sleshmahara, Pandughna (~anti-anemic), and Raktasanjanana (~hematinic). The Panduhara (~anemia treating) property of Kasisa bhasma was validated by two clinical reports that determined its significant role in the management of sickle cell anemia and IDA.[38] Recent experiments on rat models also substantiated the anti-anemic activity of Kasisa bhasma.[39]

[TAG:2]Conclusion[/TAG:2]

In India, iron deficiency is the most common cause of anemia, but as mentioned above, sometimes, iron deficiency may be masked by Vitamin B12 deficiency and Vice versa as seen in dimorphic anemia which till date remains an undermined entity. It is characterized by two different cell populations, comprising microcytic hypochromic with macrocytic normochromic RBCs. It is important to establish the correct diagnosis to avoid inappropriate therapy. Ayurvedic principles and drugs with its multidimensional approach can prove to be immensely effective in the management of this condition as evident in this case study.

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.



 
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