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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 6-10

Ayurvedic approach for management of idiopathic thrombocytopenic purpura: A case report


1 Graduate-Public Health Nutrition, Case Western Reserve University, CWRU, Cleveland, Ohio, USA
2 Department of Basic Principles, National Institute of Ayurveda, Jaipur, Rajasthan, India

Date of Submission22-Mar-2021
Date of Acceptance14-May-2021
Date of Web Publication17-Jun-2021

Correspondence Address:
Dr. Ankita Agarwal
1047, Bordentown Ave, Parlin, New Jersey 08859
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_24_21

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  Abstract 


Idiopathic thrombocytopenia is a disorder that leads to easy or excessive bleeding results from unusually low levels of platelets. Treatment modalities for Idiopathic Thrombocytopenic Purpura (ITP) are available in modern science, namely corticosteroids, etc., have a lot of side effects, and include risky surgical procedures such as splenectomy. However, Ayurveda approach gives an understanding of its causes, pathogenesis, and treatment planning. Here, a case of chronic ITP diagnosed as per western medicine is being presented, which was treated with Ayurveda modalities. The patient was diagnosed with Raktapitta (~bleeding/hemorrhagic disorder) and was treated with oral medicines mentioned in Raktapitta chikitsa along with medicated food for two months. The patient's condition was assessed based on the symptoms of Raktapitta like Atyartava (~excessive menstrual bleeding), along with standard objective parameters such as platelets count, WHO bleeding scale, and ultrasonography. Significant improvement was noted in this case in both classical signs and symptoms (Atyartava and Bhrama) as well as in objective parameters. This case gives a focus on the prognosis and treatment approach of ITP through Ayurveda point of view.

Keywords: Atyartava, Ayurveda food, idiopathic thrombocytopenic purpura, Raktapitta


How to cite this article:
Agarwal A, Panja AK. Ayurvedic approach for management of idiopathic thrombocytopenic purpura: A case report. J Ayurveda Case Rep 2021;4:6-10

How to cite this URL:
Agarwal A, Panja AK. Ayurvedic approach for management of idiopathic thrombocytopenic purpura: A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2021 Dec 4];4:6-10. Available from: http://www.ayucare.org/text.asp?2021/4/1/6/318657




  Introduction Top


Idiopathic thrombocytopenia defines as isolated low platelet count in the absence of other causes of thrombocytopenia. It is characterized by purpuric rash and an increased tendency to bleed. It can manifest in two ways as an acute condition in children and a chronic condition in adults. Chronic Idiopathic Thrombocytopenic Purpura (ITP) persists longer than six months with the specific cause being unknown.[1] Symptoms of chronic ITP include easy or excessive bruising (purpura), superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae) usually on the lower legs, bleeding from the gums or nose, blood in urine or stools, and unusually heavy menstrual flow. According to the population-based studies, ITP has an incidence of up to 3.3/100,000 adults per year in India and number of patients continuously are growing up.[2] Treatment of ITP in modern science includes several approaches such as oral corticosteroids or surgical removal of the spleen. However, long-term uses of steroids bring a lot of side effects and surgical procedure, mainly splenectomy, has immediate- and long-term side effects.[3] Therefore, there is a need to understand this disease from the other clinical science. Symptoms mentioned in ITP can be correlated with the symptoms of Raktapitta.[4] Prognosis can be made according to the severity of conditions mentioned in Raktapitta.


  Case Report Top


A 28-year-old housewife a diagnosed case of “Idiopathic Thrombocytopenia” since 2008 came to the Out Patient Department (OPD) for possibility of management for her condition. The patient presented with symptoms like on and off round circular red spots all over the body for 10 days, excessive menstruation flow, vertigo, and low platelet count (23,000/mm3). The patient first developed severe menorrhagia for 10 days in May 2008 at the age of 18 years. The patient visited Durlabhji Hospital, Jaipur, for menorrhagia along with ecchymosis patches on buccal mucosa for three days. Usually, the patient had a history of heavy menstruation flow but not more than five days and used to stop without taking any medication. Platelet count was 2000/mm3 and bone marrow aspiration was done. Bone biopsy showed marked megakaryocytic hyperplasia. There was an erythroid hyperplasia. Other vitals were normal. No diabetes mellitus, hypertension, and bronchial asthma were noted. She was diagnosed with ITP with thrombocytopenia and given treatment for 30 days. Then in April 2009, the patient visited Durlabhji Hospital, Jaipur, with the complaint of menorrhagia for 12 days and was given symptomatic treatment for 30 days. On March 25, 2010, the patient was admitted in the hospital, with the same symptoms. Platelet count was 5000/mm3.

Injection methylprednisolone, 4 units of platelets, and one-unit packed cells were given. Oral Omnacortil in the dose of 10 mg once daily was given for 10 days. The does was gradually tapered and omitted accordingly. Calcium and multivitamin were also given. In between 2010 and 2018, the patient experienced similar episodes about twice in a year and used to get similar kinds of treatment. Platelet counts never went pass above 20000/mm3. Ultrasonography (USG) of the whole abdomen revealed mild hepatomegaly with moderate steatosis (April 11, 2018). On May 6, 2018, the patient was again admitted in the hospital with the same symptoms and was diagnosed with ITP, refractory disease (intravenous immunoglobulin, Revolade), and chronic cervicitis. Platelet count was 23000/ cubic millimeter (cmm) and SGPT (Serum Glutamic Pyruvic Transaminase ) was 66 U/L (units per liter). Marrow biopsy was reported as “moderately hypercellular marrow, mild erythroid hyperplasia, normal myelopoiesis, and increased megakaryocytes with peripheral platelet destruction”. USG scan of the lower abdomen revealed chronic cervicitis. Tablet tranexa and tablet trapic MF were given. Then, the patient was advised for splenectomy. Usually, the patient had a history of heavy menstruation flow but not more than five days and used to stop without taking any medication. The patient had a history of excessive Tikshna (~sharp), Ushna (~hot) davya, Amla (~sour), and Katu (~pungent) rasa. After explaining the prognosis clearly, Ayurvedic treatment was started on September 13, 2018.

Diagnosis

The major presentation was excessive menstruation flow (~Atyaartava),[5] on and off round circular red spots (~Romkopaanuga raktapitta),[6] bleeding through buccal mucosa (~Urdhavagata raktapitta),[7] and vertigo (~Bhrama).[4] In the case, this symptom appeared initially and occurred repeatedly, but when the patient came to hospital, this was absent. The diagnosis was made as Tiryak raktapitta, which is Yapaya (~paliative) to manage.

Therapeutic focus and assessment

In this case, Kledghni peya[8] and Shali manda[9] were given as medicated food because the patient was showing symptoms of Atyaartava. Kledgani peya contains Padmakinjalka (Nelumbo nucifera Gaertn.), Prishnaparni (Uraria picta Desv.), Priyangu (Callicarpa macrophylla Vahl.), and Yava (Hordeum vulgare L.), whereas Shali manda contains Shali rice (Oryza sativa Linn.) and Mudga (Vigna radiata [L.] R. Wilczek). Ingredients of both preparations are indicated in Raktapitta.[9] Prayogika tarpana[10] is given as a general food that contains Saptaparna (Alstonia scholaris [L.] R. Br.), Musta (Cyperus rotundus L.), and roasted Yava (Hordeum vulgare L.), which absorb the Dravya (~liquid) part of Pitta and help to purify the blood. Apart from the above-medicated foods, Kiratatiktadi yoga[11] and Mahatikta ghrita[12] were given as medicine, which has a direct action on Rakta dhatu (~blood tissue). Tapyadi loha[13] and Kaharva pisti[14] were given to subside the complication such as Bhrama (~vertigo) and Pandu (~anemia). The patient was not on allopathic medication during this treatment period. For assessment, symptoms of Raktapitta, namely Atyartava, Bhrama, and objective parameters like platelets count and WHO bleeding scale[15] were used.


  Tiemline Top


Timeline for drug treatment is placed in [Table 1].
Table 1: Timeline of drug treatment

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  Follow up and outcome Top


The patient's condition was assessed in every 15 days during the active treatment of two months, whereas the condition was assessed once in a month during follow-up. Significant improvement was noted in Atyartava, Bhrama and in platelet counts. Atyartava ceased and the patient had normal bleeding in her three consecutive menstruation cycle. There was an improvement in symptoms of Bhrama. There was no bleeding through the skin during treatment. The patient did not need to get admitted in modern hospital during the treatment period of two months and while follow-up period. The patient had mild hepatomegaly with moderate steatosis, which went normal after treatment. The medicines were stopped after two months. Mahatikta ghrita and Shali manda were prescribed during follow-up period of further two months. All medicines and medicated foods were stopped after this period of follow-up. No complications have been noted during this time. At present, the patient is not taking any medicine and maintains an average platelet count of 150,000/mm3. In addition, there was no worsening of previous complaints, which encourages for further treatment planning and research in this disease through Ayurveda prospective [Table 2], [Table 3], [Table 4] and ]Graph 1].
Table 2: Before and after treatment comparison and assessment: Atyartava (grading was done as per Ayurveda parameter)

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Table 3: World health organization bleeding scale

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Table 4: Before and after treatment comparison and assessment: Bhrama (reeling of head) (grading was done as per Ayurveda parameter)

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  Discussion Top


The term Raktapitta refers to a collection of bleeding disorder, such as nasal bleeding, bleeding through vagina, ear, mouth, rectum, and urethra.[16] According to the pathology of Raktapitta, initially, Pitta gets vitiated due to the causative factors such as diet having Ushna (~hot), Tikshna (~sharp), Amla (~sour), Katu (~pungent), and Lavana (~saline) in nature and activities such as excessive exposure to heat and hot environment. Gradually vitiated Pitta further vitiates the Rakta dhatu owing to its similar properties. Both further get aggravated and exudate liquid of other successive Dhatus. As a result, this liquid gets increased in volume of blood and expels out through upper and lower parts of the body mentioned above.[17] Raktapitta disease mainly affects Raktavaha srotas (~channel circulating blood tissue) and its roots, i.e., Yakrit (~liver) and Pleeha (~spleen).[18] In this condition, vitiated blood crosses the limit of tissue barrier and travels through Raktavahi srotas in the body and eventually causes bleeding from various orifices.

Prognosis of Raktapitta depends on the association of Dosha, strength of the patient, track involved in bleeding, and severity of symptoms. Bleeding from the upper tract is curable, whereas bleeding from lower tract is palliable.[7] In addition, when bleeding leaves one channel and gets manifested in another, then it also becomes palliable.[19]

In the present case, the patient's history reveals that there was bleeding from oral mucosa which can consider as bleeding from the upper tract or Urdhvaga raktapitta.[7] The patient was also suffering from heavy menstrual flow and on and off circular spots in the form of petechiae indicating lower tract bleeding, i.e., Adhoga raktapitta and Tiryak marga gata raktapitta, respectively.[6] Vertigo occurred as a complication of excessive bleeding which is included in Pandu, a complication of Raktapitta.[20] Hence, according to these symptoms, the patient's condition comes in palliable category where bleeding manifests from one channel to another channel, mentioned above.[19] On account of palliative nature of the disease, the patient is kept on wholesome diet (~Pathya) and is asked to avoid unwholesome diet (~Apathya) for considerable time after active treatment schedule.

In Ayurveda, the treatment of Raktapitta is based on the associated Dosha and its path of manifestation, etc.[21] Food which can bring down the Ushna properties of Pitta is recommended and medicines that can reverse the pathogenesis and can purify both blood and Pitta are advised. Although both Shodhana and Shamana chikitsa are indicated in Raktapitta, the physical strength of the patient was unsuitable for Shodhana chikitsa, thus Shamana chikitsa was planned.

Peya (~medicated gruel) indicated in Adhoga raktapitta chikitsa was given as she had bleeding from the lower tract.[22] All the ingredients of the Peya are mentioned in the treatment of Raktapitta. Tarpana was given as a general food. Tapyadi loha and Kahrva pishti were given to subside the complications like vertigo etc. Mahatikta ghrita was given as it is indicated in Atyartava and also in the management of Raktapitta. Kiratatiktadi yoga was given for a longer duration as it works on Rakta dhatu. It is mentioned in Purnaravartaka jvara (~relapsing fever) when Deha-Ushma (~body temperature) pervades Dhatushma (~core tissue temperature) and afflicts the successive weak Dhatu and produce a repetition of diseases. In this context, Radkta dhatu works as Nimitta karana for the said pathogenesis. Here in Raktapitta, Kiratatiktadi yoga purifies the blood and ensures pure blood flow in the body. The patient had mild hepatomegaly which went normal after treatment. Here, hepatomegaly (Yakrita/ Pleeha vradhi) appeared as complication of irrational stoppage of bleeding without purification.[23] Hence, the treatment was focused on purification of the blood not to stop improper bleeding.


  Conclusion Top


The above-mentioned case study shows that the symptoms of chronic ITP can be successfully treated in accordance with the basic principles of Ayurveda. Apart from that, this case helps to make the proper prognosis. This study can support in further research of the treatment of ITP with the help of Ayurveda principles.

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.
Available from: https://en.m.wikipedia.org/. [Last accessed on 2021 Mar 14].  Back to cited text no. 1
    
2.
Available from: http://www.indiapediatrics.net>oct2012. [Last accessed on 2021 Mar 14].  Back to cited text no. 2
    
3.
Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3448244/. [Last accessed on 2021 Mar 14].  Back to cited text no. 3
    
4.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 9. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 428.  Back to cited text no. 4
    
5.
Panja AK, editor. Madhava Nidanam Patha. 1st ed., Ch. 9., Ver. 3. Aarsha: Jaipur; 2014. p. 73-4.  Back to cited text no. 5
    
6.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 17. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 429.  Back to cited text no. 6
    
7.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 16. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 429.  Back to cited text no. 7
    
8.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 44. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 430.  Back to cited text no. 8
    
9.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Verse 36. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 430.  Back to cited text no. 9
    
10.
Acharya YT, editor. Charaka Samhita of Agnivesha, Sutra Sthana. Ch. 23., Ver. 19-21. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 123.  Back to cited text no. 10
    
11.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 3., Ver. 343. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 427.  Back to cited text no. 11
    
12.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 7., Ver. 144-150. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 457.  Back to cited text no. 12
    
13.
Anonymous. Ayurveda Sara Sangraha. 17th ed. Kolkata: Shree Baidyanath Ayurved Bhawan Pvt. Ltd; Loha Prakarana; 2017. p. 470.  Back to cited text no. 13
    
14.
Jha CB, editor. Ayurvediya Rasashastra, Chaukhamba Surabharati Prakashana. 2nd edition. Varanasi: Ratnoparatna Prakarana; 1998. p. 431.  Back to cited text no. 14
    
15.
Platelet Transfusion: A Clinical Practice Guideline from the AABB – Scientific Figure on Research Gate. Available from: https://www.researchgate.net/figure/Summary-of-the-Modified-WHO -Bleeding-Scale_tbl2_268207748. 2015 Feb 3;162(3):205-13. doi: 10.7326/M14-1589  Back to cited text no. 15
    
16.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 15. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 429.  Back to cited text no. 16
    
17.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 8. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 428.  Back to cited text no. 17
    
18.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 10. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 428.  Back to cited text no. 18
    
19.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 21. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 429.  Back to cited text no. 19
    
20.
Panja AK, editor. Madhava Nidanam Patha. 1st ed., Ch. 9., Ver. 11. Aarsha: Jaipur; 2014. p. 75.  Back to cited text no. 20
    
21.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 30. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 430.  Back to cited text no. 21
    
22.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 32. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 430.  Back to cited text no. 22
    
23.
Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 4., Ver. 26. Varanasi: Choukhambha Surbharati Prakashan; 2005. p. 430.  Back to cited text no. 23
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
Case Report
Tiemline
Follow up and ou...
Discussion
Conclusion
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