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Tuesday, 9 December 2014

CASE STUDY OF TWO CASES OF ITP published in peer reviewed journal: Homeopathic Heritage


CASE STUDIES: Two Cases of Idiopathic Thrombocytopenia

Dr Dinesh A Kowshik, MD(Hom.)
Abstract: This paper gives an account on the Idiopathic thrombocytopenic purpura (ITP). In such cases where there is paucity of symptoms, the homeopathic approach has been demonstrated with the help of two cases from the author’s practice.
 Keywords: Idiopathic thrombocytopenic purpura, homeopathy
Introduction
Idiopathic thrombocytopenic purpura (ITP) is a disorder due to unusually low levels of platelets that leads to easy or excessive bruising and bleeding. ITP, which is also called immune thrombocytopenic purpura, affects both children and adults. Children often develop ITP after a viral infection and usually recover fully without treatment. In adults, however, the disorder is often chronic. As the name suggests, the exact cause of ITP is not known. Antibodies produced by the immune system mark the platelets for destruction. The spleen recognises the antibodies and destroys the platelets.
Clinical Presentation
Typically ITP presents with purpuric lesions (red, flat haemorrhages of pin-head size which do not blanch on pressure) or ecchymosis (large purple lesions) on skin and mucous membrane, with no symptoms suggestive of systemic illness, absence of lymph node enlargement and absence of hepato-splenomegaly. Bleeding gums, epistaxis, Mennorhagia and haematuria are common manifestations. Sometimes bleeding can occur in intracranial site which may be fatal. A normal platelet count is generally higher than 150,000/µL. Patients with ITP often have platelet counts below 20,000/µL. As the number of platelets decreases, the risk of bleeding increases. The greatest risk is when the platelet count falls below 10,000/µL that may result in internal bleeding.
In most children with ITP, the disorder follows a viral illness, such as the mumps, measles or a respiratory infection. It may be that an infection sets off the immune system, triggering it to malfunction.Women are about twice as likely to develop ITP as men are.
In allopathy, the cases of ITP are managed with steroids, intra venous immunoglobulin or platelet transfusion depending in the severity of the cases.
Homeopathic approach in cases of ITP
Idiopathic Thrombocytopenic Purpura can be regarded as a one-sided disease as its clinical manifestations are very limited. Despite the paucity of the disease symptoms, it can be easily treated with Homeopathy due to the holistic approach. ITP is an auto-immune disorder, affecting the entire body and mind, not just a single organ or a group; hence the cases can be managed in line with the Homeopathic philosophy of diseases.
Purpura Hemorrhagica /Idiopathic finds mention in the following repertories:
1.      Complete repertory- Skin: purpura: Idiopathic

2.      Boericke repertory  - Skin: purpura: Hemorrhagica
3.      Clarkes repertory    - Clinical: purpura
CASE 1 Miss P.C. aged 13yrs
18/10/2013:A young girl aged 13 years with complaints of frequent appearance of echymotic patches on thighs, arms, chest and back since 5 years presented for consultation. She was pale as a sheet, plump and short in stature. Her menstrual cycle was regular but profuse and protracted – sometimes lasting for 12 days. She was a hot patient and liked sweets very much. On examination, several enlarged glands were palpable in the cervical region. The glands were freely mobile, painless and discreet,more on the right side. She had been under the care of specialists in a referral hospital but with no significant change since 5 years. Her platelet counts never rose above 0.6 Lakhs/µl despite treatment.
She belonged to a very poor family, her father made a living by selling fruits on the railway station nearby. All through the interview, she never looked up. Her gaze was always towards her feet even as she answered my questions hesitantly. Her father who accompanied her did most of the talking.. The history was very short despite being a chronic case. Neither the patient nor the father could contribute any more symptoms from the history.
Case Analysis
Generally, the patient was hot and had a strong liking for sweets.Her menses were profuse and of long duration though only one such episode was noted the month before she came to me. Menarche was only 8 months before consultation.The girl was timid, bashful and awkward especially in front of strangers or in public.
Emphasis was given to the mental and general symptoms (including menstrual history). Since the symptoms were few, a thorough physical examination and inputs about the child’s personality came in handy to complete a picture of the case.
Repertorisation
The repertorization was as follows. Applying the filter `Hot’ helped to narrow down to the selection of drug, which chiefly pointed to Carbo vegetabilis.  The 200th potency was selected due to the patient’s age, predominant mental, general symptoms and sub-acute manifestation, which would have a bearing on the susceptibility.
Prescription and Follow Up
CarboVeg200was prescribed thrice daily for 5 days with placebo for 20 days.
06/11/2013: Follow-up- patient markedly relieved. No Echymoses. Menses regular.Glandular swelling in neck decreased and barely palpable. – no complaints.
Prescription- Carbo-veg 200 thrice daily for three days.
30/11/2013:Follow-up – Patient has no symptoms. Glands not palpable.Placebo.
20/05/2014:Diarrhea since 2 days, with rumbling abdomen which aggravated during afternoon. Mucoid stools almost painless, scanty but no blood.
Prescription- Sulphur 200 given at 2 hourly intervals 6 doses.
01/07/2014: Patient came for casual consultation as she was asymptomatic.
Hemoglobin: 10.0gm%. Platelets: 235,000/µl. No further treatment was given.
CASE 2.
03/04/2014:A 35years old male patient, an Ayurvedic doctor was diagnosed and treated as a case of Idiopathic Thrombocytopenic purpura since 6 months at a referral hospital 80Kms away at Belgaum. He had then been rushed the hospital due to complaints of epistaxis and haemoptysis, where his platelet count was found to be below 10,000/µl. He was given multiple platelet transfusions and was being managed with steroids and Dapsone after which his platelet counts settled between 0.5 to 0.8 Lakhs/µl. After six months of this treatment, his impatience brought him to homeopathy.
Despite being a qualified doctor, he was now in his family business of a hotel and liquor trade. He felt that he was unable to earn enough through his medical practice. The patient’s brother described him as an astute businessman, dominant and very egoistic. He wanted his hotel turnover to be the highest in the town. He had started to manage all the financial dealings of the family business as he was not happy with his brother’s way of doing things. He was restless, anxious and dissatisfied with his previous treatment, yet he did not trust his present homeopathic doctor to handle his case.He kept asking how long it would take me to cure him.  He suffered from insomnia due to worry about business and health.
He was sensitive to cold, and cold wet weather. His food preference was predominantly non-vegetarian and he disliked curd.
On examination, no evidence of purpuric rashes was seen. His pulse was 84/min andBP 130/90. The Platelet count was 0.65 Lakhs/µl as on 3rd April 2014
Case Analysis
The patient’s chief mental trait was impatience and egotism besides being highly censorious of his kith and kin. His desire to be `Number one’ in the business predominated his desires. He took no holidays and worked late nights balancing accounts, placing orders etc. His mental state was characteristic of an overstressed business executive. He had been constantly criticising his father and brothers. Here again, the predominant mental symptoms indicate the use of a high potency in this case.
Repertorisation

Prescription and Follow Up
03/04/2014. Prescription: Nux Vomica 200 thrice daily for 10 days. Platelet count 0.65 Lakhs/µl
14/04/2014: Platelet count 1.06 Lakhs/µl. Placebo given
18/04/2014: Platelet count: 1.54 Lakhs/ µl. Placebo given
10/05/2014. Platelet count: 1.06 Lakhs/ µl. Nux Vomica 1M 1 dose.
24/05/2014. Platelet count 1.41 Lakhs/ µl. Placebo.
09/07/2014. Painful boils in Right axilla and many on scalp. Cough with green purulent expectoration, aggravated in cold air.  Hepar sulphuris 200. (Allen’s Key notes + Complete rep. [Chest]: Eruptions: Boils: Axilla). Three doses were given as an Acute prescription.
24/08/2014. No cough or boils. Patient’s conjunctiva looks yellow. Loss of appetite with nausea and drowsiness. Serum Bilirubin: 2.1mg%. Direct Bili: 1.0mg%. SGOT: 66 IU/Lt. SGPT: 79 IU/Lt.  Prescription: Chelidonium 30 thrice daily for 5 days (Acute prescription).
On questioning repeatedly, patient finally confessed to have continued taking Dapsone. The hepatitis may have been drug induced. (www.drugs.com  › Drugs A to Z  › Dapsone.) Patient warned not to continue Dapsone.
14/09/2014. SGOT: 34 IU/Lt.  SGPT: 58 IU/Lt. Bilirubin (T): 1.2mg% Direct: 0.3mg%. Chelidonium 30 thrice daily for 5 days. (Sulphur is complementary to Chelidonium and may have been better indicated; or even Nux Vomica.  Complete rep. [Generalities]: Abuse of, poisoning with: medicaments. However, since the pathology reports indicated a lowering of the enzyme levels and Bilirubin, I decided to continue with Chelidonium)
03/10/2014. Platelet count: 2.7 Lakhs/ul. Serum GOT 28 IU/Lt. Serum GPT: 41 IU/Lt. Serum Bilirubin: 1.0mg% Direct Bili: 0.15mg%. Placebo continued.
14/10/2014. Hb 13.4gm%; Platelet count: 2.07 Lakhs/µl.
Reports
Case 1. P.C. age 13yrs/F
Case 2.Baburao Kalal  03-04-2013
Discussion
It was observed that in such one sided chronic diseases the patient is often unable to express or recollect any symptoms regarding his disease. In the absence of particular symptoms the mental and general symptoms stand out. The peculiar nature of these symptoms makes them the basis of the prescription and helps in confirming homeopathic philosophy and in justifying our method of case taking. Nux vomica is absent from the particular rubric `Purpura’, yet all other symptoms point to it being the similimum. This once again highlights that diagnosis need not be the basis of a prescription in each case. Nux Vom  however does find mention under the rubric `Ecchymosis’.
The dosage and potency for the indicated remedy was selected as is recommended by the stalwarts Boenninghausen, Kent, Farrington and Dr.Samuel Hahnemann in their Lesser Writings and Dr.C.Dunham in Homoeopathy The Science of Therapeutics. (On high potencies; Pg 263).
The two patients in the cases illustrated above showed remarkable improvement in the platelet counts soon after starting treatment. The continuance of Dapsone against the advice in the second case did not hamper the action of homeopathic medicines and the improvement in the patient’s condition continued after stopping the same.
Conclusion
Mental and general symptoms are a reliable indicator of the simillimum even when the chief complaint or the particular symptom does not come up in the repertorial analysis. Homeopathy is a safe, quick and gentle mode of treatment for idiopathic thrombocytopenia. The absence of any side effects of the homeopathic medicines and the versatility of the materia medica in promptly treating not only the presenting disease condition but also any deviations (accessory symptoms or acute conditions) that may intervene during the course of the treatment is aptly demonstrated. The use of basic diagnostic facilities to monitor the case through its progress to cure is demonstrative, conclusive and invaluable.
References

1.      De Gruchy’s Clinical Haematology in Medical Practice. 6thEdn. Pg 377-385
Authors: Frank Firkin, Colin C.David P and Bryan Rush
2.      Atlas and Text of Hematology by Dr.Tejinder Singh 2ndEdn. Pg300-302
3.      Clarke, J 2003, A Dictionary of Practical MateriaMedica, 1st edn, B.Jain Publishers, New Delhi. India
4.      Boenninghausen, The Lesser Writings, B. Jain Publishers, New Delhi, India.
  1. Boericke, W 2004, Pocket Manual of Homoeopathic Materia& Repertory,1thedn, BJainPublishers,New Delhi Clarke’s Clinical Repertory
  2. Dunham, C 2005, Homoeopathy the science of Therapeutics, reprint edn, B.Jain Publishers, New Delhi
  3. Farrington, E A 1995, Lesser Writings with Therapeutic Hints, 1stedn, BJain Publishers, New Delhi
8.      Hahnemann, S, The Lesser Writings, B. Jain Publishers, New Delhi, India.
  1. Hering, C 1997, Guiding symptoms of our MateriaMedica, 1st edn, BJain Publishers, New Delhi
  2. Kent, J T 1992, Lesser Writings,B.Jain Publishers, New Delhi, India
12.  API Textbook of medicine
13.  www.drugs.com  › Drugs A to Z  › Dapsone

3 comments:

  1. Hi Doctor,
    Can i get your contact to discuss about my niece who is suffering fron ITP for past 2+ years

    ReplyDelete
    Replies
    1. Where do you stay? Which country/city? Kindly mail me at `kodin59@yahoo.co.in'.

      Delete
  2. Sir,
    My wife 31years old diagnosed ITP, once Platelets reached 20000 but now she is taking Dapson100mg, her Platelets is 100000 on today, it drops if dose decrease. She was taking homeopathy treatment, Homeopathy Dr prescribed her 5-6 medicine but only Natphos-30 worked with Dapson, when I drop Dapson Platelets decreases drasticaly. ..what should i do now. . .?

    ReplyDelete