A case study of Necrotising Fascitis w.s.r. to Pittaja Dushta Vrana

Gopan Parvathy; Padma

A case study of Necrotising Fascitis w.s.r. to Pittaja Dushta Vrana

Parvathy G.^1*, Padma.²

DOI:

^1* Gopan Parvathy, Post Graduate Scholar, Department of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research Hospital, Bengaluru, Karnataka, India.

² Padma, Associate Professor, Department of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research Hospital, Bengaluru, Karnataka, India.

Necrotising fascitis is a spreading inflammation of the skin, deep fascia and soft tissues with extensive destruction, toxaemia commonly due to Streptococcus Pyogens infection. It is common in old age, smoking, diabetes, immunosuppressed individuals. Trauma is the precipitating factor for this disease. It can occur in limbs, lower abdomen, groin, perineum etc. It needs intensive care with appropriate antibiotics and surgical debridement. Vrana is a condition which even after the complete healing, leaves a scar over the area, which stays as long as the person is alive. Vrana which has foul odour, has abnormal colour with profuse discharge, intense pain and takes longer time to heal is said to be Dushta. Acharya has mentioned separate treatment for the management of these Vrana in detail. It is a case report of a 46 year old male patient who presented with chief complaints of pain and swelling over the dorsum of the left foot with foul smell oozing purulent discharge with blackish discolouration since 1 week. He was examined and diagnosed as necrotising fascitis and was managed with Shodhana therapy along with palliative treatment.

Keywords: Necrotising fasciitis, Vrana, Dushta Vrana, Case Report

Corresponding Author	How to Cite this Article	To Browse
Gopan Parvathy, Post Graduate Scholar, Department of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research Hospital, Bengaluru, Karnataka, India. Email:	Gopan Parvathy, Padma, A case study of Necrotising Fascitis w.s.r. to Pittaja Dushta Vrana. J Ayu Int Med Sci. 2022;7(7):185-190. Available From https://www.jaims.in/jaims/article/view/2000

Introduction

The history of Vrana is as old as man itself. Initially, humans were cave - dwellers and hunter - gatherers, but later advanced to more civilized societies. But throughout this development, physical activities, adventures, experiments and battles were inevitable and hence, wounds were integral part of human life.

Damage or destruction of a tissue or a part of the body is termed as Vrana. Long standing and unhealed Vrana is known as Dushta-Vrana.^[1]

There are external as well as internal factors which are responsible for the formation of Vrana. Necrotising fascitis is a life-threatening soft tissue infection primarily involving the superficial fascia, it is characterised by rapid destruction of tissue, systemic toxicity, and if not treated aggressively leads to morbidity and mortality.

Most cases commence with trauma to the skin surface, with seeding of bacteria. It is common in old age, smoking, diabetes, immune suppressed individuals.

The main symptom is sudden swelling and pain in the part with oedema and discolouration, necrotic area and foul smelling discharge.^[2] While seeing the signs and symptoms it can be correlated with Pittaja Dushta Vrana having symptoms like Daha, Paka and Peethaneelabha Varna of Twak.^[3]

Acharya Susrutha has explained in detail about the management of Vrana by Shastirupakrama which start from Apatharpana to Rakshavidhana Vidhi.^[4] This is a case study of necrotising fascitis with special reference to Pittaja Dushtavrana treated with both Shodhana and Ropana therapies.

Case Report

A 46 year old male with poor socioeconomic status visited our Shalyatantra OPD on 29/12/2021 complaints of pain and swelling over the dorsum of the left foot with foul smell oozing purulent discharge and blackish discolouration since 1 week.

He had a relevant past history of injury to the little toe by thorn prick. He removed the same by himself. Later he noticed swelling over the left foot and associated with pain. He visited nearby hospital and took medicine for the pain management.

After consuming medicine he got relief of pain but the swelling got increased with blackish discolouration and noticed foul smelling discharge from the skin. He was a known case of diabetes mellitus since 2 years and under medication.

On physical examination general condition of patient was good, PR – 72/min, BP – 120/80mm Hg, RR – 21/min. No history of allergy and hypertension.

On examination

Swelling over the dorsum of left foot with foul smelling purulent discharge. The floor was covered with slough. Tenderness was also present with local rise of temperature.

Laboratory investigations with CBC, ESR, urine routine and microscopy, HIV I and II, HBsAg was done and was diagnosed with hepatitis B infection with increased TC about 20,900, ESR 21mm/hr.

Methodology

Ayurveda intervention

Under aseptic precautions wound debridement was done on 29/12/2021 followed by Gomutra Arka cleaning and dressing with Panchavalkala Kashaya. A specimen of c/s was taken and was diagnosed with scanty growth of staphylococcus haemolyticus [Methicillin Resistant].

For pain management Inj Diclo 75 mg IM was advised SOS [after test dose].

Oral drugs and Panchakarma procedure

Tab Chitrakadi Vati 0-2-2 after food for 3 days was given for Deepana and Pachana.

Cap Grab 0-2-2 after food

From 5/01/2022

Avipattikara Choorna 2 tsp with ½ glass hot water at bed time
Varanadi Kashaya 15ml-0-15ml after food
Tab Punarnavadi Guggulu 2-2-2 after food
Tab Kamadugha with Mukta 1-1-1 before food
Tab Nirocil 2-0-2 before food
Asanadi Kashaya + Nishaamalakadi Kashaya 20ml-0-20ml before food.

Shodhana Therapy

After Deepana Pachana, Shodhana (Virechana) was planned. Abhayantara Snehapana was given with increasing dose from 30ml, 90ml and 200ml with Pancha Tiktaka Ghrita. After assessment of Samyak Snigdha Lakshana, Sarwanga Abhyanga and Ushna Takradhara was given for 3 days (2/01/22 to 4/01/22). Virechana was given with Trivrit Lehya (50gm) at morning 8.30 AM (4/01/22) with Draksha Rasa as Anupana. Patient had total 5 Vega. Samsarjana Krama was given for 1day.

As the Virechana Vegas are less patient was advised to take Avipattikara Choorna 2 tsp with ½ glass hot water at bedtime for 5 days.

Dhoopana was done from 4/01/2022 to 8/012022

Patient was discharged on 10/01/2022

Varanadi Kashaya 15ml-0-15ml after food
Asanadi Kashaya 15ml-0-15ml before food
Cap Grab 2-2-2 after food
Tab Kamadugha with Mukta 1-0-1 before food
Tab Nirocil 2-0-2 before food
Tab Tolpa D 1 SOS
Patient was advised to do daily dressing with Panchavalkala Kashaya

Follow-up treatment

Patient came to hospital again for follow up on 19/01/2022. Cleaning and dressing was done with Panchavalkala Kashaya and patient was advised to continue the same oral medication for one more week.

Patient visited in OPD for follow-up on 25/01/2022, cleaning and dressing done and after proper assessment given medicine was advised Cap Grab 1-0-1 after food, Varanadi Kashaya 15ml - 0 - 15ml after food, Asanadi Kashaya 15ml-0-15ml before food, Mehantaka Vati 2-2-2 before food, Tab Nirocil 1-1-1 before food and was advised to continue daily dressing with Panchavalkala Kashya.

Patient visited on 2/02/2022 and cleaning and dressing of wound was done with Jathyadi Ghrita and was advised to continue same oral medication

On 16/02/2022 patient came for follow up and it was observed that the wound has healed completely.

Intervention

First treatment plan [ 30-12-2022 to 4-01-2022]
Virechana Karma					Assessment
30-12-2021 to 1-01-2022	Snehapana with Panchatiktaka Ghrita				Till Samyak Snigdha Lakshana attained
30-12-2021 to 1-01-2022	Date	30-12-2021	31-12-2022	1-01-2022
	Amount	30ml	90ml	200ml
	Intake time	8.00 am	8.00am	8.00am
	Appetite time	12.30pm	1.30pm	2.00pm
	Stool colour and consistency	Normal	Normal and semi liquid	Normal and liquid
2-01-2022 to 3-01-2022	Sarvanga Abhyanga with Dhanwantram Taila followed by Ushna Takradhara				for 3 days
4-01-2022	Virechana with Trivrit Lehya 50gm+ 100 ml Draksha rasa as Anupana				total Vega 5
4-01-2022 to 5-01-2022	Samsarjana Karma

Shamana treatment plan 1^st phase [05-01-2022 to 10-01-2022]

SN	Medication	Dose	Anupana
1.	Avipattikara Choorna	2 tsp with HS	½ glass Hot water
2.	Varanadi Kashaya	15ml-0-15ml after food	with 30 ml Hot water
3.	Tab Punarnavadi Guggulu	2-2-2 after food	Hot Water
4.	Tab Kamadugha with Mukta	1-1-1 before food	Hot water
5.	Tab Nirocil	2-0-2 before food	Hot water
6.	Asanadi Kashaya + Nishaamalakadi Kashaya	20ml-0-20ml before food.	with 40 ml Hot water

Daily dressing with Panchavalkala Kashaya for 1 week

Shamana treatment plan 2^nd phase [11-01-2022 – 24-01-2022]

SN	Medication	Dose	Anupana
1.	Varanadi Kashaya	15ml-0-15ml after food	with 30 ml Hot water
2.	Cap Grab	2-2-2 after food	Hot Water
3.	Tab Kamadugha with Mukta	1-0-1 before food	Hot water
4.	Tab Nirocil	2-0-2 before food	Hot water
5.	Asanadi Kashaya	15ml-0-15ml before food.	with 40 ml Hot water
6.	Tab Tolpa D	1 SOS

Shamana treatment plan 3^rd phase [25-01-2022 – 1-02-2022]

SN	Medication	Dose	Anupana
1.	Varanadi Kashaya	15ml-0-15ml after food	with 30 ml Hot water
2.	Cap Grab	1-0-1 after food	Hot Water
3.	Mehantaka Vati	2-2-2 before food	Hot water
4.	Tab Nirocil	1-1-1 before food	Hot water
5.	Asanadi Kashaya	15ml-0-15ml before food.	with 40 ml Hot water

Patient was advised to continue daily dressing with Panchavalkala Kashaya.

Shamana treatment plan 4^th phase [2-02-2022 – 16-02-2022]

Cleaning and dressing of wound was done with Jathyadi Ghrita and was advised to continue same oral medication and dressing.

Investigations

Date	FBS	RBS	PPBS	TC
29-12-21	-	345 mg/dl	-	20900 cells/cumm
1-01-2022	-	-	-	18900 cells/cumm
8-01-2022	290mg/dl	-	299mg/dl	12000cells/cumm
25-01-2022	224mg/dl	-	288mg/dl	-

Discussion

Vrana management has given prime importance in the time period of Acharya Sushruta. While seeing the signs and symptoms of this patient, it can be correlated to one among the variety of Dushtavrana i.e., Pittaja Dushta Vrana.

Here our main aim was based on the management of Vrana along with the management of diabetes and hepatitis. It involves both Shodhana and Ropana. Shodhana involves both internal as well as external therapy.

Acharya Susruta mentions that Virechana Karma is indicated in Vrana which is Vatapitta Pradushta and Dheerkakalanubandha Vrana’s [chronicity of the ulcer]. Also, in the Chikitsasutra of Dushta Vrana, Acharya is telling to do Urdhwa and Adha Shodhana based on the vitiated Dosha.^[5]

In this condition the vitiated Dosha is Pitta and also patient complaints of pain we can consider this condition as Vata Dooshita Pitta Vrana. Since it an Adhosakhagata Roga and pitta is the main Dosha here Virechana was planned with Trivrit Lehya. Prior to Virechana Deepana Pachana was done for Agni Deepana and Amapachana with Chitrakadi Vati. Snehapana was done as Poorvakarma to Virechana. Since Pitta is the main Dosha involved here and also the main drug of choice for Snehapana should be having anti-inflammatory, antimicrobial as well as having the property to not increase Prameha, Panchatiktaka Ghrita was advised for Snehapana.

After Samyak Snigdha Lakshana during Visrama Kaala, patient was advised to undergo Sarvanga Abhyanga followed by Takradhara.

Here Takradhara was chosen because the patient was diabetic and was contraindicated for Swedana therapy.

After proper Shodhana therapy comes the importance of Shamana Oushadi.

Here the more vitiated Dosha is Pitta and Rakta. So, internal medications was given for the management of these Doshas and also for his diabetes management and for hepatoprotective action. As these medicines are having antimicrobial, anti-inflammatory properties, it prevented the usage of antibiotics.

Choice of Shamana Oushadi based on the stage of the wound

Initially there was pus discharge, slough and foul smell Dhoopana was the indication as per the classics. It is also having the antimicrobial property and Rakshogna property as mentioned in Agropaharaniya Adhyaya. Acharya is also telling the antimicrobial property of Dhoopana as a Rakshogna Karma.^[6]

The pus culture and sensitivity report also shown the growth of staphylococcus haemolyticus. So, Dhoopana was adopted in the initial days.

For wound care we have used Gomootra Arka for cleaning. It is having Katu, Tikta and Kashaya Rasa which was Krimighna in nature which will help in the inhibition of growth of microorganisms as well as act a Shodhana Dravya.^[7]

Dressing was done with Panchavalkala Kashaya which was having Ropana property. Studies indicate that the pharmacological action of Panchavalkala is found to have anti-inflammatory, analgesic and antimicrobial property.

Tannins present in Nyagrodha and Udumbara are antioxidants and blood purifiers with anti-inflammatory actions. This might have helped in decreasing swelling. The phytosterols and flavanoids present in them are anti-inflammatory and analgesics reducing pain.^[8]

After the discharge of the patient follow-up was done on OPD basis. When the wound became healthy with good granulation tissue and devoid of slough, for accelerating healing dressing was done with Jathyadi Ghrita.

30/12/2021

01/01/2022

14/01/2022

19/01/2022

25/01/2022

1/02/2022

Conclusion

Vrana which smells badly, having profuse discharge, discoloration, severe pain and takes prolonged time to heal is considered as Dushta vrana. The features of Dushtavrana varies depending upon the vitiated Doshas present in it. Acharya Susrutha has mentioned various aetiologies for the formation of Vrana. While going through the signs and symptoms of this patients along with the aetiologies we can correlate it with Necrotising fascitis. Necrotising fascitis is an Aganthuja Dushta Vrana where the main line of treatment is debridement and proper antibiotic coverage, in olden days our Acharya managed these condition by the help of Shashtirupakrama.

In this case we have adopted proper Shodhana as well as medication therapy in which complete healing of the ulcer was noticed within a time period of 1 month and 18 days.

Reference

1. Vagbhata, Ashtanga Hridayam; translated by Murthy S, Chowkhamba Krishnadas Academy, Varanasi; ed. 6, 2012; vol. III, Uttarasthana; ch. 25, Ver 2; pp. 235.

2. Sriram Bhat M. SRB’s Manual of Surgery. Wounds and wound healing: chapter 1A. 4th ed. New Delhi: Jaypee Brothers Medical Publishers: 2013; p. 60-61.

3. Susruta, Susrutasamhita, edited by Vaidya Jadavaji Trikamji Aacharya and Narayan Ram Acharya ‘Kavyatirtha’. Soothrasthana.Ch.22, Ver.7. Reprint, 2015edition, Varanasi:Choukhambha Sanskrit Sansthan, Kashi Sanshrit series 316; 2015.p.108.

4. Susruta, Susrutasamhitha, edited by Vaidya Jadavaji Trikamji Aacharya and Narayan Ram Acharya ‘Kavyatirtha’. Chikitsasthana.Ch.1, Ver 8. Reprint, 2015 edition, Varanasi:Choukhambha Sanskrit Sansthan, Kashi Sanshrit series 316; 2015. P.397.

5. Susruta, Susrutasamhitha, edited by Vaidya Jadavaji Trikamji Aacharya and Narayan Ram Acharya ‘Kavyatirtha’. Chikitsasthana.Ch.2, Ver 86-88. Reprint, 2015 edition, Varanasi:Choukhambha Sanskrit Sansthan, Kashi Sanshrit series 316; 2015. P.414.

6. Susruta, Susrutasamhita, edited by Vaidya Jadavaji Trikamji Aacharya and Narayan Ram Acharya ‘Kavyatirtha’. Soothrasthana.Ch.5, Ver.18. Reprint, 2015edition, Varanasi:Choukhambha Sanskrit Sansthan, Kashi Sanshrit series 316; 2015.p.21.

7. Manish Kumar Singh, P Bhat Ramesh, Sweta Tyagi. A Clinical Evaluation of Antimicrobial Activity of Gomutra Arka in Dushta Vrana. International Journal of Ayurveda and Pharma Research [INTERNET]. 2020 Nov [cited 2022 June 10];8:27-35.

8. Gajarmal Amit A, Shende MB, Chothe DS. A Clinical Evaluation of Panchavalkala – A Review Article. Unique Journal of Ayurvedic and Herbal Medicines [INTERNET]. 2014 Aug [cited 2022 Aug 13; 02(04):6-9.

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-07-01	2022-07-02	2022-07-09	2022-07-16	2022-07-23
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	19%

Case Report

Necrotising Fascitis

Journal of Ayurveda and Integrated Medical Sciences