E-ISSN:2456-3110

Case Report

Hyperbilirubinemia

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 7 August
Publisherwww.maharshicharaka.in

A case report on effect of Dronapushpi Swarasa Nasya in Kamala induced Hyperbilirubinemia

Kumar R.1*, Rajalaxmi M.2
DOI:

1* Rohit Kumar, Post Graduate Scholar, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwar College of Ayurveda, Udupi, Karnataka, India.

2 MG Rajalaxmi, Associate Professor, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwar College of Ayurveda, Udupi, Karnataka, India.

Human body eliminates metabolic wastes either through sweat, urine, or through faeces. Any derangement in the normalcy leads to building up of metabolic wastes within the body. One such condition where in there is accumulation of bilirubin in the blood is hyperbilirubinemia. Viral infection is the cause and presenting with yellowish discoloration of sclera, dark urine, pale stool, fatigue, flu like symptoms, loss of appetite etc. In Ayurveda, such symptoms are mentioned under the broad name Kamala. The line of management mainly highlights the advice of Shodhana in the form of Virechana and different Shamana Aushadhis based on the stages of the disease. In traditional folklore practice, the patients of these symptoms are treated with Tikshna, Shodhana Nasya Karma. With that practice in backdrop, a 17 years female patient presented with hyper-bilirubinaemia, was treated with Dronapushpi Swarasa Nasya ten drops to each nostrils, in a gap of 2 days. When the bilirubin level was raising gradually even after usual internal medication, this treatment was planned and administered. The bilirubin level from 5.7 was reduced to 1.4 after the treatment gradually over a period of 12 days. The patient showed gradual recovery from almost all the symptoms clinically and in haematological parameters. During the procedure nasya did not show any complications in the patients. Dronapushpi Swarasa can be effectively used to manage hyper-bilirubinaemia.

Keywords: Kamala, Virechana, Dronapushpi Swarasa, Shodhana Nasya, Hyper-Bilirubinaemia

Corresponding Author How to Cite this Article To Browse
Rohit Kumar, Post Graduate Scholar, Department of PG Studies in Panchakarma, Shri Dharmasthala Manjunatheshwar College of Ayurveda, Udupi, Karnataka, India.
Email: 		Rohit Kumar, MG Rajalaxmi, A case report on effect of Dronapushpi Swarasa Nasya in Kamala induced Hyperbilirubinemia. J Ayu Int Med Sci. 2022;7(7):191-195.
Available From
https://www.jaims.in/jaims/article/view/2009

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-07-02 2022-07-04 2022-07-11 2022-07-18 2022-07-25
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 17%

© 2022by Rohit Kumar, MG Rajalaxmiand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Kumar R et al: Dronapushpi Swarasa Nasya in Kamala induced Hyperbilirubinemia

Introduction

Jaundice, also known as icterus is a yellowish or greenish pigmentation of the skin and yellowish of the eyes due to high bilirubin levels.[1] It is commonly associated with itching. The face was having pallor and urine was also pale. Causes of jaundice vary from non-serious to potentially fatal. Levels of bilirubin in blood are normally below 1.0 mg/dl (17μmol/L) and levels over 2-3 mg/dl (34- 51μmol/L) typically results in jaundice. High bilirubin is divided into two types: unconjugated (indirect) and conjugated (direct). Conjugated bilirubin can be confirmed by finding bilirubin in the urine. Other conditions that can cause yellowish skin but are not jaundice include carotenemia from eating large amounts of certain foods and medications like rifampicin.[2] This case study shows that Ayurvedic herbs which give effective result in jaundice.

Kamala is one among the Pittaja Vyadhi and explained under Rakta Pradoshaja Vikara.[3] The Haridra Mutra, Netra and Twak are the Pratyatma Lakshana of Kamala.[3] Dronapushpi Swarasa was selected for the Nasya Karma. Dronapushpi is having Katu Tikta Rasa, Kapha Vatahara, Ushna Virya and Katu Vipaka.[3] In this patient with Kamala, who is not responding to usual internal medications, was treated with Nasya Karma ten drops of Dronapushpi Swarasa was administered into each nostril, once in a gap of two days. The idea behind the treatment was to assess its effect on hyperbilirubinemia. The result observed was promising towards the management of Kamala w.s.r. hyperbilirubinemia.

Case Report

A 17 year old female patient was said to be apparently healthy before 10 days. Gradually she developed fever, which was on and off in nature associated with yellowishness in eyes, urine, and faeces. Along with this reduced appetite. The quantity of food intake was reducing day by day. Also, there was body ache, headache, and weakness which were worsening gradually. No H/o of loose stools, vomiting. Details of the examination are given below.

Examination (Ayurvedic)

  • Nadi - 76/min
  • Mutra - Pitavarna
  • Mala - Tilapishtanibha
  • Jihva - Saama
  • Shabda - Prakruta
  • Sparsha - Ushna
  • Druk - Netra-Pitta
  • Prakruti - Vatakapha
  • Sara, Samhanana, Satmya - Madhyama
  • Aharashakti – Alpa

General examination

  • Pallor - Present
  • Icterus - Present
  • Lymph nodes - Absent
  • Clubbing - Absent
  • Oedema - Absent

Systemic examination

  • RS - NVBS
  • CVS - S1S2 heard, no murmur
  • CNS - HMF intact

Abdominal examination

Inspection

Abdomen contour - Normal

Umbilicus inverted & centrally placed.

No scar, no visible veins are present.

Palpation

Soft, non-tender

Liver firm, smooth with distinct border

Palpable measuring about 2 fingers (2.5cm) from the lower costal margin

Spleen - non palpable

Percussion

Normal tympanic note heard

Shifting dullness absent

Auscultation

Normal bowel sounds heard

Hematological report suggesting of Hyperbilirubinemia - On 18/05/2021



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Kumar R et al: Dronapushpi Swarasa Nasya in Kamala induced Hyperbilirubinemia

Haemogram

Hemoglobin - 8.0GM%

TC WBC - 5800cells/cu mm

Deferential Count of WBC

Neutrophills - 61%

Lymphocytes - 34%

Eosinophills - 02%

Monocytes - 03%

Basophills - 00%

ESR­ - 30mm/Hr

Liver Function Test

Total Billirubin - 5.7mg/Dl

Direct Billirbin - 2.9mg/Dl

Indirect Billirubin - 2.8mg/Dl

SGOT/AST - 261.0U/L

SGPT/ALT - 367.0U/L

Alkaline Phosphatase - 179.0U/L

Total Protein - 7.9g/Dl

Albumin - 3.0g/Dl

Globulin - 4.9g/Dl

A/G Ratio - 0.6Ratio

Urine Test Report

Urine Albumin - Trace

Urine Sugar - Nil

Microscopic Examination

Epithelial Cells - 2-3/Hpf

Pus Cells - 2-3/Hpf

Rbc’s - 0-1/Hpf

Casts - Nil

Crystals - Nil

Others - Nil

Urine For Bile Salt - Present

Urine For Bile Pigment - Present


Treatment: The details of internal medicine given are:

  • Aarogyavardhini Vati 1 TID
  • Mrutyunjaya Rasa 1 TID
  • Kumaryasava 20ml TID
  • Madiphala Rasyana 10ml BD B/F with hot water
  • Bhumiamalaki + Guduchi + Nimba + Bhringraja Kashaya 50 ml BD
  • Nirocil 1 TID

Intervention: Nasya procedure

Purva Karma

Medicine preparation

Fresh leaves of Dronapushpi were collected. After washing, it was grinded into a fine paste and filtered through a cloth and Swarasa/ juice was collected.

Patient preparation

After the digestion of the food, at around 11 AM procedure was done.

Pradhana Karma: Patient was made to lie down in supine posture with neck hyper extended. With dropper, 10 drops of the Swarasa was administered into each nostril. The patient was asked to spit out the secretion into the tray.

Paschat Karma: After 30 minutes of observation, patient was sent to the room and advised rest.

Observation of patient

Burning sensation in eyes, nose and headache was present. Watering of eyes and nose lasted for 3-4 hours. Headache lasted for 1 hour after the procedure. After that, patient was comfortable.

Results

In this patient, Nasya has shown significant improvements both clinically and haematologically after 2 courses of Nasya. The severity of symptoms like Pitanetra, Nakha, Twak, Anana, Mutra and Varchas, Avipaka, Dourbalya, etc. in the patient, following the treatment. After second Nasya, all the symptoms were reduced significantly. The itching, weakness reduced completely. Appetite is normal. Yellowishness reduced gradually. Liver Function Test showed significant changes which are mentioned in Table 1.


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Kumar R et al: Dronapushpi Swarasa Nasya in Kamala induced Hyperbilirubinemia

Table 1

Date Bilirubin(T) Direct Indirect SGOT SGPT
18/05/2021 5.7 2.9 2.8 261 367
21/05/2021 5.1 2.7 2.4 --- ---
22/05/2021 Nasya        
24/05/2021 Nasya        
25/05/2021 2.5 1.1 1.4 75 85
31/05/2021 1.4 0.4 1.0 43 34

Discussion

Discussion on intervention

In this case report, patient had the symptoms of Kamala. The ideal treatment in this stage of the disease will be Virechana Chikitsa. But as the patient is Durbala and the appetite was also less, the patient is not fit for Virechana. Hence initially, the patient was prescribed with internal medications. When the condition was not responding and as the haematological reports started worsening, the alternate treatment was searched. In traditional folklore practice, the Shodhana Nasya Karma is widely practiced in the management of Kamala. Hence with that idea, Rechana Nasya was selected. Dronapushpi Swarasa was selected due to its Ushna Teeksha Guna and Rechana action can be achieved through the same. After one Nasya Karma, patient was observed for any complications for 6 hours. As patient was comfortable, it was decided to administer second dose after 1 day. After this dose too, patient was comfortable and drastic, significant changes were seen clinically and haematologically. Even though, Samhitas advised Nasya Karma in the prevention and management of Jatru Urdhwa conditions, in folklore practice, Nasya is commonly advised in the management of Kamala. It is difficult to explain the mode of action of Nasya in this condition. Any published data is not available to explain the systemic action of the drug administered through the nasal route. But as the drug possessed Ushna Teekshna properties, might have removed the Sanga (as it is the Rudha Patha Kamala), it eliminated the Doshas to some extent. But there is a definite benefit achieved in the patient where drug is administered through the nasal route and benefit is seen clinically. The possible explanation may be as:

Nervous stimulation - Nasal administration of drugs causes stimulation of brain matter resulting

in stimulation of Parasympathetic nerves. All the abdominal organs are supplied by Parasympathetic nerves. The stimulation of Hepatic nerve plexus and Vagus nerve stimulates the hepatocytes and contributes in the hepatic repair. The Swarasa, due to the high concentration of phytoconstituents, when administered in high dose, helps in more stimulation of nerves. The blood supply to Nerve is through Vasa Nervosa. Some amount of the medicine may enter the systemic circulation through this route also.[5]

Lymphatic pathway - From nose, it drains to Sub mental and Sub mandibular lymph nodes. From there, on the right side, it drains into the Right Lymphatic Duct and on the left side it drains into Thoracic duct. Thoracic duct and Right Lymphatic duct open at the junction of internal jugular vein and Subclavian vein, on either side of the body. Thus, joining to the venous drainage. The lymphatic drugs thus enter the venous circulation. The larger plasma proteins or larger molecules passes / are better absorbed through the lymphatics. The nasal cavity is covered by a thin mucosa which is well vascularized. Therefore, a drug molecule can be transferred quickly across the single epithelial cell layer directly to the systemic blood circulation without first pass hepatic and intestinal metabolism. The effect is often reached within 5 min for smaller drug molecules.[6]

Conclusion

Based on the common folklore practice of Rechana Nasya in the management of Kamala, a case diagnosed as Kamala was treated with Dronapushpi Swarasa Nasya (10 drops to each nostril) of 2 sitting with a gap of 1 day. This treatment showed promising result in the management of Kamala. The Shodhana effect of Nasya along with the hepatoprotective nature of Dronapushpi helped in attaining the normalcy of the patient.

Reference

1. Davidson, Edited by brain R. Walker, Davidsons Principles and practice of medicine, 22nd edition, Daibetic neuropathy, page 831, syear-2006

2. Green JB, Bethel AN, Armstrong PW, Duse JB, Engel SS, Garg J, et al. Effect of Sitagliptin on cardiovascular outcomes in type II Diabetes. New England Journal of Medicine, 2015; 232 -242


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Kumar R et al: Dronapushpi Swarasa Nasya in Kamala induced Hyperbilirubinemia

3. Sushruta, Sushruta Samhita, Chakrapanidatta, 14th edition. 2017, Chaukamba Sanskrit Samsthan, Varanasi, Pg- 310

4. Vaidya Bapalal G, Adharsha Nighantu, Vol-II, II edition, Varanasi, Chowkambha Bharti Academy. 1999, p-279-280.

5. Rohkamm, Reinhard. Color atlas of neurology. III. by Manfred Guther.Transl.rev.by Ethan Taub.2004;p.90

6. W. Chien, K.S.E.Su, S.-F. Chang. Nasal systemic drug delivery, Marcel Dekker, Inc., New York,1989.


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