Journal of Ayurveda and Integrated Medical Sciences

The initial defence against infection with mycobacterium tuberculosis once it reaches the lower respiratory tract is the alveolar macrophages. This cell is capable of inhibiting growth of the bacillus through phagocytosis which gets suppressed in chest injuries. The stress of exercise may have allowed a reactivation of the pathogens responsible for infection.

During exercise exposure to airborne pathogens is increased due to higher rate and depth of breathing. An increase in gut permeability may also allow increased entry of gut bacterial endotoxins into the circulation particularly during prolonged exercise. Bouts of excess exercise cause temporary depression of various aspects of immune function like neutrophil, respiratory burst, lymphocyte proliferation etc. Within the respiratory tract, defense from pathogens is accomplished largely through the action of alveolar macrophages and the production of cytokines.

The alveolar macrophage is an important cell of the innate defense system located within the respiratory tract that has the capacity to take up pathogens in a nonspecific manner. The macrophage can limit replication of pathogens thus limiting further spread of the infection.

2. Vega Sandharan

It is also known as Vega Pratighata, Vega Samrodha and Gatirodha. One of the important Nidana of Rajyakshma, it is clarified that only the suppression of the urge of Mutra, Pureesha and Vata Vega are to be considered as Rajyakshma Hetu. Where the causative factor itself is an important stimulus for the aggravation of Vata urges are driven by Vayu present in different because of its Chala Guna. Suppressing the elimination of Mala leads to Mala Sanchaya. Mala Sanchaya results in Tridosha Prakopa. Suppression of Mutra, Mala and Vata leads to provokes Apanavata. Dushta Vata will further provoke Pitta and Kapha Dosha and may result in Rajayakshma.

3. Kshaya

It is understood as Dhatu Kshaya in the context of Rajyakshma. Dhatu Kshaya especially as Sara Kshaya (Shudha Dhatu not formed). Rasa and Shukra are mentioned as etiological actor for Rajayakshma depletion of Ojus or Rasa present in the Hridya takes places in following way - Anulomana and Pratilomana Kshaya

also increases the risk of drug toxicity, relapse and death once tuberculosis develops. The host protective immune mechanism of infection with mycobacterium tuberculosis depends on the interaction and cooperation between monocyte macrophage and T -lymphocyte and their cytokines. Increased risk of tuberculosis can result from alteration in the individual protective function of or the interaction between a T-lymphocytes and macrophages because of nutritional deficiency. Micronutrients deficiency is considered to be the most frequent cause of secondary immunodeficiency and infection related morbidity including tuberculosis Vitamin A has immune-competent role in human tuberculosis. Vitamin A inhibits multiplication of virulent bacilli in cultured human macrophages and has a vital role in lymphocyte proliferation and in maintaining the function of epithelial tissues. Vitamin A is essential for normal functioning of T and B lymphocytes, macrophage activity, and generation of antibody response. Concentration of vitamin E and Vitamin C was found to be significantly lower in tuberculosis patients than healthy controls. Anemia is highly prevalent among adults with pulmonary tuberculosis and deficiency on Iron could contribute in the predisposition for infection

5. Nidanarthakara Rogas

Besides this our major causes may disease act as like Jwara, Rakta Pitta , Pratishyaya and Kasa that can lead to Rajayakshma as their complication. It is also seen that during the disease like Prameha Gulma and Grahani the chances of Rajyakshma are increased. It may be because of Dhatu Kshaya and due to the chronicity nature of disease.

6. Adibala Pravrutti

Pradusta Beeja/ Shonita or Beejabhagavayaya of parents if gets afflicted with the pathology of Rajyakshma, then any progeny born in them are suffers from it. Atharveda also supports by considering it under Kshetreeya Vyadhis.

7. Upasarga

The infectious nature of the disease was clearly recognized by Sushruta included in the list of Aupasargika Rogas or contagious disease or endemic in disposition. These are transformed from one person to other by the familiarity of infectious patient.

Raktadeenam Cha Sankshayat

The stable tissue elements like Rakta etc. due to obstruction to the passage of nutrient material or Srotamsi and due to insufficiency of Upadana Rasa, it gets depleted as these Rasa and Srotamsi provide nourishment to Dhatu.

The reason behind depletion of this, Rasa containing Dhatvahara during the course of disease is at that time whatever the food is digested in the Koshta by Jatharagni is reduced to Mala or waste products and very little contributes to the formation of Ojus or Sara Bhaga of Rasa. There will be hindrance of Jatharagni due the nature of the disease as it is influenced by vitiated Dosha chiefly Kapha such Ahara Rasa produced is insufficient to maintain or to nourish the tissue elements due to incomplete transformation.

Therefore, in a Rajayakshma patient always concern should be taken particularly against the Malarakshana because Balamtasya Hi Vid Balam.

Dhatu Ushmana Chayapachayat

Normally the Dhatu of body gets metabolised by their own Ushmas or Dhatwagni / Dhatuushmana (transforming enzymes). From these Dhatu the other Dhatu get nourished through their respective Srotas (channels of circulation) e.g. - a Poshaka Rasa Dhatu would nourish the Rakta Dhatu once however if there is any obstruction to Srotas or if there is diminution of stable tissue elements like Rakta or if there is diminution of Dhatu Ushma or Dhatvagni then Rajyakshma is manifested.

According to Acharya Sushruta Prakrit Pitta is responsible for Paktikrita, Ragakruta, Ojokrita, Tejakrita, Ushmakrita. Acharya Chakrapani mention Ushma as Ushmana Rasagniadirupena Tryodashavidehan. Apachaya of Agni that leads to improper catabolic reaction. Each Dhatu has its own Agni and is called as Dhatwagni.

In a healthy person Dhatwagni helps to maintain the Dhatu and Dhatukarma. From the Ahara Rasa, all the Dhatu are nourished and in turn the essence of Dhatu i.e., Ojus is formed. Due to improper Preena by Rasa, Dhatu Poshana will be inadequate and Dhatwagni Mandya ensures. As a result, Dhatu Kshaya, Ojo Kshaya takes place and may manifest Rajyakshma and reduce the immunity of the body.

Prasara - Prakopa stage followed by Prasaravastha in which the vitiated Vata along with its Chala, Ruksha, Khara Guna vitiates other two Doshas (Pitta and Kapha) from its Sthana Srotasam Sannirodhat, settles in Ura Pradesha affecting Pranavaha Srotas, Annavaha, Rasa Vaha Srotas. Lina Marga Tisthati - ghon focus (primary tuberculosis), bhuyo Hetu Pratikshina - waiting for stimulating / precipitating factor the small size particles escaping the trapping mechanism and reach the lung. It can be understood as spreading of upper respiratory tract infection to lower respiratory infection. Bacteria is transported to alveoli.

Primary infection occur/latent tb

“Ghon focus”- phagocytosis of bacteria by neutrophils and macrophages.

Cell mediated immunity gets activated, surrounds the cell to forms granuloma (3 weeks)

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Leads to necrosis of tissue at infection site

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Term as Ghonfocus

Sthana Samsraya - Important stage for “Dosha Dushya Sammurchana”. Vitiated Vata Dosha produces start affecting Dhatu and Srotas Vitiated Vata due to Chala, Ruksha, Khara Guna it starts making Shoshana of Sthayi Dhatu , restrains and weakens them leads to Asamyak Hetu Vyuhana Karma due to Srotorodha (Gati Avarodha) leads to Dhatu Kshaya. Due to more susceptible or less immuned place created in Pranavaha Srotas by Nidana, the tubercle bacilli accumulate and when it gets the favourable condition it manifest the symptomatology.

Sthansamsraya can also be understood in 2 stages

a. Khavaigunya - In Ura Pradesha

b. Ghon focus

Due to again Nidana Sevana, adequate exposure, environmental trigger immunocompromised patient, smoking etc. leads to subsequent infection occurs in a sensitized individual who possess immunity give rise to Post Primary Tuberculosis, decrease Vyadhi Kshamatva (Vikrita Shleshma - Avalambaka Kapha)

c. Alveoli

Kshaya Avastha. Rajayakshma is respiratory dominant pulmonary tuberculosis when Pranavahasrotas is involved. When Rajayakshma Samprapti with tuberculous positivity happens in extra pulmonary organs and tissues then respective Srotas wise Rajaykshma has to be understood like when it affecting the Amashaya - Abdominal TB, when Doshas affecting the bone - skeletal TB, when Doshas are affecting the Shira - meningeal TB. Rajayakshma in the current scenario has to be diagnosed in two ways i.e., Tuberculosis infection positive Rajayakshma and negative Rajayakshma - immunological Rajayakshma just like sero positive and sero negative rheumatoid arthritis. The Chaturvidha Nidana explained in the classic mainly it indicates towards the predisposing factors that lead to decrease immunity and make the person more susceptible for infection. In understanding of Rajayakshma with reference to the modern science it can be understood as sputum AFB +ve Rajayakshma and sputum AFB -ve Rajayakshma.