E-ISSN:2456-3110

Case Report

Hepatitis E Virus

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 10 October
Publisherwww.maharshicharaka.in

A case study on Ayurvedic management on Kamala w.s.r. to Hepatitis E Virus

Banu J1*, Upadhyay A2, Garg G3
DOI:10.21760/jaims.8.10.41

1* Jasmin Banu, Post Graduate Scholar, Department Of Kayachikitsa, National Institute Of Ayurveda Deemed To Be University, Jaipur, Rajasthan, India.

2 Abhishek Upadhyay, Assistant Professor, Department of Kayachikitsa, National Institute of Ayurveda Deemed to be University, Jaipur, Rajasthan, India.

3 Gaurav Kumar Garg, Assistant Professor, Department of Kayachikitsa, National Institute of Ayurveda Deemed to be University, Jaipur, Rajasthan, India.

Hepatitis is defined as liver inflammation that can be caused on by a number of conditions, including prolonged drug use, heavy alcohol consumption, autoimmune conditions, and exposure to toxins. The term "viral hepatitis" describes the most common type of hepatitis, which is caused by an infection with a virus. In this case, report effect of Ayurveda intervention in HEV is reported. A 55-year, old non-alcoholic, married male patient from an urban area, presented with yellowish discolouration of sclera, urine, upper and lower extremities, reduced appetite, nausea, fatigue with generalized weakness and experiencing upper abdominal pain to the National Institute of Ayurveda Hospital, Jaipur, Rajasthan. On examination, icterus was present, pitting edema present on both lower legs. Hematological examination revealed altered total bilirubin, SGOT, SGPT, Triglycerides, ESR, CRP. Also, sonographic examination revealed a mild hepatomegaly in the patient. The total duration of the treatment was 2 months. The patient was assessed for improvement in hematological parameters, viral markers, and signs and symptoms. after two months, significant improvement was observed in signs and symptoms, and all altered hematological parameters, and viral markers were within normal limits. Hence, presenting this case is evidence to demonstrate the effectiveness of two months of Ayurvedic treatment in managing HEV. The total duration of the treatment was 60 days.

Keywords: Acute Viral Hepatitis, HEV, Hepatitis E virus, HAV, Hepatitis A virus, Kamala, Ayurvedic Management

Corresponding Author How to Cite this Article To Browse
Jasmin Banu, Post Graduate Scholar, Department Of Kayachikitsa, National Institute Of Ayurveda Deemed To Be University, Jaipur, Rajasthan, India.
Email: 		Banu J, Upadhyay A, Garg G, A case study on Ayurvedic management on Kamala w.s.r. to Hepatitis E Virus. J Ayu Int Med Sci. 2023;8(10):259-264.
Available From
https://jaims.in/jaims/article/view/2696

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-08-10 2023-08-15 2023-08-21 2023-08-26 2023-09-16
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 45.90%

© 2023by Banu J, Upadhyay A, Garg Gand 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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Jasmin Banu et al. Ayurvedic management on Kamala w.s.r. to Hepatitis E Virus

Introduction

Viral hepatitis is a condition characterised by inflammation and necrosis of the liver caused by hepatitis viruses, including hepatitis A, B, C, D and E.[1] Viral hepatitis is responsible for 3% of the communicable diseases which impose the highest burden in India. Hepatitis E virus (HEV) is transmitted via consuming contaminated food or water. Hepatitis E virus (HEV) is a leading cause of acute viral hepatitis in developing countries. HEV comprises four genotypes: genotypes 1 and 2 primarily infect humans, whereas genotypes 3 and 4 predominantly infect mammalian animals with sporadic cross-species transmission to humans. WHO estimates that, genotypes 1 and 2 are responsible for approximately 20.1 million HEV infections, 3.4 million symptomatic cases, 70,000 fatalities, and 3000 stillbirths every year.[2] Antiviral therapy is the primary treatment modality of current hepatitis management.

In Ayurveda, Acute viral hepatitis (AVH) has symptomatic resemblance with Kamala Roga and is brought on by the imbalance of Pitta Dosha and Rakta Dhatu[3] and also it is a disease of Dushta Raktaja Roga,[4] where cardinal symptoms are Haridra Netra (yellowish discoloration of eyes), Haridra Twaka Nakha-Aanana (yellowish discoloration of skin, nails, and face), Rakta Pitta Shakrita Mutra (reddish yellow color of feces and urinals), Hatendriya (weakness of senses), Avipaka (indigestion), Daurbalya (generalized weakness) and Aruchi (anorexia).[5] As Kamala is Paittika Vyadhi and Mridu Tikta Aushadha is mentioned in classics for the treatment principle.[6] The action of Shaman drugs were Pittahara or Pitta Rechana, Yakrutta Uttejaka ( Liver stimulant), Deepana (Appetizer), Raktashodhana (Blood purifier), Strotoshodhana (Channel purifier).

From the presenting features (constitutional symptoms) and investigation (hyperbilirubinemia, elevated hepatic enzymes, HEV IgM positive), the case was diagnosed as Hepatitis E.

The present case is about the Ayurvedic management of HEV i.e., Kamala. A 55-year-old, non-alcoholic, married male patient from an urban area known case of HTN since 3 years (not on regular medicine) visited KC OPD, NIA Jaipur, with the chief complaint of yellowish discoloration

of sclera, upper and lower extremities, dark yellow urine with a clay stool colour, from last 1 month. The patient had also complained of anorexia, nausea, fatigue with generalized weakness, experiencing upper abdominal pain from last 2 months. the patient was 5 feet 5 inch tall, weighing 80 kg, and looking unwell and tired. Also, from the Ayurvedic perspective, this case was diagnosed as Bahu Pitta Kamala or Ubhayaashrita Kamala.

History of present illness

A 55 year old male patient was asymptomatic before May 2023, used to consume daily spicy food items, tea, coffee, paratha. Then he had developed complaint of anorexia, yellowish discoloration of urine, eyes, upper and lower extremities, upper abdominal pain. Initially, these symptoms were mild, but gradually severity increased. Meanwhile, on 29 May, 2023, doctors did him liver function test (LFT) and Anti-HEV IgM and USG. Through the test report, he was found to be hepatitis E positive. He opted for the Ayurvedic treatment for better care and support. He was admitted in IPD-NIA, 5th June for 30 days.

Personal History

Name - ABCHeight - 5’5’’
Age - 55 yearsBala - Avara
Gender - MaleAppetite - Reduced
Marital status - MarriedSleep - Sound
Occupation - JewelerBowel habit - Clear, Semi- solid, clay coloured stool
Weight - 80kgBladder - Dark yellowish discoloration present
Addiction - Tea (6-8 times) since 20 yrs. 

History of Past Illness

He denied any personal or family history of liver disease and also denied taking any use of alcohol, tobacco, illicit drugs or any recent travel. He was sexually inactive from last 6 months and also not had any tattoos. He had a history of blood donation once 3 years ago and denied any previous surgeries.

Clinical Findings - General Physical Examination

At the presentation time, patient’s icteric sclera was significant, pitting edema (Grade - 2) present on both legs and gynecomastia was also present. His pulse rate was 84 bpm, regular, blood pressure was 110/80 mm of HG, respiratory rate was 16/min. and temperature was 97.2°F. No any lymph node was enlarged at that time.


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Systemic Examination

GIT examination on presentation was soft, non-distended abdomen. On palpation, mild hepatomegaly with nontender liver edge was observed and the right hypochondriac and umbilical region was tender. dull sound present during the percussion on the right hypochondriac and right lumbar region and bowel sounds were normal during auscultation.

No other any abnormal clinical findings for cardiovascular, respiratory and CNS systems was observed on systemic examination.

Ashta Vidha Pareeksha (Eight-fold examination of the patient)

Nadi: Pittaja Nadi, 84/minMala: Tilapishtha Nibha (clay-coloured)
Mutra: Peeta Varna Jiwha: Kaphavrutta
Shabda: PrakritaSparsha: Samanya, Ruksha
Druk: Haridra Peeta VarnaAkriti: Madhyama

Dashavidha Pareeksha (Ten-fold examination of patient )

Prakriti (Physical constitution): Pitta Kaphaj Dushya: Rakta and Mamsa
Aharaja Hetu: Pitttavardhak Aahara Sevana, Amla, Lavana, Viruddha BhojanPramana: Madhyama
Viharaja Hetu: AtivyayamSatmya: Madhyama
Manasika Hetu: Krodha and ChintaAhara Shakthi A) Abhyavaharana Shakti: AvaraB) Jarana Shakti: Madhyam
Dosha: Pitta and RaktaSatva: Madhyama
Vyayama Shakti: AvaraDesha: Anoopa
Sara: MadhyamSamhanan: Madhyamas
Vaya: MadhyamaBala: Avara

Investigations: The baseline investigation report showed that liver enzymes were elevated.

Hematological investigations4/6/202314/6/20234/7/202328/7/2023
Total bilirubin17.34 mg/dl11.00 mg/dl4.30 mg/dl2.746 mg/dl
Direct bilirubin10.58 mg/dl10.00 mg/dl3.76 mg/dl2.084 mg/dl
Indirect bilirubin6.76 mg/dl0.99 mg/dl0.54 mg/dl0.66 mg/dl
SGOT162.6 u/l214.8 u/l98.4 u/l68.1 U/L
SGPT92.8 u/l95.9 u/l49.9 u/l31.2 U/L
ALP77.0 IU/L134 IU/L140 IU/L151 U/L
Total protein7.92 gm/dl7.71 gm/dl8.12 gm/dl8.41 gm/dl
Albumin2.95 gm/dl2.91 gm/dl3.05 gm/dl3.75 gm/dl
Globulin4.97 gm/dl4.80 gm/dl5.07 gm/dl4.66 gm/dl
ESR114 mm/ hr--71 mm/ hr
CRPPositive---
Triglycerides450.5 mg/dl--152.8 mg/dl
HAV IgM0.19---
HBSAG (Rapid)Non- reactive--Non - reactive
HEV IgM120.839--12.78
Anti- HCV AntibodyNegative--Negative
ANA ELISA47.38 Units0.90 INDEX VALU--
Urine analysis6/6/2314/6/20234/7/23 
ProteinAbsentTraceAbsent 
BilirubinAbsentTraceAbsent 
Nitrite1+AbsentAbsent 
KetoneAbsentAbsentAbsent 
Urobilinogen0.2 mg/dl0.2 mg/dl0.2 mg/dl 


Assessment Criteria of Ubhayaashrita Kamala

SNSymptomsNormalMildModerateSevere
1.Haridrata of Netra (yellowish discolouration of sclera)0123
2.Haridrata of Tvaka(yellowish discolouration of skin)0123
3.Dourbalya (weakness)0123
4.Peetata of Mutra (yellowish discolouration of urine)0123
5.Aruchi (Anorexia)0123
6.Hrillasa (Nausea)0123

SNSymptomsBefore TreatmentAfter Treatment
1.Haridrata of Netra (yellowish discolouration of sclera)31
2.Haridrata of Tvaka (yellowish discolouration of skin)20
3.Dourbalya (weakness)31
4.Peetata of Mutra (yellowish discolouration of urine)31
5.Aruchi (Anorexia)31
6.Hrillasa (Nausea)21

USG of the whole abdomen
Jaims_2696_01.jpg


Fig. 1.a: Before the treatment

Jaims_2696_03.jpg
Fig. 1.b: After the treatment


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Before treatment (25/05/2023), liver is enlarged in size (167mm) with increased echogencity and altered echotexture and nodular wavy margins (Fig.1.a), after two months (13/08/23), there was a slight changes of liver is enlarged measuring about (145 mm) in size.

Treatment Schedule

The patient was given Ayurvedic medication for two months. the following drugs were prescribed to the patient are presented in Table 4. Throughout the treatment, as a part of Pathya the patient was advised to avoid spicy, oily and salty food. No adverse effect of the prescribed drugs also observed in the case.

DurationDrugDose and frequencyRoute of administrationAnupana
Day 1-101)       Avipattikara Churna,Pittantaka Yoga,Kutki Churna2 gm,2gm,1gm, twice a day, before foodOral Sadharana Jala
2)       Arogyavardhini Vati1 tab twice a day, after foodOralSadharana Jala
3)       Bhringrajasava +Rohitakarishta20 ml + 20ml,twice a day, after foodOralWith Equal amount of water
4)       Yakrutplihari Lauha1 tab twice a day,after foodOralSadharana Jala
5)       Cap. Phylocil1 cap twice a day, after foodOralSadharana Jala
Day 11-20Previous medications continue and add-6)       Syp Amlycure-DS 1 tsf twice a day,after food Oral -
Day 21-34Previous medications Rohitakarishta, Arogyavardhini Vati, was stopped and other medicine continueAdd7)       Punarnavadi Guggulu       2 tab twice a day, after food      Oral      Sadharana Jala
Day 35-601)       Avipattikara Churna,Pittantaka Yoga,Kutki Churna 2 gm,2gm,1gm, twice a day, before foodOral   Sadharana Jala  
2)       Bhringrajasava  20 ml, twice a dayafter foodOral  With Equal amount of water
3)       Syp Amlycure-DS1 tsf twice a day, after foodOral-
4)       Yakrutplihari Lauha1 tab twice a day,after foodOralSadharana Jala
 5)       Punarnavadi Guggulu 2 tabs twice a day, after foodOralSadharana Jala
6)       Cap. Phylocil 1 cap twice a day, after foodOralSadharana Jala

Result and Discussion

Oral medications were administered to the patient during their hospital stay for a month. Therefore, the patient had significantly improved in all symptoms after a month of medication. During a follow-up of 1 months, the patient is now progressively getting well and none of the symptoms have reoccurred.

In Ayurvedic scriptures, these medications are used to treat HEV (Kamala). both clinical and analytical parameters have improved in the present case study.

Mode of action of drugs

Arogyavardhini Vati - an Ayurvedic polyherbal formulation has been used for liver disorders. the drug contains ingredients like Triphala which is an astringent and laxative in nature. It is effective for relieving liver disorders and also useful in digestive disorders. it has antioxidative, antihepatotoxic and immunomodulator properties. The herb Chitraka is an effective agent in relieving symptoms like loss of appetite, indigestion, colitis and various liver disease.

Avipattikar Churna - It has Agni Deepana, Ama Pachana and Mriduvirechaka properties.[7]

Kutaki Churna - It has Pittavirechaniya, Deepana, Raktashuddhikara and Malabhedini properties.

Bhrigrajasava - It contains Bhringraja, Chaturjata, Pippali, Haritaki, Lavanga and Jatiphala. The main action of Bhringrajasava is observed on Vata Dosha and Kapha Dosha. It also detoxifies the Pitta Dosha. It also improves bile flow from the liver and gallbladder. If a person requires Pitta detoxification or Pitta Dosha is associated with Ama Dosha, then it is the best medicine. It helps to excrete excess Pitta and heat from the body by stimulating gallbladder and liver functions, which leads to bile flow into the intestine. Thus, it improves digestive functions, reduces Ama Dosha production and excretes excess bile in the feces.

Rohitakarishta - It contains Rohitaka, Panchkola, Trijata, Triphala,Dhataki. Rohitakarishta pacifies Kapha Dosha and Pitta Dosha. Hepatoprotective, Antidiuretic, Antitoxic, hepatic stimulant are also properties.

Tab. Amlycure DS - It has Rasayana effect on liver.

Conclusion

HEV (Kamala) patients had a significant improvement in both clinical and analytical parameters in the present case study. Neither during treatment nor the follow-up period were any unintended effects of therapy observed. Thus, it can be said that these medicines are very effective


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in managing, but further study including a larger sample size and a longer duration will be required to prove this impact.

Informed consent - Informed consent for the publication of the data was taken from the patient.

References

1. World Health Organization. Hepatitis E. [Internet]. Geneva: World Health Organization; [updated Year Month Day; cited Year Month Day]. Available from: https://www.who.int/news-room/fact-sheets/detail/hepatitis-e

2. World Health Organization. Hepatitis E. [Internet]. Geneva: World Health Organization; [updated Year Month Day; cited Year Month Day]. Available from: https://www.who.int/teams/health-product-policy-and-standards/standards-and-specifications/vaccine-standardization/hep-e#:~:text=The%20virus%20can%20cause%20large,deaths%2C%20and%203000%20stillbirths%20annually

3. Agnivesha, Kashinath Shastri P. Charaka Samhita. Chikitsa sthana, chapter 16, verse 34. Vidhyotini Hindi commentary. Varanasi: Chaukhambha Bharati Akadami; 2016. p. 491.

4. Agnivesha, Kashinath Shastri P. Charaka Samhita. Sutra sthana, chapter 28, verse 11. Vidhyotini Hindi commentary. Varanasi: Chaukhambha Bharati Akadami; 2018. p. 571.

5. Agnivesha, Kashinath Shastri P. Charaka Samhita. Chikitsa sthana, chapter 16, verse 35-36. Vidhyotini Hindi commentary. Varanasi: Chaukhambha Bharati Akadami; 2016. p. 492.

6. Agnivesha, Kashinath Shastri P. Charaka Samhita. Chikitsa sthana, chapter 16, verse 40. Vidhyotini Hindi commentary. Varanasi: Chaukhambha Bharati Akadami; 2016. p. 493.

7. Sahu AK, Upadhyay A, Bhakuni H, Attanayake AMHS, Sharma P. Effect of Ayurveda interventions in non-alcoholic grade II fatty liver associated with obesity - A case report. J Ayurveda Integr Med. Year Month Day;13(3):100605. doi: 10.1016/j.jaim.2022.100605. PMID: 35868134; PMCID: PMC9307675


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