E-ISSN:2456-3110

Case Report

Idiopathic Thrombocytopenia

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 10 October
Publisherwww.maharshicharaka.in

Ayurvedic management of Idiopathic Thrombocytopenia Purpura - A Case Study

Chaithra T M1*, Prashanth A S2
DOI:10.21760/jaims.8.10.40

1* Chaithra T M, Post Graduate Scholar, Dept Of Kayachikitsa, Ayurveda Mahavidyalaya And Hospital, Hubballi, Karnataka, India.

2 Prashanth A S, Professor, Dept of Kayachikitsa, Ayurveda Mahavidyalaya and Hospital, Hubballi, Karnataka, India.

The traditional Ayurvedic literature includes a thorough grasp of effective treatment to a majority of Modern-day health issues. Idiopathic Thrombocytopenic purpura (ITP) is one of these issues that is strengthening its roots in society. ITP is an Autoimmune disorder characterized by a low platelet count and mucocutaneous bleeding. ITP is defined as a Hematologic disorder, characterized by isolated thrombocytopenia without a clinically apparent cause. The major causes of accelerated platelet destruction include Immune thrombocytopenia, Decreased bone marrow production and increased splenic sequestration. Bleeding disorders are explained in classics under the heading of Raktapitta. ITP can be correlated with Tiryaka Raktapitta. It is Pitta pradhana tridoshaja vyadhi and it manifests as subcutaneous bleeding. In this study, a 21 year old female patient had complaints of Epistaxis, purpura, petechia, bruises since 6 months and she was treated with ayurvedic medicines. After treatment significant improvement was observed in patient’s condition, Haematological parameteres i.e, Platelet count was stable.

Keywords: Idiopathic Thrombocytopenia Purpura, Tiryak Raktapitta, Mrudu Virechana, Parisheka

Corresponding Author How to Cite this Article To Browse
Chaithra T M, Post Graduate Scholar, Dept Of Kayachikitsa, Ayurveda Mahavidyalaya And Hospital, Hubballi, Karnataka, India.
Email: 		Chaithra T M, Prashanth A S, Ayurvedic management of Idiopathic Thrombocytopenia Purpura - A Case Study. J Ayu Int Med Sci. 2023;8(10):252-258.
Available From
https://jaims.in/jaims/article/view/2832

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-08-13 2023-08-18 2023-08-23 2023-08-28 2023-09-18
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 20.90%

© 2023by Chaithra T M, Prashanth A Sand 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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Introduction

According to Acharya Vagbhata, the excessive consumption of Ushna, Tikshna, Katu, and Lavana Rasa Ahara the Pitta gets vitiate.[1] In this disease Pitta Pradhana Vata and Kapha are vitiated resulting in the imbalance of the Rakta Dhatu. This vitiated Pitta associates with Rakta and causes Raktapitta. Further vitiated Rakta flows out from all orifices including Romakupa (hair follicles) it is called as Tiryak Gata Rakthapitta. Tiryakgata Raktapitta is the Pitta Pradhana  Vyadhi  and  it were  get converted into Pitta Pradhana Tridoshaja Vyadhi, as a rule any disease will get transformed into Sannipataja in an advance stage of it. As because of its severity it is considered as Mahagada.

Immune thrombocytopenic purpura (ITP), also known as Idiopathic thrombocytopenic purpura or Immune thrombocytopenia, is a type of thrombocytopenic purpura characterized by a low platelet count and accompanied by a red-purple rash called purpura.[2],[3] It leads to an increased risk of bleeding.[2] It is an autoimmune bleeding disorder in which the immune system attacks the platelets in the blood. This imbalance affects the immune system of the body with manifestations like subcutaneous bleeding Based on this definition of ITP, it can be correlated to Triyakgata Rakthapitta in Ayurveda.

Pathology

Platelets are cells in the blood that help to stop the bleeding. Decrease in platelets can cause easy bruising, bleeding gums, and internal bleeding. In approximately 60 percent of cases, antibodies against platelets can be detected.[4] Most often these antibodies are against platelet membrane glycoproteins IIb-IIIa or Ib-IX, and are of the immunoglobulin G (IgG) type. The coating of platelets with IgG renders them susceptible to opsonization and phagocytosis by splenic macrophages, as well by Kupffer cells in the liver. The IgG auto-antibodies also damage megakaryocytes, the precursor cells to platelets. Although this is believed to contribute a minor to the decrease in the platelet count. The recent research now indicates that impaired production of the glycoprotein hormone, thrombopoietin, which is the stimulant for platelet production, may be a contributing factor to the reduction in circulating platelets. The stimulus for auto-antibody

production in ITP is probably abnormal T cell activity. Preliminary findings suggest that these T cells can be influenced by medications that target B cells, such as rituximab.

Signs and Symptoms

Signs of ITP include,

  • Spontaneous formation of Bruises (purpura) and Petechiae (tiny bruises), especially on the extremities.
  • Bleeding from the nostrils and/or gums, as well as menorrhagia (excessive menstrual bleeding), may occur if the platelet count falls below 20,000 per μl.[5]
  • The platelet count below 10,000 per μl lead to the spontaneous formation of Hematomas (blood masses) in the mouth or on other mucous membranes. Furthermore, the bleeding time from minor lacerations or abrasions is usually prolonged.
  • In cases where platelet counts drop to extremely low levels (<5,000 per μl), serious and potentially fatal complications may arise. These complications include Subarachnoid or Intracerebral Haemorrhage, lower gastrointestinal bleeding or other internal bleeding.
  • A person with ITP with an extremely low platelet count is susceptible for internal bleeding resulting from blunt Abdominal Trauma, such as in a motor vehicle crash. These complications are unlikely to occur when the platelet count is less than 20,000 per μl.[6]

Case Report

Primary data

A 21 year old female patient visited Kaya Chikitsa OPD of Ayurveda Mahavidyalaya & Hospital, Hubli on date 26/09/2022 with following details.

Patient name - ABC
Age/Sex - 21 years/ Female
Occupation - House Wife
Place - Hubballi

Chief complaints

  • Patient complained of Bruises after being struck by any object
  • Occasionally nasal bleeding since 6 months.

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Associated complaints

  • Weakness
  • Generalised body ache
  • Reduced appetite
  • Hair fall since 6 months.

History of present illness

A 21year old female patient visited to the Kayachikitsa OPD of Ayurveda Mahavidyalaya College and Hospital, Hubballi. Who was apparently normal before 6 months. Since then, she had complaints of bruises after being struck by any object, nasal bleeding occasionally, weakness, generalised body ache, reduced appetite and hair fall. Patient underwent allopathic treatment and didn’t get symptomatic relief. Hence patient visited to our hospital for Ayurvedic treatment.

Personal history

Appetite: Reduced
Bowel: Regular
Micturition: Regular
Sleep: Normal
Food: Mixed food habits
Menstrual history: post-partum status from 6 months.
Obstetrics history: P1 L1 D0 LSCS, Male,6 months.

General examination

BP: 140/80 mm of hg
Pulse: 68/ min
RR: 20/ min
Temp: 96.6 F / Afebrile
Pallor: Present
Oedema: Absent
Nails: Normal
Tongue: Dry, Redness+
Weight: 40 kg

Systemic examination

R/S: NVBS, Clear
CVS: S1S2 Heard
CNS: Conscious, Oriented
P/A: Soft, Nontender, No distension.

Nidana Panchaka

Nidana

Excessive intake of Ushna (hot), Amla (sour), Tikshna

(sharp), Vidahi (corrosive food), Kshara (alkali) food items, Atikrodha (excessive anger), Atiatapa Sevana (exposure to the sun), Ativyayama.

Poorva Roopa

Shokha Purna Galasyata, Aruchi, Ura Vidaha, Amla Udgara, Sheeta Kamitva, Klama, Chardi, Loha Gandhi Nishwasa.

Roopa

Sarvanga Dahatva Nasagata Raktastrava, Jwara, Shuka Purna Galasyata, Chardi, Amla Udgara, Klama, Aruchi.

Samprapti

Due to Nidana Sevana
↓
Pitta gets aggravated, then mixes with the Rakta and in turn vitiates the Rakta
↓
Due to the Ushna Guna of the Pitta Dosha, the Drava Tatwa of other Dhatus like Mamsa, Meda etc. oozes out of their respective tissue and gets mixed with the Rakta.
↓
This enhances the quantity of the Rakta Dhatu, beyond the normal limits
↓
This also enhances the quantity of blood flowing in the blood vessels creating immense pressure in the blood vessels
↓
Due to the pressure of the Blood and Ushmata of the Pitta, the walls of the blood vessels get damaged and the blood starts flowing through the various openings of the body.
↓
Rakta Srava will occur through Mouth, Nose, Ears, Eyes, Skin, Anus, Penis and Vagina (Navadwara)
↓
This bleeding of blood vitiated by pitta through various orifices (Navadwara) of the body is called as Raktapitta.

Samprapti Ghatakas

Dosha: Pitta Pradhana Tridoshaja
Vata: Samana, Apana, Vyana
Pitta: Pachaka, Ranjaka
Kapha: Kledaka
Dushya: Rakta, Rasa, Mamsa, Sira
Agni: Jataragni, Dhatvagni, Bhutagni
Agnidusti: Agniviparyaya


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Aama: Kosta Agnijanya
Strotas: Raktavaha, Rasavaha, Annavaha, Artava and other Srotas according to Avastha.
Srotodusti: Sanga, Vimarga Gamana, Atipravrutti
Udbhavasthana: Amapakwashaya
Sancharasthana: Raktavahinyaka, Rasavahinyaka
Adhistana: Yakruth and Pliha
Vyaktasthana: Tiryaka Bahya Srotas
Rogamarga: Bahya and Abhyantara
Sadhyasadhyata: Ekadosha - Sadhya
Dvidosha - Yapya
Sannipataja - Asadhya
Svabhava - Ashukari, Chirakari

Diagnostic criteria

CBC mainly Platelet count
BT, CT, Sr. Calcium

Treatment protocol

  • On 1st day of OPD visit the following Shamanoushadhi were advised for 15 days,

1. Laghu Sutashekhara Rasa 1-0-1, B/F
2. Sudarshana Ghana vati 1-0-1, B/F
3. Tab. Styplon 1-1-0, A/F
4. Tab. Platenza 1-0-1, A/F

  • After 15 days, patient got admitted with mild reduction in the symptoms. As condition of the patient was in Bahudoshaja Avastha, Panchakarma therapy was advised.
  • In the beginning Manjistadi Kashaya and Aragvadamrita Kashaya Parishekha for 5 days followed by 7 days of Vishrama Kala was advised.
  • After 7 days of resting period the patient was admitted again and was advised the Mrudu Virechana therapy as follows.

Procedure Medicine Duration Dosage
Vicharana SnehapanaIndukanta Ghritam5 days15 ml with food BD
Mrudu VirechanaCap Nimbamrutadi Erandam1 day1-0-1, B/F
Mrudu VirechanaManibadra Lehya 1 day20gm at 7:00 am in the morning

  • After intake of Manibadra Lehya for Virechana, 5 Vegas were observed.
  • Patient got discharged and was advised for Pathya Apathya and Shamana Oushadhis were are continued.
  • Shamanoushadhi as:

Cap Narasimha Rasyana 1-0-1, B/F

Laghusutashekhara Vati 1-0-1, B/F

Sudarshana Ghana Vati 1-0-1, B/F

Tab. Styplon 1-1-0, A/F
Tab. Platenza 1-0-1, A/F/p>

  • Follow-up details

ComplaintsShamanaoushadhis
1st follow up (7/2/2023)§   Headache§   Occurrence of Bruises were reduced§   Normal menstrual cycles were attained.  1.        Laghusutashekhara Vati 1-0-1, A/F2.        Sarivadyasava 15 ml -0-15 ml, with 45ml luke warm water, A/F3.        Drakshasava 15ml -0- 15 ml, with 45ml luke warm water, A/F4.        Tab. Platenza 1-0-1, A/F5.        Tab. Sudarshana Ghana Vati 1-1-0, B/F6.        Tab. Heap ok 0-1-0, B/F7.        Dadimastaka Churna, B/F 1 tsf -0-1 tsf with luke warm water8.        Tab. Liv 52 DS 1-0-1, A/F
2nd follow up (17/5/2023)§   Headache§   Vomiting after intake of sour substance§   Burning sensation of the bilateral feet ++1.        Laghusutashekhara Vati 1-0-1, B/F2.        Tab. Ulsant 1-1-1, B/F3.        Amlapittantaka syp 2 tsf -0-2tsf with 45 ml water, B/F4.        Tab. Platenza 1-0-1, A/F5.        Tab. Hepa ok 0-1-0, A/F6.        Tab. Thyrowave 0-0-1, B/F
3rd follow up (28/6/2023)§   Patient had no complaints of burning sensation, bruises.§   Patients felt better.1.        Syp. Stomaliv 2 tsf -0- 2tsf with 45 ml water, B/F2.        Amlapittantaka syp 2tsf -0-2 tsf with 45 ml water, B/F3.        Tab. Platenza 1-0-1, A/F4.        Tab. Hepa ok 0-1-0, A/F5.        Tab. Throwave 0-0-1, B/F

Before treatment (22/09/2022)
Jaims_2832_01.jpg

After Panchakarma (1/12/2022)
Jaims_2832_02.jpg




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After the first follow-up (20/03/2022)
Jaims_2832_03.jpg

After the second follow-up (26/06/2023)
Jaims_2832_04.jpg

Results

A significant, marked elevation in the level of platelet count are observed during the treatment period and consecutive follow-up. After the treatment, symptoms markedly reduced. The patient was advised to attend the follow-up, medication were advised and instructed to follow the Pathya.

Discussion

The disease Thrombocytopenia can be correlated with the Tiryak Gata Raktapitta. By appropriate understanding of Nidana, Samprapti, Laxana, Rogi and Roga Bala, Roga Avastha the disease is addressed by adapting multi- modality treatment procedures like Mrudu Virechana, Shamana Oushadhi Prayoga.

The mode of action of procedure and drugs are as follows:

Laghu Sutashekhara Rasa[7] is given which contains Shudha Swarna Gairika, Shunti Choorna Bhavana with Nagavalli Swarasa. Which helps in the reduction of the Ama and prevents its further formation through its Pachana effect. It especially reduces the Pitta and its Gunas like Tikshna & Amla Guna. As the Raktapitta is having Pitta predominance, this Yoga can be used here.

Sudarshana Ghana Vati[8] which is having the Pitta Rechaka, Hepatoprotective, which influence over the spleen which is the destructor of RBC cells, as it possesses the Amla Guna Pradhan Dravyas in it.

Tab styplon will acts as an Haemostatic drugs

Tab Platenza is having Hepatoprotective, it acts as Catalyser for the drugs, decreases the platelet destruction.

Parishekha, as the patient is Lactating women we can’t do the procedures which are strainfull, so Parisheka has been done. It is very helpful as fire gets extinguished by pouring water, similarly the symptoms like Daha, Dourbalya is reduced by the process of Parishekha.

Cap Narasimha Rasayana,[9] due to its Rasayana action it is helpful in Pittashaman which is very useful, as the immunity is low in Raktapitta patients.

Vicharana Snehapana, as the patient is Sneha Dweshi, having Mrudu Kostha, more of Roga Bala Vicharana Snehapana has been done with Indukantha Ghritam which is having the Gunas like Agni Uttejana and Muda Vata Anulomana.

Mrudu Virechana, As the Rogi Bala is less, so Mrudu Virechana is given to patient. It does the Pitta Rechana which is useful in the Raktapitta.

It is conducted with Nimbamrutadi Erandam[10] and Manibadra Lehyam[11] which are helpful in the Splenic disorders. Those which are acting on the Raktavaha Sroto Mula Yakrit and Pleeha.

Sarivadyasyava[12] and Drakshasava,[13] they are indicated in Rakta Prasadana, Pitta Shamana. These preparations are endowed with antioxidant, antimicrobial, anti-inflammatory properties.

Dadimastaka Choorna,[14] it helps in the Agni Sandeepana, Arochakahara, Rakta Vardaka, Muda Vata Anulomana.


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Tab Liv 52, it is a popular, Restorative Pharmaceutical preparation which is Hepatoprotective, Appetizer, Improves the digestion process. It helps in Restoring the livers functional efficiency by protecting the Parenchyma and Hepatocellular Regeneration.

Amlapittantaka Syp, Syp Stomaliv, Tab Ulsant are used to reduce the Amlapitta, and it is Digestive and Carminative.

Tab. Hepa OK, it acts as an natural liver tonic that eliminates the toxins, powerful Antioxidant, Anti- Inflammatory, Antimicrobial, Antiviral, Hepatoprotective, Immune booster.

Tab Thyrowave, it is given because the patient is known case of Hyperthyroidism.

Conclusion

Raktapitta, a Mahagada, its severity depends upon the cause and the amount of blood loss; assessed clinically (pallor pulse, BP, blood loss, etc.). When this disease changes its Marga (direction), it turns Asadhya (incurable), having grave consequences. So, it should be treated immediately, before it spreads like a forest fire. In this clinical case study, the patient has shown good improvement symptomatically during the management of the ITP. Chronic ITP needs lifelong medical management or splenectomy. With the help of Ayurvedic formulations, the patient is relived from symptoms. The drug which is used in the management of ITP possesses the properties of antioxidant, immunomodulatory, antimicrobial, hepatoprotective and anti-inflammatory. These properties of drugs prevent platelet destruction by the immunological process. Thus, the Improvement was observed in the symptoms of petechial hemorrhage, nasal bleeding, general weakness and body ache.

References

1. Vagbhata. Astanga Hrudayam. English version translated by Prof. K.R. Srikanth Murthy. Volume 2. Nidana Sthana. Chapter 3. Raktapitta Nidanam. Verse number 1. Chowkhamba Krishnadas Academy; Varanasi. Reprinted, 2010:29.

2. Pietras NM, Pearson-Shaver AL. Immune Thrombocytopenic Purpura. StatPearls. StatPearls Publishing; 2022. PMID: 32965953.

3. Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009 Mar;113(11):2386–93. doi: 10.1182/blood-2008-07-162503. PMID: 19005182.

4. Coopamah MD, Garvey MB, Freedman J, Semple JW. Cellular immune mechanisms in autoimmune thrombocytopenic purpura: An update. Transfusion Medicine Reviews. 2003 Jan;17(1):69–80. doi: 10.1053/tmrv.2003.50004. PMID: 12522773.

5. Cines DB, McMillan R. Management of adult idiopathic thrombocytopenic purpura. Annual Review of Medicine. 2005;56:425–42. doi: 10.1146/annurev.med.56.082103.104644. PMID: 15660520.

6. Immune Thrombocytopenic Purpura. The Lecturio Medical Concept Library. Retrieved July 27, 2021.

7. Krishnanadaji Maharaj's Rasatantra Sara va Siddhaprayoga Sangraha. Published by Krishna Gopal Ayurveda Bhavana. Prathama Khanda, Kharaliya Rasayana Adhikarana:546.

8. Sharangadhara. Sharangadhara Samhita of Sharangadhara Acharya. English translation, edited by Prof. K.R. Srikantha Murthy. Madhyama khanda. Chapter 6. Curna kalpana. Verse number 26–36. Chaukhambha Orientalia Varanasi. Reprint Edition 2017:88.

9. Vagbhata. Astanga Hrudayam. English version translated by Prof. K.R. Srikanth Murthy. Volume 3. Uttara Tantra. Chapter 39. Rasyana vidhi. Verse number 169–173. Chowkhamba Krishnadas Academy; Varanasi. Fifth edition, Reprinted, 2009:411.

10. Vagbhata. Astanga Hrudayam. English version translated by Prof. K.R. Srikanth Murthy. Volume 2. Chikitsa Sthana. Chapter 21. Vata Vyadhi chikitsa. Verse number 58–61. Chowkhamba Krishnadas Academy; Varanasi. Reprinted, 2010:508.

11. Vagbhata. Astanga Hrudayam. English version translated by Prof. K.R. Srikanth Murthy. Volume 2. Chikitsa Sthana. Chapter 19. Kusta chikitsa. Verse number 31–32. Chowkhamba Krishnadas Academy; Varanasi. Reprinted, 2010:476.

12. Govind Dasji Bhisagratna. Bhaisajya Ratnavali.


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Commented upon by Vaidya Shri Ambika Datta Shastri. English translation by Dr. Kanjiv Lochan. Volume 2. Chapter 38. Prameha pidaka Prakarana. Verse number 22–27. Chaukhambha Sanskrit Sansthan; Varanasi. The C.S.B Series 67. Reprint 2009:550.

13. Govind Dasji Bhisagratna. Bhaisajya Ratnavali. Commented upon by Vaidya Shri Ambika Datta Shastri. English translation by Dr. Kanjiv Lochan. Volume 1. Chapter 9. Arsa Prakarana. Verse number 170–174. Chaukhambha Sanskrit Sansthan; Varanasi. The C.S.B Series 67. Reprint 2008:606.

14. Govind Dasji Bhisagratna. Bhaisajya Ratnavali. Commented upon by Vaidya Shri Ambika Datta Shastri. English translation by Dr. Kanjiv Lochan. Volume 1. Chapter 8. Grahani Prakarana. Verse number 38–39. Chaukhambha Sanskrit Sansthan; Varanasi. The C.S.B Series 67. Reprint 2008:483–484.


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