E-ISSN:2456-3110

Review Article

Ayurveda management

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 12 December
Publisherwww.maharshicharaka.in

Understanding and approach of Ayurveda management towards a unique case of Hashimoto Thyroiditis - A Case Report

Bhagyashree K1*, Abdul K2
DOI:10.21760/jaims.8.12.38

1* Kamate Bhagyashree, Graduate Scholar, Dept of Pg Studies In Panchakarma, Muniyal Institute of Ayurveda Medical Sciences, Manipal, Karnataka, India.

2 Khader Abdul, Professor, Dept of Kayachikitsa, Sri Kalabyraveshwara Swamy Ayurvedic Medical College Hospital and Research Centre, Bangalore, Karnataka, India.

Hashimoto thyroiditis is also known as chronic autoimmune thyroiditis and chronic lymphocytic thyroiditis, is an autoimmune disease in which thyroid cells are destroyed via cell and antibody-mediated immune processes. It is the most common cause of hypothyroidism in developed countries. The Pathophysiology of Hashimoto Thyroiditis involves the formation of antithyroid antibodies that attack the thyroid tissue, causing progressive fibrosis. The condition is sometimes not diagnosed until late in the disease process. The most common laboratory findings demonstrate elevated Thyroid-Stimulating Hormone (TSH) and low Thyroxine (T4) levels, coupled with increased anti thyroid peroxidase (anti-TPO) antibodies. In Ayurveda, it can be correlated with Rasavaha Sroto Vikara, Dhatwagnimandya, Vataja Pandu, Pittavruta Vata based on symptoms. Case Report: In this present study a female patient aged 37 years, known case of Hashimoto Thyroiditis since 8 years was treated with Shiro Takradhara, Sarvanga Abhynaga, Virechana and specific Shamanaushadhi’s as per signs and symptoms. Results: After 2 months of treatment there was a significant reduction in the signs and symptoms of the disease with 70% improvement in the condition.

Keywords: Hashimoto Thyroiditis, Ayurveda, Chronic Autoimmune Thyroiditis, Chronic Lymphocytic Thyroiditis

Corresponding Author How to Cite this Article To Browse
Kamate Bhagyashree, Graduate Scholar, Dept of Pg Studies In Panchakarma, Muniyal Institute of Ayurveda Medical Sciences, Manipal, Karnataka, India.
Email: 		Bhagyashree K, Abdul K, Understanding and approach of Ayurveda management towards a unique case of Hashimoto Thyroiditis - A Case Report. J Ayu Int Med Sci. 2023;8(12):251-260.
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https://jaims.in/jaims/article/view/2969

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-10-01 2023-10-07 2023-10-14 2023-10-24 2023-11-01
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared. Nil. YES 13.52 NONE.

© 2023by Bhagyashree K, Abdul Kand 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

Hashimoto Thyroiditis, also known as chronic autoimmune Thyroiditis and chronic lymphatic Thyroiditis, is an autoimmune disease in which thyroid

cells are destroyed via cell and antibody mediated immune processes. It is the most common cause of hypothyroidism in developed countries. It is primarily a disease of women, with a sex ratio of 10:1 approximately.

In an epidemiological study conducted in India, prevalence of >20% was recorded. Incidence rate of HT is 0.54% in India. Although some sources cite diagnosis happening more so in the fifth decade of life, most women are diagnosed between the ages of 30 to 50 years.[1]

The cause of HT is thought to be a combination of genetic susceptibility and environmental factors.

The patho physiology of Hashimoto Thyroiditis involves the formation of anti-thyroid antibodies that attack the thyroid tissue, causing progressive fibrosis. The diagnosis can be challenging and consequently, the condition is sometimes not diagnosed until late in the disease process.

The most common laboratory findings demonstrate elevated Thyroid Stimulating Hormone (TSH) and low Thyroxin (T4) levels, coupled with increased anti thyroid peroxidase (anti-TPO) antibodies. This activity reviews the pathophysiology and diagnosis of Hashimoto Thyroiditis.[2]

Etiology

The aetiology of Hashimoto disease is very poorly understood. Most patients develop antibodies to a variety of thyroid antigens, the most common of which is anti-thyroid peroxidase (anti-TPO). Many also form anti thyroglobulin (anti-Tg) and TSH receptor-blocking antibodies (TBII).

These antibodies attack the thyroid tissue, eventually leading to inadequate production of thyroid hormone.[3,4]

It can be part of the Polyglandular Autoimmune Syndrome type 2 with autoimmune adrenal deficiency and type-1 DM. Hashimoto thyroiditis is also related to several other autoimmune diseases such as pernicious anaemia, adrenal insufficiency, and celiac disease.[5]

Evaluation

Hashimoto Thyroiditis is an autoimmune disorder of inadequate thyroid hormone production. The biochemical picture indicates raised thyroid-stimulating hormone (TSH) in response to low free T4. Low total T4 or free T4 level in the presence of an elevated TSH level confirms the diagnosis of primary hypothyroidism.[6]

The presence of anti-thyroid peroxidase and anti-thyroglobulin antibodies suggests Hashimoto Thyroiditis, however 10% of patients may be antibody negative. Anemia is present in 30 to 40%. There can be decreased Glomerular filtration rate (GFR), renal plasma flow, and renal free water clearance with resultant Hypernatremia. Creatinine, kinase is frequently elevated. Prolactin levels may be elevated. Elevated total cholesterol, LDL, and triglyceride levels can occur.[7]

The treatment of choice for HT is replacement of thyroid hormone. But a long term hormonal therapy is not always free from complications as well as side effects. Moreover, currently Hypothyroid patients are opting for Ayurvedic management due to dissatisfaction in modern regime. A case of HT was managed through treatment protocol based on the clinical features and managed by following Ayurveda guidelines.

After diseased condition changes in the body with manifestation of symptoms

The organ system manifestations of Hashimoto Thyroiditis are varied due to the nature of the disease. Initially patients may have bouts of hyperthyroid symptoms, as the initial destruction of thyroid cells may lead to the increased release of thyroid hormone into the bloodstream. Eventually, when enough destruction has been caused by the antibody response, patients exhibit symptoms of hypothyroidism. These symptoms are insidious, variable and may affect almost any organ system in the body.

The classic skin characteristic associated with hypothyroidism is myxoedema, which refers to the oedema-like skin condition caused by increased glycosaminoglycan deposition. This however, is uncommon and only occurs in severe cases. Skin can be scaly and dry, especially on the extensor surfaces, palms, and soles. Histological examination reveals epidermal thinning. Increased dermal mucopolysaccharides cause water retention and in


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turn pale-coloured skin seen.

The rate of hair growth slows, and hair can be dry, coarse, dull, and brittle. Diffuse or partial alopecia is not uncommon. Fatigue, exertional dyspnea, and exercise intolerance are likely associated with a combination of limited pulmonary and cardiac reserve in addition to decreased muscle strength or increased muscle fatigue. Biochemical changes in this population have shown decreased muscle oxidation of pyruvate and palmitate, increased utilization of glycogen stores, and diminished fatty acid mobilization. Muscle weakness and myopathy are important features.

The presentation may also be subclinical. Early symptoms may include constipation, fatigue, dry skin, and weight gain. More advanced symptoms may include: cold intolerance, decreased sweating, nerve deafness, peripheral neuropathy, decreased energy, depression, dementia, memory loss, muscle cramps, joint pain, hair loss, apnoea, menorrhagia, and pressure symptoms in the neck from goitre enlargement such as voice hoarseness.

Hashimoto Thyroiditis (HT) is one of the most frequent autoimmune diseases and has been reported to be associated with gastric disorders in 10% to 40% of patients. About 40% of patients with autoimmune gastritis also present with Hashimoto Thyroiditis, according to research by Cellini et al.

Chronic autoimmune gastritis (CAG) is characterized by the partial or complete disappearance of parietal cells leading to impairment of Hydrochloric acid and intrinsic factor production. The patients go on to develop hypochlorhydria-dependent iron-deficient anemia, leading to pernicious anaemia, and severe gastric atrophy.

Understanding of Hashimoto Thyroiditis in Ayurveda

In Ayurveda, there is no exact correlation to Hashimoto Thyroiditis but can be understood based on Nidana, Dosha, Dushya, Srotas, Sthana and Lakshanas.

HT is Tridoshaja mainly Pitta predominant disease where in, Jatharagni Mandya leading to the formation of Ama causing Srotorodha at various level and Dhatwagnimandya which further causes Uttarottara Dhatwagnimandya leading to Dhatu Dushti and impaired Uttarottara Dhatu Poshana showing cluster of symptoms and can be correlated

to Rasapradoshaja Vikara, Dhatwagnimandya, Vataja Pandu, Pittavruta Vata.

Patient was provisionally diagnosed as Rasa Pradoshaja Vikara,[8] Dhatwagnimandya, Pittavruta Vata[9] and Vataja Pandu[10] based on the presenting complaints like Varchashosha, Anaha, Angamarda, Ruja, Shirashula, Shopha, Ruksha Anga and Bala Kshaya. Hence Agnideepana, Amapachana, Vatanulomana, Vataja Pandu, Vataja Grahani and Vataja Jwara line of management was adopted based on presenting symptoms.

The treatment was started with internal and external therapy. The treatment protocol assigned for this patient was Dhatwagni Ama Pachana, Agnideepana and Vatanulomana. Virechana (therapeutic purgation) was administered as per Panduroga line of management.[11] Again after Shodhana Shamanaushadhi’s (pacifying medications) were prescribed based on signs and symptoms. Treatment schedule followed is enlisted at Table-1

Materials and Methods

The treatment was planned by assessing the state of Rogabala (strength of the disease) and Rogibala (strength of the patient).

The following medicines are administered to the patient for a period of 2 months.

The patient was advised to indulge in light diet.

Description of Case

A 37-year-old unmarried, female patient, belonging to middle economic status, professor by occupation, with history of irritable bowel syndrome (IBS) approached to the OPD on January 30 2023 with complaints of incomplete evacuation of stool, bloating of abdomen, whole body ache, weight loss and burning sensation over scalp region associated with increased tiredness, irritation, dry rough skin and Hair loss since last 8 years.

Patient was apparently well 8 years back, in 2015 she went for higher studies to Cambridge university London, after 2 months because of variation in atmospheric temperature suddenly patient noticed bilateral knee joint pain and swelling and she was not able to walk, for these complaints she consulted doctor on Online, they advised vegetable diet, she continued the same for 20 days and she felt mild improvement in her symptoms.


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After 2 months she discontinued diet and she was fine 2 months, after that she noticed throat pain and irritation while speaking, for these complaints patients consulted Manipal Hospital in Udupi, their they advised FNAC and thyroid profile and diagnosed as Hashimoto Thyroiditis (anti TPO- >1300, TSH>100) and prescribed Tab.

Thyronorm 50 mcg (Levothyroxin). Patient continued same medication for 5 years.

In 2020 patient shifted to Bangalore and consulted Endocrinologist they increased dose of Tab-Thyronorm to 75 mcg, she consulted same endocrinologist for 3 years.

Once the TSH level is raised again they again increased the dose of Thyronorm to 125mcg and she continued the same.

Again in 2021, she developed irregular bowel habits, hair fall, burning sensation over scalp and bilateral soles for these complaints she consulted Gastroenterologist they advised endoscopy and Vit-B12 inj. But she denied undergoing endoscopy.

Again in 2022 she developed whole body pain, irregular bowel habits so she consulted Naturopathy doctors they advised diet for 6 months, she continued same for 6months and after that she noticed marked weight loss from 62 kg to 47kg. Again she consulted Ayurveda physicians and they advised Tab. Anuloma DS, Tab. Abhra Loha, and Cap.

Imunocin, she continued same medications for 2 months but she did not noticed much relief in her symptoms, so she consulted OPD in SKAMCH & RC, Bengaluru.

Patient is a known case of Hashimoto thyroiditis since 8 years on regular medication (Thyronorm 125 mcg) at morning daily before food.

There is no history of Diabetes Mellitus, Hypertension, Cardiac problem or any other complicated diseases and there was no relevant family history of Thyroid disorders.

The appetite is reduced, sleep is disturbed, bowel is irregular and micturition is 4 to 5 times per day. All the vitals and systemic examination were within normal limits.

Thyroid Gland Examination

On Inspection Localized Temperature - Normal

Swelling - Absent Tenderness - Absent

Pallor - Present on Auscultation

On palpation Bruits - Heard on Thyroid Gland

Size - Normal

Shape - Normal

Clinical Findings

In her initial presentation, the patient had poor built, reduced sleep, moderate appetite, Visamagni (~unstable digestive functions), constipated bowel, clean tongue and clear voice.

Her intelligence was normal and had a Vata-Piitaja Prakriti with Avara Sara (~least purity of body tissue), Avara Samhanana (~ least body built), Sama Pramana (~equal body proportions), Madhyama Satmya (~medium suitability or homologation), Madhyama Satva (~medium psyche), Madhyama Vyayama Shakti (~medium physical endurance), and Madhyama Aharasakti and Jaranashakti (~medium food intake and digestive power).

Cardiovascular, Respiratory, Musculoskeletal, and Genitourinary system examinations were normal.

Where as in integumentary system examination, the skin was dry and Hair fall since 8 years.

Therapeutic Intervention

Considering nature of the disease, a two-dimensional approach was planned to arrest the progress of disease and to improve in symptoms.

The first course of treatment was given from 4th February 2023 to 8th February 2023 [Table 1].

Internally Arogyavardhini Rasa, Pippalyasava, Hamsapadadi Kashaya, Ashwagandharishta was given.

Gandharva Hastadi Taila (25ml) was given with warm milk on 3rd day for Koshta Shuddhi.

Along with these, externally Shiro Takradhara with Jatamamsi Musta Amalaki Churna + Takra, Sarvanga Abhanga with Yashtimadhu Taila followed by Sarvanga Bhashpa Sweda is given for 5 days.

In 2nd course of treatment Virechana was planned from 9th February 2023 to 16th February 2023 and advised Samsarjana karma for 5 days. [Table 2].


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Snehapana was done with Kalyanaka Ghrita + Sukumara Ghrita for 4 days, samyak snigdha lakshanas are attained on 4th day.

Sarvanga Abhaynga with Yashtimadhutaila was done for 3 days during Vishrama Kala, 4th day after Sarvanga Abhyanga and Bhashpa Sweda, 70 grams of Trivrut Avalehya was given with 100 ml Triphla Kashaya.

Patient has attained 16 Vegas and advised Samsarjana Karma for 5 days.

Third course of treatment was started from 21/2/2023- 21/5/2023. During this course internal medications, Tab.

Arogyavardhini Rasa (2BD, After food), Hinguvachadi Churna (1 tsf of Churna with butter milk, before food), Pippalyasava + Hamsapadadi Kashaya + Balarishta (9tsf BD with equal quantity of water, after food) and

Sukumara Ghrita (1tsf with hot water, empty stomach early morning) was given for 1 month.

Table 1: First course of treatment

DateInternal MedicineDoseProcedureOutcome
31/1/2023 - 8/2/20231.Tab. Arogyavardhini Rasa
2. Pippalyasava + Hamsapadadi Kashaya + Balarishta		2 tab BD
30ml with equal quantity of water, after food		1.Shiro Takradhara with Musta, Amalaki & Jatamamsi
2.Sarvanga Abhyanga
3.Sarvana Bashpa Sweda		1.Whole Body pain reduced completely.
2. Body stiffness reduced
3.Sleep improved
4. Hair texture improved
5.Felt calmness
5/2/2023Gandharva Hastadi Taila25ml with warm milk-1. 4 episodes of loose stools
2.Bloating reduced

Shiro Takradhara with Musta, Amalaki and Jatamamsi was done for 20min and whole body Abhyanga with Yashtimadhu Taila was done for 40min followed by Sarvanga Bashpa Sweda until Samyak Sweda Lakshanas attains.

Internal medications were advised along with above procedures.

Table 2: Second course of treatment

DateInternal MedicineDoseProcedureOutcome
9/2/2023- 21/2/2023--1.Snehapa with Kalyanka Ghrita + Sukumara Ghrita in Arohana Krama for 4 days
2.Vishramakala - Sarvanga Abhyanga with Yashimadhu Taila followed by Bhashpa Sweda for 3 days.
3.Virechana with Trivrut Avalehya 70 gram + 100 ml Triphala kashaya.
4.Samsarjana Karma for 5days		1.Appetite improved.
2.Sleep improved.
3.Lightness in body.
4.Dryness of skin reduced.
5.Constipation persists.
Hb - 11.2gm/dl
TSH - 6.250mIU/L

Table 3: Third course of treatment

DateInternal MedicineDoseProcedureOutcome
21/2/2023-21/5/20231.Tab. Arogyavardhini Rasa
2. Pippalyasava + Hamsapadadi Kashaya + Balarishta
3. Hinguvachadi Churna
4.Sukumara Ghrita		2 tab. BD
30ml with equal quantity of water, after food
6 grams of Churna with Takra, BD, Before food
10ml with hot water, morning empty stomach		-1.Complete evacuation of stool
2.Bloating of abdomen reduced
3.Burning sensation in scalp and all over body reduced.
4.Appetite improved.
5. Hairfall reduced

Observations

Clinical features, Serum Thyroid Function Test (TFT) values, Anti TPO and TSH levels were assessed before and after the treatment. Patient reported lightness in body, changes in hair texture and relief in irritation after Shirodhara and Sarvanga Abhyanga. Constipation and dryness of skin was reduced during Snehapana. Patient noticed improvement in appetite, sleep, dryness of skin, enhanced complexion, body pain and TSH Levels after Virechana. After administration of Shamana drug symptomatic relief was maintained.

After two months follow up, Anti TPO level comes down to 185.2 IU/ml and TSH level to 68.30mIU/L. No recurrences of previous symptoms were observed till date. The treatment made a pleasing improvement in patient’s quality of life.


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Table 4: Effect on TFT and Thyroid Parameters

ParametersNormal valuesBefore teatment (9/11/2021)After treatment (17/6/23)
TSH (mIU/ mL)0.4 - 4.2>10068.30
T3 (ng/dl)80 – 2000.850.57
T4 (μg/dl)4.6 - 10.54.924.98
Anti TPO (IU/ML)<34 U/ml>1300.0 IU/ml185.2
Anti Tg (U/ML)<60147.80 U/ml-
Hb%12-16gm/dl9.8gm/dl11.2gm/dl

Discussion

Hashimoto Thyroiditis is the most common cause of Hypothyroidism in the United States and in those areas of the world where iodine intake is adequate. The incidence is estimated to be 0.8 per 1000 per year in men and 3.5 per 1000 per year in women. Women are more often affected. The female-to-male ratio is 10:1.[12] Women are diagnosed between the ages of 30 to 50 years. Autoimmunity is the main culprit in Hashimoto Thyroiditis, impairing cellular metabolism. As HT is unique and rare case of Autoimmune disease, use of immuno-modulatory, anti-inflammatory drugs and other molecules that clears the nutrition pathway through correction of digestion and metabolism will help in breaking the pathology.

Many clinic patients complain of poor quality of life and fatigue, which are often associated with mood alterations and poor memory are common complaints, often prompting subjects to obtain standard or alternative thyroid hormone preparations. An unmanaged autoimmune condition causes chronic inflammation, the brain neurons are not able to function properly. Hence severely hypothyroid patients present with agitation and frank psychosis (“myxedema madness”).[13]

The development of Hashimoto Thyroiditis is thought to be of autoimmune origin, with lymphocyte infiltration and fibrosis as typical features.[14] The current diagnosis

is based on clinical symptoms correlating with laboratory results of elevated TSH with normal to low thyroxin levels. In Autoimmune disorders, Agni plays a major role in its pathogenesis and the manifestation of symptoms. Hence one can interpret the pathogenesis of HT in the context of Ayurveda, in which the role of Agni is foremost and through its management, normal functioning of the thyroid gland is achieved.

Ayurveda and modern medicine are derived from different theories of knowledge, especially in regards to their method of scope. Therefore, the approach to a particular disease and diagnosis differs extensively making it quite impossible to make it one to one correlation or pick up one equivalent term. At the same time without an Ayurvedic diagnosis it is difficult to visualize the complete treatment for the patient. Hence it is necessary to understand the disease in terms of Nidana, Dosha, Dushya as well as stages of progress of the disease for succeeding treatment.

On analysis of signs and symptoms, the patient was found to have Lakshanas of Dhatwagnimandya, Rasa Pradohaja Vikara, Pittavruta Vata and Vataja Pandu. Hence an apt treatment in this condition is Dhatwagni Pachana, Agnideepana and Vatanulomana. Patient was responding positively to Deepana and Pachana (corrects digestion and metabolism through augmenting the digestive fire) and Virechana (Purgative) treatment procedures. Thus, the patient was treated on the line of mitigation of and pacifying Vata (Vata Anulomana). As the patient was having vitiation of Pitta and Vata - Deepana, Pachana and Vatanulomana line of management was included in the protocol. Agni Deepana (kindle digestive fire) was done initially to correct the digestion and metabolism.

Masthishky - Shirodhara

Shirodhara is a classical, a well-established and widely practicing Ayurvedic procedure of slowly and steadily dripping medicated oil or other liquids on the forehead. By means of Abhyanga as a Purvakarma of Shirodhara would derive better results. It has anti-stress effect and it is effective in reducing serum TSH levels.

Sarvanga Abhyanga with Yashtimadhu Taila helps in mobilization of accumulated muco-polysaccrides and fat metabolism. Further it provides nourishment to the skin which reduces the dryness caused due to Hypothyroidism.

In this case patient’s stress was one of the major symptom. Stress affects the HPA axis and the level of various hormones changes in response to stress. Reactions to stress are associated with enhanced secretion of a number of hormones including Gluco-corticoids, Catecholamine’s, Growth Hormone, Prolactin and Cortisol. Cortisol is the main hormone produced in response to stress, can suppress pituitary function and keep the


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thyroid-stimulating hormone (TSH) from being released, thereby inducing hypothyroidism.[15]Hence Shirodhara has therapeutic role in the management of HT caused due to stress.

Snehapanokta Virechana

In this case, most of the symptoms are similar to that of Vataja Pandu and in Pandu Chikitsa, Virechana is the best line of management. Hence Virechana was advised in this condition. For Kapha Dosha and Kapha Samsrishta Dosha in Pitta Sthana, Virechana Karma is considered as best line of purificatory measure and best Srotoshodhaka.

Virechana is a form of Shodhana which is done for the elimination of Vikruta Pitta and Kapha and Anulomana of Vayu. Drugs capable of inducing Virechana possess Ushna, Teekshna, Sukshma, Vyavayi and Vikasi properties. The Virechana drug possessing the above properties reaches, Hrudaya by virtue of its Virya and spreads all over body. Here Hrudaya can be understood in 2 ways. Here Hrudaya can be taken as centre of nerve plexus in the brain upon which the drug may act which helps in balancing the Hypothalamo-Pituitary-Thyroid Axis causing normal secretion of Thyroid Harmone. In Hypothyroidism there will be derangement in basal metabolism which in turn leads to the accumulation of non- metabolized products such as muco-polysachride (hyaluronic acid) this Hyaluronic acid is hygroscopic in nature. In Hypothyroidism this mechanism is hampered making excess accumulation of muco polysaccharides in the body.[16]

As Kalyanaka Ghrita[17] is indicated in Pandu and Sukumara Ghrita[18] is indicated in Galaganda, Arbuda, Gulma here in this study these Yamaka Sneha was advised. Trivrat Avalehya, which is used as the Virechana Dravya in the study has action such as Anti-inflammatory, Anti- pyretic, Anti-histamine, anti-helminthic, blood purificatory, mast cell stabilizing which reduces the secretion of mucous From GIT tract. The diaphoric activity increases the secretion of sweat by

increasing temperature and perspiration. Due to this the peripheral metabolism is increased at this the toxic and metabolic bi products are drained into circulation with the help of peripheral Vaso-dilatation. In Hypothyroidism as muco-polysaccharides are accumulated this is brought into circulation and reaches liver for metabolism. The purgative activity of Trivrat Avalehya

because of presence of glycoside, it eliminates all the contents from GI tract.Once the Gastrium is emptied all the digestive enzymes will be properly synthesized and metabolism is corrected gradually thus regulates the TSH production. After Virechana Karma, Samsarjana Krama advised for 5 days later, Shamanoushadhi’s advised for 2 months.

Arogyavardhini Rasa

Arogyavardhini Rasa mainly contains mineral drugs like Parada, Gandhaka, Loha, Abraka all mainly ability to reach minute capillaries and tissue pores. Parada is such drug can transfer the blood brain barrier and there it acts on target site. Hence it has direct action over endocrine system. At the level of Thyroid gland and controls its secretions. Loha Bhasma and Abraka Bhasma and Tamra Bhasma all these are Balya, Ayushya, Vrishya and Medhya, Dhatwagnivardhana, Malashodhaka and Pakwashyadushtinashka helps in building immunity in the individual.[19] Gandharva Hastadi Taila does Vatanulomana, thus helpful in Koshtashuddi.[20]

Combined effect of Pippalyasava, Hamsapadadya Kashya and Balarishta shows better results on Ama and Agni.

Hingwashtaka Churna

Hingwashtaka Churna, which is mentioned in Ashtanga Hrudaya, Gulma Chikitsa which was given for 15 days. As it is indicated in Jatharagni Mandhya and Vataja Gulma, this case patient had indigestion, bloating of abdomen and incomplete evacuation of stool hence Hingwashtaka Churna was advised.[21]

Sukumara Ghrita

As in this study, Vataja Pandu, Vataja Grahani and Jeerna Jwara line of treatment was adopted, hence in all these conditions Ghritapana is a choice of drug. Ghritapana is considered as best Dravya in treating chronic conditions. Sukukumara Ghrita can be administered in conditions like, Shopha, Vid Vibandha and Gulma. Subjects shows improvement in bowel habits, appetite after Ghritapana.

Pippalyasava

Agnimandya and Amadosha are the important cause for much disease. Most of the drugs in Pippalyasava possesses Ushna Virya, Tikta Rasa, Katu Vipaka, Laghu Guna due to these properties it does Amapachana and improves status Agni. Pippayasava is very good remedy which cures Kshaya, Gulma, Udara, Karshya and Panduta.[22]


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Pippali acts as a Rasayana in case of Hypothyroidism. Agnimandya at Koshta level can be addressed by Agnideepana Kalpanas like Rasayanas. Rasayana work at Dhatwagni level correcting Dhatwagnimandya which are seen in Hypothyroidism like endocrine disorders. Raasyana drugs can be given in suitable formulations considering Dosha status and Vyadhi Awastha of patient.

Hamsapadadya Kashaya

Hamsapadyadi Kashaya[23] is a formulation described in Vaidya Manorama - an ancient text of Kerala for Galaganda and Gandamala is widely practiced by many Ayurvedic physicians in Kerala and other parts of the state across the country. It contains Hamsapadi, Guduchi, Nimba, Pippali, Vasa most of the drugs possess Katu, Tikta, Kashaya Rasa, Laghu, Ruksha, Tikshna Guna, Ushna-Sheeta Virya and Katu Vipaka.

Katu Rasa is Agni Deepaka, Tikta Rasa is Deepaka as well as Pachaka and hence it does Agni Deepana and Amapachana. Hence in the pathogenesis of the HT, where the Kapha and Vata are important Dosha, Rasa and Meda are the most important Dushyas and the pathology is due to Dhatvagnimandhya, the drugs present in Hamsapadyadi Kashaya seems to useful in combating the pathogenesis involved in the disease as well as relieving the symptoms exhibited in this condition.

Conclusion

HT is an Autoimmune disease in which thyroid gland is gradually destroyed. The two antibodies most commonly implicated in autoimmune thyroiditis are antibodies against thyroid peroxidase (TPO Ab) and thyroglobulin (Tg Ab). They are hypothesized to develop as a result of thyroid damage, where T-lymphocytes are sensitized to residual thyroid peroxidase and thyroglobulin, rather than as the cause of thyroid damage.

Some patients who are healthy or asymptomatic may be positive for more than one of these antibodies. Doctors who attend to such patients will most likely monitor these patients as there is a chance that they will develop some type of dysfunction with time. The Range of physical and psychiatric presentations and their potential subtle manifestations make HT a diagnosis easy to miss.

Although no disease condition similar to Hashimoto Thyroiditis is described in Ayurveda, using Yukti (skill) it can be considered as a condition which results due to Dhatvagni Mandhya, Rasa Pradoshaja Vikara, Pittavruta Vata and Vataja Pandu based on symptoms condition can be managed using Yukti.

In this case study Deepana, Pachana, Vatanulomana, Vataja Pandu, Vataja Grahani and Jwara line of management was adopted based on symptoms. Purification (Shodhana) followed by palliative therapy was found as a suitable treatment plan to manage HT. Virechana procedure is the common adopted purificatory process with maximum efficacy.

There was a significant improvement in majority of symptoms and TSH Levels after treatment.

The sustained effect is maintained during follow up periods.

Sarvanga Abhyanga, Shirodhara followed by Virechana and Shamanoushadi’s provided better results on both physical and mental ailments.

References

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