E-ISSN:2456-3110

Case Report

Managing Myasthenia Gravis

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 5 May
Publisherwww.maharshicharaka.in

An approach of Ayurveda Clinical Diagnosis in managing Myasthenia Gravis - A Case Report

Nalina DS1*, Pai S2
DOI:10.21760/jaims.9.5.50

1* Nalina DS, First Year Post Graduate Scholar, Department of Post Graduate Studies in Kayachikitsa, Alvas Ayurveda Medical College and Hospital, Moodubidire Dk District, Karnataka, India.

2 Surekha Pai, Professor Medical Director, Alva’s Ayurveda Medical College and Hospital Department of Post Graduate Studies in Kayachikitsa, Alva’s Niraamaya Multispecialty Hospital Vidyagiri, Moodubidire DK District, Karnataka, India.

Background: Myasthenia gravis (MG) is an autoimmune neuromuscular disorder leading to muscle weakness due to disrupted nerve-muscle communication. Although not explicitly described in Ayurveda texts, managing of MG requires an understanding of Nidana Panchaka and varied examination method as per Ayurveda. Brief Case Report: A 27 year old male patient presented with progressive symptoms of MG for 11 years initially Chakshurendriya Lakshana and later affecting the Mamsa Dhatu. Diagnosis was made after 8 years of onset of symptoms. Lifestyle factors and routines were identified as contributing Nidanas (causes). Conclusion: Employing Ayurvedic principles a holistic treatment approach effectively managed the patient’s symptoms, emphasizing the importance of understanding Nidana Panchaka and Pareeksha for formulating comprehensive treatment strategies. The patient’s feedback showed significant improvement and enhanced quality of life following Ayurveda treatment. This case report demonstrates the applicability of Ayurveda principles in managing complex autoimmune disorders like MG, emphasizing individualized treatment strategies focusing on the root cause and holistic well-being of the patient.

Keywords: Myasthenia gravis, Vata Vyadhi, Vyadhijnanopaya, Shadvidha Upakrama

Corresponding Author How to Cite this Article To Browse
Nalina DS, First Year Post Graduate Scholar, Department of Post Graduate Studies in Kayachikitsa, Alvas Ayurveda Medical College and Hospital, Moodubidire Dk District, Karnataka, India.
Email: 		Nalina DS, Pai S, An approach of Ayurveda Clinical Diagnosis in managing Myasthenia Gravis - A Case Report. J Ayu Int Med Sci. 2024;9(5):296-302.
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https://jaims.in/jaims/article/view/3204

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-03-05 2024-03-15 2024-03-25 2024-04-06 2024-04-18
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 21.87

© 2024by Nalina DS, Pai 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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Nalina D S et al. Approach of Ayurveda Clinical Diagnosis in managing Myasthenia Gravis

Introduction

Myasthenia gravis (MG)[1] is a chronic autoimmune neuromuscular disorder characterized by muscle weakness and fatigue. It occurs when the body's immune system mistakenly attacks and impairs the communication between nerves and muscles at the neuromuscular junction.

The Ayurvedic texts do not explicitly mention a disease akin to MG. However, in Ayurveda, comprehending the disease, known as Vyadhijnanopaya, involves understanding Nidanapanchaka[2] are essential. Nidana Panchaka were comprehended through diverse examination techniques, including Trividha[3] Pareeksha , Chaturvidha Pareeksha,[4] Dashavidha Pareeksha,[5] along with other required examination methods. A care plan with specified goals was formulated, and the patient’s progress was regularly reassessed to gauge the outcomes. In the context of evaluating the effectiveness and success of managing myasthenia gravis, the myasthenia gravis assessment tool was employed.

Case Report

A male patient from Anupa Desha (Chennai), who is of Madhya Vaya (27 years) and was leading a fairly sedentary lifestyle. He was a diagnosed case of Myasthenia gravis and not a known case of diabetes mellites, hypertension, stopped taking medication for MG 3 weeks before approaching to Alva’s Niraamaya Multispeciality Hospital, Moodbidri.

Lakshana and Doshadi Involvement

The patient initially experienced Lakshana related to their Chakshurendriya 11 years ago, with no other noticeable Lakshana for a period of over 3 years. Subsequently, after this initial phase, they began to exhibit symptoms outlined in Table 1. Due to the gradual onset of these Lakshana, the patient couldn't accurately recall their specific sequence of development. The diagnosis of MG was established 8 years after the symptoms initially appeared.

(He presented predominantly with Vatavriddi, Rasa Kshaya and Mamsa Pradosha Lakshanas, with Dusti Prakara being Sanga.)

Table 1: Chronological order of Lakshana development

LakshanaKaalaDoshaDhatu, UpadhatuMalaSrotas
Indriya Bramsha in the form of Double vision, Blurred vision11 yearsVatavriddiAshraya in ChakshuIndriyavaha
Samsra of Vartma
(Ptosis of eye - both)		11 yearsVatavriddiAshraya in ChakshuMamsavaha
Balakshaya in the form of fatigue (as the day progress Balakshaya becomes more)8 yearsVatavriddiMamsa DhatuMamsavaha
Shabda Asahishnuta8 years-Rasa KshayaRasavaha
Alpe Api Cheshtitamshramam8 yearsVatavriddiRasa KshayaRasavaha
Hridrava6 yearsKaphakshayaRasa KshayaRasavaha
Ashraddha, Aruchi, Gourava, Tandra, Angamarda6 years-RasapradoshajaRasavaha
Gurvanga, Tudhyate, Saruk, Shramiyatyartham6 years-MamsagatavataRasavaha

Nidana

During the three-year period while preparing for exams that is prior to Lakshana development, this patient adopted a challenging routine that turned as Nidana’s for the Vyadhi

Table 2: Nidana Involved

Aharaja NidanaViharaja NidanaMano Nidana
Vishamashana (Eating irregularly in response to hunger and time)Vegadharana - Mutra, Pureesha (often neglecting bathroom breaks) Kshudha, NidraUdwega, Vishada, Chinta, Dukha (Throughout this time, he became easily irritated and became anxious, sad after learning about his illness).
Samashana, Viruddhaaharasevana (His meals consisted of a combination of milk, eggs, and fruit juice in the morning, while at night, he consumed only half a liter of milk)Ratrijagarana (Frequently staying awake all night)
Sheetabhojana (He avoided freshly prepared food and ate cold meals and intake fruit juices in Kapha Kaala)Atyasana (he remained seated for extended periods)

(The above Nidana led to Agnimandya and Tridosha Prakopa along with Manasika Dosha Prakopa).

Upashaya

Based on the Chikitsa Sutra selected from Shadupakrama.[6] Upashaya was noted and hence the Chikitsa was continued till the Niraama Lakshana. As Vatavriddi[7] was the presenting Lakshanas, the Vata Dosha Chikitsa[8]


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was done and Upashaya was continued. Upashaya of Chakshurindriya Lakshana was observed with Marsha Nasya Chikitsa.

Table 3: Dashavidha Pareeksha[5]

PrakruthiKapha Vata[9]
VikruthiNidana - Agnimandya, Tridosha Prakopaka Nidana
Dosha - Vata Vriddhi and Kapha Kshaya
Dhatu - Rasa, Mamsa
Prakruti - Kapha Vata
Desha - Anupa,
Kaala - No specific Rtu Kala was observed for the Lakshana to manifest
Hetu and Linga Bala is Pravara hence Roga Bala is Pravara
SaraAvara
SamhananaPravara
PramanaPramanavatishareera
SatmyaMadhyama
SatvaMadhyama
AharashaktiAbhyavaranashakti - Avara
Jaranashakti - Avara
VyayamashaktiAvara
VayaMadhyama
Roga BalaPravara
Rogi BalaMadhyama

(As the Aharashakti and Vyayama Shakti were Avara, the Shamana type of Langhana was adopted till the attainment of Niraama Lakshana. As Balavriddhi was observed, Yapana Basti planned which is both Snehana and Shodhana)

Sadhyasaadhyata[10]

As the patient is suffering from the Vyadhi since 11 years (Deerghakaala Avasthitham) and there is continuity of Lakshanas (Nityaanushaayina), the Vyadhi can be considered as Yapya.[11]

Table 4: Samprapti[12]

SankhyaOne of the Vata Vyadhi
VidhiNija Vyadhi
Vatavriddi, Kaphakshaya, Raja, Tama
Yapya
PradhanyaVata Pradhana
Paratantra Dosha
VikalpaChala Guna of Vata
Bala KaalaAhoratra - Sanyakaala - Indicates Vata Dosha

(Agnimandya and Tridosha Prakopaka Nidana with Vata Vriddi Lakshana indicated it is not due to Swatantra Dosha Prakopa of Vata, but due to Paratantra Dosha Prakopa)

Table 5: Timeline

YearIncidence/intervention
2012Blurred vision, drooping of eyelids while studying
Went to ophthalmologist– lens correction was done.
2012-2014Burning sensation, blurred vision, double vision, drooping of eyelids, increased weight, excessive tension
Not Consulted
2014-2018Progressive vision complaints, pain in left hand, abnormal facial expression, palpitations, headache
On consultation:
Ophthalmologist-Diagnosed dry eye syndrome
Neurologist – Given anti-stress tablet
General physicians – Started Vit-B complex and Vit-B12 supplements
Improvement in ocular problems and muscle weakness
Continued the treatment
2020Eye symptoms increased drastically – unable to open eyes immediately after waking up, muscular strength reduced, palpitations, stress.
Diagnosed for Myasthenia gravis in Jan 2020. Started with Tab. Myestin and Omega3 fatty acid tablet, symptoms reduced slightly.
But started with symptoms like – frequent urination, weight gain
2021Took Homeopathy treatment for 3 months
Symptoms reduced but reoccurred
2023 JulyCame to Alva’s Ayurveda Niraamaya Hospital, Moodbidri with symptoms mentioned in Table.1

Chikitsa Sutra

jaims_3204_02.JPG


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Treatment Chart

Table 6: Shodhana Chikitsa

ProcedureMedicineMatraDays
NasyaAnu Taila6 Bindu7 days
Yoga Basti
Matra BastiDhanwantara Taila60 ml5 Days
Rajayapana BastiSaindhava
Madhu
Ksheerabala Taila
Rajayapana Kalka
Rajayapana Ksheerapaaka
Mamsa Rasa		10 gm
100 ml
100 ml
40 gm
250 ml
100 ml		3 Days

Table 7: Shamana Chikitsa

AoushadhiMatraKaalaAnupaana
Gandharvahastadi Kashaya (Freshly prepared)50 ml – 0 -50mlBefore food-
Lavana Bhaskara Churna½ tsp – 0 – 0Before foodSukoshna Jala
Brihtvata Chintamani Rasa with Gold1 – 0 – 1After foodMadhu
Prabhakara Vati1 – 0 – 111 AM - 0 - 4 PMJala
Tab. Shaddharana DS2 – 0 – 0Before foodJala
Pratimarsha Nasya with Dhanwantara 101 Taila2 Bindu Each nostrilsTwo times a day-

Table 8: Bahya Chikitsa

ProcedureMedicineDays
Udwartana (Sarvanga)Kolakulattadi Churna7 Days
Agnilepa (Sarvanga)Arka, Nirgundi, Agnimantha, Bandha, Eranda, Lashuna, Lavanga , Sarshapa , Haridra, Maricha11 days
Churna Pinda Sweda (Sarvanaga)Upanaha Churna With Dhanyamla5 Days
Akshi TarpanaJeevantyadi Ghrita7 Days
ParishekaBalaashwagandaadi & Kottamchukadi Taila7 Days

Table 9: Discharge Medicine

AoushadhiMatraKaalaAnupaana
Ashtavarga Kashayam15ml-0-15mlBefore food60 ml Sukoshna Jala
Brihat Vata Chintamani Rasa with Gold1-0-1After foodMadhu
Sanjeevani Vati1 – 0 – 1Between foodSukoshna Jala
Aswagandha Churna (50gm) + Amalaki Churna (25gm) + Guduchi Satwa (5gm)1tsp-0-1tspAfter foodSukoshna Jala

Table 10: Myasthenia Gravis Assessment Tool

Assessment ScaleDay 1Day 7Day 21
Myasthenia Gravis Activities of Daily Living (MG-ADL) = 24921
Myasthenia Gravis Quality Of Life 15 (MG - QoL15r) = 3026102
Myasthenia Gravis Composite (MGC) = 502354
Quantitative Myasthenia Gravis (QMG) = 301686

Discussion

After Roga and Rogi Pareeksha, the involvement of Ama Dosha was evident in the Samprapti along with Rasa and Mamsa Dhatu Dushti,[17] along with involvement of Mano Dosha. As Nidana have contributed to Agnidushti and subsequent Ama Dosha Utpatti, Ama Dosha Chikitsa was planned first and as the Roga and Rogi Bala was Pravara and Madhyama respectively, Abhyantara and Bahya Langhana Chikitsa was planned and continued till Nirama Lakshana. Marsha Nasya was done as Chakshu was one of the Adhishtana.

After attainment of Nirama Lakshana, Vata Vyadhi Chikitsa was adopted focusing on Mamsa Dhatu as well. Paratantra Dosha Prakopa was evident by the Upashaya of Lakshana from Ama Dosha Chikitsa. As the Sadhyasadhyata of Vyadhi was understood as Yapya along with Mamsa Dhatu as Dooshya, Yapana Basti was planned. For Dhatu Samyata, Rasayana Chikitsa was planned in discharge medication. As it is Yapya Vyadhi, patient may require to undergo further Chikitsa in future based on regular reassessment.

Conclusion

In our Samhita, it is mentioned that a Vaidya, even if unable to label a disease, can effectively treat it by grasping the Hetu, Vishamata of Dosha Dhatu And Mala, as well as the Adhishtan.[18]. Understanding of Nidana Panchaka, and Pareeksha in detail gives us an in-depth understanding of Vyadhi, this helps in formulation of Chikitsa Sutra that encompasses all aspects of Chikitsa. Both in Grahani Chikitsa[19] and Vata Vyadhi Chikitsa it is mentioned that Jataragni Dushti and Amadosha Utpatti is an important Nidana that can lead to different diseases including Vata Vyadhi. More so, Vata Vyadhi has been explained as Dhatu Kshaya Janya and Margavarodha Janya.[20] Based on the above understanding, Amadosha Chikitsa followed by Vata Vyadhi Chikitsa has shown effectiveness of Chikitsa in this patient. However, the sustenance of the improvement is the key element that has to be ascertained during subsequent follow up.

Patient’s perspective on the treatment received

I have been suffering with blurred vision, contraction of Eyes, slurred speech


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since 9 years. I had visited various hospitals to know the exact cause of symptoms and its treatment. They diagnosed it as MG. But all my efforts were gone vain and I didn’t received accurate treatment for Myasthenia Gravis.

I further went for Ayurveda treatment at Alva’s Niraamaya Ayurveda Hospital, Vidyagiri, Moodbidri, for Mysthenia Gravis Ayurveda treatment, I had been under the supervision & treatment by Doctor Sajith Sir & Doctor Surekha Madam for nearly one month. During that period they have given various Ayurvedic procedures along with diet & yoga. My severities of symptoms were reduced gradually and my quality of life is improved to a greater extent. Nearly 80 % of symptoms, mainly muscle weakness, and eye related symptoms are reduced during the course period which improved my quality of life physical & mental health.

Now I am feeling well & healthy, because of improvement in the symptoms reduction is sustained and I am leading the quality life with more smile and happiness and I have great confidence about my life, carrier which I lacked before. I am very thankful to the Doctor Sajith Sir & Surekha Madam, medical team, all the staff, Interns & PG doctors of Niraamaya Ayurveda Hospital for their special, excellent treatment, hospitality, great care provided to me.

Declaration of Patient Consent

The authors certify that they have obtained patient consent form, where the patient has given his consent for reporting the case and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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