Nija Shotha

Shreya Shanbhag; Ranjitha; AS Patil

doi:10.21760/jaims.9.9.49

Nija Shotha - A Clinical Case Report

Shanbhag S^1*, Ranjitha², AS Patil³

DOI:10.21760/jaims.9.9.49

^1* Shreya Shanbhag, Post Graduate Scholar, Department of Roganidana, Government Ayurveda Medical College, Bengaluru, Karnataka, India.

² Ranjitha, Associate Professor, Department of Roganidana, Government Ayurveda Medical College, Bengaluru, Karnataka, India.

³ AS Patil, Professor and HOD, Department of Roganidana, Government Ayurveda Medical College, Bengaluru, Karnataka, India.

Shotha is defined as the one which is Shareera Ekadeshe Sthitha involving Tridoshas and having Ashraya is Twak, Mamsa.[1] Nija Shotha is one where the involvement of the Vatadi Doshas is first followed by development of Vedanadi Lakshanas.[2] It has different Nidanas, and a case of Shotha with Sneha Vibrama Nidana is included in the current study. Present case report is of a male patient aged 62 years who is a k/c/o HTN since 3 months, K/C/O Kushta since 18 years, and presented with symptoms of severe pain & swelling in bilateral lower limbs since 1 week. Upon close inspection, it was discovered to have been evolved after Kushta, with Sneha Vibhrama serving as the primary Nidana. He was treated with Bahya Chiktitsa & Shamana Aushadis, resulting in a considerable reduction of Shotha & Vedana and was followed with Virechana after which the symptoms were completely reduced. This case illustrates how Shotha develops due to Vyadhikarshana, wherein Sneha Vibrama functions as a Vyanjaka Hetu for the disease progression.

Keywords: Nija Shotha, Sneha Vibhrama, Vyadhikarshana, Vyanjaka Hetu

Corresponding Author	How to Cite this Article	To Browse
Shreya Shanbhag, Post Graduate Scholar, Department of Roganidana, Government Ayurveda Medical College, Bengaluru, Karnataka, India. Email:	Shanbhag S, Ranjitha, AS Patil, Nija Shotha - A Clinical Case Report. J Ayu Int Med Sci. 2024;9(9):306-312. Available From https://jaims.in/jaims/article/view/3581

Introduction

Shotha, one of the Mahagadas,^[3] has its Ashraya in the Twak Mamsa and can be a symptom of any disease / an independent disease / a complication of a disease. Utseda is the primary Lakshana. Although more Vrana Vastu may be involved, they are regarded as the principal Ashraya. It can be categorized as Nija and Agantuja Shotha based on Nidanas.^[4] Vatadi Dosha Dushana occurs first in Nija and is followed by Vedanadi Lakshana. Mithyopachara, Na Cha Dehashuddhi, Kshara Amla Teekshnadi Sevana, Gara Nishevana, Mithya Samsarjana, Kusta Pidaka Adi Vyadhi, Ati Madya Sevana are some of the Nidanas.^[5] The Vidahi and Abhishyandi Guna of the Ahara Viharas influence the normal Snighda Sheeta Agneya Guna of the Srotas; this results in impairment of the regular functioning and normal transport mechanism of the Srotas due to the Avrutamarga, which leads to the development of Shotha. Apravartana of the Upasthita Doshas in the instance of Sneha Vibhrama is obstructing the Srotas and resulting in the formation of Shotha. Depending on the Dosha involved, Shotha can also be classified as Sarvanga Ekanga and Vatadi Bheda.^[6] Though all the Doshas are involved in the development of Shotha classification is done based on the Adhikadoshalinga.^[7]

Case Report

A 62 years male presented with c/o swelling associated with burning sensation in bilateral lower limbs since 1 week and also fever since 1 day. He has a history of Kushta from past 18 years and alcohol and tobacco chewing since 35 years. The lesions developed initially as a small black coloured macule over the left knee joint. Later it gradually spread to left elbow, right knee, and scalp over a period of time. He consulted many physicians but found no relief. After about 3-4 years lesions started spreading to whole of the body. He again consulted allopathic physician where lesions reduced but on stopping the medicines the lesions reappeared. This continued for about 5-6 years. Lesions then spread to whole body. He then consulted an Ayurveda physician where he was advised with a Shodhana Chikitsa. He started Snehapana but did not continue it and left in between without completing the treatment after which complaints further increased.

Later again he consulted Ayurveda physician and once again started with Snehapana but again he left after 2 days after which he developed severe swelling in bilateral lower limbs and lesions also increased. Later he took allopathy treatment and the complaints subsided. Presently patient has reddish brown lesions all over the body associated with pain and itching and also powdery and blood discharge. Because this he has developed swelling over bilateral lower limb which is reddish in colour associated with pain and burning sensation, pitting in nature and also fever since 1 day.

Clinical findings and diagnostic assessment

On physical examination it was found that the distribution of lesions was mainly on the extensor surface then spreading centripetally to the trunk. Lesions were annular, reddish black macules. Candle grease sign and auspitz sign were positive. Swelling was seen over bilateral lower limbs which was reddish in colour. On palpation warmth and tenderness was present and also pitting was seen. When seen in terms of Trividha Pareeksha,^[8]

Table 1: TrividhaPareeksha of Shotha and Kusta respectively

Pareeksha	Shotha	Twak
Darshana	Reddish, Tanu Twacha Srava absent	Reddish brown skin lesions all over the body, powdery discharge + Srava absent, no bleeding spots seen
Sparshana	Ushma + Ruja + pitting +	Khara + Ruja -
Prashna	Satata shoola Nishkriyatva burning sensation + Pain is continuous in nature, Pipeelikabhiriva Samsrushana at midnight	Ruja absent Kandu +

Nidana Panchaka

Nidana

Utpadaka Hetu: Vyadhi Karshana from Kusta
Vyanjaka Hetu: Snehavibhrama
Ati Atapa Sevana
Ati Madya Pana
Ati Ushna Teekshna Kshara Sevana
Mithya Upachara like Yana Adi

Purvaroopa

Mild swelling over bilateral lower limb from 1 week

Roopa

Rakta Varna Shotha Over Bilateral Lower Limb
Teevra Ruja
Daha
Pitting

Upashaya

Sneha, Ushna

Anupashaya

Long standing, cold

Samprapti

Sankhya: Based on Nidana: 2 Nija and Agantuja, Dosha Bhedhena 7
Pradhanya: Vata Vriddhatama, Pitta Vriddhatara, Kapha Vriddha
Vidhi: Nija Shotha, Daruna Vyadhi
Vikalpa: Rooksha, Sookshma Guna Vriddhi of Vata
Ushna Guna Vriddhi of Pitta
Sheeta Guna Vriddhi of Kapha
Bala Kala: Ruja more at midnight, Shotha is Divabali

Flow Chart 1: Samprapti involved in development of Shotha due to Sneha Vibhrama

All the above said Nidana
↓
Prakopa of all the three Doshas simultaneously
↓
Shithilata of the Twagadi Ashrayas
↓
Sthanasamshraya of the Doshas in these Ashrayas
↓
Kusta - no proper treatment taken (on and off allopathy medication)
↓
Leena Avastha of the Doshas over a period of time
↓
Snehapana taken caused Vriddhi of the Doshas trying to attain Upasthita Avastha
↓
Because of Sneha Vibhrama and other Mithya Ahara Vihara
↓
Further Dosha Prakopa along with the Vriddha Doshas

↓
Khavaigunyata created in the Twak Mamsa of the Adhosakthi
↓
Lodgment of the Prakupita Doshas
↓
Shotha

Diagnosis: Based on the Shotha Lakshanas^[9-11] found

Table 2: Shotha Lakshanas found in present case

Vataja	Pittaja
Aruna Varna	Tamravabhasa
Kshipra Utthana Prashamana	Kshiprautthana Prashamana
Peedyate	Ushna
Pipeelikabhiriva Samsprushyate	Mrudu, Tanutwak
Snehoshnam Cha Pranashyet	Jwararta

Therapeutic intervention

The patient received treatment in the inpatient department following a thorough history and examination. For five days, Soothashekara Rasa, Kaishora Guggulu, Mahamanjistadi Kwatha, Panchatiktaka Kashaya along with Bahya Chikitsa, which included Alepa with Dashanga Lepa, Abhyanga with Brihat Marichadi Taila, and Parisheka with Dashamoola Kashaya, were administered. Following this Shotha reduced considerably and also Ruja reduced completely. Following this patient was started with Shodhana Chikitsa.

Table 3: Chikitsa adapted and results

Chikitsa	Dravya used	Duration	Result
Alepa	Dashanga Lepa	1-5 days	Reduction in redness Burning sensation reduced
Parisheka	Dashamoola Kashaya	1-5 days	Reduction in redness Mild reduction in pain
Abhyanga	Brihath Marichyadi Taila	6-10 days	Drastic reduction in pain and swelling
Snehapana	Mahatiktaka Ghrita	11-14 days	Swelling and pain reduced completely Snighdata in the dry skin lesions
Vishrama Kala	Sarvanga Abhyanga with Brihath Marichyadi Taila followed by Bashpa Sweda	15-17 days	Snighdata in the lesions
Virechana	Trivrit Leha	18th day	22 Vegas Shotha and pain were reduced completely Powdery lesions were absent

He was given Snehapana with Mahatiktaka Ghruta for 4 days. After attaining Sneha Siddhi Lakshanas it was followed with Sarvanga Abhyanga with Brihat Marichyadi Taila followed with Bashpa Sweda and advised to follow proper diet for Virechana in Vishrama Kala. After 3 days of Vishrama Kala he was given Virechana with Trivrut Leha 40gm and attained Pravara Shuddhi with 22 Vegas. Following Shodhana, Shotha disappeared and skin lesions significantly decreased. The burning and pain were lessened, and there was no longer any powdery discharge.

Figure 1: Swelling before the treatment

Figure 2 and 3: After Bahya Chikitsa and Shamana Aushadi

Figure 4 and 5: After 15 days of treatment

Discussion

Kusta when its long standing without proper Chikitsa, Doshas become Leena and Dhatugata.^[12] Whenever there are favorable conditions symptoms are expressed. Snehapana does Vriddhi and Vishyandana of the Doshas and also there is increase in the Apyamsha because of the properties of Sneha. Instead of undergoing Pachana, the Snehapana for Shodhana performs Vriddhi by combining with the Doshas, aiding in the attainment of the Upasthita Dosha Avastha and facilitating easy passage through the Srotas without being struck. However, there was the Apravartana of the Doshas when there was Sneha Vibhrama and Mithya Upachara, Vriddha Doshas entered the Bahi Siras and becomes Shakhagata. Because of following Astamahadoshakara Bhavas^[13] like Yana, Ati Chankramana, and Atiasana following Snehavibrama, Khavaigunyata was created in the Adhoshareera, and also Vriddha Doshas caused the further vitiation of the Twak and Mamsa because of which Doshas got Sthana Samshraya in the Twak and Mamsa of Sakthi led to development of Shotha.

Considering the Shotha to be acute in condition Bahya Chikitsa was chosen primarily. Alepa was thus planned initially as it is considered as Adya Upakrama^[14] in Shotha and also it is Sarvashotha Pradhana Chikitsa.^[15] Dashanga Lepa having the ingredients Shireesha (Albizia lebbeck), Yashtimadhu (Glycyrrhiza glabra), Nata (Valeriana wallichi), Chandana (Santalum album), Ela (Elittaria cardamomum), Jatamansi (Nardostchys jatamansi), Haridra (Curcuma longa), Daruharidra (Berberis aristata), Kusta (Saussurea lappa), Hrivera (Pavonia odorata)^[16] is considered to have anti-inflammatory action and also it is Pittahara and has a direct indication in Shotha. There was a great reduction in redness and burning sensation following Lepa. Along with the Shamana Aushadas Sootashekara Rasa, Kaishora Guggulu later changed to Yogaraja Guggulu, Mahamanjisthadi Kashaya with Panchatiktaka Kashaya because of its Vata Pittahara Guna helped in reducing pain and burning sensation. Simultaneously Parisheka was advised by Dashamoola Kashaya. As this was Pittasamsrusta Avasta and associated with Kusta Lakshanas Drava Sweda was advised and as Dashamoola is a Shothahara Dravya^[17] along with Vata Kapha Hara and Shoolahara Guna helped in reducing pain and swelling considerably.

This line of treatment was followed for 5 days later was advised Abhyanga with Brihat Marichyadi Taila for 3 days which helped in reducing the pain completely.

After Atyayika Lakshanika Chikitsa Shodhana was the line of management chosen for the elimination of the Dushita Doshas from the body. Virechana was the treatment opted as it is indicated in Adhosthita Shotha^[18] and also because of the involvement of Kusta. After proper assessment of the Agni, Snehapana was given with Mahatiktaka Ghrita as Tiktasadhita Ghrita is indicated in Pitta Anilaja Shotha^[19] and also it is indicated in Vata Pittaja Kusta. After following with Vishrama Kala of 3 days with Sarvanga Abhyanga with Brihat Marichyadi Taila and Bashpa Sweda Virechana was given with Trivrut Leha 40gm along with Dugdha Anupana as it is considered to be Sarvarogapha and Vatapittahara.^[20]

After proper Virechana, Samsarjana Krama was followed strictly following which there was a complete reduction in the Shotha and significant improvement in the skin lesions. Redness, burning sensation, and powdery discharge of the lesions reduced significantly. The patient was in follow-up for the next 2 months during which there was no recurrence of pain, swelling, or any development of new lesions. Thus, Bahya Chikitsa along with proper Shodhana gave a good prognosis.

Conclusion

The present case was considered as a case of Nija Shotha manifested as a result of long-standing Kusta acting as Utpadaka Hetu along with Sneha Vibhrama^[21] and other Mithya Upachara like the Yana Adi, improper Pathya, Madyapana, etc. acting as the Vyanjaka Hetu. This led to the progression of the course of the disease Kusta leading to the development of Shotha. After proper analysis of the Nidana for Shotha development, Lakshanika Chikitsa was planned followed up with Shodhana which gave significant results.

References

1. Acharya Sushrutha, Vaidya Yadavji Trikamji Acharya (ed). Sushrutha Samhitha with Nibandha Sangraha commentary of Shri Dalhanacharya, reprint edition of 2015, Sutra Sthana, chapter 17, shloka 3, page 81

2. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021,sutra sthana, chapter 18, shloka 5 chakrapani commentry, page 106
3. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021,chikitsa sthana ,chapter 12, shloka 3, page 482
4. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, chikitsa sthana ,chapter 12, shloka 4, page 482
5. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, chikitsa sthana ,chapter 12, shloka 6, page 482
6. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, chikitsa sthana, chapter 12, shloka 4, page 482
7. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, chikitsa sthana, chapter 12, shloka 10, page 483
8. Acharya Sushrutha, Vaidya Yadavji Trikamji Acharya (ed). Sushrutha Samhitha with Nibandha Sangraha commentary of Shri Dalhanacharya, reprint edition of 2015, Sutra Sthana, chapter 10, shloka 5, page 43
9. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021,sutra sthana, chapter 18, shloka 7, page 106

10. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka, redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, chikitsa sthana, chapter 12, shloka 12,13,14, page 483,484
11. Acharya Sushrutha, Vaidya Yadavji Trikamji Acharya (ed). Sushrutha Samhitha with Nibandha Sangraha commentary of Shri Dalhanacharya, reprint edition of 2015, Sutra Sthana, chapter 17, shloka 4, page 82
12. Acharya Vagbhata, Bhishagacharya Harishastri Paradakara Vaidya (ed). Ashtanga Hridayam with commentaries of Arunadatta and Hemadri, reprint edition of 2017, nidana sthana, chapter 14, shloka 4, page 524
13. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, siddhi sthana, chapter 12, shloka 11, page 730
14. Acharya Sushrutha, Vaidya Yadavji Trikamji Acharya (ed). Sushrutha Samhitha with Nibandha Sangraha commentary of Shri Dalhanacharya, reprint edition of 2015, Sutra Sthana, chapter 18, shloka 3, page 84
15. Acharya Sushrutha, Vaidya Yadavji Trikamji Acharya (ed). Sushrutha Samhitha with Nibandha Sangraha commentary of Shri Dalhanacharya, reprint edition of 2015, Sutra Sthana, chapter 18, shloka 3, page 84
16. Prof Siddhi Nidana Mishra, Bhaishajya Ratnavali of Kaviraj Govind das sen edited with siddiprada hindi commentary, 57/19, Chaukhamba Surbharati Prakashan, Varanasi,
17. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, sutra sthana, chapter 4, shloka 16, page 64
18. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, chikitsa sthana, chapter 12, shloka 17, page 484

19. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, chikitsa sthana, chapter 12, shloka 18, page 484
20. Acharya Agnivesha, Vaidya Yadavji Trikamji Acharya (ed) Charaka Samhita, revised by Acharya Charaka,redacted by Acharya Dridhabala with Ayurvedadipika commentary by Sri Chakrapanidatta, reprint edition of 2021, kalpa sthana, chapter 7, shloka 6, page 662
21. Acharya Vagbhata, Bhishagacharya Harishastri Paradakara Vaidya (ed). Ashtanga Hridayam with commentaries of Arunadatta and Hemadri, reprint edition of 2017, sutra sthana, chapter 16, shloka 33, page 250

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2024-08-13	2024-08-23	2024-09-03	2024-09-13	2024-09-24
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
None	Nil	Yes	13.87

Case Report

Journal of Ayurveda and Integrated Medical Sciences

Nija Shotha - A Clinical Case Report

Shanbhag S1*, Ranjitha2, AS Patil3

Introduction

Case Report

Discussion

Conclusion

References

Shanbhag S^1*, Ranjitha², AS Patil³