Case presentations: THROMBOCYTOPAENIA AND LEUCOPAENIA OF DENGUE FEVER: A CASE SERIES by Prof. Ranjit Nimbalkar

Introduction: 

Dengue fever, generally doesn’t cause much harm or is not fatal in normal adults. But of course there are chances of its landing into Dengue shock syndrome, where complications of hypotension & tissue edema are common. Dengue haemorrhagic fever is another dangerous condition, where due to bone marrow depression, there is considerable fall in white cells & platelets, causing a risk of secondary infections & bleeding disorders respectively. As per the studies, children are moresusceptible to thrombocytopaenia^1,2.

In this case series, 5 cases of post dengue thrombocytopenic patients have been included. All showed gradual fall of WBCs & Platelets will be presented. All the 5 patients were previously treated by their family doctors for symptoms like fever, headache & body ache³. Dengue NS1 was positive. They were relieved from these symptoms like fever, bodyache etc., but still showing gradual downfall in WBC & platelet counts. They were treated by Ayurvedic Herbal combination only for increasing these counts.

The combination was made up of 8 herbs, viz. Aamalaki (Emblicaofficinalis), Musta (CyperusRotundus), Guduchi⁴ (Tinosporacordifolia), Yashtimadhu (Glycirrhizaglabra), Bala (Sidacordifolia), Pippali (Piper longum), Patola (Trichosanthesdioeca) &Vidari (Purariatuberose).

The clinical details of these subjects are tabulated as under:

Case 1:

14/Mpatient showed onset of symptoms like severe headache, fever & chills on 14 Oct 2014.he was treated symptomatically by his family physician. Symptoms were relieving slowly. His Dengue NS1 came positive after 4 days of onset, i.e. on 18/10/2014. His platelets & WBCs started to show steady fall from 1,76,000/cmm& 3530/cmm to 99,000/cmm& 2050/cmm respectively, in 6 days thereafter. Ayurvedic treatment was started. He was given the powders of herbs as mentioned in the table, 500mg each, 4 times a day. CBC was done periodically. Within 6 days, his reports came to normal.

	Name	O.M.
	Age/gender	14/M
14/10/2014	Symptoms occurred	Severe headache, fever with chills.
18/10/2014	Dengue NS1 date	Positive
18/10/2014	Plt count	1,76,000/cmm
	TLC	3530/cmm
19/10/2014	Plt count	1,61,000/cmm
	TLC	3200/cmm
21/10/2014	Plt count	1,30,000/cmm
	TLC	1940/cmm
23/10/2014	Plt count	1,05,000/cmm
	TLC	2150/cmm
24/10/2014	Plt count	99,000/cmm
	TLC	2050/cmm
24/10/2014	Rx started	Dhatri, musta, guduchi, yashti, bala, pippali, patola,  vidari. All powders 500 mg each, 4 times a day with honey
25/10/2014	Plt count	1,35,000/cmm
	TLC	2550/cmm
27/10/2014	Plt count	2,50,000/cmm
	TLC	2880/cmm
30/10/2014	Plt count	3,63,000/cmm
	TLC	5400/cmm

Case 2:

11/M patient showed onset of symptoms like severe headache & fevers on 16 Oct 2014.he was treated symptomatically by his family physician. Symptoms were relieving slowly. His Dengue NS1 came positive after 4 days of onset, i.e. on 20/10/2014. His platelets & WBCs started to show steady fall from 1,88,000/cmm& 3400/cmm to 1,00,000/cmm& 2900/cmm respectively, in 7 days thereafter. At this count his family opted for Ayurvedic treatment instead of admission. He was given the powders of herbs as mentioned in the table, 500mg each, 4 times a day. CBC was done periodicaly. Within 3 days, his reports came to normal.

	Name	YT
	Age/gender	11/M
16/10/2014	Symptoms occurred	Severe headache, high grade fever.
20/10/2014	Den NS1	Positive
17/10/2014	Plt count	1,88,000/cmm
	TLC	3400/cmm
19/10/2014	Plt count	1,86,000/cmm
	TLC	2900/cmm
20/10/2014	Plt count	1,56,000/cmm
	TLC	2900/cmm
22/10/2014	Plt count	1,33,000/cmm
	TLC	3100/cmm
24/10/2014	Plt count	1,00,000/cmm
	TLC	3800/cmm
24/10/2014	Rx started	Dhatri, musta, guduchi, yashti, bala, pippali, patola, vidari. All powders 500 mg each, 4 times a day with honey
25/10/2014	Plt count	1,33,000/cmm
	TLC	4000/cmm
27/10/2014	Plt count	2,79,000/cmm
	TLC	4300/cmm
30/10/2014	Plt count	3,65,000/cmm
	TLC	4600/cmm

Case 3:

11/M showed onset of symptoms like severe headache, bodyache & fevers on 25 oct2014. He was treated symptomatically by his family physician. Symptoms were relieving slowly. His Dengue NS1 came positive after 5 days of onset, i.e. on 31/10/2014. His platelets & WBCs started to show steady fall from 1,25,000/cmm& 3690/cmm  to 1,00,000/cmm& 2490/cmm respectively, in 4 days thereafter. At this count his family opted for Ayurvedic treatment instead of admission. He was given the powders of herbs as mentioned in the table, 500mg each, 4 times a day. CBC was done everyday. Within 3 days, his reports came to normal.

	Name	CC
	Age/gender	11/M
25/10/2014	Symptoms occurred	Severe headache, body ache, mild to moderate fever.
31/10/2014	Den NS1	Positive
31/10/2014	Plt count	1,25,000/cmm
	TLC	3690/cmm
2/11/2014	Plt count	1,21,000/cmm
	TLC	2680/cmm
3/11/2014	Plt count	1,00,000/cmm
	TLC	2490/cmm
3/11/2014	Rx started	Dhatri, musta, guduchi, yashti, bala, pippali, patola, vidari. All powders 500 mg each, 4 times a day with honey
4/11/2014	Plt count	1,05,000/cmm
	TLC	2890/cmm
6/11/2014	Plt count	1,05,000/cmm
	TLC	3950/cmm
7/11/2014	Plt count	1,45,000/cmm
	TLC	4250/cmm
9/11/2014	Plt count	1,75,000/cmm
	TLC	5200/cmm
10/11/2014	Plt count	3,40,000/cmm
	TLC	6,640/cmm

Case 4:

21/M pt started c/o fever with chills on 14^th Aug 2015. Took antibiotic treatment from local doctor. Fever continued. Dengue NS1 came positive on 17^th August. Platelet count 1,00,000/cmm. TLC, 3900/cmm.Repeated platelet count on 17 Aug 2015.Platelets 70,000/cmm.

Started Ayurveda treatment. Platelets on 21 Aug came out to be 1,14,000/cmm and TLC 8300/cmm. Repeat hemogram on 25 Aug showed platelets 2,26,000/cmm and TLC 7000/cmm.

	Name	PJ
	Age/gender	21/M
14/08/2015	Symptoms occurred	Chills, body ache, mild to moderate fever.
17/08/2015	Den NS1	Positive
	Plt count	1,00,000/cmm
	TLC	3900/cmm
19/08/2015	Plt count	70,000/cmm
	TLC	2500
19/08/2015	Rx started	Dhatri, musta, guduchi, yashti, bala, pippali, patola, vidari. All powders 500 mg each, 4 times a day with honey
21/08/2015	Plt count	1,14,000/cmm
	TLC	8300/cmm
25/08/2015	Plt count	2,26,000/cmm
	TLC	7000/cmm

Case 5:

24/M pt started c/o high grade fever 104⁰ F on 27 Aug 2015. Hemogram was normal. Dengue NS1 came positive on 28 Aug 2015. Platelets 36000/cmm and TLC 3200/cmm. admitted in hospital.

On 30 Aug 2015, platelets further declined to 20,000/cmm and on 31 Aug 2015, 15,000/cmm.

Ayurveda treatment started on 31 Aug 2015. Platelets were not infused. Patient was only under observation.On 1 Sep 2015, platelets fellupto 8,000/cmm and TLC was 9,000/cmm. Still as there was no active bleeding, treating doctor did not infuse platelets. On 3^rd Sep, 2015, platelets became 32,000/cmm, on 4^th Sep, 82,000/cmm, on 5^th Sep 1,32,000/cmm. Pt was discharged.

	Name	VG
	Age/gender	24/M
27/08/2015	Symptoms occurred	high grade fever.
29/08/2015	Den NS1	Positive
	Plt count	36,000/cmm
	TLC	3200/cmm
30/08/2015	Plt count	20,000/cmm
	TLC	3200/cmm
31/08/2015	Plt count	15,000/cmm
	TLC	6600/cmm
31/08/2015	Rx started	Dhatri, musta, guduchi, yashti, bala, pippali, patola, vidari. All powders 500 mg each, 4 times a day with honey
1/09/2015	Plt count	8,000/cmm
	TLC	9,000/cmm
3/09/2015	Plt count	32,000/cmm
	TLC	7000/cmm
4/09/2015	Plt count	82,000/cmm
	TLC	Not done
5/09/2015	Plt count	1,32,000/cmm
	TLC	10,200/cmm

From the above tables, it is can be said that all the subjects responded really well to the Ayurvedic Herbal combination.

              Assembling Samprapti:

Symptom	DushtaDosha	DushtaDooshya	Gunas
Severe headache	Vataprakopa	Rasa,Rakta	Rooksha, Chala
Severe bodyache	Vataprakopa	Asthi, Majja	Rooksha, Chala
High grade fever	Pitta prakopa	Rasa,Rakta	Ushna,Teekshna
Possibility of bleeding	Pitta prakopa	Rasa, Rakta	Ushna,Teekshna  & Drava

As per above logic, the vitiated Gunas came to be: Rooksha, Chala, Ushna, Teekshna& Drava. Vitiated Doshas to be Vata & Pitta. Rasavaha, Raktavaha, Asthivaha & Majjavahasrotasas were found to be vitiated.

Moolasthanas of these srotasas, viz. Hrudaya, Yakrut, Pleeha, Meda, Asthi & Sandhi were also considered during coining of the herbal formulation.

In view of all this logic, powders of following herbs were selected:

1.      Aamalaki                     Emblicaofficinalis                    Sheeta, Rasayana

2.      Musta                           CyperusRotundus                    Sheeta, Manda, Sugandhi

3.      Guduchi                       Tinosporacordifolia                 Rasayana, Jwaraghna

4.      Yashtimadhu               Glycirrhizaglabra                    Sheeta, Snigdha

5.      Bala                             Sidacordifolia                          Sheeta, Rasayana, Balya

6.      Pippali                         Piper longum                           Ushna, Rasayana for Rakta

7.      Patola                           Trichosanthesdioeca                Sheeta, Balya, Rasayana

8.      Vidari                          Purariatuberosa                      Sheeta, Balya, Rasayana

Powders of all were mixed together & given to the subjects with honey, 4 times a day. 500mg of each herb i.e. total 4gm medicine to be taken at a time.

Other regimen like soft & light diet, rest & plenty of Luke warm water orally, was advised to all. Haemogram was advised everyday or alternate day as per need.

From the above tables it is quite clear that all the patients responded to the Ayurvedic Herbal combination quickly & were out of danger zone in less than 7 days. Thus they escaped the hospitalisation & hazards of platelet infusion. All the cost& loss of working hours was also saved.

Conclusion:

Ayurvedic herbal combination can be effectively tried at the very first instance of thrombocytopenia & leucopoenia, to avoid further complications. Of course we all need to generate huge data to make some final statement, but still, this study can be considered as pilot study.

If you want to try this combination for your patients, a kind request to use it in a precise manner and keep proper documentation of all the results, so that we can approach the scientific world with genuine documentated results.

References:

1.      Expert Review of Anti-Infective Therapy Dengue Fever: Diagnosis and Treatment; VirojWiwanitkit;  Disclosures;Expert Rev Anti Infect Ther. 2010;8(7):841-845.

2.  Dengue fever with thrombocytopenia: studies towards defining vulnerability of bleeding.

(PMID:7786355); García S, Morales R, Hunter RF; Department of Internal Medicine, HospitalUniversitario Ramón Ruiz Arnau; Boletin de la AsociacionMedica de Puerto Rico [1995, 87(1-2):2-7]; Type: Journal Article, Research Support, U.S. Gov't, P.H.S.

3. The natural history of dengue illness based on a study of hospitalised patients in Singapore.

(PMID:10487075; Tai DY, Chee YC, Chan KW; Department of General Medicine, Tan Tock Seng Hospital, Singapore; Singapore Medical Journal [1999, 40(4):238-242]

Type: Journal Article

4.  21 Health Effects of Alkaloids from African Medicinal Plants;V Kuete - Toxicological Survey of African Medicinal Plants, 2014 - researchgate.net

Case Courtesy & Presentation:

Dr. Ranjit Nimbalkar

       Ph.D. (sch.), M.D. (Rognidan); 

      Professor 

      Dept of RogNidan, Ashtang AyurvedMahavidyalaya, 

      Pune 411030, Maharashtra, India

      Mobile No.: +91 9850066935 

      Email: drranjitn@rediffmail.com

       Clinic Address:

       Anubandha Healthcare

       495, Sadashiv Peth,

       Opposite Doorvankur Dining Hall,

       Tilak Road, Pune: 411030, Maharashtra, India.

Compiled & Edited by

Dr.Surendra A. Soni

M.D.,PhD (KC)

Associate Professor

Dept. of Kaya-chikitsa

Govt. Ayurveda College

Vadodara Gujarat, India.

Email: surendraasoni@gmail.com