|Year : 2022 | Volume
| Issue : 3 | Page : 196-199
Ayurveda treatment for granulomatosis with polyangiitis: A case report
Santosh K Bhatted, Diksha N Kabra
Department of Panchakarma, All India Institute of Ayurveda, New Delhi, India
|Date of Submission||11-May-2022|
|Date of Acceptance||18-Aug-2022|
|Date of Web Publication||30-Sep-2022|
Diksha N Kabra
Department of Panchakarma, All India Institute of Ayurveda, Academic Block, 7th Floor, Sarita Vihar, New Delhi 110076
Source of Support: None, Conflict of Interest: None
Granulomatosis with polyangiitis (GPA) was formerly known as Wegener’s granulomatosis. As its name implies, the disease is associated with a necrotizing granulomatous inflammation with vasculitis of small and medium blood vessels induced by antineutrophil cytoplasmic antibodies (ANCA). Here, we present a case of a 42-year-old woman with severe arthralgia associated with fever and obstructive uropathy. Blood investigations revealed a high level of C-ANCA, C-reactive protein, erythrocyte sedimentation rate, and reduced hemoglobin level. She had a history of rheumatic heart disease in the childhood. The patient was treated with Ayurvedic oral drugs for 3 months. After 1 month of follow-up period, the patient showed a significant improvement in presenting symptoms as well as laboratory investigations. There was a significant reduction in swelling and tenderness over both ankle joints. Presently, the patient is stable with Ayurvedic medications. The case study shows a ray of hope toward the management of GPA with holistic Ayurveda medications with satisfactory outcome and contentment of the patient. However, more studies should be observed for definite conclusion.
Keywords: Amavata, Ayurveda, GPA
|How to cite this article:|
Bhatted SK, Kabra DN. Ayurveda treatment for granulomatosis with polyangiitis: A case report. J Indian Sys Medicine 2022;10:196-9
| Introduction|| |
Granulomatosis with polyangiitis (GPA), previously referred to as Wegener’s granulomatosis, is a rare, idiopathic, systemic, autoinflammatory disease. The respiratory tract is most often affected in limited forms of the disease; however, the upper and lower respiratory tract, systemic vasculitis, and necrotizing glomerulonephritis are the characteristic components of the disease triad. The prevalence of GPA is about three in 100,000. Both genders are affected equally and at all ages, with the mean age of onset in the fourth decade. The exact etiology of GPA is still under research. Some environmental factors and exposure to microbial infections appear to be relevant in the pathogenesis of the disease. These external agents may be the reason for a nonspecific immune reaction with increased cytokine levels, which further elevate antineutrophil cytoplasmic antibodies (ANCA) levels and lead to cell destruction. Early diagnosis is challenging because of nonspecific clinical symptoms in the early stage although it is necessary to reduce mortality as well as further complications of disease. The current available treatment is corticosteroids such as prednisone, which helps suppress immune system. Other drugs such as methotrexate, rituximab, cyclophosphamides, which also lead to the suppression of immunity, are used for treating GPA.
| Patient Information|| |
Here, we present a case of a 42-year-old woman with no known comorbidities. She was attended at tertiary Ayurveda hospital attached to teaching institute at New Delhi, on August 9, 2021, complaining of obstructive uropathy and severe arthralgia associated with fever. The patient was suffering from the disease for 1 year. There was a history of rheumatic heart disease diagnosed in her childhood for that she had injection penicillin for about 10 years. She used to have joint pain, but it was not troublesome to affect day-to-day activities. The history revealed that she had impaired hearing before 1 year, and it was managed with some medicines from ENT consultation. There was a history of COVID vaccination after that she had developed joint pain and fever, which persisted for 2–3 weeks. About 2 months before, she was hospitalized for obstructive uropathy with arthralgia.
| Diagnostic Criteria|| |
Laboratory investigations revealed that her hemoglobin was 6.9 g/dL only. She was suspected to be suffering from rheumatic arthritis, but related investigations did not support the provisional diagnosis. She had visited many hospitals, and later she was diagnosed as a case of Wegner’s granulomatosis/GPA based on C-ANCA as it was more than 100. She was treated with tablet Omnacortil 40 mg, tablet Dytor 10 mg, and tablet Voveran 50 mg per day. This management provided some relief in pain. At a lapse of 1 month, she had similar complaints for that she visited Ayurveda hospital at New Delhi.
| Clinical Findings|| |
The patient was of medium built with body weight of 60 kg and height of 165 cm. She is of Kapha Pitta Prakriti, assessed with a tool developed by CCRAS. She had Madhyam Aharshakti (medium food intake) and Madhyam Jaranshakti (medium digestive power). On examination, the patient was pale. Neurological and cardiorespiratory examinations were normal. There was edema over the medial side of bilateral ankle joint with tenderness of grade 2. Pain was present at bilateral wrist joint, shoulder joints with visual analogue scale (VAS) 7/10. There was blackish discoloration over the medial side of bilateral lower limbs.
Investigations dated on July 31, 2021 denoted the following: hemoglobin = 7.90 g/dL, erythrocyte sedimentation rate (ESR) = 44 mm/h, C-reactive protein (CRP) = 141.51 mg/L, C-ANCA > 100 U/mL, and HLA-B27 was negative.
| Disease Course|| |
Details are described in [Table 1].
| Timeline|| |
Timeline is described in [Figure 1].
| Diagnostic Focus|| |
The patient was presented with pain in multiple joints, fever, obstruction of urine, weight loss, and skin discoloration in the lower limb, which were suggestive of Wegener’s granulomatosis. The patient was already a diagnosed case of Wegener’s granulomatosis. Rheumatic arthritis and other small vessel inflammatory diseases were the differential diagnoses of the case. These conditions are ruled out with related blood investigation. Positive C-ANCA was the confirmatory test for the diagnosis of GPA. Aalasya (lethargy), Janu, Jangha, Uru, Kati, Ansa, Hasta, Pada, Sandhi Nistoda (multiple joint pain), Shwayathu (swelling); these are the clinical manifestations of Amavata. The clinical presentation of GPA resembles Amavata. Hence, Amavata was considered as Ayurvedic diagnosis of the case.
| Therapeutic Intervention|| |
The patient was treated with Amruttotaram Kashaya 30 mL, Maharasnadi Kashaya 30 mL, Dashamula Kashaya 40 mL twice a day before food, tablet Punarnavadi Mandoor 250 mg thrice a day, tablet Simhanad Guggulu 500 mg thrice a day after food, Hingvashtak Churna 3 g twice a day before food, for initial 1 month.
After this initial treatment, she was administered tablet Saptamruta Lauha 250 mg thrice a day, tablet Laghumalini Vasant 250 mg thrice a day, Indukanta Kashayam 20 mL twice a day, Maharasnadi Kashaya 30 mL twice a day, Amruttotaram Kashaya 30 mL twice a day, Hingvashtak Churna 3 g twice a day orally for later 2 months [Table 2].
| Follow-up and Outcome|| |
The patient’s condition was assessed with Birmingham Vasculitis Activity Score for Wegener’s granulomatosis for the disease activity of Wegener’s granulomatosis. Score was 13 at the initial time before starting the treatment, and it was reduced to 10 in the first month. It is further reduced to 06 after 2 months of intervention. After 3 months of follow-up, it was reduced to 0. Swelling over the ankle region was also reduced significantly, tenderness was absent after 3 months of treatment. Discoloration over the medial side of lower limb was also reduced significantly. The patient was asymptomatic during follow-up period of 3 months. Also, her tablet Omnacortil dose was reduced to 5 mg from 40 mg after 3 months of treatment. NSAIDS were not needed after 3 months of treatment.
| Discussion|| |
GPA disease closely resembles Amavata as described in the classical Ayurveda texts. So, the above given treatment was focused upon the correction of Kapha and Vata Dosha along with Amapachana and correcting impairment of Rasa and Raktavaha Srotasa.
Punarnava Mandoor contains a maximum number of drugs having Katu (pungent), Tikta (bitter) Rasa, and Ushna virya (hot potency); because of this, it pacifies Kapha Dosha and cleans the Srotasa (channels). This drug is described as useful in the management of Shotha (swelling), Shula (pain), and Pandu (anemia).Punarnava is known to possess diuretic action because of which it reduces Shotha, and it reduces Kleda and Dustha Rasa Dhatu. The second most important content in this formulation is Mandoora (iron oxide), which significantly treats iron-deficiency anemia.
Simhanad Guggulu is one among the choice of drug in treating rheumatic conditions. It is indicated in Shula, Amavata.Simhanad Guggulu has Vatakaphashamaka (pacifies Vata and Kapha Dosha) and Amapachaka (digesting toxic substance) properties, which help in breaking down the pathogenesis of disease. Dashamoola has anti-inflammatory and analgesic activity.Dashamula Kashaya is widely used for treating arthritic conditions as well as it shows a significant reduction in swelling. Dashamula Kashaya is indicated for Shotha Roga. It possesses Vata Kaphaghna properties (the palliation of Vata and Kapha Dosha). Hingvashtak Churna is indicated in Vataroga; here it implies Kosthagata Vata, which manifests as the retention of urine and feces. The underlying pathology in Kosthagata Vata is the formation of Ama due to reduced digestive power.
Maharasnadi Kwatha is a polyherbal preparation. This therapeutic combination has Vata-shamak (the palliation of Vata Dosha), Kapha-shamak (the palliation of Kapha Dosha), Aam-pachan (the digestion of toxic wastes), Deepan (empowering agni/digestive fire.), Vedana-sthapana (the subsidence of pain) properties, which help in curing disease. The contents of Amruttotaram Kashaya have Katu (pungent) Rasa and Ushna Virya (hot potency). Amruttotaram Kashaya has Agnideepaka, Amapachaka, and Anulomaka properties.
Saptamruta Lauha is a herbomineral preparation, which is prepared by Triphala Churna, i.e., Amalaki, Bibhitaka, and Haritaki (Emblica officinalis, Terminalia bellirica, and Terminalia chebula resp), Yashthimadhu (Glycyrrhiza glabra), and Lauha Bhasma (calcined iron). The main constituent of this preparation is Lauha Bhasma, which has Rasayana (rejuvenation) properties and helpful to increase hemoglobin in the body.
Laghumalini Vasant is one of the Vasant Kalpa, which is Madhura and Balya. It contains Shuddha Kharpara (zinc ore) and Maricha (Piper nigrum) with Navneeta (butter).Kharpara mainly acts on Rasavaha Srotasa, Rasa Dhatvagni, which cures the Agnimandya. Rasa Dhatu is one of the important causative factors in the pathology of Amavata and Shotha Roga; by curing it, one can break the pathology of Amavata and Shotha. Indukanta Kashaya possesses Tikta, Katu Rasa along with Ushna Virya. It has Kaphavata Shamaka properties, Amapachaka, and Jvarahara properties and acts as Srotoshodhaka and Balavardhaka.
All the above said drugs possess Amapachaka, Srotoshodhaka, Balavardhaka, Shulahara, Rasayana properties, and they act upon Kapha and Vata Doshas, which help in breaking down the pathophysiology of Amavata. After 3 months of treatment, her C-ANCA levels reduced to 13.74, which was more than 100 before treatment as well as CRP reduced to 11.20 from 141.5 mg/L and ESR was 42 mm/h. Clinical data and in vitro experimental results point to the pathogenic pathways involved in the tissue lesion development, in which ANCA, cellular immunity, neutrophils extracellular traps, fibroblasts, vascular endothelial cells, and inflammatory mediators play a major role. A maximum of above drugs show anti-inflammatory, antioxidant, immunomodulatory, and analgesic effects. This will help resolve the pathology of the disease. Because GPA is an autoimmune and inflammatory disease, all the above drugs have shown a good result in reducing all the signs and symptoms of GPA.
| Conclusion|| |
The case study shows that GPA can be efficiently managed with Ayurvedic drugs based on the treatment of Amavata. The significant decline was observed in levels of C-ANCA and CRP after the completion of 3 months of treatment. Also, the patient was asymptomatic at the end of treatment. The treatment showed a significant improvement in terms of both objective (laboratory) and subjective parameters (clinical symptomatology). From this observation of a single case of GPA effectively managed through Ayurveda medicine is worth to mention as it gives a lead to conduct clinical trials in this direction to provide a safe treatment option to the autoimmune inflammatory conditions associated with arthralgia and vasculitis in general and GPA in particular.
Declaration of patient consent
Written consent is obtained from the patient for the publication of this case study. The patient was well satisfied with provided treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kubaisi B, Samra KA, Stephen Foster C Granulomatosis with polyangiitis (Wegener’s disease): An updated review of ocular disease manifestations. Intractable Rare Dis Res 2016;5:61-9.
Šoštarič K, Lovrec Krstić T, Slanič A, Caf P A rare case of granulomatosis with polyangiitis presenting as retroperitoneal fibrosis in the peri-iliac region causing hydronephrosis. Cureus 2021;13:e17295.
Begum S, Srinivasan S, Kathirvelu S, Vaithy A Limited granulomatosis with polyangiitis presenting as an isolated lung lesion. Indian J Pathol Microbiol 2020;63:611-4.
Mishra SN Pandurogadhikara. In: Bhaisajya Ratnavali of Kaviraj Govind Das Sen. Edited with Siddhiprada Hindi commentary. Varanasi: Chaukhambha Surbharati Production; 2019. p. 381.
Mishra S, Aeri V, Gaur PK, Jachak SM Phytochemical, therapeutic, and ethnopharmacological overview for a traditionally important herb: Boerhavia diffusa Linn. Biomed Res Int 2014;2014:808302.
Parekar RR, Bolegave SS, Marathe PA, Rege NN Experimental evaluation of analgesic, anti-inflammatory and anti-platelet potential of Dashamoola. J Ayurveda Integr Med 2015;6:11-8.
Mishra SN Agnimandyarogadhikara. In: Bhaisajya Ratnavali of Kaviraj Govind Das Sen. Edited with Siddhiprada Hindi commentary. Varanasi: Chaukhambha Surbharati Production; 2019. p. 342.
Mangal A, Shubhasree MN, Devi P, Jadhav AD, Prasad SA, Kumar K, et al
. Clinical evaluation of Vatari Guggulu, Maharasnadi Kwatha and Narayan Taila in the management of osteoarthritis knee. J Ayurveda Integr Med 2017;8:200-4.
Jadhao UA, Ingole RK Standardization of Saptamruta Loha. Int Res J Pharm 2014;5:773-7.
Walunj MB, Patgiri B, Shukla VJ, Prajapati PK Standard manufacturing procedure for Laghumalini Vasanta rasa in context of Bhavana (levigation). Ayu 2015;36:180-7.
Csernok E, Gross WL Current understanding of the pathogenesis of granulomatosis with polyangiitis (Wegener’s). Expert Rev Clin Immunol 2013;9:641-8.
[Table 1], [Table 2]