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Table of Contents
CASE REPORTS
Year : 2022  |  Volume : 10  |  Issue : 3  |  Page : 200-204

Non-invasive management of suppurative skin nodule (metastatic cutaneous abscess): a suspected case of tuberculous gumma: “a case report.”


Department of Kayachikitsa (Internal Medicine), All India Institute of Ayurveda, New Delhi, India

Date of Submission19-Apr-2022
Date of Acceptance04-Jun-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
  Reetu
Department of Kayachikitsa (Internal Medicine), All India Institute of Ayurveda, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jism.jism_35_22

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  Abstract 

The paradigm of cutaneous adverse drug reactions (CADRs) due to the resurgence of Dushi-visha (~cumulative poison) is less reported. Clinical evidence of Dushi-visha is not commonly diagnosed in the clinics. This is the era of polypharmacy; the long duration of medication along with a multi-therapeutic approach causes drug intolerance and complicates with reduced assimilation. Improper elimination causes an increased concentration of these medicines in the plasma and produces toxic side effects. These cumulative endotoxins are termed as Dushi-visha in Ayurveda. A 60-year-old male diagnosed with abdominal tuberculosis had undergone anti-tubercular treatment and suffered from pyogenic abscess over back, and rectal area, around the umbilical area. Pus culture isolated coagulase-negative Staphylococcus. In due course of time, the patient took treatment but abscess continued to develop over different parts of the body. This is a suspected case of tuberculous gumma based on clinical presentation and history of the disease, and according to Ayurveda, this is a case of Dushi-visha. The classical treatment of an abscess is focussed on incision and drainage, but this case was handled with Vishaghna chikitsa (~anti-toxin treatment) and other potential treatments considering the resurgence of Dushi-visha without any surgical intervention. Many conditions, which generally seem idiopathic due to lack of proper history, may be due to reactivation of Dushi-visha. This case report opens up the way to clinically identify and potentially treat the condition with Ayurveda.

Keywords: Abscess, anti-tubercular treatment, cumulative poison, Dushi-visha, Vishaghna


How to cite this article:
Reetu &, Kajaria D. Non-invasive management of suppurative skin nodule (metastatic cutaneous abscess): a suspected case of tuberculous gumma: “a case report.”. J Indian Sys Medicine 2022;10:200-4

How to cite this URL:
Reetu &, Kajaria D. Non-invasive management of suppurative skin nodule (metastatic cutaneous abscess): a suspected case of tuberculous gumma: “a case report.”. J Indian Sys Medicine [serial online] 2022 [cited 2022 Dec 6];10:200-4. Available from: https://www.joinsysmed.com/text.asp?2022/10/3/200/357682




  Introduction Top


Tuberculosis is a potentially serious infection that causes morbidity and mortality in developing countries. Cutaneous adverse drug reactions (CADRs) are also commonly seen among adverse drug reactions (ADRs). Sharma et al.[1] reported the incidence of CADRs due to anti-tubercular treatment (ATT), in which maculopapular rash was commonest (42.5%).

The use of various medicines can lead to chronic cumulative toxicity, which acts like antigen (poison specifically as it can even provoke an acute immune response) in the later stage of life. ATT causes hepatocellular and mixed type hepatotoxicity of the liver.[2]Dushi-visha is a substance that is not properly metabolized or excreted out of the body, has less potency, and due to Avarana of Kapha it stays in the body for years together[3] and has the potential of combining with different Dhatus (~bodily tissues) to produce various clinical manifestations. When any poison gets into the body, it first combines with Rakta dhatu (~blood tissues) and exhibits acute and chronic responses (immensely/very little depending on the strength) including the skin. As referred earlier, ATT affects the liver which is the seat of Raktavaha srotasa (~blood channels), which vitiates to manifest various clinical conditions such as Vidradhi (~abscess), Pidka (~furuncle), and others.


  Patient Information Top


A 60-year-male with a body weight of 55.7 kg came to the OPD of Kayachikitsa with complaints of swelling in the bilateral foot on and off for 7 days. He had weakness, joint pain, and headache for the past 2 years. Along with these complaints, he had recurrent cystic swelling over different parts of the body with pus discharge largest on the superior angle of the left scapula and inability to gain weight, anorexia, and indigestion for the past 22 years.

A significant past history of amoebic liver abscess, abdominal tuberculosis, road traffic accident (multiple ribs and right scapula fracture), renal cyst, renal calculi, and benign prostatic hyperplasia was also noted. There was surgical history of exploratory laparotomy for tubercular ileal perforation and acute peritonitis in 1998. The patient took multiple medications since 1980 starting with anti-amoebic followed by ATT in 1998 continuously for 9 months. He had taken non-steroidal anti-inflammatory drugs (NSAIDs) for a longer duration, antibiotics multiple times, and other multiple medications for other conditions.


  Clinical Findings Top


The patient’s general condition was fair on arrival, having blood pressure of 122/66 mmHg, pulse rate 80/min, temperature 97.1° F, and edema over bilateral foot pitting in nature.

Physical Examination

On local examination, a cystic swelling adjacent to the superior angle of the left scapula well-defined margins, fluctuant, mild tender, non-pulsatile abscess measuring approximately 3 cm (diameter)*1.5 cm (height) was present with tenderness around the abscess along with a mild increase in local temperature. The abscess was of grade 3, according to EGS grading for skin and soft tissue infections.[4] It was non-complicated and positive for coagulase-negative Staphylococcus in pus culture conducted in December 2019.

In Ayurvedic perspective, the patient was examined and found to be Vata-pitta-dominant Prakriti (humor) associated with vitiation of Rakta and Mamsa dhatu (Dushya), having Avara-aahara shakti (reduced appetite) and vyayama shakti (reduced exercise capacity).


  Timelines Top


A detailed timeline of events is summarized in [Figure 1].
Figure 1: Timeline of events

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  Diagnostic Assessment Top


Based on clinical findings, history, and physical examinations, considering this case as chronic reactivation of Dushi-visha presented as Raktadusti in the form of Vidhradhi due to long-term use of multiple medications was the provisional diagnosis that has to be confirmed by Upshaya-anupshaya, which is treated with Vishaghna chikitsa along with Rasayana chikitsa.


  Therapeutic Intervention Top


Treatment included oral agents as well as local treatment, which is summarized with details of the time of intake/application, adjuvant, and so on in [Table 1].
Table 1: Drugs with dosage and Anupana during different time periods

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  Outcome Top


Changes in objective and subjective parameters are summarized in [Table 2] and [Table 3][Figure 2] and [Figure 3].
Table 2: Symptoms confined to abscesses and their grading during follow-ups

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Table 3: Systemic symptoms and their grading during different follow-ups

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Figure 2: Before treatment figures

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Figure 3: After treatment figures

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  Discussion Top


In the present scenario, co-morbidities are being a part of every individual’s life, which incorporated the use of multiple medications from an early age. Long duration of use of multiple medications causes drug intolerance and finally, its poor assimilation and improper elimination cause its accumulation in the plasma which acts as antigen (~Dushi-visha) provoking immune responses. Accumulated toxins (Dushi-visha) may get associated with different Dhatus and manifest their respective symptoms.[5] In this case, Dushi-visha (chronic in nature) originated due to irrational and long-duration use of multiple drugs such as anti-amoebic, NSAID,[6] and ATT compromising liver functions and ultimately causing vitiation of Rakta dhatu (liver is supposed to be the seat of Raktavaha srotasa and vitiation of Srotasa causes vitiation of Dhatu). In the present case, visualization of etiological factors (Hetus) as per Ayurveda is also a very interesting finding. Diva-swapna (sleeping in the daytime), appearance of symptoms such as Avipaka (indigestion as signified by heaviness in the abdomen after taking the meal and feeling of nausea after meal), Arochaka (~reduced appetite), Dhatukshaya (as signified by the reduced exercise capacity, reduced body weight, lack of enthusiasm, and so on), Padashotha (~swelling in legs)[5] as well as symptoms of vitiation of Rakta dhatu like Pidka, Vidradhi, and Shiro-ruka (headache) on seasonal variation/climatic changes were well emphasized by the patient.

The treatment is planned based on the Vishaghna chikitsa (Agada), Raktashodhaka (~treatment for purifying blood), and Sroto-shodhaka chikitsa. The treatment was planned in a stepwise manner.

In step 1, mainly Vishaghna (~anti-toxin treatment), Raktashodhaka (~blood purifier), and Rasayana chikitsa (~immunomodulator) were given. Vishagna chikitsa comprises the use of herb such as Shirisha (Albizzia lebbeck) which is having anti-toxic,[7] anti-allergic, antiseptic, antibacterial, and anti-ulcerogenic properties.[7]Ashwatha (Ficus religiosa) having anti-toxin,[8] blood purifier (Raktashodhaka), and healing (Vranaropana)[9] properties were used to fulfill all three aspects of treatment. Amalaki (Emblica officinalis) and Haritaki (Terminalia chebula) were used for Rasayana purpose (reported for having antioxidant, antimicrobial, and anti-ulcerogenic[7] properties). Khadirarista (a proprietary Ayurvedic medicine) was used in this case as it is indicated for the treatment of Mamsa-gatavisha (~toxins accumulated deeper in the muscle tissues—superficial fascia)[10] as well as Kustha (~treatment of infectious skin diseases) and Vidradhi (which involves vitiation of Twacha, Mamsa, Meda, and Rakta). For local application, Dashangalepa (powder of herbs that can be pasted on different vehicles, viz., cow urine, oil, milk, water, etc. as per the selection of physician) was prescribed. Dashangalepa, having herbs that are used in Visha-chikitsa as well, is used to reduce local inflammatory reactions such as swelling, hyperemia, tenderness, and local temperature. In addition to Dashangalepa, Haridra is added which is also Vishaghna,[11] so composite action is seen.

Step 2: At this stage, Vishagna chikitsa was continued along with Rakta-shodhaka and Raktavaha srotomula (Yakruta and Pliha) Shodhaka chikitsa. Nimba churna (Azadirachta indica) is indicated to reduce swelling of Apakwavrana (~non-suppurated) and to cleanse Pakwavrana (~suppurated),[12] which is worthwhile in this case to cleanse the purulent discharge from the abscess. Herb like Nagarmotha churna (Cyperus rotandus) was used due to its Laghu; Ruksha guna causes depletion of Kapha avarana (Sroto-shodhaka) and also purifies blood to further reduce the association of Dushi-visha. Along with proper management of Kapha and Rakta treatment was also targeted to Srotomula, considering this drugs such as Kumaryasava[13] and Rohitakarista were used to prevent further skin manifestations due to Raktavaha sroto-dushti.

Step 3: The patient was finally put on Rasayana therapy with Haritaki and Amalaki churna in the dose of 2 g each twice a day with lukewarm water for 2 months, followed by complete discontinuation of all medicines after complete recovery and communication to the patient about the treatment completion.


  Conclusion Top


This case study gives a perspective to identify the clinical manifestation of Dushi-visha and the utility of Vishaghna chikitsa in the management of toxic drug reactions/drug allergies. There are many valuable concepts in Ayurveda, and an unexplored treasure of medicines has to be searched to provide solutions for autoimmune/idiopathic diseases.

Future Scope

Further such clinical studies can be conducted on a larger scale.

Limitation of the study

A sufficient number of cases are required to definitely establish the effect of treatment.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma RK, Verma GK, Tegta GR, Sood S, Rattan R, Gupta M Spectrum of cutaneous adverse drug reactions to anti-tubercular drugs and safe therapy after re-challenge—A retrospective study. Indian Dermatol Online J 2020;11:177-81.  Back to cited text no. 1
    
2.
Yimer G, Gry M, Amogne W, Makonnen E, Habtewold A, Petros Z, et al. Evaluation of patterns of liver toxicity in patients on antiretroviral and anti-tuberculosis drugs: A prospective four arm observational study in Ethiopian patients. PLoS One 2014;9:e94271.  Back to cited text no. 2
    
3.
Pt. Hari Sadasiva Sastri Bhishagacarya, editor. Astanga Hridaya by Vagbhata, Uttaraantantra; Vishapratishedadhyaya: 35/34, Varanasi: Chaukhambha Subharati Prakashana; 2017. p. 904.  Back to cited text no. 3
    
4.
Savage S, Li S, Utter G, Cox J, Wydo S, Cahill K, et al. The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: A multicentre validation study. J Trauma Acute Care Surg 2019;86:601-8.  Back to cited text no. 4
    
5.
Vaidya Yadavji Trikamji Acharya, editor. Sushruta Samhita by Sushruta, Kalpasthana; SthavaravishavigyanIiyakalpadhyaya: 2/30, Varanasi: Chaukhambha Subharati Prakashana; 2017. p. 565.  Back to cited text no. 5
    
6.
Bessone F Non-steroidal anti-inflammatory drugs: What is the actual risk of liver damage? World J Gastroenterol 2010;16:5651-61.  Back to cited text no. 6
    
7.
NishaKumari Ojha N Critical analysis of Charakokta Mahakashaya in the management of respiratory allergic disorders (RAD). J Homeo Ayur Med 2013;02.  Back to cited text no. 7
    
8.
Patil P, Barsagade P, Umekar MJ. A review on Ficus religiosa: An alternative treatment for heart blockage. Sch Acad J Pharm 2020;09:108-19.  Back to cited text no. 8
    
9.
Chunekar Krishnachand. Bhavprakasha Nighantu. Vatadi Varga, 5/3, Varanasi: Chaukhambha Subharati Prakashana; 2015. p. 501.  Back to cited text no. 9
    
10.
Vaidya Yadavji, Trikamji Acharya, editors. Caraka Samhita by Agnivesa, Chikitsasthana; Vishachikitsadhyaya: 23/188, Varanasi: Chaukhambha Subharati Prakashana; 2016. p. 579.  Back to cited text no. 10
    
11.
Vaidya Yadavji, Trikamji Acharya editors. Caraka Samhita by Agnivesa, Sutrasthana; Shadvirechanashatashritiyadhyaya: 4/11, Varanasi: Chaukhambha Subharati Prakashana; 2016. p. 33.  Back to cited text no. 11
    
12.
Ojha J, Mishra U Dhanwantari Nighantu, Guduchyadivarga, 1/31–33, Varanasi: Chaukhambha Subharati Prakashana; 2016. p. 15.  Back to cited text no. 12
    
13.
Ahmad S, Khan M, Gupta A, Sastry J Hepatoprotective potential of Kumaryasava and its concentrate against CCl4-induced hepatic toxicity in Wistar rats. J Pharm Bioall Sci 2015;7:297.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
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Outcome
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