Featured Case

MODERN DIAGNOSIS: Klebsiella pneumoniae infection

ABOUT THE DISEASE:

Klebsiella is a type of bacteria commonly found in nature. In humans, the bacteria are often present in parts of the digestive tract where they do not generally cause health issues. In the United States, Klebsiella pneumoniae and Klebsiella oxytoca are the two strains responsible for most of the human sickness. Many Klebsiella infections are acquired in the hospital setting or in long-term care facilities. In fact, Klebsiella accounts for up to 8% of all hospital-acquired infections. People with a compromised immune system and/or people who have an implanted medical device (such as a urinary catheter or airway tube) are more at risk for Klebsiella infections. Extensive use of antibiotics has resulted in the development of antibiotic-resistant strains of Klebsiella. These infections can be more aggressive and difficult to treat. Whenever klebsiella gets into other areas of the body, it can lead to a range of illnesses, including pneumonia, bloodstream infections, meningitis, and urinary tract infections.

Prognosis: Klebsiella species bacteria are antibiotic resistant. Hence, the disease is difficult to cure when it affects different organ systems at a particular time. The prognosis of Klebsiella pneumonaie is poor, especially in patients who are alcoholic, diabetic, have nosocomial infection or have septicemia.

In this case report, a 44 year old female patient  complained of reddish painful eruptions in the face and body since 6 days. She first consulted an allopathic doctor and underwent standard of care. The  painful eruptions mostly increased and spread all over her face, while it subsided in the body. She felt intense pain and was advised to come for ayurvedic treatment.

Image 1. Baseline photos of infection dated 10.2.2023

Diagnostic Criteria: Urine Culture and sensitivity test, swab test

Image 2. Baseline Swab test confirming the biomedical diagnosis dated 11.2.2023

Treatment: Given the low occurrence of K. pneumoniae in the community, the treatment should follow standard guidelines for antibiotic therapy. Once infection with K. pneumoniae is either suspected or confirmed, antibiotic treatment should be tailored to local antibiotic sensitivities. Current regimens for community-acquired K. pneumoniae include a 14-day treatment with either a third or fourth-generation cephalosporin as monotherapy or a respiratory quinolone as monotherapy or either of the previous regimes in conjunction with an aminoglycoside. If the patient is penicillin-allergic, then a course of aztreonam or a respiratory quinolone should be undertaken. For nosocomial infections, a carbapenem can be used as monotherapy until sensitivities are reported.

This patient underwent standard of care, but the painful eruptions mostly increased and spread all over her face, while it subsided in the body. She felt intense pain and was advised to come for ayurvedic treatment.

Reference

1. Wang G, Zhao G, Chao X, Xie L, Wang H. The Characteristic of Virulence, Biofilm and Antibiotic Resistance of Klebsiella pneumoniae. Int J Environ Res Public Health. 2020 Aug 28;17(17):6278. doi: 10.3390/ijerph17176278. PMID: 32872324; PMCID: PMC7503635.

AYURVEDIC DIAGNOSIS: Paittika Visarpam

About the Disease:

Taking into consideration the clinical presentation, the treating physician has correlated the disease to Paittika Visarpam. 

Tvacha word in Ayurveda is derived from the word ‘Tvac’ which means ‘to cover something’. It is first line of defense which protects body in various ways. According to Ayurvedic classics, Twacha Rogas are produced by the imbalance of Tridoshas-Dhatus and Raktadushti. 

Visarpa is a disease that primarily affects the skin. This is so called because of the spreading nature of the disease like a snake. 

विविधं सर्पति यतो विसर्पस्तेन स स्मृतः। परिसर्पो/थवा नाम्ना सर्वतः परिसर्पणात्॥११॥ (CS.Ci.6)

This is often been compared to erysipelas and herpes due to similarity in presentation. Since erysipelas doesn’t have elevated blisters, this can be ruled out. But most of the types of visarpa mimic erysipelas. In few types of erysipelas we can find symptoms similar to herpes zoster. 

Causative Factors: 

Caraka in Visarpa cikitsadhyaya, clearly explains the causative factors that lead to the pathology. Excess intake of lavana, alma, katu and ushna dravya, food products like dadhyamla, mastu, shukta, sura, sauvira etc will vitiate the dosas. 

विषवाताग्निदोषाच्च विसर्पाणां समुद्भवः॥२१॥

एतैर्निदानैर्व्यामिश्रैः कुपिता मारुतादयः।

दूष्यान् सन्दूष्य रक्तादीन् विसर्पन्त्यहिताशिनाम्॥२२॥ (CS.Ci.6) 

By the indulgence in causative factors, the vatadi dosa get aggravated and further vitiate. The raktadi chats, thus causing Visarpa. 

Lakshana: This patient has been specifically identified as suffering from Pittaja Visarpam. The symptoms are 

तस्य रूपाणि- ज्वरस्तृष्णा मूर्च्चा मोहश्चर्दिररोचको/ग़्गभेदः स्वेदो/तिमात्रमन्तर्दाहः प्रलापः शिरोरुक् चक्षुषोराकुलत्वमस्वप्नमरतिर्भ्रमः शीतवातवारितर्शो/तिमात्रं हरितहारिद्रनेत्रमूत्रवर्चस्त्वं हरितहारिद्ररूपदर्शनं च, यस्मिंश्चावकासे विसर्पो/नुसर्पति सो/वकाशस्ताम्रहरितहारिद्रनीलकृष्णरक्तानां वर्णानामन्यतमं पुष्यति, सोत्सेधैश्चातिमात्रं दाहसम्भेदनपरीतैः स्फोटकैरुपचीयते तुल्यवर्णास्रावैश्चिरपाकैश्च, निदानोक्तानि चास्य नोपछेरते विपरीतानि चोपशेरत इति पित्तविसर्पः॥३२॥ (CS.Ci.6) 

The prominent symptoms are fever, thirst, giddiness, anorexia, body ache, burning sensation, headache etc. It is of a rapidly spreadably spreading nature. In this patient, the prominent symptoms were painful eruptions that were rapidly spreading. 

Types of Visarpa: 

स च सप्तविधो दोषैर्विञेयः सप्तधातुकः।पृथक् त्रयस्त्रिभिश्चैको विसर्पो द्वन्द्वजास्त्रयः॥१२॥

वातिकः पैत्तिकश्चैव कफजः सान्निपातिकः। चत्वार एते विसर्पा वक्ष्यन्ते द्वन्द्वजास्त्रयः॥१३॥

आग्नेयो वातपित्ताभ्यां ग्रन्थ्याख्यः कफवातजः। यस्तु कर्दमको घोरः स पित्तकफसम्भवः॥१४॥ (CS.Ci.6)

There are 7 types of Visarpa. The Era dosaja are 3 in number- vataja, pittaja and kaphaja. The Dvandvaja are 3 in number- Vatapitta, Vatakapha and Pittakapha. If the visarpa is caused by vitiated Vatapitta it is called as Agneya, Vatakapha is called as Granthi and Pittakapha is called as Karma Visarpa. The combination of all the vitiated tridosa causing visarpa is the sannipataja type. In this case report, the patient is a 44 year old female patient  who complained of reddish painful eruptions in face and body since 6 days. She had consulted an allopathic doctor and underwent standard of care. The  painful eruptions mostly increased and spread all over her face, while it subsided in the body. She felt intense pain and was advised to come for ayurvedic treatment. Based on the clinical evaluation, the treating physician has confirmed the diagnosis as Pittaja Visarpam. 

Sadhyasadhyata of Visarpa: Visarpa caused by single dosha i.e. vataja, pittaja and kaphaja types are curable.
Among the visarpa caused by two doshas, agni visarpa (vata-pitta) and kardama visarpa (pitta- kapha) can be cured if they are not associated with complications and if the disease has not acicted to the vital organs and tissues, blood vessels, ligaments, muscles and Tuids of the body provided they are promptly treated and treatment continued till the disease goes away. If these conditions are not treated properly they may kill the person just like the poison of a snake. Granthi Visarpa (vata-kapha) should be treated as soon as possible. Granthi visarpa shall not be treated if associated with complications.
Sannipataja Visarpa (caused by all three doshas) is not curable since it has spread over into all the tissues, has tendency to form and spread quickly and the treatment strategies are mutually antagonistic amongst the doshas. 

As this patient was diagnosed as an Ekadosa Pradhana visarpa- pittaja, it is sadhya.

Treatment: 

Caraka in Cikitsadhyaya of Visarpa that the treatments followed should be opposite properties of the vitiated pitta. General lines of treatment followed are:

• Principles of treating Visarpa:
  Visarpa vis-à-vis blisters (erysipelas, herpes, dermatitis herpetiformis etc) should be promptly attended by the below said measures –
  Langhana – fasting or lightening measures (to rectify metabolism, to digest ama or immature essence of digestion in circulation which is toxic to all cells)
  Rukshana – to remove excess and unnecessary Tuidity in the body
  Virechana – therapeutic purgation for expelling the morbid pitta and reduce the inTammatory process in the body
  Vamana – therapeutic emesis for expelling the vitiated kapha from the body and to reduce excess kleda or unwanted blockage of srotas in the body
  Lepa – application of medicinal pastes to hasten re recovery process and to heal the lesions (blisters)
  Seka – stream pouring or sprinkling of medicinal fluids over the blisters to heal them Raktamokshana – bloodletting to remove the contaminated blood, also heals infections Avidahi ahara – non-corrosive foods
• The Physicians also assess the Sthana and the Avastha of the dosa involved and then the treatment protocols are planned. 

Rationale of treatment as explained by the Physician: The specific reason for choosing the medicine and therapy has been tabulated and presented. 

Table 1. The medicine and the rationale for the choice

Reference

1. https://www.easyayurveda.com/2016/10/30/visarpa-causes-types-treatment-medicines/
2. Singh et al. AYURVEDA AND MODERN PERSPECTIVE ON VISARPA AND ITS MANAGEMENT THROUGH CLASSICAL APPROACHES. wjpmr, 2020,6(12), 136-138. 

OUTCOME MEASURES

The 44 year old female patient complained of reddish painful eruptions in face and body since 6 days. She first consulted an allopathic doctor and underwent standard of care. The  painful eruptions mostly increased and spread all over her face, while it subsided in the body. She felt intense pain and was advised to come for ayurvedic treatment.

Assessment: Subjective and objective parameters were assessed to analyse the outcome of the treatment.

Subjective parameters: With 2 weeks of Ayurvedic treatment, the patient noticed significant relief in symptoms. After 1 month of treatment, the lesions completely healed and the patient attained normal skin tone.  

Objective parameters: A culture and sensitivity test was done after 13 days indicated that there was no microbial manifestation. 

Image 1. Image taken of the patient after treatment dated 16.3.2023. 

Image 2. Blood culture and sensitivity test done during treatment dated 23.2.2023