From the case diary
Behçet's disease
Dr. S.Gopakumar MD (Ay)
MD – Roganidana, MD – Kayachikitsa
Associate Professor
Dept of Roganidana
Govt Ayurveda College, Pariyaram, Kannur.
Immunity is considered as a double edged sword by the pathologists of current medical generation. There are so many examples for this consideration and one among them is Behcet disease. Behçet disease (Behçet's syndrome) is a chronic condition due to disturbances in the body’s immune system. Immune system, which normally protects the body against infections through controlled inflammation, becomes overactive and produces unpredictable outbreaks of exaggerated inflammation. This extra inflammation affects blood vessels, usually the small ones. As a result, symptoms occur wherever there is a patch of inflammation, and can be anywhere where there is a blood supply. The features….
There are three levels of certainty for diagnosis:
- International Study Group diagnostic guidelines (very strict for research purposes)
- Practical clinical diagnosis (generally agreed pattern but not as strict)
- 'Suspected' or 'Possible' diagnosis (incomplete pattern of symptoms)
There is no specific pathological test for Behçet disease at present. It is diagnosed clinically by specific patterns of symptoms and repeated outbreaks. Other causes for these symptoms have to be ruled out before making the diagnosis. The symptoms do not have to occur together, but can have happened at any time.
1. International Study Group diagnostic guidelines
Patients should have -
- oral (aphthous) ulcers (any shape, size or number at least 3 times in any 12 months), along with 2 out of the following 4 "hallmark" symptoms:
- genital ulcers (including anal ulcers and spots in the genital region and swollen testicles or epididymitis in men),
- skin lesions (papulo-pustules, folliculitis, erythema nodosum, acne in post-adolescents not on corticosteroids),
- eye inflammation (iritis, uveitis, retinal vasculitis, cells in the vitreous),
- pathergy reaction (papule >2 mm dia. 24-48 hrs or more after needle-prick).
2. Practical clinical diagnosis Patients must have -
along with 1 of the 4 hallmark symptoms above and with 2 of the symptoms below:
- arthritis/arthralgia,
- nervous system symptoms,
- stomach and/or bowel inflammation,
- deep vein thrombosis,
- superficial thrombophlebitis,
- cardio-vascular problems of inflammatory origin,
- inflammatory problems in chest and lungs,
- problems with hearing and/or balance,
- extreme exhaustion,
- changes of personality, psychoses,
- any other members of the family with a diagnosis of Behçet disease.
3. 'Suspected' or 'Possible' diagnosis Usually given when someone does not have mouth ulcers or has mouth ulcers but does not have 1 of the 4 hallmark symptoms but has other symptoms and signs of inflammation and other causes for these have been ruled out.
Treatment
Current treatment is aimed at easing the symptoms, reducing inflammation, and controlling the immune system.
A Case of Behchet’s disease
The author got a chance to treat a patient with Behcet’s disease recently. The patient was an Italian priest of the age 50 with moderate obesity The disease was diagnosed quite earlier and he had undergone modern medical treatment for a good period. He presented with the complaints of multiple oral ulcers. There were significant skin lesions as maculo – papular rashes especially in the lower limbs and back. Arthritis of the joints of the lower limbs was also associated.The past history revealed folliculitis and genital ulceres. Apart from the Behcht’s disease,the patient was a known diabetic for the last 10 years.
After analyzing the medical reports the following tretment strategy was adopted. Since the basic nature of the disease was over activity of immune system, the concept of Athyagni at Dhathu level was explorred further. Since the major clinical features were of a Pitha- Raktha origin at different dhathu levels, the over activity of the Dhathwagni was suspected. The skin lesions,oral ulcers and inflammed joints were considerd as the clinical reflections of dhathwagni.An initial sodhana with Avipathi choorna was done targeting the pitha samana,Rakthaprasadana and Vathanulomana. Snehapana as vicharana was given with Mahathikthaka ghritha after creating good agnideepthi in koshta.But the patient was doubtful against the effects of ghee,as he was moderately obese. Hence after three days the ghritha was stopped and switched over to Mahathikthakam Kashaya. Thriphala choorna was administered along with same ghritha at bed time. Mahathikthakam kashaya was welected because of its good effects on pitha spectrum of inflammatory conditions. Thriphala choorna was selected due to its action in skin, ulcers and eye. Moreover being a drug with Rasayana property Thriphala, can check the immune related pathological events. Seka with Ksheerivriksha twak kwadha was also administerd in the local ulcers. For kabala, Thriphala kashaya was the option. Chandraprabha gulika was also given as he was diabetic. The patient was asked to continue his usual modern medicines for diabetes.
After three weeks of treatment, the patient reported that he is not developing any fresh skin papules as it was not the case earlier. Oral ulcers started healing and the patient reported good digestive functions. The arthritic complaints didn’t get much relief as the main focus was given to the over active pitha dosha.In the second phase, external application with Nalpamaradi kera was suggested. The target was the minor arteries and reccurent skin inflammations.Since the patient was ready to take ghritha by this time Mahathikthaka ghritha was started internally as vicharana. Patient was asked to consume fruits like dadima, amalaki and avoid spicy fast foods and alcohol. After this course of treatment, one more virechana was administered. The benefits were significant and now he is receiving the treatments for arthritis complaints.
The concept of Dhathugatha Athyagni is to be further explorred in treating such conditions. Rasayanas with Pithasamana will have more role to play in such clinical states. Sathavari,Gudoochi etc may be better choices in such over active immune responses.
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