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STILL’S DISEASE – CASE STUDY

Published by : Abhishitha K on:16-05-17 06:43 PM

ABSTRACT:



Still’s disease (AOSD) is a rare systemic inflammatory disease characterized by the classic triad of persistent high fever, joint pain and a distinct salmond coloured bumpy rash. Tests for RA factor and ANA are usually negative. But serum feritine is elevated.  A 29 year old  patient having polyarthralgia and occasional fever with a provisional diagnosis  of stills disease was successfully managed following the classical methods of Ayurveda at VPSV Ayurveda college hospital. Considering the symptoms, the group of diseases that arrives for a differential diagnosis are amavata and vatarakta . Unlike amavata the presentation was jwara pradhana with minimal ama features. Thus diagnosed as a case of vatharakta in uttana stage . Treatment principles were designed with a combination of ama pachana strategies in amavatha along with exclusive methods of vataraktha. Drugs of vataraktha pool were judiciously selected and administered in the patient considering stage of disease with assessment of dosha dushya kala etc. 



KEY WORDS:



Vatarakta, amapachana



INTRODUCTION:



Still’s disease accounts for 10-20% of all cases of JRA. It is rare in adults, a majority of whom are between 20 and 35 years of age at onset of symptoms. Of all patients with Still’s disease, 100% have high intermittent fever; 100% have joint inflammation and pain, muscle pain with fevers, and develop persistent chronic arthritis. Ninety-five percent (95%) have the faint salmon-colored skin rash. Eighty-five percent (85%) have swelling of the lymph glands or enlargement of the spleen and liver; and 85% have a marked increase in the white blood cell count. Adult Still’s disease is a rare type of inflammatory arthritis that is similar to rheumatoid arthritis. It shares characteristics of systemic-onset juvenile idiopathic arthritis, but it begins in adulthood. Inflammation may affect a few joints at first, but may advance to include more joints over time. Some people may have only one bout of the illness followed by lasting remission, while others may develop chronic arthritis .Symptoms usually begin with a high fever that spikes once or twice a day and a salmon-pink rash on the trunk, arms or legs. Other symptoms include sore throat and swollen lymph nodes in the neck. A few weeks after these initial symptoms, joints and muscles begin aching. These aches last at least two weeks. The most commonly affected joints are the knee and wrist. The ankles, shoulders, elbows and finger joints may also be involved .Diagnosis is based on review of symptoms and medical history, such as the appearance of the rash and recent fevers of unexplained origin. There is no single test that can diagnose adult Still’s disease. Instead, blood tests are performed to rule out other conditions with similar symptoms. Other tests, such as X-rays, may be done to check for damage caused by inflammation. Patients in the early acute stage of adult Still’s disease are given non -steroidal anti-inflammatory drugs (NSAIDs), such as naproxen or ibuprofen, and corticosteroids to reduce pain and inflammation. Immunosuppressive drugs, such as methotrexate and biologic response modifiers, may be needed in more severe cases or if the arthritis becomes chronic.Still’s disease is named after the English physician Sir George F. Still (1861-1941). Patients with Still’s disease usually present with systemic (body wide) symptoms. A direct reference to stills may not be available while the symptoms these may be correlated as either amavata or vatarakta and treated accordingly.



CASE PRESENTATION:



A moderately built 29 year old male patient (non-alcoholic & non-smoker) consulted at college hospital in 2014 with presentation of severe  pain and burning sensation of joints esp.  knee joint ( R > L ) ,elbow joint ( B/L) pain, along with occasional sore throat and fever  since 6 months. Upon interrogation it was found that patient used to work at the baking section of bakery. 10 years before he had a presentation with sudden rise of temperature associated with headache and multiple joint pain. Fever subsided within 2 days, however knee joint pain persisted (right >left), which was later managed by Allopathic followed by Ayurvedic medication. Patient got considerable relief. The symptoms did not recur till  6 months before where he had a similar presentation as before with intermittent fever, occasional sore throat and poly-arthralgia associated with morning stiffness which persisted for following 6 months.  Reddish small papules were also noticed over anterior aspect of chest. He was taken to govt. medical college Calicut and was thoroughly evaluated. ANA report was found negative. USG abdomen showed fatty hepatomegaly with ESR repeatedly less than 10. Later proceeded with FNAC lymph nodes (posterior cervical), suggestive of reactive hyperplasia lymph node. Other parameters were within normal limits. Rectal examination revealed Grade 1 hemorrhoids.



In view of fever >3 weeks, sore throat with poly arthralgia, minimal elevation of transaminase, negative ANA and RA factor, posterior cervical lymphadenopathy- diagnosis of Still’s disease was kept as provisional diagnosis and given medication. However patient did not get considerable relief.



Meanwhile he consulted at college hospital. By then he had severe burning sensation over joints affected. Stretching pain was also experienced over calf region.



While analyzing his personal history, it was noted that the patient had a good appetite, normal bowel and micturition. His sleep  occassionally disturbed. Systemic examinations revealed restricted range of motion of right knee joint along with mild warmth and grade 1 tenderness. After carefull assessment  he was initially given internal medications and later admitted at college hospital.









































DATE



MEDICINE



DOSE



CONDITION OF PATIENT



02/05/2014



Amruthotharam kashayam


Simhanada guggulu


Trivrit lehyam


Cap Arthrotex


 



60ml Bd


1 Bd


1 Tsp Hs


1 Bd



Fever subsided



25/05/2014



Rasnerandadi kashayam


Kaisora guggulu


Tab Arthretforte



60ml Bd


2 Bd


1 Bd



Pain reduced


Patient comfortable



01/06/2014



Indukantham kashayam


Migrakot Tab


Exitox Tab


 



60ml Bd


1 Bd


1 Bd



Pain reduced considerably


Burning sensation persisted


 


 



05/06/2014



Mahamanjishtadi kashayam


Kaisora guggulu


Bonton


 



60mlBd


2 Bd


1 Bd



Burning sensation reduced



15/06/2016



Mahamanjishtadi kashayam


Kaisora guggulu


Bonton


Cap Legrain


 



60mlBD


2 BD


1 BD


1 BD



Burning sensation reduced




 



Amruthothara kashaya  60 ml bd was the initial drug of choice which has guduchi as its main ingredient which has been mentioned as agrya aushada in vatarakta treatment.  Amapachana and agni deepana were the main targets. simhanada guggulu being specifically indicated in condition of ama associated with sandi shoola were also given in a dose of 1 tablet bd. In order to manage the skin rashes trivret lehyam I tsp hs also adviced. Patient started responding to medication. Fever subsided while burning sensation and pain persisted .Later considering resolved ama stage rasnerandadi kashaya was administered 60 ml bd. Main ingredients being rasna errand vari sahachara etc with specific vata nashaKa , shophagna property.  kaissora guggulu ( 1-0-1) having a raktha prasadana property was also administered. It is also specifically indicated in tridoshaja vataraktha agnimadya etc. With an immunomodulating intention these were followed by Indukantha kashaya 60 ml bd. Further follow up was done with mahamanjistadi kashaya 60 ml bd , kaissora guggulu (1-0-1) and bonton (1-0-1)



 



Patient was admitted for a period of 47 days and rendered following treatments as summarised.



Date of admission : 02/07/2014



Date of discharge : 18/08/2014



 

































































S.NO.



   PROCEDURE



DRUG USED



NO. OF DAYS



1.



VIRECHANA



AVIPATHY CHOORNA IN DRAKSHA SWARASA(200ml)



1



2.



SIRAVEDHA



 



1



3.



ABHYANGA



PINDATHAILA



6



4.



PATHRAPOTALA SWEDA



ERANDA,DATURA,NIRGUNDI,VASA,


ARKA PATHRA,SHIGRU



7



5.



VIRECANA



AVIPATHY CHURNA (25 GM)IN DRAKSHA SWARASA



1



6.



PIZHINJUTHADAVAL



PINDA THAILAM



7



7.



KSHEERAVASTHI



 



2



8.



UPANAHA



 



7


 



9.



SHASHTIKAPINDA SWEDA



 



7




Having pittotara vatarakta presentation , virechana ,the best method of treatment was adopted. It is claimed pittasya sarpishaha panam swadu sheethahi virechanam….. avipathi was administered along with draksha swarasa.



Considering purely vatarakta line of treatment siraveda was employed as it is best for vata dosha pervading whole body. Prior employing a mild shodana,  snehana is necessary thus following 7 days abhyanga was done with pinda thaila. pinda thaila being pittahara sparsha sheetha and vataraktha rujapaha .Following Pathrapotala sweda was employed for following 7 days. 14 days of sweda brought out considerable relief in pain and aching type presentation. Again mrdu shodana was employed in form of virechana with  avipathi choorna in draksha swarasa. . Burning sensation reduced markedly ,Patient became more comfortable In order to further bring about control over aggravated pitta and vata dosha pinzhinju thadaval was employed with pinda thaila. It being a kind of drava sweda is best for alleviating pitta.



Patient had good response to the treatments rendered. Acharya vagbata has mention vasthi,one among the panchakarma procedures, as the best treatment methodology in vataraktha management. It is indicated when there is strong aggravation of vata dosha as well as vitiation of rakta dhatu. As it bypasses the portal circulation has got excellent action in gut.



After the vasthi procedure patient became more comfortable , pain appeared concentrated localy in the knee joints while burning senstionbecame almost nil. Thus upanaha was adviced over the region . Considering the ojokshaya , in order to bring about mild nourishment mild sweda was employed as shashtika pinda sweda.



 



Follow up after discharge;





































DATE



MEDICINE



DOSE



CONDITION OF PATIENT



07/09/2014



Kokilaksham kashayam +


Amruthotharam kashayam


Tab Exitox


Cap Guduchi


 



60ml BD


 


1 BD


1 BD



Rashes over trunk faded



31/03/2015



Mahamanjishtadi kashayam


Kaisoraguggulu


Cap Guduchi


Shashtika tailam



60ml BD


2 BD


1 BD


E/A


 



Rashes over trunk almost became nil.



03/05/2015



Patolakadurohinyadi kashayam


Avipathi churnam


 


Mahamanjishtadi kashayam


Cap Guduchi


 



60ml BD


 


1 Tsp with honey HS


60ml BD


1 BD



Pain persisted around right knee joint



10/05/2015



Vasaguluchyadi kashayam


Mahamanjishtadi kashayam


Pravala bhasmam


Trivrit lehyam


 



60ml BD


60ml BD


1 Tsp BD


1 Tsp HS



Pain in knee joint (R) reduced mild



17/05/2015



Mahamanjishtadi kashayam


KAisora guggulu


Cap Guduchi


 

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