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  Table of Contents  
CASE STUDY
Year : 2017  |  Volume : 38  |  Issue : 1  |  Page : 62-65  

Antiphospholipid antibody syndrome - A case report


1 Department of Kayachikitsa, PG Studies and Research Center, Kleu's Shri B M K Ayurveda Mahavidyalaya, Belgaum, India
2 Shri Dhanvantari Ayurveda College Hospital and Research Centre, Uttara Kannada, Karnataka, India

Date of Web Publication20-Apr-2018

Correspondence Address:
Dr. Sameer N Naik
Department of Kayachikitsa, Kleu's Shri B M K Ayurveda Mahavidyalaya, Shahapur, Belgaum - 590 003, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ayu.AYU_57_16

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   Abstract 


Anti-phospholipid antibody (APLA) syndrome is defined by the presence of thrombo-embolic complications and pregnancy morbidity in the presence of persistently increased titers of APLA syndrome. Its clinical presentation can be diverse and any organ can be involved with a current impact in the most surgical and medical specialties. Here, the case of a 34-year-old young lady with APLA syndrome presented with the cerebral venous thrombosis and subsequently deep vein thrombosis of the left leg veins. Three classes of APLAs (IgG, IgM and activated protein C) were elevated. There were no clinical or laboratory evidence for other autoimmune or systemic illnesses. The patient is under treatment of Ruksha Tikshna Virechana (purgation) with Haritaki (Terminalia chebula Retz.) and Goarka (extract of cow's urine) with the concept of Kaphaja Shotha (nonpitting edema) and got significant result in both subjective and objective parameters.

Keywords: Goarka, Haritaki, Ruksha Virechana, thromboembolism


How to cite this article:
Naik SN, Raghavendra Y. Antiphospholipid antibody syndrome - A case report. AYU 2017;38:62-5

How to cite this URL:
Naik SN, Raghavendra Y. Antiphospholipid antibody syndrome - A case report. AYU [serial online] 2017 [cited 2019 Sep 23];38:62-5. Available from: http://www.ayujournal.org/text.asp?2017/38/1/62/230784




   Introduction Top


Anti-phospholipid antibody (APLA) syndrome is complex diseases rarely seen in day-to-day practice. APLA is very diverse and can occur in a variety of clinical presentation. The authors therefore present the case of a 34-year-old female with multiple thrombotic events and the presence of APLAs, in the light of Ruksha Tikshna Virechana (purgation) with Haritaki (Terminalia chebula Retz.) and Goarka (extract of cow's urine), is one of the remedies to treat Kaphaja Shotha.


   Case Report Top


A 34-year-old female presented with pain in all major joints of both upper and lower limb of a 4-year history even after treating with non-steroidal anti-inflammatory drugs (NSAIDs) by a local doctor. Detailed history revealed that on July 15, 2012, she was admitted to the nephrology department for the chief complaints of bilateral pedal edema, peri-orbital edema (since 3 months), mild breathlessness, and sore throat (since 3 days) presented with 3.5 mg/dl serum creatinine, provisionally diagnosed as a case of acute renal failure (ARF) secondary to NSAID and treated symptomatically. Laboratory reports also showed hypoalbuminemia with proteinuria which leads to suspect lupus nephropathy and was treated with ciprofloxacin and salt and fluid restriction. During treatment, she developed severe headache and magnetic resonance (MR) imaging-brain revealed right frontal hemorrhagic infarction suggestive of venous infarction.

The patient had repeated epileptic attacks for three times, and the laboratory reports showed leukocytosis at 14,000 predominantly with eosinophilia, i.e., 22.9%. Laboratory test done on August 28, 2012, showed anticardiolipin (aCL) antibody (antiphospholipid)-IgG positive and aCL antibody (antiphospholipid)-IgM negative, but the same test was repeated on September 24, 2012, as the test should be repeated to confirm diagnosis as aCL antibodies: aCL IgG or IgM antibodies present at moderate or high levels in the blood on two or more occasions at least 6 weeks apart [1] [Table 1]. At the same time, other tests such as factor V Leiden mutation analysis – not detected, anti-thrombin III activity in plasma was 118.00 (80%–120%); near to upper limit. Activated protein C (APC) resistance test was positive; lupus anticoagulant was absent. An MR venogram of the head and neck demonstrated filling defect in the internal jugular vein, sigmoid sinus, and transverse sinus on the left side suggestive of thrombosis. Above-explained laboratory parameters confirmed the diagnosis as APLA syndrome. She was advised to continue tablet warfarin and tablet eptoin in the prescribed dose.
Table 1: Hematological findings before, during, and after the treatment

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With this history, on December 25, 2012, she consulted Kayachikitsa outpatient department, with a chief complaint of the left leg severe pain with edema, unable to sit either on a chair or on ground and pain in joints of both extremities, she was advised for admission. On January 1, 2013, she was admitted to the hospital under Kayachikitsa Department. A color Doppler of the left leg showed the presence of deep vein thrombosis.

Vyadhi Vinischaya (diagnosis): Kaphaja Shotha[2] (nonpitting edema).

Chikitsa Upakaramas: In Kaphaja Shotha, Kshara-Katu-Ushna Yukth Dravya such as Gomutra, Takra, Asava[3]and Haritaki uses with Gomutra[4] are indicated.

Treatment given

Ruksha Tikshna Virechana w ith Haritaki Choorna 20 g + Goarka 30 ml with Ushnajala as Anupana [Table 2] and Sthanika Chikitsa with Valuka Sweda and Erandmoola Kashaya Pareesheka to painful joints were given during the course of admission. During menstruation, the treatment was discontinued.
Table 2: Course and duration of Nitya Tikshna Virechana during admission up to the reduction of Shotha (swelling)

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   Results Top


Data based on clinical presentation were collected before, during and after treatment and are presented in the tabular form.

Subjective parameters

Buerger's test are the subjective parameters [Table 3] and pain in multiple joint, stiffness in multiple joints, tenderness in multiple joints, swelling [Table 4] and [Figure 1], [Figure 2], deformity in multiple joints, seizures episodes, Homan's sign, Moses sign and peripheral pulses.
Table 3: Subjective parameters before, during, and after the treatment

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Table 4: Measurement of both upper and lower limbs in centimeters

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Figure 1: Color Doppler of left lower limb on June 24, 2013 (during treatment)

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Figure 2: Color Doppler of left lower limb on July 23, 2014 (after treatment)

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Objective parameters

(i) Hematological investigations [Table 1] such as cardiolipin antibody-IgG, cardiolipin antibody-IgM, APC, homocysteine, antinuclear antibody, erythrocyte sedimentation rate; (ii) prothrombin time international normalized ratio (PT-INR) periodical monitoring [Table 5]; and (iii) radiological findings that are color doppler evaluation of the left lower limb vessels [Table 6] and [Figure 3], [Figure 4], [Figure 5] are the objective parameters.
Table 5: Monthly monitoring of prothrombin time-international normalized ratio (confirmed by coagulometer)

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Table 6: Radiological findings: Color Doppler evaluation of left lower limb vessels

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Figure 3: Edema of lower limb before the treatment

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Figure 4: Edema of lower limb after the treatment

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Figure 5: Color Doppler of left lower limb on February 26, 2013 (before treatment)

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   Discussion Top


Antiphospholipid antibody syndrome

The term APLA syndrome denotes the clinical association between APLAs and a syndrome of hypercoagulability.[5],[6] It is an autoimmune disease characterized by the presence of thromboembolic complications and pregnancy morbidity in the presence of persistently increased titers of APLAs.[7] The most commonly detected subgroups of APLAs are lupus anticoagulant, aCL, and anti-beta-2-glycoprotein 1 antibodies. Lupus anticoagulant antibodies are associated with thromboembolic events rather than clinical bleeding. APLAs can interfere with both pro- and anti-coagulant pathways

Probable mode of action

Gomutra Haritaki Nitya Tikshna Virechana might have acted to prevent further thrombosis along with recanalization of thrombosed veins without any thromboembolism [Figure 3]. Studies have showed that Gomutra[8] and Haritaki[9] as immune modulatory in action by which we can assume that the other associated symptoms might have reduced.

Anticipated action

In this patient based on subjective and objective findings, it was observed that, near complete recanalization of completely thrombosed veins without the history of thromboembolism. Antithrombotic activities of Haritaki and Goarka are not yet proven; further studies are needed to find the efficacy of Goarka-Haritaki in resolving, preventing further thrombus formation and recanalization of thrombosed vein without a history of any embolism.

Future treatment planning

Treatment will be continued by monitoring PT-INR every month and are planning to conduct MR venogram to rule out the presence of thrombus.


   Conclusion Top


Though APS is an autoimmune condition with limited treatment options, if properly treated as per the basic principles of Ayurveda under the light of Shotha Chikitsa promising results can be obtained which gives a hope for its further approach without any adverse effects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Pierangeli SS, Colden-Stanfield M, Liu X, Barker JH, Anderson GL, Harris EN, et al. Antiphospholipid antibodies from antiphospholipid syndrome patients activate endothelial cells in vitro and in vivo. Circulation 1999;99:1997-2002.  Back to cited text no. 1
    
2.
Aacharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Reprint edition. Ch. 12, Ver. 14. Varanasi: Chaukhamba Sanskrit Sansthan; 2009. p. 484.  Back to cited text no. 2
    
3.
Aacharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Reprint edition. Ch. 12, Ver. 19. Varanasi: Chaukhamba Sanskrit Sansthan; 2009. p. 484.  Back to cited text no. 3
    
4.
Aacharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana. Reprint edition. Ch. 12, Ver. 21-22. Varanasi: Chaukhamba Sanskrit Sansthan; 2009. p. 484.  Back to cited text no. 4
    
5.
Levine JS, Branch DW, Rauch J. The antiphospholipid syndrome. N Engl J Med 2002;346:752-63.  Back to cited text no. 5
    
6.
Hughes GR, Harris NN, Gharavi AE. The anticardiolipin syndrome. J Rheumatol 1986;13:486-9.  Back to cited text no. 6
    
7.
Devreese K, Peerlinck K, Hoylaerts MF. Thrombotic risk assessment in the antiphospholipid syndrome requires more than the quantification of lupus anticoagulants. Blood 2010;115:870-8.  Back to cited text no. 7
    
8.
Gosavi DD, Sachdev D, Salwe K. Immunomodulatory and antioxidant effect of Gomutra ark in rats. J MGIMS 2011;16:37-41.  Back to cited text no. 8
    
9.
Gupta, Bhadohi SRN. Biological and pharmacological properties of Terminalia chebula retz. (haritaki)- an overview. Int J Pharm Pharm Sci 2012;Vol 4, Suppl 3;62-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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