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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 133-137

Ayurvedic management of non-healing ulcer caused by viper bite: A case report


Department of Agadatantra, SDM College of Ayurveda, Hassan, Karnataka, India

Date of Submission26-Sep-2020
Date of Acceptance10-Feb-2021
Date of Web Publication18-Mar-2021

Correspondence Address:
Dr. Nataraj Ramegowda Hanchinamane
Department of Agadatantra, SDM College of Ayurveda, Hassan - 573 201, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_75_20

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  Abstract 


The development of non-healing ulcers following viper snakebite is very common in victims who survive the bite, and severity of symptoms depends on the venom's potency. Swelling of the bitten part and spreading cellulitis are the common manifestations. In the event of recovery, surviving victims may develop necrosis of the skin, muscles, tendons, and even bones. Various secondary infections leading to suppuration and gangrene may necessitate amputation to avoid further complications. It becomes obligatory to take proper care of local suppurative lesions infected secondarily by a variety of bacteria. A 38-year-old male farmer reported to the outpatient department with complaints of nonhealing ulcer on dorsum of the right foot since three months associated with swelling around the ulcer up to knee, pain, with burning sensation, and discoloration around the ulcer. Initially, ulcer was treated with conventional protocol by local hospital; however, the ulcer was not healed even after three months. Thus, victim visited Ayurveda hospital for further management. Ulcer was managed using Ayurvedic principles including local treatments namely paste made up of Dhattura (Datura metel Linn.) and Nimba (Azadirachta indica Linn), Parantyadi taila pichu and oral administration of Bilavdi agada, Maha manjishtadi kashaya, and Gandhaka rasayana. This treatment protocol has shown significant results with complete healing of ulcer in three months.

Keywords: Dhattura, Nimba, non-healing ulcer, viper bite


How to cite this article:
Hanchinamane NR. Ayurvedic management of non-healing ulcer caused by viper bite: A case report. J Ayurveda Case Rep 2020;3:133-7

How to cite this URL:
Hanchinamane NR. Ayurvedic management of non-healing ulcer caused by viper bite: A case report. J Ayurveda Case Rep [serial online] 2020 [cited 2021 Oct 25];3:133-7. Available from: http://www.ayucare.org/text.asp?2020/3/4/133/311506




  Introduction Top


Snakebite is a life-threatening emergency that poses a major concern in tropical and subtropical countries. About five million snake bites occur each year and resulting 81,000–138,000 deaths annually worldwide.[1] Snakebite causes both local and systemic effects. Among the five families of snakes, Viperidae, Crotalidae, and Colubridae bites primarily cause local complications like bleeding.[2] Local envenoming of snake bites produces soft-tissue problems namely pain, edema, ecchymosis, blisters, and cellulitis. Snake venom has proteolytic properties those results in extensive tissue necrosis. Viper venom has platelet aggregating activity and also thrombin like effect which produces thrombocytopenia and hypofibrinogenemia.[3] As a result, they cause local venous vasculopathy causing swelling, blisters and necrosis. Literature shows that there is 2%–3% chance of necrosis with viper venom.[4] The blisters rupture and along with tissue necrosis acts as a source for bacterial colonization. The oral flora of the snake also contains multiple microorganisms which again act as a source for secondary bacterial infection.[5]

In general, ulcers are managed by using infection control methods, ulcer healing, surgical repair, fasciotomy, and amputation but these modalities have got the limitations and also results in few complications. This necessitates for better methods of ulcer management using Ayurvedic principles in specifically through the principles of Ayurveda. The practice of Agada tantra a branch of Ayurveda exclusively focuses on the management of such conditions.

The management of Mandali sarpa visha (~viper bite) with its complications has been mentioned in Ayurveda that includes modalities such as Pariseka (~irrigation), Avagaha (~immersion), and Lepa (~application of medicated paste).[6]

Classics mentioned Dirgha kala anubandhativam (~chronic in nature) to indicate chronic ulcers (~Dusta vrana).[7] It's a type of Vrana with vitiated Tridoshas that is difficult to heal due to the presence of Srava (~discharge), Putipuyamamsa (~slough with pus), Vedana (~pain), etc., The signs and symptoms of Dusta vrana are mentioned in the classics are Ativivrita (~broad base), Bhairava (~ugly look), Gandha (~offensive odor), Putipuya mamsa, Vedana, and Dirgha kala anubhandi. Such manifestations are Kricchrasadhya (~difficult to treat).[8]

Acharya sushruta has mentioned Sapta upakrama (~seven therapeutic procedures) to manage Dusta vrana and to achieve complete healing without further complications.[9] These procedures are purposefully described for debridement of necrotic tissue, maintenance of favorable moist ulcer environment that can facilitate healing and addressing to host tissues to retain nutritional, metabolic, and circulatory status.


  Case Report Top


A 38-year-old male farmer reported to the outpatient department with complaints of old nonhealing ulcer on dorsum of the right foot since three months associated with swelling around the ulcer up to knee, pain, with burning sensation, and discoloration around the ulcer. History revealed an incident of snakebite three months back, while he was working in the field during evening hours. He suffered with bleeding, burning sensation, and pain at the site of bite. Then he was taken to a local traditional folklore practitioner who is known for treating such cases, where he was administered Anjana (~collyrium) preparation applied over conjunctiva and some herbal paste over site of bite and he was sent back to home. However, symptoms were not reduced till evening, and swelling increased considerably so he got admitted to Community Health Center (CHC) near to his locality where his case was confirmed as viper bite manifestation, and treatment was given. He was not sure whether anti snake venom was administered or not (treatment history documents were not available with the victim). He was discharged from CHC after four days however swelling and pain were persisting. To manage this, he visited folklore practitioner and was treated with local herbal paste application and oral medications for about 45 days, but swelling and pain persisted. Again he got admitted to government allopathic hospital. Further, he was given an incision at site of bite and treated with analgesics, antibiotic medications with intravenous fluids for a week and later he was discharged from the hospital.

After discharge from the hospital, he was given ulcer dressing and symptomatic treatment such as analgesics and antibiotics by local doctor for 30 days but there was no sign of healing, with no significant reduction in the size of ulcer. Hence, he was referred to Ayurveda hospital by treating doctor for further management. After the informed consent, he was admitted to Agada tantra ward for further management.

General examination of the victim revealed that he was moderately built, with 69 kg of weight. No lymphadenopathy observed and all other vitals were with in normal limits. Local examination revealed a firm ulcer of 10 cm × 4 cm in size over dorsum of the right foot [Figure 1], with swelling around the ulcer and serosanguineous discharge. Signs of inflammation with increased temperature around the ulcer, decreased pain perception, irregular edges emitting offensive odor, and the floor were covered with slough. Routine blood investigation revealed increased erythrocyte sedimentation rate (34 mm) and increased fasting blood sugar (285 mg/dl). Other hematological parameters were with in normal range.
Figure 1: Ulcer before the treatment at the time of admission

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Based on the history, signs and symptoms, and local examination case was diagnosed as Visha janya dusta vrana (~nonhealing ulcer due to poisonous bite). He was advised for admission and treatment protocol was planned based on principles of Vishahara chikitsa (~anti-poison treatment), Vrana shodhana and Ropana (~ulcer cleaning and Healing), Agada prayoga (~antidotes) to promote ulcer healing, and appropriate Prameha hara chikitsa (~anti-hyperglycemic treatment) to reduce the raised blood glucose levels.


  Timeline Top


After the informed consent treatment was initiated from the first-day admission (July 10, 2018). Further treatment was carried out in three schedules. The total duration of the treatment was 90 days. During treatment lemon juice, Pachavalkala kashaya, Aragvadadi kashaya were used for cleaning the ulcer [Figure 2]. Paste made up leaves of Dhattura and Nimba, and Parantyadi taila was used for lepa [Figure 3]. Bilavdi agada, Gandhaka rasayana, and Mahmanjishtadi kashaya were advised orally in different schedules of treatment.
Figure 2: Ulcer after debridement and lemon juice wash

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Figure 3: Application of Dhattura leaf paste on day one

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  Follow Up and Outcome Top


On observing the healing phase of ulcer, the patient was discharged from the hospital after 21 days of hospital care. Good amount of granulation tissue was observed, swelling and pain were significantly reduced. During the first follow-up, half of the ulcer area was covered with almost no swelling around the lesion and reduced pain. During the second follow-up, at the completion of 90 days of treatment, ulcer was completely covered leaving behind the scar over the affected part. Skin color around the area also attained normal skin color with complete reduction in edema and pain [Figure 4],[Figure 5],[Figure 6].
Figure 4: After 7 days of treatment

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Figure 5: After 60 days of treatment

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Figure 6: After 90 days of treatment

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  Discussion Top


The use of Lemon juice for cleaning is widely practiced by traditional snake bite healers. Citric acid has antiseptic property. It also helps in enhancing epithelialization, which further promotes healing. Its synergistic antioxidant property also prevents free radical damage and may stabilize lysosomal enzymes needed for collagen synthesis. These results indicate that citric acid present in the juice is highly effective in control of infecting organism, which is paramount to the success of healing.[10]

The use of paste made from leaves of Dhatura and Nimba along with Parantyadi taila (~a medicated oil) is advised in Visha jyotsinika for the management of Visha janya dusta vrana,[11] and Bilvadi agada (~antidote prepared using Aegle marmelos L.) said to be best anti-toxic drug which can be used in many poisonous conditions including snake bites.[12] Aragvadadi kashaya and Panchavalkala Kashaya have been mentioned in the context of management of Dusta vrana,[13] which is also reported to have antimicrobial properties.[14] Thus, combination of all these formulations might have helped in the management by promoting healing and reducing local as well as systemic symptoms.

Chiravilvadi kashayam and Mahamanjishtadi kashayam were helped to control the increased blood glucose levels by increasing the Agni (~metabolism). Mahamanjishtadi kashayam also helped in wound healing due to its Rakta shodhana (~blood purifying), Varna prasadana (~imparting color) properties. By the end of 90 days, complete wound healing was observed with the prescribed Ayurveda regimen [Figure 7]. After wound healing, there was minimum scar formation. No adverse effect was noticed during the treatment.
Figure 7: Timeline of interventions

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  Conclusion Top


Ulcer was completely healed in three months of treatment using the Ayurveda treatment protocol. This case study suggests that proper application of ayurvedic principles along with a selection of suitable drug combination can give encouraging results in the management of post viper bite ulcers thus preventing further complications like amputation.

Limitation

Swab culture was not taken from the ulcer which would have helped to understand the organism involved and to evaluate the possible antimicrobial effect of the medicines used in the study.

Declaration of the patient consent

Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO Neglected Tropical Diseases/Snakebites; Snakebite Envenoming – A Strategy for Prevention and Control. WHO Document Production Services; Switzerland. Available from: https://apps.who.int/iris/bitstream/handle/10665/324838/9789241515641-eng.pdf?ua=1/. [Last accessed on 2021 Feb 10 at 11:58].  Back to cited text no. 1
    
2.
Nelson BK. Snake envenomation incidence, clinical presentation and management. Med Toxicol Adverse Drug Exp 1989;4:17-31.  Back to cited text no. 2
    
3.
Rojnuckarin P, Mahasandana S, Intragumthornchai T, Sutcharitchan P, Swasdikul D. Prognostic factors of green pit viper bites. Am J Trop Med Hyg 1998;58:22-5.  Back to cited text no. 3
    
4.
Nagoba BS, Deshmukh SR, Wadher BJ, Mahabaleshwar L, Gandhi RC, Kulkarni PB, et al. Treatment of superficial pseudomonal infections with citric acid: An effective and economical approach. J Hosp Infect 1998;40:155-7.  Back to cited text no. 4
    
5.
Dehghani R, Sharif MR, Moniri R, Sharif A, Kashani HH. The identification of bacterial flora in oral cavity of snakes. Comp Clin Pathol 2016;25:279-83.  Back to cited text no. 5
    
6.
Murthy SK, editor. Ashtanga Hridayam of Vagbhata, English Translation. Ch. 36, Ver. 61-65. Varanasi: Chukhambha Publisher's Academy; 2009. p. 335.  Back to cited text no. 6
    
7.
Acharya YT, editor. Commentary Nibandha Sangrha of Dalhancharya on Sushruta Samhita of Sushruta, Sutra Sthana. Ch. 22, Ver. 7. Varanasi: Chaukhamba Surbharati Prakashan; 2014. p. 108.  Back to cited text no. 7
    
8.
Acharya YT, editor. Commentary Nibandha Sangrha of Dalhancharya on Sushruta Samhita of Sushruta, Sutra Sthana. Ch. 22, Ver. 6. Varanasi: Chaukhamba Surbharati Prakashan; 2014. p. 108.  Back to cited text no. 8
    
9.
Acharya YT, editor. Commentary Nibandha Sangrha of Dalhancharya on Sushruta Samhita of Sushruta, Chikitsa Sthana. Ch. 1, Ver. 9. Varanasi: Chaukhamba Surbharati Prakashan; 2014. p. 398.  Back to cited text no. 9
    
10.
Nagoba B, Patil Dawale C, Raju R, Wadher B, Chidrawar S, Selkar S, et al. Citric acid treatment of post operative wound infections in HIV/AIDS patients. J Tissue Viability 2014;23:24-8.  Back to cited text no. 10
    
11.
Sreekrishnan CM, Asha KV. Visha Vaidya Jyotsinika English Translation. Ch. 6. Kerala: Department of Agada Tantra, Vaidyaratnam P. S Varrier Ayurveda College Kottakkal; 2009. p. 66-7.  Back to cited text no. 11
    
12.
Sreekrishnan CM, Asha KV. Visha Vaidya Jyotsinika English Translation. Ch. 15. Kerala: Department of Agada Tantra, Vaidyaratnam P. S Varrier Ayurveda College Kottakkal; 2009. p. 160.  Back to cited text no. 12
    
13.
Murthy SK, Ashtanga Hridayam of Vagbhata, Sutra Sthana. Ch. 15, Ver. 17-18, Vol. 2. Varanasi: Chukhambha Publishers' Academy; 2009. p. 245.  Back to cited text no. 13
    
14.
Meena RK, Dudhamal T, Gupta SK, Mahanta V. Wound healing potential of Panchavalkala formulations in a postfistulectomy wound. Anc Sci Life J 2015;35:118-21.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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Abstract
Introduction
Case Report
Timeline
Follow Up and Ou...
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