|Year : 2021 | Volume
| Issue : 2 | Page : 44-49
Ayurvedic management of co-infection of Herpes zoster ophthalmicus in COVID-19 patient: A case report
Shantala T. R. Priyadarshini1, KK Remitha2, S Priyanka1
1 Dr. Vijaya's Ayurveda Research Center, Mysore, Karnataka, India
2 Department of Rachana Shareera, Sushrutha Ayurvedic Medical College and Hospital, Bengaluru, Karnataka, India
|Date of Submission||18-Jun-2021|
|Date of Acceptance||08-Jul-2021|
|Date of Web Publication||16-Aug-2021|
Dr. Shantala T. R. Priyadarshini
Chief Consultant at - Dr. Vijaya's Ayurveda Research and Treatment Center, Rukmini Netra chikitsayala, Jayanagar, Mysore - 570 014, Karnataka
Source of Support: None, Conflict of Interest: None
COVID-19 patients have cutaneous manifestations such as herpes zoster, urticaria, chilblains, purpura, livedo racemosa, chickenpox-like eruptions in very small percentage. However, the major focus is on pulmonary and cardiac symptoms as it leads to increased mortality. Globally, many cases of herpes zoster as coinfection of COVID-19 are observed. Here, a 65-year-old female with Herpes Zoster Ophthalmicus (HZO) managed by Ayurveda stand-alone treatment is reported. She tested RT-PCR (Real-Time Polymerase Chain Reaction) positive, had mild COVID-19 symptoms, and preferred home isolation and Ayurveda treatment. The patient was monitored twice daily through teleconference (zoom/video calls), photographs of the condition were procured, and guidance was sent in return. Initially, the patient complained of fever, pain, and burning sensation in scalp, left ear, and eye with left periorbital swelling. Once the fever subsided, the patient developed vomiting and loose stools as COVID-19 symptoms. There was complete relief from all the symptoms in four weeks, and the medicines for the postherpetic lesions were continued for another week. Treatment of herpes coinfection in COVID-19 under home isolation is in itself a challenge requiring leech application. However, the case was managed with Ayurveda oral medications and topical therapies such as Seka and Bidalaka to achieve relief from pain, burning sensation, and swelling. The drugs and therapies used in the above case assisted increasing circulation relieving pain thereby, assuring good sleep and faster respite from all symptoms. This case is reported to add to clinical literature and to showcase the importance of local therapies and teleconsultation in condition like HZO associated with COVID-19.
Keywords: Ayurveda, Bidalaka, COVID-19, herpes zoster ophthalmicus, Seka, Shatadhouta ghrita
|How to cite this article:|
Priyadarshini ST, Remitha K K, Priyanka S. Ayurvedic management of co-infection of Herpes zoster ophthalmicus in COVID-19 patient: A case report. J Ayurveda Case Rep 2021;4:44-9
|How to cite this URL:|
Priyadarshini ST, Remitha K K, Priyanka S. Ayurvedic management of co-infection of Herpes zoster ophthalmicus in COVID-19 patient: A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2021 Oct 25];4:44-9. Available from: http://www.ayucare.org/text.asp?2021/4/2/44/323905
| Introduction|| |
With each day bringing up new challenges, the medical fraternity and scientists all over the world are working tirelessly to understand the SARS-CoV-2 infection better. Few of the risk factors associated with the COVID-19 are coinfections and secondary infections. Various cutaneous manifestations such as herpes zoster, urticaria, chilblains, purpura, livedo racemosa, chickenpox-like eruptions have been observed to be associated with COVID-19.
This year too, a few cases of coinfection of herpes which could be of varied intensity have been recorded.,, Since ancient times, herpes known as Visarpa has had effective and rapid treatment in Ayurvedic treatises. Pittaja abhishyanda, a type of Abhishyanda. (~conjunctivitis), presents with burning sensation, redness, and swelling around the eyes, which are hallmark symptoms of Pittaja visarpa. Hence, this condition has to be treated on the lines of Pittaja abhishyanda and Rakta mokshana (~blood-letting) with Jalauka (~leech) is the choice of management.,,
It is important to report a coinfection of Herpes Zoster Ophthalmicus (HZO) treated online with Ayurvedic medicines providing rapid and complete relief as it is unique. Pain management without leech application or Rasa aushadhi shall be an additional and promising contribution in these exigent times. The case is unique as treatment of herpes ophthalmicus as a coinfection in COVID-19 has not been reported in Ayurveda. Adding this accomplishment to literature shall impart more confidence in young practitioners.
| Patient Information|| |
A 65-year-old South Indian female initially presented with mild fever (100°F), pain, and burning sensation behind her left ear and scalp. The next day, vesicles developed on the left temple, below the eyebrow, on the sides of nose (Hutchinson's sign is defined as skin lesions at the tip, side, or root of the nose) [Figure 1]. This is a strong predictor of ocular inflammation in HZO, especially if both branches of the nasociliary nerve are involved followed by periorbital swelling. Gradually, pain and swelling aggravated, causing loss of appetite and sleep disturbances. She did not have anosmia, but anorexia was considerable and she was not able to relish food. Although burning sensation and pain were intense associated with loss of appetite and sleep disturbances, the patient preferred to continue only with Ayurvedic medicines. By the 2nd week, she developed digestive problems such as vomiting, indigestion, flatulence, and loose stools with mild rise in temperature (99°F). The patient was a primary contact and tested positive in RT-PCR (Real-Time Polymerase Chain Reaction) for COVID-19 and hence diagnosed clinically as a coinfection of herpes ophthalmicus in COVID-19. She is a known diabetic for six years, on Ayurvedic oral medication and a vivid practitioner of Pranayama and meditation. The blood sugar levels are under control during the treatment period.
| Clinical Findings|| |
She weighed 52 kg and her height was 151 cm. No history of hypertension was reported. Blood pressure could not be recorded as it was a teleconsultation and she underwent the treatment under home isolation. Rogi pariksha was done and monitored through video calls. Subjective assessment was done using a scale similar to Zoster-Specific Brief Pain Inventory (ZBPI) questionnaire (designed by the consultant but not validated) and the findings are depicted at [Graph 1].
Roga and Rogi pariksha
Prakriti of the patient was Vata kaphaja; Vikruti was Vata pitta pradhana tridosha; Sara was Madhyama; Satwa was Pravara; Satmya was Madhyama; Vyayama shakti was Uttama; and Abhyavaharana and Jarana shakti were Alpa.
| Timeline|| |
The detailed timelines of treatment protocol with observations are placed in [Table 1].
| Diagnostic Assessment|| |
The details of subjective and objective criteria are given in [Table 2].
| Therapeutic Intervention|| |
Since the patient had tested COVID-19 positive and was under home quarantine, the therapies were done by her family members with regular monitoring through teleconsultation. Consequently, leech therapy could not be administered. Hence, it was challenging to manage pain and burning sensation. The patient's family members were taught to conduct Seka using clean bottles in hygienic and cautious manner. Seka was followed by Bidalaka and application of Shatadhouta ghrita, respectively [Table 1].
| Follow-Up and Outcome|| |
When the patient consulted for the first time, she had redness, pain, and burning sensation in the eye and behind the left ear associated with fever [Figure 2],[Figure 3],[Figure 4]. Fever subsided within one day. By the end of 1st week, she developed periorbital swelling with pus secretion in the left eye [Figure 5]. Once the therapies were started, especially repeated Seka and Bidalaka, pain and burning sensation in eyes considerably came down. As these symptoms subsided, anxiety level came down, appetite improved, and she was able to sleep better. Judicious administration of Seka and Bidalaka with the oral medications acted with synergy, and hence, the patient got relief from symptoms within four weeks. The external application of Shatadhouta ghrita was continued for another week to mitigate postherpetic lesions. During the course of treatment, no secondary infection or complications were reported or elicited, so the patient got total relief from all symptoms [Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12].
|Figure 2: Observation during the 1st week (April 18, 2021) with rashes on temple, forehead, and scalp|
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|Figure 3: Observation during the 1st week (April 19, 2021) complaining pain and burning sensation|
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|Figure 4: Observation during the 1st week (April 20, 2021) slight swelling noted|
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|Figure 5: Observation during the 1st week (April 21, 2021) with pus discharge, swelling, and burning sensation|
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|Figure 6: Observation during the 1st week (April 22, 2021) complaining of unable to open eyes|
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|Figure 7: Observation during the 1st week (April 23, 2021) though redness and swelling persist; able to open eyes slightly|
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|Figure 8: Observation during beginning 2nd week (April 30, 2021) reduced pain and burning|
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|Figure 10: Observation during the 3rd week (May 04, 2021) slight discomfort|
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|Figure 11: Observation during the 3rd week (May 08, 2021) all symptoms reduced|
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|Figure 12: Observation during the 4th week (May 10, 2021) postherpetic ulcer also healed|
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| Discussion|| |
HZO, commonly known as ophthalmic zoster or shingles, is caused by the reactivation of Varicella-Zoster Virus (VZV). It is characterized by a unilateral painful skin rash in one or more dermatome distributions of the trigeminal nerve. What makes this case different is its coexistence with COVID-19. Due to the similarities in symptoms and the predominance of Dosha (Daha, Raga, Srava, Sambrambha), the case was treated on the lines of management of Pittaja abhishyanda., This case had Hutchinson's sign very specific to herpes zoster opthalmicus along with other symptoms, so the case was diagnosed as HZO. A detailed eye examination using slit lamp or VZV laboratory test could not be done as the case was managed by teleconsultation.
The Ayurvedic herbs such as Amrita [Tinospora cordifolia (Willd.) Miers], Yashtimadhu (Glycyrrhiza glabra L.), Chandana (Santalum album L.), Amalaki (Emblica officinalis Gaertn.), Nimba (Azadirachta indica A. Juss.), and Jati (Jasminum grandiflorum L.) used in Seka have Pittahara properties. After every sitting of Parisheka, swelling, itching, and burning sensation were observed to be reduced. As the swelling receded, pain also subsided without using any conventional analgesics. Seka karma, possibly enhances cellular penetration, thus helps in easy absorption of active principles aided in relief.
Another therapy adopted in this case was Bidalaka with Shatadhouta ghrita (~a medicated ghee). Bidalaka is the local application of medicine over closed eyes excluding Pakshma (~eyelashes) and is the primary line of treatment for eye diseases. It plays an important role in the treatment modality of Abhishyanda too. Triphala churna along with Nimba patra kalka and Saindhava lavana (~rock salt) is used here for Bidalaka that is effective as an anti-inflammatory and antimicrobial. External application of Shatadohuta ghrita which is a known medicine of nanoparticle size; on the lesions accentuated the healing due to a faster cellular penetration. It has been proven to hasten epithelialization and is an excellent drug to lower burning sensation and scarring in skin diseases and burns.
This study provides evidence toward potential efficacy and safety of Seka and Bidalaka in the treatment of Abhishyanda. Pain scale similar to ZBPI questionnaire was sent to the patient and the answers were recorded [Graph 1]. Seka helped to improve the circulation locally; thereby, pain, burning sensation, and swelling could be mitigated. Bidalaka effectively reduced the symptoms such as increased discharge, pricking, burning, and redness. Apart from quick relief, no adverse effect was reported. The efficacy of Kriya kalpa (~ocular therapeutics), which works on a transcutaneous drug delivery, not only depends on the procedures but also on the choice of medications, and in this patient, the use of Pitta-vata hara dravyas assisted in better management.
Amrita satwa is given internally at frequent intervals aided in the mitigation of fever and digestive disturbances. It has been proven to be a good antiviral agent, especially in COVID-19. Sleep and appetite were improved, and burning sensation in the eyes was reduced by Chandanasava. Apart from the medicines, meditation along with Pranayama aided early recovery by improving circulation and reducing stress. The patient was a known practitioner of transcendental meditation during which Pranayama was also taught.
| Conclusion|| |
Online consultation with latest technology surely helps in maintaining and enhancing the morale of the patient to assist in faster recovery. Treatment of herpes coinfection in COVID-19 under home isolation in itself is a challenge requiring leech application. Considering this, the case, managed solely with oral medications and topical therapies to achieve relief from the symptoms, is definitely a value addition to the therapeutic literature. Challenging cases can be managed by Ayurveda alone, and large-scale studies are recommended.
Declaration of 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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Daneshgaran G, Dubin DP, Gould DJ. Cutaneous manifestations of COVID-19: An evidence-based review. Am J Clin Dermatol 2020;21:627-39.
Ferreira A, Romao T, Macedo Y, Pupe C, Nascimento O. COVID-19 and herpes zoster co-infection presenting with trigeminal neuropathy. Eur J Neurol 2020;27:1748-50.
Hernandez JM, Singam H, Babu A, Aslam S, Lakshmi S. SARS-CoV-2 infection (COVID-19) and herpes simplex virus-1 conjunctivitis: Concurrent viral infections or a cause-effect result? Cureus 2021;13:e12592.
Altaf I. Herpes zoster coinfection and the current COVID-19 pandemic. Saudi Crit Care J 2020;4:130-3. [Full text]
Mahanta VD, Foram J, Dudhamal TS, Gupta SK. Jalaukavacharana (Leech application) and adjuvant therapy in the management of infected wounds. J AyuCaRe 2017;1:13-7.
Nakanekar A, Khobarkar P, Dhotkar S. Management of herpes zoster in Ayurveda through medicinal leeches and other composite Ayurveda Treatment. J Ayurveda Integr Med 2020;11:352-6.
Shatri AD, editor. Hindi Commentary of Tatwa Sandipika on Sushruta Samhita of Sushruta, Uttar Tantra. Ch. 6., Ver. 5. Varanasi: Chaukhambha Sanskrit Sansthan; 2016. p. 34.
Tripathi B, editor. Nirmala Hindi Commentary on Ashtanaga Hridaya of Srimad Vagbhatta, Uttara Sthana. Ch. 15., Ver. 3-5. Delhi: Chaukhambha Sanskrita Pratishthana; 2014.p. 984.
Sampathkumar P, Drage LA, Martin DP. Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clin Proc 2009;84:274-80.
Saha S, Ghosh S. Tinospora cordifolia
: One plant, many roles. Anc Sci Life 2012;31:151-9.
Fiore C, Eisenhut M, Krausse R, Ragazzi E, Pellati D, Armanini D, et al.
Antiviral effects of Glycyrrhiza
species. Phytother Res 2008;22:141-8.
Moy RL, Levenson C. Sandalwood album oil as a botanical therapeutic in dermatology. J Clin Aesthet Dermatol 2017;10:34-9.
Kumar A, Tantry BA, Rahiman S, Gupta U. Comparative study of antimicrobial activity and phytochemical analysis of methanolic and aqueous extracts of the fruit of Emblica officinalis
against pathogenic bacteria. J Tradit Chin Med 2011;31:246-50.
Saleem S, Muhammad G, Hussain MA, Bukhari SN. A comprehensive review of phytochemical profile, bioactives for pharmaceuticals, and pharmacological attributes of Azadirachta indica
. Phytother Res 2018;32:1241-72.
Vidyasagar PS, editor. Sharangdhar Samhita of Sharangdhara; Uttar Tantra. Ch. 13., Ver. 30. Varanasi: Chaukhamba Surbharati Prakashan; 2013. p. 383.
Peterson CT, Denniston K, Chopra D. Therapeutic uses of triphala in ayurvedic medicine. J Altern Complement Med 2017;23:607-14.
Manogaran S, Sulochana N, Kavimani S. Anti – Inflammatory and antimicrobial activities of the root, bark and leaves of Azadirachta indica
. Anc Sci Life 1998;18:29-34.
Deshpande S, Deshpande A, Tupkari S, Agnihotri A. Shata dhauta ghrita – A case study. Indian J Tradit Knowl 2009;8:387-91.
Pande Vishal V, Patel Vipul P, Zarekar Nilesh S, Pandit Shubham R, Pote Ajinkya K. Investigation of effects of shata dhauta ghrita on the skin permeation of fluconazole loaded topical antifungal nanolipogel. J Pharm Sci Res 2020;12:948-56.
Babu B, Ravi M, Ashok Kumar BN, Sudheendra VH, Ravishankar B. Burn wound healing potential of Plain gritha, Shatadhauta ghrita and Sahasradhauta ghrita on wistar albino rats. Indian J Tradit Knowl 2015;14:273-8.
Berti JJ, Lipsky JJ. Transcutaneous drug delivery: A practical review. Mayo Clin Proc 1995;70:581-6.
Upadhyay AK, Kumar K, Kumar A, Mishra HS. Tinospora cordifolia
(Willd.) Hook. F. and Thoms. (Guduchi) – Validation of the Ayurvedic pharmacology through experimental and clinical studies. Int J Ayurveda Res 2010;1:112-21.
Das SG, editor. Hindi commentary Bhiashajya ratnavali with Bhramashankar Mishra's Vidyotini; Chapter 90, Verse 27-35. Varanasi: Chaukamba Prakashana; Reprint 2011. p. 1182.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2]