|Year : 2021 | Volume
| Issue : 2 | Page : 68-72
Ayurvedic management of subacute thyroiditis: A case report
Shashidhar H Doddamani1, MN Shubhashree1, Rinky Thakur2, Raghavendra Naik1
1 Clinical Research, Central Ayurveda Research Institute, CCRAS, Bengaluru, India
2 WCD Vertical, NITI Aayog, New Delhi, India
|Date of Submission||27-Aug-2020|
|Date of Acceptance||08-Jun-2021|
|Date of Web Publication||16-Aug-2021|
Dr. Shashidhar H Doddamani
#12, Manavarthekaval, Uttarahalli Hobli, Kanakapura Main Road, Talaghattapura Post, Bengaluru - 560 109, Karnataka
Source of Support: None, Conflict of Interest: None
Subacute Thyroiditis (SAT) is an acute inflammatory disorder presumed to be caused by a viral infection or a postviral inflammatory process. Autoimmunity may play a secondary role in this disorder. Although, SAT is a self-limiting condition associated with a tri-phasic clinical course of hyper, hypo, and euthyroidism. It is a rare clinical entity involving symptoms such as fever, upper respiratory tract infection, and thyroid tenderness. Diagnosis is based on clinical findings and laboratory reports. A 23-year-old male with the symptoms of hyperthyroidism was under the consultation of endocrinologist, who prescribed medicines. However, the patient was reluctant to take allopathic medicine and approached for Ayurvedic intervention. After basic examinations, he was prescribed with Trikatu churna, Shiva gutika and Arogya vardhini vati for one year with the intermittent gap. As the thyroid values fluctuate from hyper to hypo, it is often perplexing for a treating physician unless proper follow-up is done by the same physician. This paper aims at bringing awareness among clinicians regarding the condition “SAT” to instill confidence. Management of SAT involves the administration of non-steroidal anti-inflammatory drugs or aspirin, thyroid hormone, and glucocorticoids. However, all these were avoided and were successfully managed with Ayurvedic medication. Such studies highlight the promising scope of traditional medicine in endocrinal disorders.
Keywords: Arogya vardhini vati, subacute thyroiditis, Shiva gutika, Trikatu churna, Vishamagni
|How to cite this article:|
Doddamani SH, Shubhashree M N, Thakur R, Naik R. Ayurvedic management of subacute thyroiditis: A case report. J Ayurveda Case Rep 2021;4:68-72
|How to cite this URL:|
Doddamani SH, Shubhashree M N, Thakur R, Naik R. Ayurvedic management of subacute thyroiditis: A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2021 Oct 25];4:68-72. Available from: http://www.ayucare.org/text.asp?2021/4/2/68/323909
| Introduction|| |
Subacute Thyroiditis (SAT) also called “De Quervain's thyroiditis” or “subacute granulomatous thyroiditis” is possibly a viral, inflammatory thyroid disorder usually associated with thyroid pain and systemic symptoms. SAT comprises nearly 3–6% of all thyroid lesions. From Eastern India, 12 cases were reported from April 2010 to July 2012. The clinical course includes three characteristic phases. There is an early hyperthyroid phase caused by leakage of follicular contents and preformed thyroid hormone lasting 3 to 6 weeks. This phase is followed by a hypothyroid phase in 30% of patients, which is caused by depletion of preformed thyroid hormone and may last for several months. There is then typically eventual recovery, with patients resuming their euthyroid state. The case is managed with salicylates, nonsteroidal anti-inflammatory drugs, analgesics, and corticosteroids in the initial 2 to 6 weeks and later hormonal therapy, and in rare cases, thyroidectomy is resorted to. Although it is self-limiting, 15% of people end up in permanent hypothyroidism.
There is no specific disease described in Ayurveda, which correlates with symptoms seen in this case. Based on the signs and symptoms, the condition is considered as the state of Vishamaagni (~unstable metabolism) at Dhatu level. This case report discusses the successful management of SAT with Ayurvedic herbo-mineral formulation viz, Trikatu churna, Shiva gutika, and Arogya vardhini vati.
| Patient Information|| |
A 23-year-old male patient approached to OPD with complaints of neck pain and sore throat associated with fever, anorexia, and generalized body ache for one week. On retrieval of past medical records, it was noted that he had approached an endocrinologist for these complaints. Ultrasonography showed inflammatory involvement of the thyroid gland. Initial thyroid tests revealed hyperthyroidism and was prescribed with allopathic medicines (carbimazole and a beta-blocker). In addition, the endocrinologist warned the patient about the possibility of jaundice as a side effect of the prescribed drugs. The patient was hesitant to take the prescribed medicines and approached for Ayurvedic treatment without taking prescribed medicines.
| Clinical Findings|| |
The results of the psychological examination showed agitation, restlessness, and anxiety. On examination, body temperature was 40°C, pulse rate was 102/min and blood pressure was 140/80 mmHg. There was tenderness in the neck region and difficulty in swallowing. Thyroid was tender and swollen. He weighed 51 kg and his Body Mass Index (BMI) was 17.
Laboratory investigations revealed raised Erythrocyte Sedimentation Rate (ESR). Hemoglobin (Hb%) and random blood sugar were within the normal limits [Table 1]. Results of thyroid profile suggestive of thyrotoxicosis, a medical condition caused by an excessive amount of thyroid hormones in the bloodstream. As the condition was inflammatory, the patient presented with symptoms such as fever, raised ESR, and hyperthyroidism. Thyroid scan features are suggestive of an inflammatory involvement of the gland. As the condition was unusual, it was suspected to be having SAT and Ayurvedic treatment was initiated and observed for few weeks for the changes in thyroid profile. After 12 weeks, the patient reported increased Thyroid-Stimulating Hormone (TSH > 100 μIU/ml). Hence, the diagnosis was confirmed as SAT.
| Timeline|| |
The detailed timeline is given in [Table 2].
| Therapeutic Intervention|| |
The treatment was planned based on the involvement of Dosha (~humor), Dushya (~vitiated dhatus), and Agni (~digestive and metabolic capacity). Initially, due to the involvement of Pitta dosha, there was fever and inflammation. For which 500 mg Trikatu churna [Powders of Shunthi (Zingiber officinale Roscoe.), Pippali (Piper nigrum L.) and Maricha (Piper longum L.)] twice daily before food with hot water for 15 days was given for correcting the Agni and Amapachana. Then, the line of treatment was aimed at mitigating Vata-kapha and strengthening the Dhatus by Rasayana (~rejuvenation). Later, 500 mg each of Shiva gutika and Arogya vardhini vati twice daily after food with water along with 500 mg Trikatu churna were given. After every three months of consumption, 15 days of rest period was given [Table 2].
| Follow-Up and Outcome|| |
The patient was asked to visit for regular treatment and follow-up to OPD once in 15 days. As the patient presented with neck pain, sore throat associated with fever, anorexia, and generalized body ache along with lowered TSH values which are unusual in Graves' disease, the patient was closely monitored and observed for the sign and symptoms and change in Triiodothyronine, Thyroxine and TSH values apprehending the phases of SAT [Table 3].
|Table 3: Interpretation and diagnosis of subacute thyroiditis with thyroid profile|
Click here to view
Thyroid function returns to normal within 12–18 months in 80% of patients. Approximately 5-10% of patients have permanent thyroid dysfunction, usually hypothyroidism, after an episode of SAT. However, with Ayurveda treatment, it was achieved within nine months and a follow-up for the next six months' period revealed that the patient was euthyroid without landing into hypothyroid condition. Ultrasound scan of the neck revealed normal thyroid functioning after treatment.
| Discussion|| |
The treatment modality of SAT is directed toward the management of pain and thyroid dysfunction. The hypothyroid phase in SAT is usually mild and transient, and typically it does not require treatment. However, if symptoms present or the TSH level is elevated, the patient needs replacement therapy with levothyroxine.
Although carbimazole and beta-blocker were prescribed by endocrinologist, the patient did not preferred using them considering possible side effects leading to icterus. With the intention of avoiding side effects, the patient refused the modern medication and approached Ayurvedic medication. Though the case was diagnosed as the phase of hyperthyroidism, is transiently seen. This is followed by hypothyroidism with TSH values more than 100 μIU/ml.
This case was analyzed according to Ayurvedic principles and the treatment was planned. There is no specific disease described in Ayurveda, which correlates with symptoms seen in the above patient. But the case is a classic example of Vishamagni at Dhatu level since it showed the signs and symptoms of hyperthyroidism followed by hypothyroidism. For which Agni-deepana and Amapachana were given for initial 15 days to correct Jatharagni. Shotha is due to Kapha and Kantha is the region of Udanavata. So, the line of treatment aimed at mitigating Vata-kapha and strengthening the Dhatu by Rasayana. Considering the auto-immune, inflammatory nature of the disease; drugs like Shiva gutika, Arogya vardhini vati and Trikatu churna which are having analgesic immunomodulatory and anti-inflammatory properties were advised. Shiva gutika is a herbo-mineral preparation explained as Rasayana in classical texts of Ayurveda. Shilajatu, the main ingredient of Shiva gutika has significant anti-inflammatory, analgesic, immune-modulatory, antiviral and antioxidant activity.,,
Shilajatu is useful in alleviating Tridoshas (~three humours). It possesses Rasayana property and useful in treating Shotha (~inflammation). It is said that there is no such disease which cannot be managed with Shilajatu. Shilajatu is also used as Yogavaha as it increases efficacy of many drugs. Apart from this, the other drugs in Shiva gutika have Kapha-vata shamaka property. The active principle of Trikatu is piperine, which is mainly responsible for enhancing the bioavailability of administered drugs. The possible mode of action of the Trikatu churna may be due to its property of thermogenesis and its action as bioavailability enhancer. The Ushna guna and Katu rasa of Trikatu stimulates Pitta. It has predominance of Agni, Vayu and Akasha mahabhuta, which is responsible for Kapha shamana. It has Deepana (~enhancing metabolic fire) and Pachana (~enhancing digestion) property and it promotes Agni. Besides Tikshna ensures tissue penetration thereby showing its action on Agni at the Dhatwagni (~metabolic fire) and Bhutagni level. Arogya vardhini compound is an emerging herbo-mineral formulation of thirteen ingredients formulated for the treatment of metabolic disorders. Compounds of Arogya vardhini compounds like Kajjali (~combination of Mercury and Sulphur) have Yogavahi (~increasing potency of formulation and not altering the pharmacological action of contents in combinations) and Rasayana property.
Although the level of TSH was more than 100 μIU/ml necessitating levothyroxine supplementation, yet it was not given, instead he was treated for Vishama agni (~unstable metabolism). Both hyperthyroidism and hypothyroidism phases were managed on the lines of Vishama agni chikitsa. The case study is of significance as it proposes a nonhormonal mode of treatment for SAT. This is one of the rare condition which may be confusing as it shifts from hyperthyroidism to hypothyroidism and then to euthyroidism. Although it is an uncommon condition, yet it is considered the most common cause of painful thyroiditis.
It is also learnt that SAT cases attain euthyroid/normal within 12–18 months. However, with Ayurveda treatment, it was achieved within nine months earlier than the mentioned period. It is also mentioned that 5% of people become permanently hypothyroid, however, in this particular case, follow-up after four and seven months has revealed that the TSH values have remained within the normal limits. Trikatu was discontinued for 15 days after three months. Safety profiles (renal and liver function tests) were also within normal limits [Table 4]. USG has also revealed normal functioning of thyroid. Weight gain of 6 kg has also been observed after six months of treatment.
| Conclusion|| |
SAT is an unusual clinical condition involving symptoms such as fever, upper respiratory tract infection, and thyroid tenderness. The present study highlights successful management of SAT with Trikatu churna, Shiva gutika and Arogya vardhini vati. Though this is a self-limiting condition, which attains euthyroid or normal within 12–16 months, it was achieved within nine months with Ayurvedic medication. Moreover, the chance of turning into permanent hypothyroid condition is also prevented in this case. Even after a follow-up of seven months, the TSH values have remained within the normal limits showing the promising scope of traditional medicine in endocrinal disorders.
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|| |
Fatourechi V, Aniszewski JP, Fatourechi GZ, Atkinson EJ, Jacobsen SJ. Clinical features and outcome of subacute thyroiditis in an incidence cohort: Olmsted County, Minnesota, study. J Clin Endocrinol Metab 2003;88:2100-5.
Singer PA. Thyroiditis. Acute, subacute, and chronic. Med Clin North Am 1991;75:61-77.
Das S. Subacute thyroiditis: An uncommon cause of fever of unknown origin. Indian J Endocrinol Metab 2012;16:S340-1.
Samuels MH. Subacute, silent, and postpartum thyroiditis. Med Clin North Am 2012;96:223-33.
Mishra SN, editor. Hindi Commentary Siddhiprada of Kaviraj Sen on Bhaishajya Ratnavali. Ch. 73., Ver. 148-71. Varanasi: Choukhamba Surbharati Prakashan; 2015. p. 120-1.
Mishra SN, editor. Hindi Commentary Siddhiprada of Kaviraj Sen on Bhaishajya Ratnavali. Ch. 54., Ver. 117. Varanasi: Choukhamba Surbharati Prakashan; 2015. p. 871.
Paradakara BH, editor. Commentaries Sarvangasundara of Arunadatta and Ayurveda Rasayana of Hemadri on Astanga Hridayam of Vagbhata. Sutra Sthana. Ch. 12., Ver. 53. Varanasi: Chaukhambha Orientalia; 1998. p. 201.
Paradakara BH, editor. Commentaries Sarvangasundara of Arunadatta and Ayurveda Rasayana of Hemadri on Astanga Hridayam of Vagbhata. Sutra Sthana. Ch. 12., Ver. 5. Varanasi: Chaukhambha Orientalia; 1998. p. 193.
Peterson CT, Denniston K, Chopra D. Therapeutic uses of triphala in ayurvedic medicine. J Altern Complement Med 2017;23:607-14.
Murunikkara V, Rasool M. Trikatu, an herbal compound as immunomodulatory and anti-inflammatory agent in the treatment of rheumatoid arthritis – An experimental study. Cell Immunol 2014;287:62-8.
Dwivedy R, editor. Hindi Commentary Vaidyaprabha of Chakrapanidatta on Chakradatta. Rasayanadhikara. Ver. 168-177. Varanasi: Choukhamba Sanskrti Bhavan; 1997. p. 428.
Ghosal S. Chemistry of shilajit, An immunomodulatory Ayurvedic Rasayan. Pure Appl Chem 1990;62:1285-8.
Ghosal S, Lal J, Singh SK, Dasgupta G, Bhaduri J, Mukhopadhyay M, et al.
Mast cell protecting effects of shilajit and its constituents. Phytother Res 1989;3:249-52.
Wilson E, Rajamanickam GV, Dubey GP, Klose P, Musial F, Saha FJ, et al.
Review on shilajit used in traditional Indian medicine. J Ethnopharmacol 2011;136:1-9.
Acharya SB, Frotan MH, Goel RK, Tripathi SK, Das PK. Pharmacological actions of Shilajit. Indian J Exp Biol 1988;26:775-7.
Bhaumik S, Chattapadhay S, Ghosal S. Effects of Shilajit on mouse peritoneal macrophages. Phytother Res 1993;7:425-7.
Acharya YT, editor. Commentary Ayurveda Deepika on Charaka Samhita of Agnivesha, Chikitsa Sthana. Ch. 1., Ver. 65. Varanasi: Chaukambha Prakashan; 2016. p. 386.
Gupta GD, Sujatha N, Dhanik A, Rai NP. Clinical evaluation of Shilajatu Rasayana in patients with HIV Infection. Ayu 2010;31:28-32.
] [Full text]
Atal CK, Zutshi U, Rao PG. Scientific evidence on the role of Ayurvedic herbals on bioavailability of drugs. J Ethnopharmacol 1981;4:229-32.
Johri RK, Zutshi U. An Ayurvedic formulation 'Trikatu' and its constituents. J Ethnopharmacol 1992;37:85-91.
Shetty SN, Mengi S, Vaidya R, Vaidya AD. A study of standardized extracts of Picrorhiza kurroa Royle ex Benth in experimental nonalcoholic fatty liver disease. J Ayurveda Integr Med 2010;1:203-10.
] [Full text]
Padhar BC, Dave AR, Goyal M. Clinical study of Arogyavardhini compound and lifestyle modification in management of metabolic syndrome: A double-blind placebo controlled randomized clinical trial. Ayu 2019;40:171-8. [Full text]
Alfadda AA, Sallam RM, Elawad GE, Aldhukair H, Alyahya MM. Subacute thyroiditis: Clinical presentation and long term outcome. Int J Endocrinol 2014;2014:794943.
[Table 1], [Table 2], [Table 3], [Table 4]