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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 74-79

A report on the management of Galaganda (colloid multinodular goiter) through Ayurveda approaches


Department of Roga Nidan Evum Vikriti Vigyan, All India Institute of Ayurveda, New Delhi, India

Date of Submission16-Dec-2020
Date of Acceptance23-May-2022
Date of Web Publication28-Jun-2022

Correspondence Address:
Dr. Shalini Rai
Department of Rognidan Evum Vikriti Vigyan, All India Institute of Ayurveda, Sarita Vihar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_85_20

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  Abstract 


Multinodular goiter (MNG) is one of the most common endocrine disorders affecting the thyroid gland with a higher prevalence in the female population. It may be due to abnormalities of iodine supplies or metabolism or dyshormonogenesis, resulting in nodules of different sizes filled with colloid-rich material. This case report documents the successful management of Galaganda (~colloid MNG [Bethesda Grade 2]) with Ayurvedic oral medicines. A 60-year-old female, with chief complaints of Galashotha (~swelling in the throat), Sankocha (~tightness and tense feeling in the neck), Amlapitta (~hyperacidity), Vibaddhata (~constipation), and Aadhmana (~gas formation) has visited for the Ayurvedic treatment for her condition in September 2018. She was administered Ayurveda treatment based on the principles of Deepanapachana (~improving the digestion and metabolism), Sroto shodhana (~cleansing of the bowel and circulatory channels), Sanshamana (~pacifying treatment), and Satwavajaya chikitsa (~patient counseling). Based on the condition, Amarasundari vati, Vridhivadhika vati, Kanchanara kashayam and a herbo-mineral compound in capsule form along with a regulated diet and lifestyle were prescribed for the initial three months. The patient showed improvement in subjective and objective parameters with improvement in quality of life. However, since recurrences are commonly reported in MNG, the medicines were continued for a period of 12 months. No side effects have been observed during the therapeutic period. The patient was followed up for another 12 months and no recurrences have been noted even after stopping the treatment.

Keywords: Ayurveda, colloid goiter, Galaganda, Granthi


How to cite this article:
Sharma A, Rai S, More A. A report on the management of Galaganda (colloid multinodular goiter) through Ayurveda approaches. J Ayurveda Case Rep 2022;5:74-9

How to cite this URL:
Sharma A, Rai S, More A. A report on the management of Galaganda (colloid multinodular goiter) through Ayurveda approaches. J Ayurveda Case Rep [serial online] 2022 [cited 2022 Aug 13];5:74-9. Available from: http://www.ayucare.org/text.asp?2022/5/2/74/348702




  Introduction Top


Multinodular goiter (MNG) is the most common disorder of the thyroid gland, seen in about 8.5% of the population,[1] found more commonly in women,[2] especially in the aged since it is a late complication of simple goiter. In India, the prevalence in the community is reported about 12.2%,[3] especially more in areas of iodine deficiency. The incidence of MNG in the area with sufficient iodine intake has also been documented in reports. These nodules may be only the growth fusion of localized colloid-filled follicles or more or less discrete adenoma or cysts. MNG is generally euthyroid,[4] but in a few cases may develop thyrotoxicosis, resulting in toxic nodular goiter.[5] The nodules in <5% of cases may change into follicular type carcinoma.[6] The treatment plans according to conventional systems of medicines depend on several factors and include thyroid hormone suppressive therapy, radioiodine therapy,[7] and surgery. The benefits of hormone suppressive therapy and surgery are still debatable.[8] Surgery further causes undue risk for certain patient populations, particularly in elderly patients with underlying cardiopulmonary disease. Postoperative complications include injury to recurrent laryngeal nerve, trachea, and parathyroid glands[9] along with the chances of recurrence (35% to 45%)[8],[10] and complications of general anesthesia. Such conditions can be managed through Ayurveda approaches. Here, a case of MNG managed through Ayurvedic oral medicines based on Ayurvedic concepts is presented.


  Patient Information Top


A 60-year-old housewife, reported into the outpatient department with the symptoms of a sensation of tightness in the neck, radiating to the jaw, ears, and up to the posterior portion of the head for most of the time, for more than a year, along with diffuse swelling on both sides of the neck. She felt discomfort during swallowing food and uneasiness on lying down. She also complained of a coating sensation in the throat, acidity, constipation, and excessive gas formation for four months. Her appetite and sleep were reduced. She had no family history of goiter and was normotensive (normal blood pressure [BP]) and nondiabetic. There is no history of surgery, drug allergy, and addiction. In 2017, she was diagnosed to be suffering from MNG and was advised for total thyroidectomy. The patient refused because of postsurgery risks explained to her and opted for Ayurvedic remedy in September 2018. She was well explained about the treatment plan and prognosis of her illness and her due written informed consent was recorded before initiating the treatment. No treatment was taken by the patient before visiting to the Ayurveda center for treatment.


  Clinical Findings Top


She was of moderate built with a weight of 65 kg and a height of 5 feet 4 inches. She was afebrile with BP of 120/70 mmHg; normal pulse (78/min) and respiratory rate (18/min). The vision was diminished for near and distant; the tongue was coated and voice was clear. Pallor, icterus, clubbing, cyanosis, edema, and lymphadenopathy were absent. She was anxious with increased stress levels and disturbed sleep patterns. Neck examination showed bilateral diffuse, smooth, mobile swelling on the neck with variable (soft to firm and nodular) consistency, which moved upward on deglutition. Tenderness, palpable thrill, bruit, and cervical lymphadenopathy were absent.

Dashavidha pareeksha (~Tenfold examination)

Prakruti (~physical constitution) was Vata-pittaja; Satva (~psycic condition), Sara (~excellence of Dushya or tissue elements) and Samhanana (~compactness of tissues or organs) were Madhyama (~moderate). Aahara shakti (~power of intake and digestion of food) was Alpa (~sluggish); Satmya (~homologation) and Pramana (~measurement of body constituents) were Madhyama (~moderate); Vyayama shakti (~power of performing exercise) was Heena (~poor). Roga prakriti was found to be Vata-kapha pradhana. Lack of proper sleep, stress, and anxiety may be precipitated by the condition.


  Diagnostic Assessment Top


The thyroid profile of the patient was normal with thyroid-stimulating hormone 2.96 μIU/ml, triiodothyronine (T3) 1.20 ng/dl, and thyroxine (T4) 9.12 μg/dl. Ultrasound of thyroid revealed bulky right lobe of thyroid measuring 40 mm × 21 mm × 15 mm (vol. 6 cc) and showed increased vascularity and few cystic components within. The left lobe of the thyroid was also bulky measuring 36 mm × 23 mm × 22 mm (vol. 10 cc) and showed an ill-defined hyperechoic cyst measuring 21 mm × 20 mm × 19 mm [Figure 1]. Fine-needle aspiration biopsy reports available with the patient revealed the case to be of nodular colloid goiter with cystic changes (Bethesda grade 2). Thyroid antibodies could not be performed as the patient could not afford it.
Figure 1: Ultrasound Neck for Thyroid before treatment

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  Timeline and Therapeutic Intervention Top


Based on Dashavidha pareeksha, the patient and disease both were found to be of moderate strength and so it was planned to manage her with oral medications [Table 1]. The patient was advised to follow normal timings for food and take light to digest freshly prepared foods and refrain from all heavy to digest food items such as dairy products, jaggery, refined products, sour items, cabbage, cauliflower, and turnip. She was advised to avoid stress, day sleep, and awakening till late at night.
Table 1: Therapeutic interventions including dose administrated and duration

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Table 2: Main ingredients of Herbo-mineral compound used

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  Follow-Up and Outcome Top


The patient started showing response to the treatment in subjective symptoms after seven days of Deepana-pachana (~improving the digestion and metabolism) and Koshtha shodhana (~cleansing of the bowels) with Shivakshara pachana churna[11] and Virechana yoga comprising of Svarnapatri (Cassia angustifolia Vahl.), Haritaki (Terminalia chebula Retz.), Yashti (Glycyrrhiza glabra Linn.), Mishreya (Foeniculum vulgare Mill.), and Eranda taila (oil of Ricinus communis Linn.). Responses observed in other symptoms are placed in [Table 3].
Table 3: Day wise symptomatic assessment

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At the end of the initial three months, the patient was evaluated clinically for changes in symptoms and through ultrasound of the thyroid gland. Her ultrasound report showed the normal size of bilateral lobes of the thyroid (right lobe measures 26 mm × 22 mm × 22 mm and left lobe measures 25 mm × 17 mm × 15 mm), reduced volume of cysts, and disappearance of cysts of 21 mm × 20 mm × 19 mm from the left lobe. Heterogeneous echo textures of bilateral lobes of thyroid with few cystic components were only remaining [Figure 2]. It was planned to maintain the patient on the same drugs for a further period of 12 months, with regular follow-up at an interval of a month. The treatment was stopped in December 2019. After this period, ultrasound reports could not be repeated due to the COVID-19 pandemic after which the patient was followed up telephonically. The patient reported significant improvement in all her symptoms by the last follow-up in November 2020. Treatment was stopped after this follow-up. After stopping the treatment, the patient was further followed-up for another year through telephone. No relapses or any other complaints were noticed during this period.
Figure 2: Ultrasound Neck for Thyroid after three month of treatment

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  Discussion Top


The case described above was managed on the lines of treatment of Galganda (~goiter)[12] and Granthi (~cyst),[13] focusing on correction of Jatharagni and Medodhatvagni (~digestion and metabolism process at the gross and subtle level going on in the body and all its tissue process) along with the regulation of Vata, Kapha, Rakta, Mamsa, and Medas. The Ayurvedic pathogenesis of colloid nodular goiter can be better understood with the concepts of these two diseases together. Vitiated Vata may be one of the reasons for abnormal functioning of the thyroid gland along with its increased cell division to form swelling. Kaphadosha causing Shotha (~swelling), Agnimandya (~diminished digestion and metabolism in the body and the tissues) along with vitiated Meda dhatu (~adipose tissue) lodge in Griva (~neck) and create a glandular enlargement in that region that is defined as Galganda.[14] When these deranged Vata and Kapha doshas additionally vitiate Mamsa dhatu (~muscle tissue) and Rakta (~blood), a raised swelling called as Granthi is produced, which correlates to cystic swellings that are benign in nature. It is thereby seen that vitiated Vata and Kapha along with vitiated Meda dhatu are the main causative factors of this disease, considering from both perspectives described above along with derangement of the Agni.

Treatment was initiated with Deepana-Pachana, followed by Srotoshodhana (~cleansing of the bowel and circulatory channels). The drugs in further treatment were so chosen that they simultaneously acted on Granthi and Galaganda. Kanchnara (Bauhinia variegata [L.] Benth) is the drug of choice for Galganda, Granthi, and Medodhatu dushti.[15] Amarsundari vati[16] and Vridivadhika vati[17] mitigate Vata dosha and Kapha dosha, thus normalizing the regulatory functions of the body[18] including cell division, and growth;[19] and decreases the size of the Granthi.[16],[17] Further, these drugs also correct the digestive, absorptive, metabolic, and assimilative functions of the body correcting Medodhatwagni dushti (~defect of adipose tissue metabolism).[16]

Visha (~poisonous drugs) as Vatsnabha (Aconitum ferox Wall. ex Ser.) and Bhallataka (Semicarpus anacardium Linn.) are used as a content judiciously, after proper processing to harness their restorative and potentiating effects.[20],[21] Being a poison, they also have the property of deep penetration and fast action, due to which they spread rapidly and assimilate quickly, clearing the circulatory pathways to the most subtle level of the cells and within. Bhallataka is a potent immunomodulator as well as anti-inflammatory drug.[22] Vacha (Acorus calamus Linn.) is a bitter tonic with Lekhana karma (~scraping properties) and is thus useful in tumors, growths, etc.[23] Amalaki (Emblica officinalis Gaertn.), Hareetaki (Terminalia chebula Retz.), and Vibheetaki (Terminalia bellerica Roxb.) are well-known immunomodulatory drugs.[24] Anti-proliferative, antioxidant, anti-inflammatory, immunomodulatory effect of Punarnava (Boerhavia diffusa Linn.) extract is useful in the tumors and even malignant changes without any toxic effect.[25] Similar properties of extracts of drugs as Vasa (Adhatoda vasica [Linn.] Nees),[26],[27] Shigru (Moringa oleifera Lam.),[28] Guduchi (Tinospora cordifolia [Wild.] Miers),[29] and Yashti (Glycerrhiza glabra Linn.)[30] are established in vitro and in vivo study. Ethanolic extract of Varuna (Crataeva nurvala Buch. Ham.) also has antioxidant and anti-inflammatory properties[31] and so possibly has a role on the thyroid gland and normalizing its function.

Despite having metallic components, the herbo-mineral compound administered for about 15 months has not created any inconvenience in the patient neither during the treatment period nor during the follow-up. The overall approaches and modalities of Ayurveda treatment have helped in managing the condition.


  Conclusion Top


The above case report provides evidence to the fact that oral Ayurvedic treatment is effective in managing Colloid MNG effectively without giving any chances of developing adverse effects. No signs of relapses were observed during the follow-up period. Since this is a single-case study, there is a need for a study involving an increased number of patients to establish the effectiveness of Ayurvedic treatment.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Unnikrishnan AG, Kalra S, Baruah M, Nair G, Nair V, Bantwal G, et al. Endocrine society of India management guidelines for patients with thyroid nodules: A position statement. Indian J Endocrinol Metab 2011;15:2-8.  Back to cited text no. 1
    
2.
Brix TH, Kyvik KO, Hegedüs L. Major role of genes in the etiology of simple goiter in females: A population-based twin study. J Clin Endocrinol Metab 1999;84:3071-5.  Back to cited text no. 2
    
3.
Usha Menon V, Sundaram KR, Unnikrishnan AG, Jayakumar RV, Nair V, Kumar H. High prevalence of undetected thyroid disorders in an iodine sufficient adult south Indian population. J Indian Med Assoc 2009;107:72-7.  Back to cited text no. 3
    
4.
Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dhatariya K, et al., editors. Endotext. South Dartmouth: MDText.com, Inc.; 2000. Available from: http://www.ncbi.nlm.nih.gov/books/NBK285569/. [Last accessed on 2021 Nov 06].  Back to cited text no. 4
    
5.
Mohan H. Text Book of Pathology, the Endocrine System. 4th ed. New Delhi: Japee Brothers Medical Publishers (P) Ltd.; 2000. p. 792-3.  Back to cited text no. 5
    
6.
Krohn K, Führer D, Bayer Y, Eszlinger M, Brauer V, Neumann S, et al. Molecular pathogenesis of euthyroid and toxic multinodular goiter. Endocr Rev 2005;26:504-24.  Back to cited text no. 6
    
7.
Knobel M. Which is the ideal treatment for benign diffuse and multinodular non-toxic goiters? Front Endocrinol (Lausanne) 2016;7:48.  Back to cited text no. 7
    
8.
Bahn RS, Castro MR. Approach to the patient with nontoxic multinodular goiter. J Clin Endocrinol Metab 2011;96:1202-12.  Back to cited text no. 8
    
9.
Berghout A, Wiersinga WM, Drexhage HA, van Trotsenburg P, Smits NJ, van der Gaag RD, et al. The long-term outcome of thyroidectomy for sporadic non-toxic goitre. Clin Endocrinol (Oxf) 1989;31:193-9.  Back to cited text no. 9
    
10.
Röjdmark J, Järhult J. High long term recurrence rate after subtotal thyroidectomy for nodular goitre. Eur J Surg 1995;161:725-7.  Back to cited text no. 10
    
11.
Anonymous. Ayurveda Sara Sangraha. Nagpur: Shri Ayurved Bhawanpvt Ltd.; Reprint 2017. p. 586.  Back to cited text no. 11
    
12.
Sharma AR, editor. Sushruta Samhita of Sushruta, Nidana Sthana. Ch. 11, Ver. 22. Varanasi: Chaukhambha Surbharati Prakashan; Reprint 2004. p. 543.  Back to cited text no. 12
    
13.
Sharma AR, editor. Sushruta Samhita of Sushruta, Nidana Sthana. Ch. 11, Ver. 3. Varanasi: Chaukhambha Surbharati Prakashan; Reprint 2004. p. 539.  Back to cited text no. 13
    
14.
Sharma AR, editor. Sushruta Samhita of Sushruta, Nidana Sthana. Ch. 11, Ver. 29. Varanasi: Chaukhambha Surbharati Prakashan; Reprint 2004. p. 545.  Back to cited text no. 14
    
15.
Sharma PV. Dravyaguna Vijnana II. Varanasi: Chaukhambha Prakashan; Reprint 2015.  Back to cited text no. 15
    
16.
Anonymous. Ayurveda Sara Sangraha. Nagpur: Shri Ayurved Bhawan Pvt. Ltd.; Reprint 2017. p. 248.  Back to cited text no. 16
    
17.
Mishra SN, editor. Bhaishajya Ratnavali of Kaviraj Govind Das Sen, Vridhirogadikar. Ch. 43, Ver. 74-78. Varanasi: Chaukhambha Surbharti Prakashan; 2016. p. 795.  Back to cited text no. 17
    
18.
Aacharya YT, editor. Charaka Samhita by Agnivesha, Sutra Sthana. Ch. 12, Ver. 8. Varanasi: Chaukhambha Prakashan; 2006. p. 79.  Back to cited text no. 18
    
19.
Acharya YT, editor. Sushruta Samhita of Sushruta with Nibandha Sangraha Commentary of Dalhanacharya and Nyayachandrika Panjika of Shrigayadas Acharya. Shareera Sthana; Sharer Sankhya Vyakaranam Shareeram. Ver. 3. Varanasi: Chaukhambha Surbharti Prakashan; 2018. p. 363.  Back to cited text no. 19
    
20.
Rastogi S. A review of aconite (Vatsanabha) usage in Ayurvedic formulations: Traditional views and their references. Spatula DD 2011;1:233-44.  Back to cited text no. 20
    
21.
Aacharya YT, editor. Charaka Samhita by Agnivesha, Chikitsa Sthana. Ch. 1-2, Ver. 13-19. Varanasi: Chaukhambha Prakashan; 2006. p. 382-3.  Back to cited text no. 21
    
22.
Ramprasath VR, Shanthi P, Sachdanandam P. Immunomodulatory and anti-inflammatory effects of Semecarpus anacardium LINN. Nut milk extract in experimental inflammatory conditions. Biol Pharm Bull 2006;29:693-700.  Back to cited text no. 22
    
23.
Pulok K, Kumar V, Mal M, Houghton PJ. Acorus calamus: Scientific validation of Ayurvedic tradition from natural resources. Pharm Biol 2007;45:651-66.  Back to cited text no. 23
    
24.
Srikumar R, Jeya Parthasarathy N, Sheela Devi R. Immunomodulatory activity of triphala on neutrophil functions. Biol Pharm Bull 2005;28:1398-403.  Back to cited text no. 24
    
25.
Mishra S, Aeri V, Gaur PK, Jachak SM. Phytochemical, therapeutic, and ethnopharmacological overview for a traditionally important herb: Boerhavia diffusa Linn. Biomed Res Int 2014;2014:808302.  Back to cited text no. 25
    
26.
Nikhitha JN, Swathy KS, Chandran RP. In vitro anticancer activity of ethanol extract of Adhatoda vasica Nees on human ovarian cancer cell lines. J Genet Eng Biotechnol 2021;19:116.  Back to cited text no. 26
    
27.
Gheware A, Dholakia D, Kannan S, Panda L, Rani R, Pattnaik BR, et al. Adhatoda vasica attenuates inflammatory and hypoxic responses in preclinical mouse models: Potential for repurposing in COVID-19-like conditions. Respir Res 2021;22:99.  Back to cited text no. 27
    
28.
Berkovich L, Earon G, Ron I, Rimmon A, Vexler A, Lev-Ari S. Moringa Oleifera aqueous leaf extract down-regulates nuclear factor-kappaB and increases cytotoxic effect of chemotherapy in pancreatic cancer cells. BMC Complement Altern Med 2013;13:212.  Back to cited text no. 28
    
29.
Mishra R, Kaur G. Aqueous ethanolic extract of Tinospora cordifolia as a potential candidate for differentiation based therapy of glioblastomas. PLoS One 2013;8:e78764.  Back to cited text no. 29
    
30.
Sharma V, Katiyar A, Agrawal RC. Glycyrrhiza glabra: Chemistry and pharmacological activity. Sweeteners 2017;87-100. [Doi: 10.1007/978-3-319-27027-2_21].  Back to cited text no. 30
    
31.
Choucry MA, Khalil MN, El Awdan SA. Protective action of Crateva nurvala Buch. ham extracts against renal ischaemia reperfusion injury in rats via antioxidant and anti-inflammatory activities. J Ethnopharmacol 2018;214:47-57.  Back to cited text no. 31
    


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    Tables

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