1

DETAILS

This is also a variety of Vitalvana-sannipéta jvara, it is called 'akshepaka' because the patient

throws or moves his hand and feet violently very often i.e. convulsions.

Comperisionly it is krikach sannipataj jvara.

EPIDEMIOLOGY- Meningococcus bacteria 

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NIDANA

- Sankirna sthana nivasa

- Atidurbala and nirdhana

- Nasagata roga

- Pratisyay(cold) 

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SYMPTOMS

1. Severe headache & vomiting

2. Shitapratiti(rigors)

3. Kampa(tremors)

4. Griva stambadha(neck stiffness)

5. Stiffness in limbs

6. Continuous fever

7. Tranda(drowsiness)

8. Moha(confusion)

9. Pralapa(delirium)

10.Apeksha(convulsion)

11.Red rashes over body

12. There is contraction of muscles of the back and neck, he feels difficulty in moving his neck because of the stiffness 

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SAMPRAPTI GHATAKA

DOSHA-tridosha

DUSYA-rasa,lasika

SROTAS-sangyavaha,rasavaha

ADHISTHAN-mastiska,sususma 

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TREATMENT

Acute medical care should be provided in a modern Hospital. Ayurvedic medicines indicated after the 'Emergency management' are Suvarna Bhupati Rasa, or Yogendra Rasa. "Hiranya garbha pottali rasa" is a reputed heart tonic, it should be prescribed in this condition as it strengthens the muscles of heart and soothens the brain. 

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UPADRAVA

not mention

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PRICIPAL OF CHIKITSA 

1. 1st 4-6 din langhan karaye.

2. Trishna- shadang paniya sevana

3. Prusta bhag me hot water beg seka

4. Tivrajvar- cold water bandage 

8

MENINGITIS (Cerebrospinal fever) 

Definition: is an inflammation of the arachnoid layer of the meninges and the fluid that circulates, in the ventricles and sub-arachnoid space (CSF), caused by bacterial infection

Etiologic agents: the causes of bacterial meningitis vary with age:

• Infants (< 1 year): E. coli, group-B streptococcus, Listeria monocytogenous are the commonest causative agents.

• Young children/toddlers (age 1- 6 years ) : Haemophilus influenza, Meningococcus account for > 50 % of cases

• Adolescents and Adults: Meningococcus, Pneumococcus are the commonest

etiologies

• In immunocompromised hosts and cancer patients: Listeria, Staphylococcus, Pseudomonas aeruginosa etc.

Rout of infection:

• Droplet infection through the upper airways: E.g. In Meningococcus meningitis, with possibly epidemic spread

• Haematogenous spread: e.g. in Pneumococcus pneumonia

• Contagious spread from adjacent sites : e.g. in otitis media , sinusitis

• Direct: e.g. in open head injury

Clinical presentation;

• Incubation period: the incubation period for Meningococcal meningitis may range from 1-10 days, but mostly the clinical manifestations occur within in 2-4 days

• Meningitis may manifest as an acute fulminant illness that progress rapidly in few hours or as a subacute infection that progressively worsens over several days.

• The classic clinical triad of meningitis is fever, headache and nuchal rigidity (neck stiffness) , which are seen in > 90 % of patients . • Alteration in metal status can occur in > 75 % of patients and can vary from lethargy to comma.

• Nausea and vomiting are common symptoms.

• Avoiding light (photophobia) is seen in some patients.

• Seizure occurs as part of the initial presentation of bacterial meningitis, or during the course of the illness in 20-40 % of patients

• In Meningococcal meningitis of sudden onset with severe course, patients develop diffuse erythromatus maculopapular rash which rapidly becomes petechial, purpural or bullos lesions. The petichiae are found on the trunk, lower extremities, in the mucous membrane and the conjunctiva, and occasionally on the palms and soles.

• In older and debilitated patients the symptoms of meningitis may be subtle.

Meningeal signs are clinical signs often sound in patients with meningitis

• Neck stiffness when head is flexed passively

• Kerning’s sign: when one leg which is flexed at the hip and knee joints, is passively extended at the knee joint, the other leg flexes at the knee.

• Brudzinski’s sign: Upon passively flexing the head, one notices flexion of both legs at the knees

Note: These classic meningeal signs may not be seen in infants, old persons and patients in coma.

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Complications:

• Brain edema,

• Hydrocephalus

• Brain abscess,

• Septic vein thrombosis

• Hearing impairment

• Fulminant meningococcal sepsis: Waterhouse-Friedrichsen syndrome is a clinical condition resulting from hemorrhagic necrosis of the adrenal gland, with multi-organ failure. Patients are hypotensive or in shock. Disseminated intravascular coagulation

(DIC) with skin and mucosal purpura and bleedings are commonly seen associated features.

Diagnostic approach

• History, physical examination,

• Search for possible source of infection(pneumonia , otitis media , sinusitis ,head injury)

• CSF analysis

• Identify the organism from CSF and blood (culture, PCR etc.)

• Serologic antibody test : latex agglutination test

Laboratory findings:

General signs of inflammation: leukocytosis, CRP and ESR ↑ CSF analysis:

• Gross appearance and opening pressure : CSF looks turbid and the opening pressure is increased ( due to raised intra cranial pressure )

• Cell count and differential : polymorphonuclear leukocytosis

• Biochemical tests : glucose is decreases and protein in the CSF is elevated

• Gram stain Culture and sensitivity 

Differential diagnosis:

• Virally caused meningoencephalitis (Coxsackie-, Echo-, Mumps-virus, HIV, measles, CMV, VZV, HSV)

• Chronic meningitis : Tuberculous meningitis , Cryptococcal meningitis

• Subarachnoid hemorrhage

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Treatment:

A. Antibiotic Therapy

1. Empirical antibiotic therapy:

Bacterial meningitis is a medical emergency and antibiotics should be initiated immediately before the results of the CSF gram stain and culture are known.

Antibiotics should be given intravenously, at higher doses

• In adults without underlying disease: Ceftriaxone 2 gm IV BID plus Ampicilline 2 gm IV QID for 2 weeks.

• Crystalline Penicillin 3-4 million IU, IV every 4 hours plus Choramphnicole 1gm IV QID are alternative antibiotics for a resource limited setting .

• Patients with ENT infection or head injury: Ceftriaxone 2 gm IV BID and Vancomycin 1 gm IV BID + treatment of the underlying cause.

• If suspected hospital-acquired infection: Ceftriaxone 2 gm IV BID plus Vancomycin 1 gm IV BID plus Gentamycin (80 mg TID)

• In immunodeficient patients: Ceftriaxone 2 gm IV BID plus Vancomycin 1 gm IV BID plus Ampicillin (2g IV QID)

2. Specific antibiotic therapy: is given when the specific etiologic agent is identified through gram stain or culture

• N. meningitidis : Even though Ceftriaxone or Cefotaxim provide adequate empirical coverage , Penicillin G remains the drug of choice for N. Meningitides Crystalline Penicillin 3-4 million IU, IV every 4 hours for 7 -10 days may be adequate.

• Pneumococcal meningitis: Antibiotic therapy in initiated with Cephalosporins plus Vancomycine Ceftriaxone 2 gm IV BID and Vancomycin 1 gm IV BID for 2 weeks

• H. influenza : Ceftriaxone 2 gm IV BID for 1- 14 days may be enough Choramphnicole 1gm IV QID may be an alternative antibiotic, for patients who may not afford Ceftriaxone.

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B. Symptomatic and adjunctive Therapy

• Steroids:

o Dexamethason when initiated before antibiotic therapy reduces the number of unfavourable outcomes, including death and neurologic complications. It is mainly advantageous in children, predominantly with meningitis due to H. Influenza and S. Pneumoniae.

Dose: Dexamethason10 mg IV 15-20 minutes before the first dose of antibiotics and 4 mg IV QID for 4 days

• Treat increased intracranial pressure:

o Elevation of the patients head to 30-45o

o Intubation and hyperventilation ( till PaCO2 is lowered to 25-30 mmHg )

o Mannitol IV infusion

• Regulate water and electrolyte balance,

• Thromboembolism prophylaxis

• Patients with meningococcal meningitis should be isolated.

Chemoprophylaxis: In case of N. Meningitides, all close contact to the patient should be given chemoprophylaxis with:-

• Rifampicin 600 mg PO BID for 2 days in adults and 10mg/kg PO BID for children > 1 yr.

• Ciprofloxacin 750 mg PO stat can be given as an alternative for adults. 

PATHYA-

- Purana Sali, Mudga, Masoor, Parval, Karela, Sahijan, Choulai, Gaduchi, Jeevanti, Makoya, Manukka, Anar, Laghu Ahar, Yavagu, Peya, Vilepi, Yava, Lajamanda, Daliya

APATHYA-

- Guru, vidahi, vistambhi, dushita jala sevana, ankurita anna, tilkuta, sweet, chole, lassi, chana dal

- Vegadharana, vyayama, divasvapna, sanana, adhyasana

NISHEDHJA-

- Nava jvar me divasvapna, snana, abhyanga, maithuna, krodha, dhimi hava   

RASODHI/BHASMA/PISTI-(120-250MG WITH MADHU/USHNODAKA)

- Murchantak rasa

- Vatakulantak rasa

- Mahalaxmivilas rasa

- Sutsekhar rasa

- Mayur piccha bhasma

- Saptamrit loha

- Chaturbhuj rasa

VATI-(250-500MG WITH USHNA JALA)

- Sanjeevani vati-(vidang,nagar,pippali,abhaya,vibhitaki,vacha,guduchi,bhallataka,visha)

- Shoubhagya vati-(rasasindura,dvikshar,trilavan,loha,trikatu,triphala)

- Sansamani vati-(guduchi)

- Vishatindukadi vati-(kuchala,mustak,parpat,triphala)

- Jayavati-(suddha visha,trikatu,motha,haridra,nimbapatra,bidanga)

- Amrita satva-(guduchi)

- Karanjadi vati-(karanj beej,parpat,atish,guduchi,patol,kutki)

CURNA-(3-6GM WITH MADHU/USHNODAKA)

- Sudarshan curna-(triphala,trimada,atish,chirayata)

- Panchkol curna-(pippali,pippalimula,chavya,chitrak,sunthi)

- Sitophaladi curna-(dalchini,ela,pippali,vanshlochan,mishri)

- Talisadi curna-(talisa,marich,sunthi,pippali,vanshlochan,mishri)

- Lavangadi curna-(lavanga,sheetal chini,khas,sveta chandana,tagar,bhringraja,motha)

- Drakshadi curna-(draksha,harad,mustak,kutki,amaltas,parpat)

KAVATH/ASAV/ARISHTA-(20-40ML WITH SAMABHAG WATER)

- Kiratiktadi kvatha-9chiryata,motha,minbachal,guduchi,kantkari)

- Dasamula kvatha-(brihat & laghu panchmula)

- Brihat panchmuadi kvatha-(bilva,agnimatha,shayonak)

- Bhunimbadi kvatha-(chirayata,motha,guduchi,brihati,kantakari,pushkar mula)

- Satpuspadi kvatha-(sounf,sunth,vacha,kuth,khas,mustak)

GHRITA(20-30ML WITH USHNODAKA)

- Panchtikta ghrita-(patol,saptaparna,nimba,vasa,guduchi)

- Amritadhya ghrita-9guduchi,mulethi,draksha)

- Shatpalak ghrita-(pippali,pippali mula, chavya,chitrak,sunthi,saindhav)

- Chandanadi ghrita-(svetachandan,vasa,karanj)

AVLEHA-(20-30 GM WITH DUGDHA)

- Drakshavaleha-(draksha,madhur varga aushadhiya)

- Chyavanprash-(amla,trikatu,jeevaniyagana)