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NIDANA

There are many modern fevers, which according to Ayurveda may be included among Sannipatta jvaras. The most important among them are fevers of enteric group like typhoid fever and para-typhoid fever.

In Ayurveda texts, we come across the description of 'Manthara jvara'.

NIDANA-

1. Atimarga gamana

2. Ati upavasa

3. Dusita sthana niwasa

4. Dushita ahara

Visista nidana-

Agantuka nidana-bacillus typhosus bacterial infection.

PURVA RUPA-

1. Sirovyatha(Headache)

2. Arichi(anorexia)

3. Baichaini(restlessness)

4. Tama pravesa(darkness in front of eyes)

5. Avasada(depression)

6. Malabaddata(constipation) 

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SAMPRAPTI GHATAKA

It is comparition with pittolavana sannipataja jwara.

SAMPRAPTI GHATAKA-

DOSHA-tridosha

DUSYA-rasa,rakta

SROTAS-annavaha,rasavaha

ADHISTHAN-antra 

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SYMPTOMS

1st week symptoms-

1. Jwaradhikya(hyperpyrexia103-104’f)

2. Plihavriddhi(splenomegaly)

3. Jivha malin and raktavarna(tongue coated & reddish)

4. Adhyamana(flatulence)

5. Vibandha(constipation)

6. Red spots on neck, abdomen & chest area)

2nd week symptoms-

1. Jwaradhikya(hyperpyrexia103-104’f)

2. Pralapa(delirium)

3. Tranda(drowsiness)

4. Kasa(cough)

5. Furrowed tounge,dry with reddish coloration)

6. Durbalya(weakness)

7. Mukhashosa(dryness of mouth)

8. Arati(restlessness)

9. In hyperpyrexia pulse is normal(dicrotic pulse)

10.Blood mixed stool 

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Sadhyaasadhyata- 

Following codition jwara is asadhya-

1. Atiraktasrava(excessive bleeding)

2. Tivra nadigati(increase pulse rate)

3. Udarasula(acute pain in abdominal)

4. Tendency of raised body temperature during morning hours and night)

5. Atidourbalya(excessive weakness)

6. Hastapada kampa(tremors in hands & feet)

7. Intestinal bleeding 

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UPADRAVA

1. Antrashaya(intestinal tuberculosis)

2. Visaktata(toxaemia)

3. Raktasrava(haemorrhage)

4. Udavaranakala sotha(peritonitis)

5. Antra vidarana(intestinal perforation)

6. Vakka sotha(nephritis) 

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TREATMENT

General treatment as indicated in Sannipata jvara. to bring down the temperature should be adopted.

The patient should be kept in perfect rest in bed with least movement and exertion. 'Shadanga paniya' is recommended to releive thirst, burning sensation. Suitable antibiotics should be used in consultation with modern doctor.

Ayurvedic drugs Godanti mishran is good antipyretic, and makharadwaja 125 mg daily with honey or juice of betel leaf, found to be useful as a rejunative. The main treatment is to maintain the strength and vitality of the patient.

Paratyphoid The signs and symptoms in para typhoid are milder than that of Typhoid. The condition are not so acute. Treatment is also the same as that of typhoid. 

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PRICIPAL OF CHIKITSA 

1. First langhana

2. Ugra vega avastha me 1st pitta then kapaha & vata chikitsa

3. Vibandha hone pe kostha shodhana

Amaltas ka guda 20gm -> kavatha

4. Antra pradaha hone pe sheeta, tikta, madhura dravya prayoga 

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TYPHOID (ENTERIC) FEVER 

Definition: Typhoid fever is a systemic infection characterized by fever and abdominal pain caused by dissemination of Salmonella typhi and occasionally by S. paratyphi A and B and S.typhimarium, all of which are non capsulated, gram negative motile bacteria.

Epidemiology

• Human beings are the only hosts for S. typhi and S.paratyphi. Thus enteric fever is transmitted only thorough close contact with acutely infected individuals or chronic carriers through ingestion of contaminated food or water.

• Chronic carriers are the source of infection harboring the organisms in their gall bladder (especially in the presence of gall stones) and rarely at other sites. It affects people of all ages and both sexes. Enteric fever is endemic in most developing countries.

• Currently the disease is observed at a great frequency in AIDS patients than the general population.

INCUBATION PERIOD- 8-14 DAYS

Pathogenesis

Following ingestion of the organism in contaminated food or drink, Salmonella typhi passes the gastric barrier and reach the upper small intestine where the bacilli invade the intestinal epithelium and they are engulfed by phagosoms which reside in the Peyer’s patches. The bacilli multiply and enter the blood stream and cause transient bacteremia. At this stage the

Salmonellae disseminate throughout the body in macrophages via lymphatic and colonize reticuloendothilial tissue (liver, spleen, lymph nodes, and bone marrow). Patients have relatively fewer or no signs and symptoms during this initial incubation period. Signs and symptoms,

including fever and abdominal pain result when a critical number of bacteria have replicated. During weeks after initial colonization, further inflammation of the Peyer’s patches may result enlargement and necrosis which may result intestinal hemorrhage and perforation. Infection may become persistent and invade the gall bladder. The clinical phase of the disease depends on host defense and bacterial multiplication.

Clinical Manifestation

The incubation period varies from 3-60 days. The manifestation is dependent on inoculum size,state of host defense and the duration of the disease. The Severity of the illness may range from mild, brief illness to acute, severe disease with central nervous system involvement and death.

First week

• Fever is high grade, with a daily increase in a step-ladder pattern for the 1st one week and then becomes persistent.

• Headache , malaise , Abdominal pain

• Initially diarrhea or loss stole followed by constipation in adults, diarrhea is dominate feature in children

• Relative bradycardia

• Splenomegally Hepatomegaly

• “Rose spots” not commonly seen in black patients. In whites it appears as small,pale red, blanching macules commonly over chest & abdomen, lasting for 2-3 days.

• Epistaxis

Second week

• Fever becomes continuous

• The patient becomes very ill and withdrawn confused, delirious and sometimes may be even comatose

Third Week

• The patient goes to a pattern of “typhoidal state" characterized by extreme toxemia,

disorientation, and “pea-soup” diarrhea and sometimes may be complicated by intestinal perforation and hemorrhage.

Fourth Week

• Fever starts to decrease and the patient may deferveresce with resolution of symptoms. At this point patient may lose weight.

• Relapse may occur in 10% of cases.

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Complications of Typhoid fever

• Gastrointestinal perforation and hemorrhage: are late complications that may occur in the 3rd or 4th week. May develop despite clinical improvement. These complications are life threatening and need immediate medical and surgical interventions

• Other Less common complications

Hepatitis

Meningitis .

Arthritis, osteomyelitis

Parotitis and orchitis

Nephritis

Myocarditis

Bronchitis and pneumonia

N.B these complications can be prevented by prompt diagnosis and treatment

Chronic Carriers

• Approximately 1- 5 % of patient with Enteric fever become asymptomatic chronic carriers

• They shed S.typhi in either urine or stool for > 1 year

• Incidence of Chronic carriage is high in women and among patients with biliary

abnormality (e.g. gall stone, carcinoma of gall bladder) and other GI malignancies.

Diagnosis

Can be suggested by the presence of

Persistent fever

Relative bradycardia, which was found to occur in 86% of Ethiopians.

Rose spots, which occurs in 70% of whites and 20% of Ethiopians.

Leucopenia

But definitive diagnosis of the disease requires laboratory tests.

1. Isolation of the organism by blood, stool or urine culture is diagnostic.

o The yield of recovery of the organism differs depending on the specimen cultured and the duration of clinical disease;

o Blood culture -mostly (up to 90%) patients have positive culture in the 1st week, and only 50% by the 3rd week. The yield is much lower if patient has taken antibiotics prior to the test.

o Stool culture is negative in the first week and becomes positive in 75% of patients in the 3rd week. Urine culture parallels stool culture. Widal test for O and H antigens

• The O (somatic) antigen shows active infection whereas the H (flagellar) antigen could be indicative of past infection or immunization for typhoid.

• Widal test has certain limitations, and to make a diagnosis of current infection a 4X (fold) rise in titer on paired sera taken during the acute and convalescence phases is necessary.

Limitations of Widal test

• It is non specific and a positive test could be due to Infection by other salmonellae (as the antigen used for the test is also shared by other salmonellae)Recent vaccination for typhoid

Past typhoid (already treated)

• The demonstration of 4- fold rise in titer on paired sera is not useful for the treatment of acute cases, as this requires waiting for the convalescence phase of the disease and at this stage if the patient is lucky recovery will occur.

Treatment

Antibiotic therapy is curative. These drugs can be given either orally or intravenous, depending on patient condition (able to take orally or not), severity of the disease. One should note that fever may persist for 4-6 days despite effective antibiotic treatment

Oral drugs

First Line

Nowadays 4-amino quinolones are the drugs of choice because of their effectiveness on multidrug resistant typhoid, and low relapse and carrier rates. Ciprofloxacin, norfloxacin, ofloxacin, and pefloxacin are all equally effective.

• Ciprofoxacin: 500mg PO BID for 10 days

• Ceftriaxone 1-2 gm IM or IV for 10 -14 days

4- amino quinolones are not recommended for use in children and pregnant women because of their observed potentialdamaging effect on cartilage of the growing animals. However, in severe infections especially by MDR strains, we have to outweigh the benefits and the potential risks.

Alternative

• Azithromycine 1 gm PO daily for 5 days

• Chloramphenicol 500 mg Po QID for 14 days

• Norfloxacin 400mg twice daily for 10 days

Chloramphenicol is very cheap and also quite effective with initial doses of 3 - 4 g/d for adults, with clinical response observed in 24 - 48hrs after initiation. Dose should be reduced to 2g/d when fever starts to decrease (usually after 5 - 6 days), and continued to complete 2 weeks treatment.

Intravenous drugs are recommended for critically sick patients who are admiited or for patients who are unable to take oral drugs

• Ceftriaxone 2-4gm once a day for 3 days and then 1- 2gm IV/IM for a total of 10- 14days.

• Intravenous Chloramphenical 1gm IV QID for 2-3 days and then start PO medication as soon as the patient can take oral medication. This is a drug of choice for patients that need parenteral therapy especially in Ethiopia (mainly for cost reason).

Problems of antibiotic treatment

• Multidrug resistant (MDR) S.typhi is reported in different parts of the world, especially Indian subcontinent and Southeast Asia. Hence if resistance is suspected in an area, the preferred treatment would be with quinolones, azithromycin or third generation cephalosporins

• Early use of antibiotics is associated with high rate of relapse (up to 20%) as compared to untreated cases (where the relapse rate is 5 - 10%). This is due to inhibition of adequate development of immune response by early therapy.

• Eradication of chronic carrier state requires prolonged treatment with

Ciprofloxacin for 4 weeks is effective and much better than the other drugs Ampicillin or Amoxicillin 100mg/kg/d taken with Probenecid 30mg/kg/day for 6 weeks.

Co-trimexazole (160/800mg twice a day) plus Rifampicin 600mg orally/d for 6weeks..

N.B. Drug treatment does not eradicate infection in 40% of the chronic carriers. Hence surgical resection of the gall bladder may sometimes be necessary.

Prevention and control

• Improve environmental sanitation

• Identification and treatment of Chronic carriers

• Avoid food handling by chronic carriers

• Vaccination for travelers to endemic areas

o Live oral vaccine (TY21a) 3 doses can be given to those over 6 years. Protective for several years

o Purified Vi polysaccharide vaccine given in a single dose to those over 2 years and HIV positives, is as effective as live vaccine.

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)

- Sutshekhar rasa-

- Praval panchamrit-(praval,mukta,sankh,sukti,varatika)

- Chintamani chaturmukha rasa-(parad,gandhak,abhrakh,vatsanabh,jayphala)

- Karpura rasa-(hingula,aphima,mustak,karpura,jatiphala)

- Ramban rasa-(parad,vatsanabh,lavanga,gandhak,maricha)

- Yogendra rasa-(rasasindur,svarna,kantloha,abhrak)

- Bol parpati-(bol,gandhak,parad)

- Navayas loha-(triphala,trikatu,loha)

VATI-(250-500MG WITH USHNA JALA)

- Madhurantak vati-(muktapisti,kasturi,kesar,jayphala,javitri,loung)

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

- Sansamani vati-(guduchi)

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)

- Chandanadi kvatha

- Kiratiktadi kvatha

- Mustadi kvatha

- Lohasava-9loha,triphala,vidanga,munakka)

- Drakshsava

- Chandan kiratiktadi kvatha-(raktchandan,yavasa,sounth)