Cardiac Failure Due to Cardiomyopathy in a Patient of Chronic Lymphocytic Leukemia

This is the medical story of a man, Mr X, 65 years of age, the husband of a long term patient of mine. He came to me In May 2012, with a complaint of breathlessness and chronic pain in his right knee. He had a history of recurrent URTI’s for which he would take a course of antibiotics along with whatever the physician prescribed. He didn’t have much faith in homeopathy. He had seen some physicians in a well known city hospital who suggested he may have Sarcoidosis, from initial lab investigations.

A repeat CBC a few days later showed a high total white blood cell count, about 31,600.

CBC  14/6/2012 :Haemoglobin 12.3 WBC 31,300  Lymphocytes 74.9 Neutrophils 19.7 Platelet Counts 169,000

Immediately, I advised him to see a hematologist, who confirmed over the next couple of weeks that he was indeed suffering from Chronic Lymphocytic Leukemia, following a battery of blood tests.

The early constitutional case analysis suggested Lachesis as his constitutional remedy. We started on Lachesis LM2, 5 drops in half a cup of water, 1 teaspoonful, once a day. He seemed to do well on it with the occasional URTI needing a specific remedy. The LM potency was changed every 2 months or so – till he went up to Lachesis LM7. At this point he went for a holiday to the US in May 2013, and kept well there. But on his return, he developed a URTI that quickly became an LRTI with fever and cough. Very quickly, he developed a wheeze and was unable to breathe – he panicked. The notes state

6^th July 2013
“-  I shifted to Lachesis LM 8
– The cough worsened so much I wasn’t  able to rest even for an hour
– Along with this rather silent cough .. as if my intestines are trying to come out… can’t breath for those few minutes… a dry, silent cough.
– Entire night I was comfortable only if I sat in erect position leaning forward.
– There is no relief with Arsenic 200.
– I became feverish yesterday with fever ranging between 100 and 103. I took the fresh dose of Lachesis LM8 as well as Meftal Forte (evening, midnight and today morning).
– I went to the physician to have an opinion but have not started the antibiotic line of treatment. I have only started a session of nebulizer. “
At this stage we’re still under the impression it is a lung related issue.

Kali Carb 200 gave no relief.

But that night he got desperate and thought he was going to suffocate to death. So he got admitted into a nursing home for investigations and emergency management.

2-D ECHO revealed Low Ejection Fraction – 25%
Diagnosed with Cardiomyopathy: Started on Protocol
Nikoran 5mg 1-0-1 (cardiac medication)
Augmentin 625 mg 1-1-1 X5  (antibiotic)
Azee 500 mg 1-0-0 X5  (antibiotic)
Forcan 50 mg 1-0-0 x5  (anti fungal)
Deryphylline ® 1 daily  (bronchodilator)
Romilast (B) 10 MG 1 daily  (anti histaminic)
Cardace 2.5 mg 1-0-0 (ACE inhibitor)
Aldactone 25 mg 1-0-0 (Potassium-sparing diuretic)
Lanoxin 2.5 mg ½ tablet-0-0 (Digoxin)

Here we see that the attending physicians had no idea what brought up this episode of cardiomyopathy – bacterial infection? allergy? fungus? – let’s treat all three!
-they had to deal with the lung status of wheezing and pulmonary edema – hence bronchodilator, diuretic were given
– they had to treat the cardiac failure hence digoxin, ACE inhibitor and Nikoran were given to improve cardiac muscle contraction along with increasing cardiac muscle perfusion.

At this point, I was not yet well versed with cardiology, the study of which started the following year. I put him on a homeopathic protocol as I understood then – constitutional remedy along with cardiac muscle stimulant. It’s important to realize, whatever one does, reliance on the action of the constitutional remedy is paramount and supportive to any other remedy.

In retrospect, it was wise of him to get admitted and get all his investigations done. We had now a clear clinical diagnosis and an idea of what other specific management (cardiac) was required besides the CLL status. He did not tell me at this point that his ECG also showed an OLD SEPTAL INFARCTION (q wave in V1 to V3) with LAHB (left anterior hemi block). This I discovered one year later when he sent me all his old investigations. When this infarction occurred is anyone’s guess!

August 2013: Lachesis LM8, Strophanthus LM2
Sept 2013: Lachesis LM9, Strophanthus LM3, Crataegus Q (cardiac failure)
Nov 2013: Lachesis LM10, Strophanthus LM4, Crataegus Q: all once a day
Merc Sol 200 (once a week) for enlarged lymph nodes which he tended to have either in the cervical region or in the inguinal area

Dec 4th 2013: Again he developed infective lower respiratory symptoms that suggested some cardiac component as well. I prescribed Thuja 1M as antimiasmatic and because of other modalities and green expectoration.

“I took THUJA 1M
– cough is worse than it was,

• Mucus is more, thick and light green and comes out when I cough.
  – Cough reduces when I sit quietly at one place but if I change the position  like lie down on bed, it returns.
  – Mental state: I’m constantly in a state of feeling ‘out of the race’ and not very happy with it. I have developed a feeling of regret that I could have done a better job of my life, my career.

He was afraid of a repeat of the previous episode in July and quickly went to see a physician who gave him .. ANTIBIOTICS .

I chided him about this, promising him that there would be consequences to this dependence on antibiotics. They did not relieve him completely and I had to finally prescribe for the acute left over symptomatology of night cough and weakness.

Dec 17^th 2013: Follow up
– Swelling of the nodes has reduced considerably
– ache around both my nostrils, that spreads into the upper gums on the right hand side.
– boil has become visible on the inner edge of the left nostril
–  Boil on the gum

Rx in addition to Lachesis LM10, Strophanthus LM4, Merc sol 200 , Crataegus Q: TUBERCULINUM 200

• Jan 8th 2014
  – Dizziness – like I can’t walk straight,
  < getting up from lying position
  Allopathic protocol modified for side effects – some drugs changed
• Jan 15^th 2014
  First Cardiac related improvement: 2DECHO
  8.2013: Severe Pulmonary Hypertension; PASP=83mmHG, EF – 25 %
  15.1.2014: Mild Pulmonary Hypertension; PASP=38mmHG, EF – 25-30%
  BUT, LA and LV more DILATED:

Rx: Myocardium 200 once a week was added to the earlier protocol
Myocardium is a sarcode prepared from heart muscle and is available locally (Zorashtrian Pharmacy, Princess Street, Mumbai). I considered it to be a specific stimulant for cardiac muscle that would hopefully promote the regeneration of weakened and dilated myocytes (cardiac muscle cells).

This picture suggested that though the cardiac pulmonary hypertension had been relieved (possibly the effect of Crataegus Q and Myocardium 200), the cardiac muscle had gone into compensation by becoming more dilated – this dilatation also resulted in more leakiness (regurgitation) of the Mitral and Aortic valves. It also suggested that the stress factors on the heart – increased exertion and volume overload – were not controlled by the patient in his habits and lifestyle. I make a special mention here – that it is important to ask patients about their adherence to lifestyle changes and instructions given. The areas where changes are necessary include diet, exercise, fluid intake and occupational habits. People are often not aware how much their unhealthy lifestyle and habits affect their health – till they land up in the emergency room!

In this patient’s case, though he was maintaining a good diet control, he was in fluid overload. ALL patients of cardiac failure and poor ejection fraction (EF) less than 40% are instructed to restrict total fluid intake over 24 hours to 1.5 liters a day. He was drinking much more than advised, as he felt very thirsty throughout the day. Low blood pressure also made him feel weak, in addition to the diuretic, he constantly felt the need to have fluids. Secondly, he was not restricting his physical activity to what his cardiac capacity was comfortable with. He wanted to climb 2 flights of stairs to his office and went for brisk walks in an attempt to “strengthen” his heart and lungs. He was firmly instructed to engage in very minimum physical activity until his ejection fraction (EF) would increase above 35%. This was a difficult restriction for him!

At this juncture, I also began to doubt the effect of Lachesis. I felt that though it seemed close, it was not close enough as a constitutional. In retrospect it did not prevent the cardiac episode from worsening, and it seemed that these were sequelae of a viral infection of the lower respiratory tract that finally affected the heart resulting in a Viral Myocarditis (Homeopathy Treatment of Myocarditis ) in July 2013. In a short period of time, a couple of weeks or so that this took to develop, he had ended up with cardiomyopathy and an ejection fraction of 25%! If Lachesis was a good constitutional, it should have prevented this development. Besides this, the cardiac and respiratory symptoms kept recurring in some way or another.

I decided to look for another remedy following the next incident in Jan 2014 when the CBC suggested that the bone marrow function was compromised. For me this confirmed that the Lachesis was not having a deeply constitutional effect.

• Jan 25^th 2014
  CBC: Immature Lymphocytes flood the peripheral smear – 76%,
  Platelets 1,20,000,
  Hb had tended to be low very frequently
• Repertoization:

– blood; ANEMIA; cancerous complaints, in

– blood; ANEMIA; production of red blood cells impaired; pernicious

– blood; COAGULATION; difficult, absent, hemophilia

– generalities; WOUNDS; bleeding; freely
Remedies: CROTALUS HORRIDUS,  PHOS

Fortunately, for the last six months I was treating his son for various chronic problems and he was doing very well on his constitutional medication. No prizes for guessing what it was?! Crot. Horridus!  Immediately we switched to Crot. Horridus LM 10, 5 drops daily, 1^st cup, 1 teaspoonful as the dose.

Feb 14 2014: On Crot. Horr LM10 (Stopped Stophanthus)
Myocardium 200, Crataegus Q

Hemoglobin 13.5 in Jan 2014 and Feb 2014.
WBC total count is 48,000 against 35,300 (in Jan)
The lymphocytes – 75.0 and there is no mention of atypical lymphocytes.
Platelet count improved: 1,20,000 (Jan 2014) and now 1,83,000 (Feb 2014).
-Cough has not worsened
– Phlegm too remains.
Fever (temp 100) evening went away by night. No fever today.

Here we see an immediate constitutional response to the Crot. Horridus. The bone marrow showed immediate change for the better. It is definitely a reliable remedy for his CLL and hence will be supportive for his cardiac status as well. Thereafter he remained clinical stable for at least 8 months. The report below however shows the total count increasing. It is not doubling as expected in malignant CLL, but has increased. I see this as the effect following the earlier increase of immature lymphocytes (that now do not exist) – and also the long term effect of repeated courses of antibiotics the previous year.

Here are comparative CBC reports over a year which show good bone marrow stability, following the one freak report of immature leucocytes above. This is the quality of life homeopathic treatment offers.

Test Done	30th Sept 2014		3rd Nov 2014		5th Sept 2015		5th Oct 2015
RBC Parameters
Haemoglobin	13.5		14		13.4		13.5
RBC	4.58		4.57		4.6		4.73
PCV	42		41.3		40.8		41.4
MCV	92		90		89		88
RDW	12		11.3		14.3		15.1
WBC Parameters
WBC Total Count	96,000		99,600		1,27,500		1,15,900
WBC differential count
Lymphocytes	90		80		87		92
Neutrophils	7		14		6		5
Immature Leukocytes				1		1
Immature Leukocytes
Platelet Counts	1,46,000		1,48,000		1,61,000		1,47,000
PCT	0.138		0.132		0.151		0.143
Test Done	30th Sept 2014		3rd Nov 2014		5th Sept 2015		5th Oct 2015

 

March 2014 – He had stopped taking Lasix (without my knowledge) as he felt like it was making him more thirsty and he could not control his fluid intake. It was also making him feel weak. He started with typical symptoms of fluid overload resulting in pulmonary edema. This fluid overload happens because the cardiac muscle is not able to pump with required capacity. There is also regurgitation due to the dilated valves, resulting in excess fluid settling into the lung parenchyma. This is overcome by draining excess fluid with the help of a regular diuretic, the dose of which is reduced and adjusted according the clinical condition. He was advised to restart Lasix 40 daily.
His symptoms were: Frequent coughing spells, breathless till 3 am
On Lasix, there is no cough now, though the throat remains rough.

Since some symptoms persisted even after giving him lasix, here was the right juncture to see the effect of the acute homeopathic simillimum.

More about symptoms:
Phlegm is present in the chest come out with coughing
Thirsty all the time but keeping within the liquid limit of 1.5 lt.
Unable to sit without a/c. After 3 am but before that I wake up due to cough and breathlessness.
Obviously fearful of suffocation as he experienced it last year.

On repertorization, Aconite and Digitalis came up. Aconite is a very good cardiac remedy.  According to Boger: The Sphere of Action :
“NERVES Medulla,  NERVES sympathetic,  NERVES vagus.,  NERVES respiratory center., HEART Arterial, HEART circulation,  Viscera larynx , Viscera chest, Viscera abdomen.”

It is not difficult to understand the pathophysiology of the Aconite action – it acts on the parasympathetic and sympathetic nervous system, bringing them into balance, allowing for adequate vasoconstriction, reducing vasodilatation that allows the fluid to escape out into areas that collect fluid like the viscera of chest and abdomen. In its collective action, it is able to balance the cardiac and respiratory instability by bringing the nerve and blood vessels into optimum function.

Rx  Aconite 200 one dose per day for 3 days, DIGITALIS 30 to be continued daily after that.
He was immediately relieved with a dose of Aconite 200, but I continued it for the next 3 days, once a day. When he was asymptomatic, he started on the Digitalis 30.

June 2014:
Crategus 3X since 24th Jan(2 pills thrice a day)
Crot. LM 27.
Myocardium 200 (1 pill twice a week)
Scrrhinum 1M twice a week (instead of Carc as it was not having an effect on the CLL and white cell count)
Digitalis 30 (twice a day since April 2014)
Merc Sol 1M ( twice a week)

CARDIAC STATUS EVALUTATION

Comparative 2DECHO reports – as shown below suggested the LVEF was improving following Aconite treatment; Lasix continued, and Digitalis 30 started.

2D ECHO DATE	Ejection Fraction	PASP	LVEDP
Aug 2013	< 25%	83 mm Hg (very high)
Jan 2014	25-30%	38 mm Hg (moderately high)
Jan 2015	25 – 30%	27.3 mm Hg	Raised E/E’ = 20
May 2015	25 -30%	22 mm Hg (normal)	Normal = 14
Sept 2015	30-35% (Much improved!)	24 mm Hg (normal)	Normal

 

This suggests great functional improvement of the cardiac muscle, but the generalized dilatation of the Left Atrium and Left ventricle has yet to respond.

ECG  reports:

 

October 2014 : Clinical Stability continues. But to keep his counts clinically stable, I felt we needed to change the LM potency every 4 weeks and hence by October 2015 he was already on Crot. H. LM17.

These are clinical decisions one is able to make and medications adjusted when a patient follows up consistently and does repeated blood tests to give one an idea of the clinical pattern. This patient was very cooperative and hence this is a beautiful case to illustrate the positive response to homeopathic management and medication.

Swelling of 2-3 lymph nodes groin area – none in the neck but the uneasiness decreases.
Myocardium 200 twice a week.
Carcinosin 1m once a week (Cancer)
Merc Sol 1m once a week (Lymph nodes)
Crot. Horridus LM 17
Crataegus Oxy Q 5 drops daily.

Dec 5th 2014: The patient went for a follow up to the same oncologist after 2 years since the diagnosis. The Oncologist’s opinion was very favourable for the treatment given so far. He could not explain how the patient was maintaining himself well; the lymphocytic doubling rate was not as expected, it was very low and slow to progress and the bone marrow status was very stable.

According to the Oncologist:

-Rare to see the rise in Haemoglobin.
-Positive is the stabilized numbers of platelets.
-He ‘grudgingly’ accepts t could be effect of homeopathy, calls it unusual.
-It is expected in CLL and the numbers would increase to much higher levels -Unsure about the prognosis.
-He does not expect WBC count to reduce

The Roller coaster with the patient continues. He remains stable over all in his cardiac status and CLL, but is very susceptible to infections in the environment.

September 2015

He developed a fever with suffocative cough at night for which I initially prescribed Bryonia 200 and Antim tart 200.  In a couple of days, he came up with typical Drosera symptoms and so we switched to Drosera 200 daily.
Diagnosis: Pneumonia RMZ on Xray.
Rx Drosera 200  based on the homeopathic characteristics. Chronic medication protocol was continued (NO ANTIBIOTICS – treated at HOME). He took about two weeks to recover completely.

 

February – March 2016

 
Diagnosis: Herpes Zoster (Pic – left) followed by generalized adult onset Chicken Pox (Pic – right)!

This was precipitated by an over ambitions experiment on his part to improve cardiac function by an exercise regiment suggested by one of the leading heart institutes in the area.
Rx Crot. H.  LM35..then LM 36.., Ledum 1M, Hypericum 1M, and other cardiac medication continued both homeopathic and allopathic).

One patch of herpes zoster on his chest (see pic above) developed a secondary infection due to constant blood stained discharge oozing from the herpes vesicles.
A course of antibiotics then had to be given when he developed high fever with shivering and seemed like he was going into secondary infection with possible septicaemia– Amoxycillin 500 with potassium Clavunate 125 twice a day for 7 days (treated at Home) acted immediately and the infection was controlled within 24 hours. Homeopathic medication was continued through all this time.
He has recovered almost completely from the Herpes Zoster as well as Chicken Pox as of date, May 2016.

May 2016: PRESENT STATUS

Conclusion:

Mr. X is now 68 years old. He is totally convinced about the power of the simllimum remedy to get him out of difficulty at every stage. He would have liked to be totally on homeopathy for his cardiac problems as well. I advised him it is wiser to take the minimum required allopathic support, given that we are also dealing with CLL.

He gave his family and himself a fright with the Herpes Zoster and complicated with Adult Chicken Pox – which was an indication of how fragile his immune system is. We are toeing a fine line of health, precarious to say the least. He has realized he needs to be careful not to stress his health and immunity to avoid repeated infections. He has to make additional lifestyle choices that support the homeopathic treatment.

And the story is still in the making …

 

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