The condition of a patient during initial consultation:
The patient was an 11-year old girl, thin, tall, blond, living in the city of Tomsk. She came for the first time n December 1998. After repeated medical observation and treatment in a specialized in-patient department of a RCH (Regional Children`s Hospital) in the city of Tomsk, the patient was diagnosed with Juvenile Rheumatoid Arthritis (JRA), articular-visceral form, highly active, seropositive, galloping course. The most recent admission to the hospital was in October-November, 1998. During the first interview the patient complained of swelling, pains and stiffness in almost all the small and large joints, and particularly metacarpophalangeal and proximal interphalangeal hand joints, wrists, ankles, elbow and knee joints. The pains bothered her round-the-clock, aggravating during motion and still persisting at rest. The stiffness would increase by the morning hours and decrease during motion. During medical examination the joints were found significantly swollen and deformed. The movement amplitude was significantly limited (elbow and knee joints in particular). Clinical: ESR increased up to 48 mm/hr, rheumatoid factor (RF) – up to 1:128 (with norms 1:20); urine protein 0,2-1,2 g/l and hematuria up to 1.800.000/microliter (cm3), the latter indicating kidneys being involved in the process, with immune inflammation and glomerular epithelium affection. LE-cells – not found.
Figure 1 Development of the Disease
Personal medical history
There was no any pathology of joints in the family medical history. According to the personal history the girl was born healthy and the parents were also healthy. The girl was breast fed for 12 months, with growth and development within norms, vaccinations having been done according to the schedule. At the age of 18 months (see the red section of the figure) the patient developed recurrent frequent (3-4 times a year) and long-lasting acute respiratory infections (ARI) with high fever up to 39C, which was followed by repeated antibiotics. At the age of 20 months the patient developed an infantile eczema (the face, arms and body having been affected), which was treated by the antihistamine medications and ointments. At the age of 3 years she was hospitalized 3 times within a period of 6 months. The first admission was due to acute dysentery, the rest of the admissions were due to the dysentery carriage, for which she received antibiotics repeatedly. At the age of 4-5 years the patient had frequent acutes with fever up to 39C. At the age of 6 years – the first cystitis manifested (see the yellow section of the figure), accompanied by pains while urinating, urine leukocytosis – was admitted to the children`s hospital with another antibiotic administered.. The cystitis developed into a chronic form, with the recurrent exacerbations with cutting pains and urine leukocytosis up to the age of 8 years, which was treated with uroseptic medications (with the following hospital admission). Multiple allergic reactions followed (see the green section of the figure): stomatitis alternating atopic dermatitis, pollinosis, allergic vulvovaginitis, respiratory allergosis with persistent cough. At the age of 6.5 years – in spite of all the vaccinations, including DPT, the patient was hospitalized because of whooping cough (laboratory diagnosed). In the hospital ascariasis was discovered as well, for which anthelmintic treatment was given (Pyrantel). At the age of 7 years the patient was diagnosed with streptococcal impetigo – dermatological treatment. At 7.5 years the patient was infected with chicken-pox. Up to the age of 9 the patient being frequently sick with ARI, tonsillites, otites, was repeatedly given antibiotics (the most recent febrile fever occurred at about 9 years old, see the figure – the arrow at the end of red section). At the age of 9 years (January 1997) the patient got a tick-borne encephalitis vaccine – after which she developed frequent headaches, weakness, rapid fatigability (headaches didn`t allow her to attend physical training lessons at school). Because of this the patient was treated by a neurologist having been diagnosed with intracranial hypertension. In August 1997 at the age of 9 years and 9 months the main complaint outburst: acute polyarthritis of large and small joints (shortly before the onset of the disease the patient got tick-borne encephalitis revaccination in the end of Spring 1997).
In October – November 1997 the girl underwent a medical observation with the following treatment in the Children’s Hospital No.1 in the city of Tomsk. Clinical: ESR increase up to 52 mm/hr, RF 1:64, with urine hematuria already showing 20 000/mcl (сm3). At first she was diagnosed with reactive chlamydia arthritis (based on revealing IgM titer 1:200 and positive PCR in throat and vulva swabs). The diagnosis was changed into the Reiter’s Syndrome, the change being based on chlamydiosis and chronic cystitis exacerbation. The patient was given a long-term course of antibiotics (including Sumamed) and antiviral medications (Reaferon, Viferon). She got NSAIDs as a long-term treatment (ortofen, indomethacin, voltaren i/m, delagil). Nevertheless the disease progressed over the year. The patient had to quit attending school and missed the whole school year. In Summer and Autumn 1998 (at the age of 10. 5 she was twice hospitalized in the RCH of the Tomsk city. The girl was diagnosed there with JRA, got sulfasalazine with no effect. Pain syndrome was increasing, with RF titer increasing up to 1:128, hematuria increasing up to 400 000 – 1800000/mcl (cm3). Since August 1998 had been taking Rhus-tox (12, 30, 200), Phosph, Calc-carb, Chin-ars, Merc-dulc in different potencies, and some complex homeopathy with no effect.
Other symptoms: According to the patient’s mother the girl was modest, bashful, mild, patient and very sympathetic (3). In July 1997, shortly before the development of the main disease she worried a lot (3) about her mother who was taken to a hospital because of some rib fractures. The girl was afraid of dogs (2), thunderstorms (1), had a fear that something might happen to her loved ones (2). She loves smoked food (3), spicy (2), milk (2). She was not thirsty. Her sleep was restless because of the pains in the joints; she often changed her position in sleep. Up to the age of 6 she used to grind her teeth in sleep; had sleepwalking, encopresis (with stool being formed), enuresis during the day (everything before 6 y.o.).
It has to be noted that the girl was born healthy with favorable inheritance. Till the age of 18 months she had no diseases and, most likely, by that time she was in the group A (according to the Levels of Health scale). Later the reactivity of her organism sharply increased, with the girl being frequently sick, so she appeared to have been in the group B (4th level). It is worth mentioning that there were no unfavorable factors discovered, that could possibly influence her organism in the period up to the age of 18 months. Reasoning logically one can conclude that the only essential factor affecting the defending system of the organism as a whole could be the vaccinations (given the relevant predisposition and sensitivity of the organism). The mentioned above fact is of the utmost importance. After the age of 18 months another significant factor disturbing the defense mechanism, including the immune system, was an inadequate ARI treatment, notably the repeated prescription of antibiotics and antipyretic medications. Because of all the above-mentioned the overall reactivity of the organism continued to increase even more, and up to the age of 6 the girl had only frequent acute inflammatory processes of different types with high fever. This on one hand, shows the healthy activity of the defense system, not allowing a chronic disease development. On the other hand, the patient’s level of health was constantly decreasing from the 4th to the 5-6th. Since the age of 6 one can note chronic cystitis, which was the reason for another of the hospitalization episodes with the increasing amount of antibiotics given. Nonetheless, the patient stayed in the group B up to the age of 8.5 – 9. Afterwards, in spite of the general aggravation (headaches, fatigability, physical exertion inability), the girl stopped developing high fever and acutes. It is at this moment that her organism was brought into the group C (7th level). Most probably, the additional factor of the immune system disturbance was the tick-borne encephalitis vaccination, which could have become “the last straw” for the already disturbed organism. Thereby, the severe degenerative pathology manifestation at the age of 9 years 9 months was, in fact, predetermined for the patient since the moment of an abrupt suppression of the organism reactivity and the following group of health decrease (the group C).
Prognosis: In correctly treating cases of C group patients the prognosis is the following: long-range recuperation, which can last for the period from 4-6 months to several years. During the treatment several remedies can be needed, one after another. During the process of recuperation we expect the appearance of reactions, that is the range of the pathologies, which were suppressed with the former improper (suppressive) treatments. Also one expects regeneration of the ability of the organism to produce acute inflammations and high fever. The initial aggravation of the articular syndrome and kidney symptoms is unlikely for the reason of having no effect from chemotherapy and the full clinical picture of the disease is present at the beginning of the treatment.
Figure 2 Repertorization
In 1998 I didn’t have Radar yet and repertorized manually using Kent’s Repertory. I studied and differentiated the same remedies: the repertorization of the symptoms gives as main remedies: Causticum, Phosphorus, Carcinosinum and Tuberculinum. The fact that a strong anxiety for the mother`s health in the patient triggered the disease is in favor of Causticum or Phosphorus. To confirm Tuberculinum we’d like to have marked irritability and discontent and some other keynotes also, like a desire for fat, a fear of cats or teeth grinding at night, but not before 6 y.o. (most probably Tuberculinum was an underlying remedy). Carcinosinum is a person who is fastidious, easily offended, sensitive to reprimands very much with the cancer in the family anamnesis. To confirm Phosphorus we’d like to see some other keynotes (for example a desire for company, thirst, a desire for ice-cream and cold drinks). But the main keynotes, mental-emotional essence and the physical pathology of the patient are in favor of Causticum. I decided to start with low potency because of the severity of the pathology, rather low level of health and because I was not absolutely sure in my prescription.
Prescription (12.12.1998): Causticum LM6 (to dissolve 10 globules in 250 ml of water, to take 1 teaspoon daily in the morning, before the meal), to reduce NSAIDs with the amelioration.
Consultation on the 03.02.99: The articular syndrome (pain, swelling, stiffness of all the joints) ameliorated by 10-15% without initial aggravation, in spite of the complete NSAID being cancelled at once with the beginning of the treatment. The amelioration lasted for the first two weeks, but then slowed down, despite daily remedy intake. The general state got better. ESR = 40 mm/hr, hematuria fell to 105.000/microliter, urine protein 0,59 g/l (clinical tests made on the 02.02.99). Conclusion: good remedy action, but the potency was too low; no changes in modalities. Prescription: Causticum 200 three doses for 3 days in a row, then Causticum 1M three doses for 3 days in a row.
Consultation on the 28.04.99: The pains in the joints somewhat aggravated in the period of 05 – 11th of February with the following amelioration by the time of next observation (amelioration by 30%). From the 24th of March to the 31st of March – vesicular eruptions of the palms with burning sensation and following desquamation. Simultaneously the patient developed the symptoms of stomatitis with strong pain in the mouth (similar to food allergy in the past), pain in the bladder, urethra and frequent urination (similar to cyctitis exacerbations in the personal medical history). Seven tiny flat (up to 4 mm) warts on the back of right hand appeared in April. ESR = 37 mm/hr, hematuria 130.000/microliter, urine protein 0.68 g/l, creatinine 60.4. Conclusion: good remedy action, return of old symptoms. Prescription: PL.
Consultation on the 04.06.99: The patient had the symptoms of ulcerative stomatitis in May, for the whole month. There were 2 episodes of high fever up to 38,2C, each of lasted for 1-3 days. No changes in the articular syndrome since April. Hematuria 185.000/microliter, urine protein 0,85 g/l. Prescription: Causticum LM 30 three doses for 3 days in a row.
Consultation on the 08.07.99: Pains in the joints slightly aggravated. The patient became more irritable. A desire for sweets appeared (2), an increased desire for bacon (2) and milk (3). The symptoms of stomatitis decreased. Hematuria 71.000/microliter, urine protein 1,27 g/l, ESR – 37 mm/hr. Conclusion: Causticum ameliorated the joint condition by 30% and hematuria by 90-95% , but there was no improvement observed for 3 months. There are changes in the modalities (the desires for fat, smoked bacon, sweets, milk increased) and irritability appeared.
The above mentioned changes in the organism’s functioning indicate a new remedy. Prescription: Tuberculinum LM12 every other day in the morning before the meal for a month.
Consultation on the 08.09.99: Pains in the joints are less and shifted lower (the knees and ankle joints were the most painful). The general state and the articular syndrome got 40%. The girl was able to continue studying at school (homeschooling). Stomatitis symptoms aggravated (there are aphthae being constantly present in her mouth). Hematuria counts 23 000/ microliter, urine protein – 0,51g/l. Conclusion: Tuberculinum had a positive effect. The treatment is to be continued.
Consultation on the 10.12.99: Against the treatment background there was an apparent amelioration observed: pains in the joints got 90% less, ESR lowered to 23 mm/hr, urine protein lowered to 0,27 g/l, with hematuria being not higher than 20.000/microliter. Though, during the last week before the consultation an aggravation took place: the pains in the joints reappeared both during the day and night, ESR increased up to 41 mm/hr, urine protein-up to 1,0 g/l. During last few months, in spite of the amelioration, the girl became more reserved, didn’t want to meet friends, became more warm blooded (2), developed a strong desire for salty fish and red caviar (3), the desire for smoked food decreased – the patient quit eating bacon. Conclusion: Tuberculinum positively affected both the main pathology and the general health state, with modalities of the case having been changed. A new remedy is necessary. Prescription: Natrium muriaticum 200 – 3 doses for 3 days.
Consultation on the 09.02.00: Over the first 3-4 days the pains in the joints were almost gone gradually (there were some insignificant pains only waking up in the morning). In January there were some skin eruptions registered, with palms, fingers, feet itching (no ointment was used). Over the last week the pains in the joints increased. The desire for red caviar (3). Hematuria 31.000/microliter, urine protein – 1,19 g/l. Conclusion: the remedy had a positive effect; given the rough morphological changes in the kidney glomerular epithelium the treatment is to be continued using a lower potency. Prescription: Natrium muriaticum LM12 once in 4 days.
Consultation on the 04.05.00: There are pains in the joints on and off, though being 90% less in comparison with the original level (in comparison with the pain level in the fall 1999). The flat warts on the back of the right palm are still present. ESR – 34 mm/hr, hematuria 12,2 – 22,5 000./microliter., urine protein 0,39-0,59g/l. The desire for fish and caviar disappeared, the desire for the smoked food (but not for the fat) increased; the desire for sweets decreased. Psychologically the girl was normal. Conclusion: the positive original effect of Natrium muriaticum decelerated, with the changed modalities indicating Causticum again (that acted well in the beginning of the treatment). Prescription: Causticum 200 – 3 doses for 3 days in a row (given the positive effect in the beginning of the treatment).
Consultation on the 13.07.00: The next day after Causticum 200 (already on the 05.05) there appeared a large boil below the right scapula (gone itself with no treatment). The pains in the joints decreased and hardly bothered the patient. 18.05 – ARI with 37.8 fever, with some cough and coryza (without the articular syndrome aggravating). An apparent aversion to sweets appeared (3). Hematuria count decreased significantly – to 4000/microliter. ESR count lowered to 16 mm/hr, urine protein lowered to 0,35 г/л. Conclusion: Causticum had a deep and positive effect, and it is proved by the ARI development with the fever (which the patient never had over the previous 3 years of the JRA development ). A proving symptom (aversion to sweets) along with the amelioration of both general state and the local symptoms of the patient supports the remedy choice. Prescription: Causticum LM 30 once a month.
Consultation on the 25.11.00: Pains in the joints hardly bother the patient since Summer (except mild monthly pains, which occur and last for 1-2 days after intake of Causticum LM 30). Overall state of health is normal and the patient started attending classes at school since September. Hematuria 5.000/microliter, urine protein 0,06 g/l., ESR – 26 mm/hr. Prescription: PL (mild pains occurring once a month after the remedy intake prove the remaining sensitivity to the remedy; a good state of the patient`s health allow a treatment gap).
Consultation on the 04.04.01: Pains in the joints almost didn`t bother the patient until the dental treatment with some local anaesthesia several days before. Swelling and pain in the left knee joint manifested. The general state is good. The warts disappeared from the right hand. In December and in March there were two ARI with high fever up to 38,7 C for 3-4 days. Hematuria stopped, urine protein – 0,08 g/l, ESR – 21 mm/hr. Prescription: Causticum 200, three doses for 3 days in a row (the remedy acted well, the relapse occurred due to the dental treatment being an antidote).
Consultation on the 17.07.01: Some eruptions with strong itching manifested in the area of chest and neck in May (disappeared without any treatment). The patients still undergoes the dental treatment and develops every now and then mild pains in the left knee joint and feet joints. Erythrocytes in urine 500/microliter (within norms), urine protein 0.03 (within norms), ESR 12 mm/hr. Conclusion: the treatment gave good effect, but the organism is still not balanced, some dose of the remedy is indicated to stimulate the defense system further. Prescription: Causticum LM30 once a month.
Consultation on the 02.10.01: The patient was hardly bothered by the joints. Streptococcal impetigo manifested in August on the left hand, on the right arm and on the right hip, then disappeared on its own within a week (a similar episode had occurred at the age of 7 years, but then treated with antibiotics). Erythrocytes in urine 250/microliter (within norms), urine protein slightly increased 0,2 g/l (the clinical tests were done when the patient was sick with ARI with cough and coryza), ESR 14 mm/hr. Prescription: To proceed with the treatment (the return of streptococcal impetigo is a proof of the treatment being correct).
Consultation on the 20.03.02: The joints do not bother the patient. There were some mild symptoms of stomatitis and itching atopic dermatitis. The patient had an ARI with fever of 38C in December. Recently the patient had ARI again, and pains in joints in the night and in the morning reappeared. A psychological state is good. The patient became more warm-blooded. Erythrocytes in urine 2,000/microliter, urine protein 0,06 g/l, ESR 25 mm/hr. Prescription: Causticum 200, three doses for three days in a row (a relapse occurred due to the ARI).
Consultation on the 31.08.02: The patient felt good until 4 days ago when there appeared pains in the joints. Erythrocytes in urine 500/microliter, urine protein 0,03; ESR 10 mm/hr. Prescription: Causticum 200, three doses for three days in a row.
21.03.03: The state is good. There were mild symptoms of stomatitis and atopic dermatitis periodically. Erythrocytes in urine 0, urine protein 0.06 g/l, ESR 10 mm/hr, RF is 1:4 (norms are up to 1:32), CRP – 0, AS(L)O – 250 МЕ/ml (within norms). Conclusion: within the period of six months the patient got no any homeopathic remedies, there are no signs of disease, according to the laboratory test results as well. Prescription: PL
03.09.03: The state is good. There are no complaints. The joints did not bother the patient, even during ARI with high fever up to 40C (in August, no specific treatment). The menstruation manifested (there had been three periods by the moment of the consultation, the process went normally without pains, every period beginning in 30 days). Erythrocytes in urine 250/microliter. (within norms), urine protein 0,06 g/l, ESR 5 mm/hr. Prescription: PL
28.04.04: There are no joint complaints, even the noticeable “knottiness” of the finger joints is gone – the joints look normal. In December the patient had a flu with 40 C fever, persisting for 4 days, – she took some complex homeopathy for the flu herself (Gireel, Traumeel). Since half a year she has had severe headaches up to 4 times a month, that were not treated. There were several episodes of menses delay up to 1,5 -2 months. The patient is warm blooded, she uncovers her feet at night. Urine: 0-1 rbc/fov (norm), protein 0,03 – 0,16 g/l, ESR – 5-7 mm/hr. Conclusion: Noticeable positive dynamics. 40 C fever episodes provide the evidence of the high activity of the defense mechanism of the organism; headaches appearing is likely to be a step in the recovery process. A new remedy is not obvious. Prescription: PL.
05.04.05: The patient is bothered by her menses delay up to 2 months. There are no other complaints. ARI with 39 C fever in December. The desire for the smoked food reappeared (2), aversion to sweets (2). Conclusion: the significant menstrual delay has been observed since over 1 year ago; the main modalities have not changed considerably still indicating Causticum. Prescription: Causticum 200 2 doses.
14.03.06: The patient felt well till February. Her menstrual cycle normalized. She graduated school, entered a college. In February she got a flu with 38 C fever, which wasn’t treated. Afterwards the patient had some weakness, sleepiness, itching eruptions on her feet which she treated herself with Thuja oil externally. This treatment brought back pains in all the joints in 24 hours (the pain disappeared itself). There appeared 5 large warts on the right big finger (most likely, it was the proving of Thuja). The warts still has been present for more than a month. Against the ARI background the tests showed: urine RBC 7-10 in the FOV (5.000/microliter), urine protein 0,68 g/l, ESR – 7 mm/hr. Conclusion: the slight provocation of articular pains and finger warts appearance by Thuja oil shows both the patient’s sensitivity towards Thuja and the arthritis predisposition (together with predisposition to warts on the hands) not having been gone fully. Causticum normalized the menstrual cycle which shows it’s deep action on the patient’s organism. The finger warts is a mutual symptom for both Thuja and Causticum. Prescription: Causticum 200 2 doses for 2 days in a row.
25.10.07: The patient feels well. There are no joint complaints. Warts disappeared a long time ago (the patient doesn’t remember exactly when). In February she had an ARI (with 39 fever lasting for 4 days), the same acute repeated in October (37.5), – neither acute was treated. Urine RBC -– 0-1-2/fov, urine protein up to 0.3-0.4 g/l, ESR – 8-10 mm/hr. The patient noticed her shoe size diminishing over the 2 last years from the 40th to the 38th (the scale used in Russia) – 2 sizes less because of the toe joints size diminishing. The patient was surprised, considering her “knotty” joints to have been normal. The menstrual cycle is stable lasting for 30 days. Conclusion: the patient has not been treated for 1.5 years, nevertheless, the recovery process goes on, showing no need for a remedy Prescription: PL.
26.06.09: The patient has been pregnant for 9 weeks. A year ago she got married, moved to Almaty (Kazakhstan). Over the last year the patient has had some moderate pains in the joints at times. She noticed that the joints were affected by wet weather, rain, which had never happened beforе. Since last 3 days there has been an aggravation against the ARI background with 40 C fever (persisting for 24 hours). Fear of dogs is still present (2). There is daily desire for bacon, sausages, smoked food (3), desire for fat (2), desire for sweets appeared (1), frequent perspiration all over the whole body during sleep (new symptom). Urine RBC – 0-1/fov, urine protein 0,25 g/l, ESR – 15 mm/hr. Conclusion: the organism formed a Tuberculinum picture again, – the remedy that already showed a positive effect in the past, following the healing action of Causticum. This time the remedy picture was more clear than before. Prescription: Tuberculinum LMXII (20 globules/ 250 ml water) – 1 teaspoon every second day in the morning.
27.01.10: Natural delivery (the child was born healthy). The patient had been taking Tuberculinum LM12 till the 30th week of pregnancy. She had neither general, nor articular complaints. Urine tests – within norms ( urine RBC 0-1, urine protein 0 – 0,08 g/l). A moderate physiological lowering of hemoglobin to 104 g/l was noticed. No other remedies were given.
16.08.11: In September, 2010 the patient experienced some stress: her husband divorced and left her alone with a child. The patient had to stop breastfeeding and start working. The menstruation reappeared since Spring of 2011, the joints would hurt and get swollen, morning stiffness returned. Lately the patient has an aggravation jf the joint pains. Within the period of last year the patient became more warm-blooded, weepy, started feeling the flushes of heat, could hardly tolerate stuffy atmosphere (3), stopped eating smoked food, developed an aversion to fat (2), to eggs (2), a desire for sweets (2). Conclusion: there is an aggravation due to the stress along with the picture of a new remedy. Prescription: Pulsatilla 30 daily for 2 weeks.
09.01.12: The effect from Pulsatilla was temporary: immediate amelioration, then the symptoms returned (after 2-3 weeks). Additionally the patient became chilly, would put her arms and affected joints into the warm water, developed an aversion to sweets. On the 08th of October the patient took Causticum 200 (two doses, the prescription was made via e-mail), which first brought about quick aggravation for a week, then marked amelioration, then the pains returned. The patient has been taking Causticum LM12 every second day up to the 08th of December without any effect. The joint pains were worse by the morning time and during the daytime and better by the evening time (no painkillers, the patient continues working). Psychologically – the patient suffers from the separation from her husband, keeps all the grief inside, weeps while alone. A desire for extra salt (2) and salty fish (2) appeared; an aversion to fat (2) and aversion to smoked food still exists. She started drinking water more. Conclusion: apparently, the prescription of Pulsatilla was a mistake for the reason of a short remedy action, bringing about some palliative effect and changing the case. Causticum did not help in such a situation, despite the aversion to sweets and amelioration from warmth. After the case had been studied properly the picture of Nat-mur became obvious (which should have been prescribed instead of Pulsatilla). Prescription: Natrium muriaticum 200, three doses for 3 days in a row.