Abstract– This is a case of acute severe bacillary dysentery with diabetic ketosis and dehydration treated at Dr. M.L.Dhawale Memorial hospital, Palghar. It represents a typical medical emergency in a rural hospital practice. Though the patient was acutely distressed and critical, the case was successfully managed on sound homoeopathic principles. This case highlights the challenges faced by hospital based homoeopathic physicians. The uniqueness of this case is in the way various homoeopathic concepts have been applied in the management of the patient. Young homoeopathic clinicians are the main contributors to the advancement of the homoeopathic science in this regard, to bring it at par with its modern counterpart.
Mr L.C, a 50 year old male patient was brought by the relatives to the emergency room at 5.30 am. He was attended to on arrival by the emergency homoeopathic physician.
Patient appeared drowsy and was unable to give history, so this was obtained from his relatives. They revealed that the patient had been suffering from high fever, abdominal cramps and bloody diarrhoea for 2 days. He had passed about 50 stools in the last 24 hours. His appetite was reduced but he was feeling thirsty. They had no idea of when he had last passed urine.
Tongue dry, eyeballs sunken, tissue turgor reduced
Temp- 101.8 0F
Blood pressure- 90/50mmHg
Respiratory System – clear
Cardio Vascular System – S1S2 normal
Per Abdomen – soft; liver and spleen not palpable, moderate tenderness all over the lower quadrant of abdomen.
HGT (random blood sugar), Urine sugar and Urine ketones were done immediately in the emergency room. The ECG was done too, considering his age, to assess the underlying cardiac status.
Urine sugar- ++++
Urine ketones- moderate
ECG- Within normal limits
Based on the above information, the emergency physician had prescribed colocynth 1M 1 dose on arrival at 6 am. I was called to attend the case at 9 am.
The initial clinical assessment indicated a possible diagnosis of:
1. Acute bacillary dysentery with moderate to severe dehydration and toxaemia.
2. Diabetic ketosis with impending acidosis.
What is diabetic ketosis?
Diabetic ketosis is a condition precipitated in a patient with uncontrolled blood sugar levels when facing the stress of infection, dehydration, starvation, surgery etc.
The deficiency of insulin and secretion of stress hormones lead to over- production of glucose and ketone bodies by the liver. Ketone bodies being acidic, lead to disturbance of acid- base balance of the body fluids resulting in acidosis (increased acidity of the blood). Also there is a profound loss of water and electrolytes leading to dehydration and electrolyte imbalance.
Ketoacidosis is a major medical emergency and remains a serious cause of death.
Given this emergency presentation, the patient was advised admission in the In-Patient Department.
Indications for admission:
1. To administer emergency treatment on arrival.
2. Close monitoring of vital clinical parameters.
3. To establish a definitive diagnosis.
4. To assess and prevent potential complications.
5. To relieve the subjective distress of the patient i.e. Fever, pain, diarrhoea, weakness.
6. To observe and obtain a detailed homoeopathic history.
7. To record in detail the follow up of emergency treatment and assess the remedy response, so as to prescribe, in time, the second prescription.
8. To relieve the anxiety of the patient and his relatives.
In Patient Management–
a. Stabilization of the patient-
1. An intravenous line was inserted and IV fluids were started.
2. A urinary catheter was inserted to allow input- output charting.
3. Patient was given a head low to assist hypotension.
4. He was given a bed pan to avoid moving about that could cause a postural drop of blood pressure.
b. Initiation of diagnostic assessment-
1. Blood was collected before administering intravenous fluids for stabilizing the patient and investigations were sent to the laboratory. These included: CBC, ESR, RBS, BUN, S. Creatinine, S. Electrolytes, Widal test
2. Urine routine and stool routine were also sent for analysis.
3. An abdominal sonography was scheduled.
4. An MD physician’s opinion was planned.
a. Establishment of the final diagnosis-
1. The following investigation reports were received:
2. MD Physicians’ opinion and proposed line of treatment:
MD Physician’s diagnostic assessment was: Acute dysentery with dehydration and diabetic ketosis.
He advised: IV antibiotics and amoebicide, anti-emetic, ranitidine, anti- diarrhoeal, antimotility agent, lactobacilli, along with aggressive IV fluid administration.
Also: SOS insulin administration and constant monitoring of the hydration and urinary ketones.
The physician suggested that the patient be shifted to the ICU, under modern medicine management within 24 hours, if patient’s condition did not improve.
3. Differential diagnoses and final diagnosis:
A. Differential diagnoses of dysentery:
1. Bacillary dysentery (Shigellosis)
2. Amoebic dysentery
3. Enteric fever, paratyphoid infection
4. E coli infection
5. First episode of IBD (ulcerative colitis or crohn’s colitis)
6. Campylobacter infection
Shigellosis or commonly known bacillary dysentery is an infection by the gram negative bacteria shigella, causing ulcerative inflammation of the colon. It has a feco-oral route of transmission, has a very short incubation period of 24-48 hours and gives rise to severe symptoms early in the course of illness. There is moderate to high grade fever, 20-30 stools with intense cramping in the abdomen and profuse bleeding. Toxins produced by the organisms are responsible for the toxaemia associated with the illness. Stool examination reveals lot of RBCs and pus cells. It is known to be the most severe form of dysentery.
Amoebic colitis is caused due to the infection with the protozoa, Entamoeba histolytica. It is also transmitted by the feco- oral route and has a long incubation period of about 2-3 weeks. It is responsible for an ulcerative inflammation of the colon with milder symptoms. More severe form of infection is associated with about 8-10 stools in a day with mucus and blood and mild pain in the lower abdomen.The bleeding is not as severe as in bacillary dysentery. There is hardly any evidence of fever, toxicity and dehydration except in fulminant cases and in the immune- compromised. Stool examination shows the trophozoite forms of amoeba which is a diagnostic sign.
E-coli are normal flora of the Gut. Yet the pathogenic strains can infect the small intestines and are responsible for a mild to moderate form of diarrhoea. Stools are generally watery, profuse and not bloody or mucoid. There is hardly any tenesmus and abdominal cramping although mild with pain and fever might be present.
Campylobacter are gram negative bacilli which infect the small intestine and give rise to diarrhoea. Infection is contracted from uncooked poultry and meat. It is a common form of infection in the non-vegetarians. Constitutional features such as fever, malaise, headache, body ache are common. There are diarrhoeas 8-10 in a day with abdominal pain. Tenesmus and bleeding might occur. Toxicity might be seen in a few cases. Yet it is milder as compared to shigellosis in its severity and form and is often self-limiting.
Salmonella infection, causing typhoid or paratyphoid fever is another clinical syndrome where they present with fever, diarrhoea and toxaemia. It’s a system infection carried by the lymphoid tissue of the intestines to the blood stream. Persistent fever is the main presentation. Other symptoms such as headache, nausea, vomiting, and constipation are the commonest accompaniments. Diarrhoea does occur but is generally of a milder type. Gradual onset and progress with general toxicity are prominent.
First episode of inflammatory bowel disease (Crohn’s disease or ulcerative colitis) is the last possibility. They are immunological disorders with no infective pathology. Sudden onset of painless or painful diarrhoea with blood and mucus and few constitutional features is the presentation. Differentiating features are the age of onset which is generally in the 2nd to 3rd decade and the milder variety of symptoms which it has. It does not respond to antibiotics, anti- protozoal or anti-diarrhoeal measures.
In this case, the onset, character, severity and progress of illness all correspond to the shigellosis syndrome and hence the final diagnosis is shigellosis.
B. Diabetes in this case is an accidental finding. The presence of ketone bodies in the urine points to the presence of diabetic ketosis.
Causes of diabetic ketosis-
1. Underlying uncontrolled blood sugar levels
3. Reduced intake of adequate calories or starvation
Although acidosis is a biochemical diagnosis established on Blood Gas Analysis, drowsiness was an indicator of developing acidosis.
Final diagnosis– Acute bacillary dysentery with moderate dehydration, hypokalemia and hypernatremia with diabetic ketosis and impending acidosis
b. Risk assessment and prognosis-
Glycosuria and ketonuria are the findings suggestive of hyperglycaemic ketotic state. As the compensatory mechanisms i.e. the acid- base balance of the body are utilized and exhausted, frank acidosis with coma may supervene. Infection and dehydration always add to the effect making it a vicious circle. Hence, correction of dehydration, infection control and regulation of blood sugars are the cornerstone of treatment need to be started immediately and simultaneously to reverse these symptoms and avoid further complications.