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.
c. Homoeopathic history taking-
A well taken case is half cured.
The first prescription of Colocynth 1M was based on cramps and dysentery. We waited 12 hours to observe its effect. After 12 hours the patient, his symptoms and objective parameters remained the same and it was necessary for a case review and change of prescription.
In this case, patient was unable to give us a history because of prostration and drowsiness when he was admitted. This was only possible once the patient’s clinical condition was stabilized. It was important in the first few hours of admission to give auxiliary modes of treatment i.e. IV fluids. He was then more alert and co-operative and could be questioned for a detailed homoeopathic history.
Two days ago the patient had eaten (home-made) meat after which the complaints started. He complained of fever and intense body ache 2-3 hours after eating the meat. There was no chilliness or chills with the fever. On visiting a general physician, he was given two injections. He felt better and went to work the next day.
Patient felt ok till about 6.00pm. In the evening fever and body ache returned. Loose motions started around the same time. He began to pass stool every half an hourly, scanty, with mucus and blood. The bleeding consisted of fresh blood. There was a cramping pain in peri-umbilical region and lower quadrant of abdomen which was worse before stools and substantially relieved after passing stools.
There were no time or food modalities to the pain or diarrhoea. Patient could not sleep that whole night and was feeling extremely weak right since the loose motions started. He was unable to even talk due to the prostration. The rubrics considered were:
- Appetite reduced with no desire to eat
- Thirst- feels thirstier. Other characteristics of thirst were not available.
- Urine- passed with stools, scanty
Even after correction of dehydration there was no change in this symptomatology.
Patient looked exhausted. Although he was co-operative, he could not even talk properly. Eliciting the history took a long time, with frequent pauses in between. He wanted to sleep and covered himself with two thick coverings because he was feeling cold.
Analysis of the history:
d. Homoeopathic analysis of the case–
1. Totality of characteristic symptoms:
§ Ailments from eating meat
§ Weakness3 diarrhoea during
§ Bodyache3 fever during
§ Thirsty2 fever during
§ Fever chilliness2 with
§ Pain in abdomen < stool before3
§ Pain in abdomen > stool after2
Drowsiness was not taken into the totality as drowsiness had developed late in the course of illness and was in fact a sign (not symptom) of impending acidosis. It was considered common and pathognomonic and not characteristic.
Weakness although an expected symptom after so many diarrhoeal stools was still taken in the totality as it presented itself right at the onset before the dehydration set in and represented characteristic expression thrown by the susceptibility.
2. Repertorization of the totality-
3. MateriaMedica differentiation with final remedy-
From the above totality and repertorization, the following remedies were differentiated-
Arsenic Album, Bryonia Alba, RhusToxicodendron, Nux Vomica, Colchicum Autumnale, Merc Corrosives and Merc Solubilis.
Bryonia alba is a remedy which produces pathologies and symptoms with a gradual effect. It mainly corresponds to first and second stage of inflammation with exudation. Sharp stitches, bursting headache, thirst for large quantities and irritability of the mind are the key characteristics of this remedy. Being a plant remedy its depth of action is superficial and does not correspond to the ulcerative inflammation and destruction of the mucosa and bleeding and toxicity of the case.
In this particular case it covers the symptoms of intense body ache and increased thirst. It does not cover the causative modality, onset of complaints, the main concomitant of the illness i.e. profound weakness and the pathogenesis. Hence it is ruled out.
Nux vomica comes close as it covers the causation, symptoms of chilliness, body ache, cramps in abdomen. It does not cover the great weakness the patient has. Hallmark symptoms of Nux vomica in dysentery, i.e. ineffectuality and unsatisfactory evacuations, are not present. It also does not reach the depth of the case as for the pathology, systemic toxicity and haemorrhages. Hence it is ruled out.
Colchicum has in its general symptomatology intense chilliness, severe nausea especially on sight and smell of food and a great motion aggravation. These symptoms come up during any illness as pointers to this remedy when it is indicated. The case in hand has no characteristic indications of the remedy and hence it is not the simillimum for this case.
Mercurius solubilis and Mercurius corrosives are the next closest remedies with respect to the pathogenesis, depth of the disease, and the symptomatology. Both Merc sol and Merc cor have the symptom of rectal tenesmus that continues for hours after stools with a “not got done feeling”. Apart from the characteristic “ailments from” and concomitants which are not been covered by the remedies, the patient also reports to be much better after passing stools, which is quite contradictory to the Merc group in its symptom presentation especially in rectal diseases. Hence these two remedies are ruled out.
Rhus toxicodendron and arsenicum album were the closest remedies. RhusTox covered the intense body ache, chilliness and thirst. It also comes close to the case in terms of the intestinal pathology of infection, ulceration and bleeding and associated toxaemia. Yet, it’s depth of action lacks capacity at the level of metabolic decompensation which is so important in the pathogenesis of this case. At the symptom level it does not cover the most important ones in the evaluation, i.e. the ailments from and the weakness.
Arsenicum album covered all symptoms of the totality especially the ailments from, and the most prominent concomitant of weakness prostration. Apart from infection, ulcerations, bleeding and toxaemia, it also has diabetes with failed compensation in its pathogenesis. So, arsenic was not only the pathological similimum, but covered the portrait of the disease as well and hence was selected as the similimum.
4. Susceptibility Assessment – Moderate to high
Susceptibility assessment of the case is crucial and it has reflections on potency and posology. There are various parameters which determine the deviation of susceptibility from the state of health e.g. pathology, stage of disease, sensitivity, miasmatic influence, remedy correspondence, vitality and immunity.
In this case, there is a fulminant infection in an undiagnosed diabetic patient. The onset and pace of the disease is fast with a severe ulcerative inflammation and destruction at the tissue level and metabolic decompensation. The severe onslaught of the disease indicates high virulence of the organism. Yet, the number of intense and characteristic symptoms including sensations, modalities and concomitants indicate a high sensitivity and reactivity.
Intense weakness, bleeding and the pathology with its typical evolution point towards tubercular miasm in the case. Also the simillimum corresponds to the case in its symptomatology, pathology and evolution quite closely.
Although immunity is weakened due to underlying diabetes, the general vitality is more or less preserved even after such a severe onslaught of the disease.
Hence, the susceptibility is in a moderate to high zone.
5. Planning and programming of the treatment-
e. Final remedy with posology–
ARSENICUM ALBUM 1M every 4 hours.
Assessment of susceptibility is the indicator to posology. In this case the susceptibility was in moderate to high zone which allowed selection of a high potency. Acuteness of infection, urgency and severity of the scenario warranted a frequent repetition.
a. Auxiliary and ancillary mode of treatment-
Dehydration and ketoacidosis both had led to fluid and electrolyte disturbances in this case. In a metabolically challenged system fluid and electrolyte disturbances could persist and could lead to serious consequences.
There was an evidence of hypokalemia, and hypernatremia. With normal renal (kidney) function it was easy and safe to correct the above abnormalities.
The only ancillary mode of treatment used was IV fluid administration which corrected the dehydration and the fluid electrolyte imbalance. Fluids of choice are crystalloids, specifically Ringer Lactate and Normal saline.
In a diabetic patient dextrose or dextrose containing solutions are best to be avoided. Ringer lactate is an isotonic, alkalinizing fluid which provides K+, Cl- ions. It is low in Na+ ions and hence it is best suited for the case. It also provides with the lactate ions which are responsible for its alkalinizing effect through their conversion to CO2 and water in the liver.
As fluids are restored, there is hemodilution and renal conservation of Na+ stops which results in reduction in the Na+ concentration and hence need for Na+ ions. So, NACL i.e. Normal saline also needed to be given.
Hence Ringer Lactate and Normal Saline were alternated for the correction of fluids, electrolytes and acidosis.
b. Dietary modifications and hygiene-
A diabetic and diarrhoea diet was recommended. The patient is asked to avoid direct ingestion of glucose or sucrose. Likewise fats and proteins are also to be kept out of the diet till he recovered from the acute illness. Fibre foods were avoided.