Keywords: Immune thrombocytopenic purpura, homoeopathy
Immune thrombocytopenia (ITP), also known as idiopathic thrombocytopenic purpura, is an autoimmune disease characterized by a low platelet count of less than 100 x109/L lasting for more than three months.1 There are two kinds of immune thrombocytopenic purpura: acute and chronic.
Typically, acute ITP is seen in children following a viral infection while adults exhibit the chronic form.1 About 20% of children with acute ITP progress to develop chronic ITP.2 ITP is also classified as primary type (idiopathic) and secondary type (associated with conditions such as lupus, hepatitis and HIV) depending on the etiology.3
Anti-platelet antibodies bind to surface proteins on platelets, causing splenic sequestration and phagocytosis by mononuclear macrophages, decreasing platelet life span. Insufficient compensation from increased platelet synthesis by bone marrow cells leads to reduction in the number of circulating platelets causing thrombocytopenia.1
Clinically, the majority of the cases are asymptomatic. However, a few people may occasionally present with mild symptoms such as petechiae, purpura, and epistaxis.ITP is a diagnosis of exclusion. CBC, coagulation panel and bone marrow biopsy help in differential diagnosis. 1 Treatment recommendations vary depending on the severity of the condition.
Use of corticosteroids, IVIG or anti-D immunoglobulins is indicated as first line of treatment for patients with non-life-threatening symptoms.4 Children with little or no symptoms can be managed with observation alone regardless of platelet count.
Second-line treatments such as use of thrombopoietin receptor agonists, rituximab and splenectomy may be recommended to manage chronic/severe cases.4 Patients with life-threatening complications such as gastrointestinal hemorrhages and neurological symptoms should receive immediate platelet transfusions and haemostatic control interventions when necessary.2
Studies suggest that the primary response to corticosteroid therapy is significant only in 15-20% of the cases and splenectomy carries both surgical and anesthetic risks.1 Hence, if an alternative therapy that provides an effective and safe management of the disease may be available, it would be welcome.
There are earlier case reports for the beneficial use of homeopathic treatment in autoimmune conditions.5,6,7 Here, we present to you a case of child suffering from ITP managed with classical homeopathy.
A female patient aged 6 years was diagnosed with chronic immune thrombocytopenia in 2011 following an episode of acute respiratory viral illness (ARVI). The use of glucocorticoids, immunoglobulin and interferon initially had a good therapeutic effect, but it didn’t last long which led to a crisis in 2015. At this point, the patient sought homeopathic treatment. The first consultation took place on 28/10/2015. The symptoms available for prescription were as follows:
- Small hemorrhagic rashes all over the body, more on the eyelids (+)
- Skin-purpura hemorrhagica (+++)
- Muscle pain- wandering (++)
- Redness of the lips (++)
- Heat flushes (++)
Physical general symptoms:
- Thermals: hot (+++)
- She doesn’t tolerate stuffiness well, always asks to open windows (+++)
- Cold touch amelioration (+)
- Desires: milk (++), potatoes (+++), chicken (++), sour cream (+), butter (+++), eggs (++).
- Aversion: vegetables (++), soups (+), cheeses (++)
- Sleep position – on her back, with her hands over the head (++)
- Thirstless (+++)
The mother described the patient as constantly seeks attention when she is sick. She likes to be caressed. She loves her hands and legs to be caressed and loves to have somebody sitting next to her. She loves to be comforted. She needs to be picked up, hugged and kissed. Usually, her nature is balanced but during her illness, her mood often varies, and she feels better by consolation.
- Mood-changeable (++)
- Mind-wants to be caressed, fondled with (++)
- Mind-consolation amelioration (+++)
At 32 weeks, the mother developed an exacerbation of bronchial asthma and took baclazone and salbutamol for a month. The emotional state of the mother during pregnancy was disturbed due to misunderstandings with her husband. The labor was difficult leading to an increase in fetal hypoxia hence, the patient was delivered through caesarean section under general anesthesia.
In the postpartum (early postoperative) period, the mother developed a fever in the first three days. Before the mother finished taking the course of antibiotics, the child was weaned. During this period, the child developed a rash. Klebsiella was detected in the feces, and she received conventional treatment.
Further details of past history are recorded in table 1.
Table 1: Past history of the case
|2011||· ARVI (rhinopharyngitis) with body temperature of 37.5 0C.
· During the treatment, a complication developed in the form of catarrhal tuba otitis media. CBC revealed a decrease in the level of platelets to 123 X109(08.11. 2011).
· After rhinopharyngitis, the patient developed nasal congestion, she began snoring at night. In December 2011, an ENT doctor diagnosed her with chronic adenoiditis and recommended long-term use of the drug Zyrtec (histamine receptor blocker).
|· She was treated with Nurofen (Ibuprofen) and IRS-19 (an immunomodulator).
· Otitis was treated with amoxicillin
|2012-2013||· In June 2012, a routine medical examination diagnosed abrasion in the external genital area.
· A low platelet count of 10X 109was shown by CBC. She hospitalizedand was diagnosed with immune thrombocytopenia,.
· The child was discharged with a normal platelet count of 224 X 109. The examination also revealed antibodies to the Epstein-Barr virus and Cytomegalovirus. The clinical and laboratory remission of thrombocytopenia lasted until March 2014, the platelet count was normal for 2 years.
· Over the 2-year period of remission of ITP, she suffered from ARVI, had purulent rhinopharyngitis once in October 2013- without any fever lasting for 35 days (local treatment).
|The patient was treated with Prednisolone 2 mg / kg (7 tablets of 5 mg for 21 days with subsequent gradual withdrawal) and
Intravenous administration of human immunoglobulin, hemostatics (aminocaproic acid, dicinone), interferons.
|2014||· A decrease in the level of platelets to (45 X109) was again at the beginning of March 2014
· By the end of March, the girl developed ARVI (rhinopharyngitis) lasting more than 1 month. An increase in temperature upto 37.2oC was noted.
· During the ARVI, the platelet count increased from 55 X109(26.03.2014) to 90 X109 (18.04.2014).
· The patient was again examined for the presence of antibodies to the Epstein-Barr virus (EBV) and Cytomegalovirus (CMV), an increase in the latter’s titers was noted.
· With treatment, the platelet count significantly decreased to 14X 109.
· Then, from the fall of 2014, she suffered ARVI, with minor symptoms every month. With the introduction of interferon, a fever developed and a hemorrhagic rash appeared. The platelet count dropped to 10 X109. Due to the high risk of spontaneous bleeding, pulse therapy with Methylprednisolone 450 mg was carried out for 3 days.
The result of the treatment was an increase in the level of platelets in the range of 90-100 X 109. The hematologist recommended taking human recombinant interferon alpha-2a at a dose of 1 million units. – 3 times a week throughout the year.
|· From early April to mid-May, treatment with Isoprinazine and Viferon was carried out.
· In early December, the hematologist suggested to start treatment with reaferon medication (interferon) – 1 million units s/c.
|2015||She received Interferon subcutaneously throughout the year. She had no ARVI. Her platelet count before October 2015 was 130 x 109. In October 2015, the platelet count dropped to 29.6 x 109. The mother decided to start homeopathic treatment.|
Family history: Father – hypertension Mother – bronchial asthma. No blood diseases were found in the family.
Diagnosis:Immune thrombocytopenic purpura (ICD 10- D69.3)8
Case analysis and prescription:
After a thorough case taking, Pulsatilla 12CH daily, once a day (with an increase in potency by 1CH every 2 weeks), was prescribed on 28/10/2015. The strategy of prescription was based on essence and totality of the case (figure 1).
Figure 1: Repertorial result on Vithoulkas compass (as on 28/10/2015)
Professor Vithoulkas describes this mild, yielding, affectionate and changeable nature in Pulsatilla. The follow up details of the case with laboratory investigations are recorded in table 2.
Table 2: follow up of the case
|Date:||Symptoms:||Platelet count (/L)||Prescription:|
|28/10/2015 to 26/11/2015||· There was no initial homeopathic exacerbation after taking the remedy.
· The platelet count rose steadily over 4 weeks.
· Frequency of fever episodes reduced.
· Purpuric spots reduced.
|29.6 X 109 to
160 X 109
|Pulsatilla 12CH once a day with an increase in potency by 1CH every 2 weeks|
|28/11/2015||· Bouts of fever intensified (up to 10 times a day).
· The child became whiny.
· Nasal discharge noted
|–||Pulsatilla 15CH every hour until the symptoms ARVI decrease|
|10/12/2015||· No nasal discharge noted.
· Heat flushes reduced.
|· 26.5 X 109
(as on 3/12/2015)
· 103 X 109
(as on 25/12/2015)
|Pulsatilla 15CH daily, with an increase in potency by 1CH every 2 weeks.|
|10/01/2016||· Increased frequency of heat flushes reappeared (up to 10-15 times a day)
· The child again became more tearful and touchier.
· No other changes noted in physicalgenerals symptoms.
|· Platelet count decreased to 37.6X 109 (as on 15/01/2016)
· 38.4 X 109(as on 25/01/2016)
|Pulsatilla 17CH – 3 times a day|
|02/02/2016||· The attacks of fever and heat flushes increased up to 20 times a day.
· Tearfulness increased with a desire for consolation.
· No other changes in the symptoms.
|· After 1 week, the platelet level decreased even further to 28.2 X 109
· increase in platelet count continued until mid-March, amounting to 163.2 X 109
(as on 16/03/2016)
|· Pulsatilla 18CH, once a day every day.
· On 06/02/2016, assuming that the medicines were not potentised properly, Pulsatilla 30CH – once a day was prescribed.
|19/02/2016||· Fever reduced
· Emotionally better
|58.3 X 109||Pulsatilla 30CH once a week|
|2017||· On 16/03/2017, symptoms of ARVI appeared
· A fever of temperature- 38.2oC for 2 days.
· Nasal discharge present.
· Heat flushes ameliorated by ling down on cold floor.
· The symptoms of the disease subsided within 1 week and the platelet count returned to normal, amounting to positive clinical and laboratory dynamics until the end of the year.
|· Until the end of February, the platelet count remained stable at 169.6 X 109 (as on 24/01/2017)
· 192.5 X 109 (as on 08/02/2017)
· 210 X 109 (as on 15/02/2017)
|Pulsatilla 200 CH one dose|
|27/06/2017||· Heat flushes relapsed up to 10 times a day.
· No other changes in symptomatology.
|Platelet count dropped to 135 X 109.||Pulsatilla 200CH one dose|
|2018-2019||· On 03/01/2018, the child developed a fever with a temperature of 38.6oC.
· Patient was diagnosed with acute polysinusitis (bilateral purulent maxillary ethmoiditis)
|During admission, the platelet count was 195 X 109.
During discharge: 221 X 109 (12/01/2018).
|Antibiotic therapy was given.|
|June 2018||· Patient was diagnosed with chickenpox and a fever of temperature 38.7oC.||Decrease in the platelet level to
132 X 109
(as on 15/06/2018)
|Pulsatilla 200 CH one dose|
|03/08/2018||· After chickenpox until present day, the platelet counts are within the physiological normal range.
· Patient is emotionally better.
· No other complaints.
|160 X 109||placebo|
|2019||· Child had ARVI three times with a temperature rise of up to 38.6oC||–||At each such episode, Pulsatilla 200 CH one dose was prescribed.|
|10/01/2020||· No more recurrent fevers.
· No purpuric spots noted
· Patient is balanced emotionally.
· No other complaints noted.
· Generally better.
|The last recorded platelet level is 248 X 109 (10/01/2020).||placebo|
Immunogenic thrombocytopenia is one of the most common bleeding disorders in children which often resolves spontaneously or with therapy.9 However, treatment of children with clinically significant symptoms is an ongoing challenge as therapies offer short term remission and have significant adverse effects.10
The human being always works as an integrated totality of mental, emotional and physical levels.11 Any disturbance that transcends the threshold produces signs and symptoms on one or more of these three levels. A classical homeopathic approach involves the investigation of these signs and symptoms along with the causative factors of disease consequents such as – hereditary, epigenetic influences and suppressive treatments in the past to build an integrated picture of the disease and prescribes a remedy which will stimulate the organism to spontaneously cure itself.11,12
The “Levels of Health” concept by professor Vithoulkas classifies health into four groups (A-D) and 12 levels (1-12).13 Patients belonging to group B suffer from recurrent infections. These patients with frequent infections risk the danger of dropping to lower level if they continue to take drugs which suppress the immune system.13
When organism descends a level down and enters group C, the acute diseases cease to appear and chronic diseases start to manifest. If these patients are treated homeopathically, they may begin to develop acute disease with high fever indicating that the treatment was successful.
After the reappearance of acutes and amelioration of the chronic condition, homeopathic treatment must be continued with strategic medicines in order to build resistance to the acute diseases and avoid relapse of the chronic condition.12
The above presented case example was born in group B lower level (5-6) which was additionally aggravated by maternal stress, use of steroids by the mother during pregnancy, complications during childbirth and vaccinations.
Further suppression of the ARVI with the use of drugs produced an immune suppression lowering the state of health (group C -level 7), following which acute conditions ceased. The onset of thrombocytopenia in 2011 coincides with the use of drugs (IRS-19, Nurofen, Amoxicillin, Zyrtec) which in their side effects produce thrombocytopenia.14
After homoeopathic treatment for two months, he patient started to develop acute infections again. This reappearance of acutes marks an encouraging sign that the treatment is correct and the chronic condition improved drastically, giving undeniable evidence to the link between efficiency of immune system and high fever (figure 2)15
Figure 2: Dynamics of the platelet level during the observation period from 2015 to 2020
The Modified Naranjo Criteria for Homeopathy (MONARCH) causality assessment provided a score of 12, suggesting a significant causal relationship to the treatment (Table 3).16
Table 3 : Modified Naranjo Criteria for Homeopathy (MONARCH) – for causality assessment
|Criteria||Y||N||Not sure/NA||Score in case|
|1. Was there an improvement in the main symptom or condition for which the homeopathic medicine was prescribed?||2||-1||0||2|
|2. Did the clinical improvement occur within a plausible time frame relative to the drug intake?||1||-2||0||1|
|3. Was there an initial aggravation of symptoms?||1||0||0||0|
|4. Did the effect encompass more than the main symptom or condition, i.e., were other symptoms ultimately improved or changed?||1||0||0||1|
|5. Did overall well-being improve?||1||0||0||1|
|6 (A) Direction of cure: did some symptoms improve in the opposite order of the development of symptoms of the disease?||1||0||0||1|
|6 (B) Direction of cure: did at least two of the following aspects apply to the order of improvement of symptoms:- from organs of more importance to those of less importance, from deeper to more superficial aspects of the individual, from the top downwards||1||0||0||1|
|7. Did “old symptoms” (defined as non-seasonal and non-cyclical symptoms that were previously thought to have resolved) reappear temporarily during the course of improvement?||1||0||0||1|
|8. Are there alternate causes (other than the medicine) that with a high probability could have caused the improvement? (consider known course of disease, other forms of treatment, and other clinically relevant interventions)||-3||1||0||1|
|9. Was the health improvement confirmed by any objective evidence? ( laboratory investigation of platelet count)||2||0||0||2|
|10. Did repeat dosing, if conducted, create similar clinical improvement?||1||0||0||1|
Previous studies have shown evidence for beneficial outcomes for use of classical homeopathy in serious pathologies, including ITP.17,18,7 This case demonstrates that classical homeopathy can be used as a substitute therapy in cases of immune thrombocytopenia (ITP) which not only helps in long term management but also improves overall health quality. Hence, homeopathy must be examined further in light of such evidence.
ITP is an autoimmune condition, and it necessitates a multifaceted strategy to its treatment that goes beyond mere remission to enhance overall quality of life. This case report demonstrates a positive outcome for the use of classical homoeopathy in the treatment of ITP. However, extensive research is required to ascertain the advantages observed here.
- Vaillant AAJ, Gupta N. ITP-Immune Thrombocytopenic Purpura. StatPearls. Published online December 30, 2020. Accessed September 2, 2021. https://www.ncbi.nlm.nih.gov/books/NBK537240/
- Swinkels M, Rijkers M, Voorberg J, Vidarsson G, Leebeek FWG, Jansen AJG. Emerging Concepts in Immune Thrombocytopenia. Front Immunol. 2018;9(APR):880. doi:10.3389/FIMMU.2018.00880
- Audia S, Mahévas M, Nivet M, Ouandji S, Ciudad M, Bonnotte B. Immune Thrombocytopenia: Recent Advances in Pathogenesis and Treatments. HemaSphere. 2021;5(6). doi:10.1097/HS9.0000000000000574
- Cuker A. Transitioning patients with immune thrombocytopenia to second‐line therapy: Challenges and best practices. Am J Hematol. 2018;93(6):816. doi:10.1002/AJH.25092
- Mahesh S, Shah V, Mallappa M, Vithoulkas G. Psoriasis cases of same diagnosis but different phenotypes—Management through individualized homeopathic therapy. Clin Case Reports. 2019;7(8):1499-1507. doi:10.1002/ccr3.2197
- Mahesh S, Mallappa M, Tsintzas D, Vithoulkas G. Homeopathic treatment of vitiligo: A report of fourteen cases. Am J Case Rep. 2017;18:1276-1283. doi:10.12659/AJCR.905340
- Jamdar N, Mahesh S. DSM. Idiopthic thrombocytopenic purpura managed with classical homoeopathy : a case report. Similia Aust J homoeoapthic Med. Published online June 2021:25-27. doi:volume 34
- 2021 ICD-10-CM Diagnosis Code D69.3: Immune thrombocytopenic purpura. Accessed September 2, 2021. https://www.icd10data.com/ICD10CM/Codes/D50-D89/D65-D69/D69-/D69.3
- JM D, AB G. Pediatric ITP: is it different from adult ITP? Hematol Am Soc Hematol Educ Progr. 2018;2018(1):405-411. doi:10.1182/ASHEDUCATION-2018.1.405
- Cooper N, Cines DB. The child with immune thrombocytopenia: to treat or not to treat, is that still the question? Haematologica. 2019;104(11):2132. doi:10.3324/HAEMATOL.2019.229179
- Hanhemann S. Organon of Medicine. B.Jain publishers; 1994.
- Vithoulkas G and Tiller.w. The Science of Homeopathy. 7th Edition.; 2014.
- Vithoulkas G. Levels of Health.; 2017.
- H M, A S, M A, P K. Amoxicillin/Clavulanic Acid-induced thrombocytopenia. Hosp Pharm. 2014;49(10):956-960. doi:10.1310/HPJ4910-956
- Mahesh S, Mallappa M, Habchi O, et al. Appearance of Acute Inflammatory State Indicates Improvement in Atopic Dermatitis Cases Under Classical Homeopathic Treatment: A Case Series. Clin Med Insights Case Rep. 2021;14:1179547621994103. doi:10.1177/1179547621994103
- Lamba CD, Gupta VK, Van Haselen R, et al. Evaluation of the Modified Naranjo Criteria for Assessing Causal Attribution of Clinical Outcome to Homeopathic Intervention as Presented in Case Reports. Homeopathy. 2020;109(4):191-197. doi:10.1055/s-0040-1701251
- Tenzera L, Djindjic B, Mihajlovic-Elez O, Pulparampil BJ, Mahesh S, Vithoulkas G. Improvements in long standing cardiac pathologies by individualized homeopathic remedies: A case series. SAGE Open Med Case Reports. 2018;6:2050313X1879281. doi:10.1177/2050313X18792813
- Mahesh S, Mahesh M, Vithoulkas G. Could Homeopathy Become An Alternative Therapy In Dengue Fever? An example Of 10 Case Studies. J Med Life. 2018;11(1):75-82.