Homoeopathic Approach in Dengue Fever

Reprinted with permission from the Indian Journal of Applied Homoeopathy where it first appeared. https://www.jimshomeocollege.com/ijah-publications/

INTRODUCTION

Dengue is an acute mosquito transmitted viral disease characterized by fever, headache, muscle and joint pains, rash, nausea and vomiting. Dengue fever (Homeopathy Treatment for Dengue Fever) is usually self-limited, biphasic febrile illness, its presentation may range from asymptomatic to Dengue Hemorrhagic Fever (DHF) and fatal shock (Dengue Shock Syndrome-DSS). The illness is more severe and begins more suddenly in adults, infection is asymptomatic in 80% of infants and children. In 2013 dengue was estimated to be responsible for approximately 3.2 million severe cases and 9000 deaths worldwide. In India the case fatality rate is about 3-5%.

Causative organism

It is an arbovirus from Genus –Flavivirus. It is the most common among all arbovirus infections. There are four 4 serotypes (DENV-1, 2, 3 & 4) of infections identified. Infection with one serotype does not include solid immunity to the other. Hence, individual may suffer from dengue fever more than once.

Epidemiology

Large number of cases regularly occurs in urban, suburban and rural areas, with increasing proportion of Dengue Hemorrhagic Fever and Dengue Shock Syndrome. In India during 2013, about 74168 cases were reported with 168 deaths. Case fatality rate was 0.22%. The highest numbers of cases were reported from Punjab followed by Tamilnadu, Gujarat, Kerala and Andhra Pradesh.

Transmission

Dengue is transmitted via Aedes aegypti mosquitoes. It is transmitted by female mosquitos’, bites during day time only.

Incubation period2 – 7 days

CLINICAL PRESENTATION:

– Classical Dengue

• Dengue Hemorrhagic fever
• Dengue Shock Syndrome

CLASSICAL DENGUE

• Sudden onset of chills and high fever with intense headache
• Retro-orbital pain with photophobia
• Muscle and joints pain which prevent all movements
• Intense myalgia ; BREAK BONE FEVER
• Constitutional symptoms like extreme weakness, anorexia, constipation, altered taste sensation, colicky abdominal pain, sore throat and general depression.
• Typical morbilliform rash spreading centripetally to face; trunk & limbs, spares palms & soles with first 24-48hrs. Lasting for 1-5 days, resolves with desquamation.

DENGUE HEMORRHAGIC FEVER (DHF)

• Occurs especially in children and young females
• Pre-circulating anti-dengue antibody is predominant risk factor. It may be acquired from previous infection with different serotype or in the form of trans-placental transfer.
• Leakage in plasma takes place in DHF & extravasations occur in the endothelial gaps due to increased capillary permeability.

              Onset– 3^rd to 7^th days of illness

Criteria for diagnosis of DHF

• Fever or H/O fever lasting 2-7 days
• Hemorrhagic tendencies indicated by any of the following: Positive tourniquet test, Petechie, ecchymosis or purpura, bleeding from mucosa, gastrointestinal tract, injection sites or other locations
• Enlargement of liver
• Thrombocytopenia : platelet count < 1,00,000/mm3
• Hemo-concentration : hematocrit increased by > 20%

Plasma leakage evidenced 

Rise in haematocrit> 20%

• Fall in haematocrit> 20% after IV fluids
• Positive tourniquet test i.e. appearance of more than 20 petechiae per 2.5 cm² on inflating sphygmomanometer cuff for 5 minutes.

DENGUE SHOCK SYNDROME

All the criteria of DHF plus, Shock – manifested by rapid and weak pulse with narrowing of the pulse pressure  20 mmHg or less) or hypotension, tachycardia, with the presence of cold, clammy skin & restlessness.

Grades of Dengue…

Grade I – fever + non-specific constitutional symptoms. The only hemorrhagic manifestation is a positive tourniquet test.

Grade II – manifestations in grade I plus patient with spontaneous bleeding, usually in form of skin hemorrhage.

Grade III – circulatory failure by rapid and weak pulse, narrowing of pulse pressure or hypotension with the presence of cold clammy skin and restlessness.

Grade IV – profound shock with undetectable blood pressure and pulse.

Warning signs for shock…

• Intense, sustained abdominal pain
• Persistent vomiting
• Restless or lethargy
• Sudden change from fever to hypothermia with sweating and prostration.

INVESTIGATIONS.

Probable diagnosis

Serological tests

1. NS1 Ag Rapid tests
2. ELISA for IgM (for recent infection) – Appear within 5 days, persists for months 3.ELISA IgG (for Chronic infection)

Confirmed diagnosis

1. Culture is positive within first 5 days (sensitivity< 50%); can also obtain culture from liver at autopsy.
2. Detection of virus in tissue, serum, or CSF by IHC, IFA or ELISA
3. Increased specific IgG or IgM
4. WBC decreased (2,000-5,000/uL) with toxic granulation of leukocytes and neutropenia; may have marked atypical lymphocytes.
5. In DHF, decreased platelets (<1,00,000/uL) with impaired aggregation, prolonged prothrombin time in severe cases of DHF. DIC may occur.
6. Increased transaminase (5,00-1,000 U/L) and bilirubin indicating decreased hepatic & renal functions.
7. RT-PCR: Detection of genomic sequence of virus by RT-PCR (sensitivity > 90% early, <10% in 7 days). Reverse transcriptase polymerase chain reaction (RT-PCR) sensitive and specific for detection of viral RNA. But this test is still a research tool.

COMPLICATIONS

• Bleeding
• ARDS
• Renal failure
• Hepatic failure
• Encephalopathy

Homeopathic Treatment Approach in Dengue:

CASE – 1

PRELIMINARY INFORMATION

Name- Mr. S.S Age- 32 years Sex- M Marital status- Married Occupation- Machine supervisor

Date of admission- 27/9/09

C/o Generalized body pains since 5 days – severe pain as if body would break, followed by fever. Fever paroxysm- heat all over the body but the head more hot, with insipid taste ³ and dryness of mouth³. Patient took allopathic treatment without relief but, the fever pattern changed.

Since yesterday – Mild feverishness with nausea worse eating solid food³_,better by drinking² and pain in eyes, worse opening eyes³ better closing eyes³.  Insipid taste³ and dryness of mouth³ still present. Thirst – small quantity and occasionally large quantity.

Investigations as on 25-9-09 were: CBC- Hb: 14.2, WBC- 2600, N 56, L 41  E02,  platelet count- 67,000,  Urine routine- RBC- 2-4/hpf, Pus.Cells- 1-2/hpf

ON EXAMINATION FINDINGS-

GC:		Fair, No pallor, icterus, edema, cyanosis, No lymphadenopathy
Eyes:		Congestion ++
Skin:		Fine macular erythematous rash on extremities, blanching on pressure ++
Temp:		99.4oF, Maximum temperature recorded on the day of admission was 100.8O F
Pulse:		74/min
BP:		110/80 mmHg
RS:		Clear
CVS:		S1S2 heard
PA:		Soft L0S0

 

INVESTIGATIONS BEFORE ADMISSION	INVESTIGATIONS ON THE DAY OF ADMISSION
CBC- Hb: 14.2 WBC- 2600            N56 L41  E02            platelet count- 67,000 Urine routine- RBC- 2-4/hpf P.C- 1-2/hpf	CBC- Hb: 15.06 WBC: 4,800            N52  L43  E02 platelet count- 1,02,000 Widal test-  O-1:60 H-1:60 AH and BH- nil PS for MP- negative Malaria antigen- negative

PROBABLE DIAGNOSIS with DIFFERNTIAL DIAGNOSES-

1. Dengue fever
2. Viral fever
3. Malaria

Reasons for consideration of Dengue fever as the diagnosis-

1. Prominence of Myalgia in the symptomatology
2. Fever low grade and more or less continuous type
3. Presence of a macular blanching rash
4. Leucopenia, a normal or increasing hematocrit
5. A continuous low platelet count

INVESTIGATION:  on 28/9/09 Dengue IgM and IgG POSITIVE.

FINAL DIAGNOSIS- Dengue fever

Full homoeopathic history was taken on the day of admission and fever totality as well as the chronic Constitutional totality were erected.

FEVER TOTALITY-

• Change-in fever paroxysms of fever due to allopathic medicines
• Thirst increased fever during
• Nausea < eating after3
• Head pain < stooping3
• Dryness of mouth fever during3
• Insipid taste3

DIFFERENTIAL REMEDIES-

Nux Vomica, Pulsatilla and Sepia come close on Repertorization.

In Nux Vomica, chilliness is marked along with body ache, cannot bear to uncover. Patient is thirsty during chills and thirstless during fever. Low back pain is hall mark along with aching limbs during fever. NuxVom has loud, painful retching and water brash along with nausea. Gastric bilious symptoms are present during apyrexia.

Pulsatilla has slow insidious onset with subdued mild symptomatology. Thirstlessness is a hallmark of Pulsatilla along with loathing for food which is worse on eating. Taste is bad especially in the morning with white coated tongue.

Sepia is the remedy for irregular fever with changing paroxysm especially caused by medicinal intervention allopathic or homoeopathic. Sepia feels extremely chilly. Nausea not better by eating is hallmark concomitant during fevers. Sepia has thirst during chill and though thirsty during heat, less thirst compared to chilliness stage.

Sepia 200 1 dose was given on morning of 28/9/09 as the indicated remedy for the fever.

FOLLOW UPS: –

Date	Follow up	Platelet Count	Action
28/9/09 evening	No fever, Chilliness – better. Body ache, headache, nausea, eye pain – improved, Appetite and thirst improved. Sleep better. Maximum temp- 99.2F	1,05,000	Placebo
29/9/09	Asymptomatic ,Temp- Afebrile	98,000	Placebo
30/9/09	Asymptomatic, Maximum Temp- 99 F	1,15,000	Placebo
1/10/09	Asymptomatic, Temp- Afebrile	1,40,000	Placebo
2/10/09	Fine rash on abdomen and extremities, Afebrile  Patient was discharged from the hospital.	1,40,000	Placebo
5/10/09	Rash absent, Pt was Afebrile & asymptomatic	2,50,000	Placebo

DISCUSSION:-

Patient came for 5-6 days after onset of illness. He had been to a general practitioners for conventional medicine which did not completely relive him, but simply changed the pattern of fever, fortunately the concomitants persisted in spite of intervention, which, helped in forming totality.

It is important to trace the journey of patient and evolution of symptoms while treating fevers. Eliciting onset, duration and progress of each symptom is key to erecting homoeopathic totality.

Post Repertorization seemingly indicated remedies emerge like in this case,Pulsatilla, Nux Vomica, Sepia and Arsenic. Materia Medica references help understand the finer nuances of remedy differentiation.

Susceptibility assessment based on severity of illness, pace of disease and characteristic that emerge during acute episode help determine the dosage and potency. In this case patient presented with moderate intensity of illness and preserved individualistic characteristics in form of concomitants in spite of allopathic treatment received by him before switching to homoeopathy. This indicated only moderate deviation from state of health which could be restored back with single stimulation of indicated remedy.

Close follow up of the patients is essential, even though patient might report betterment in subjective symptoms.Close observation of objective criteria’s like leucopenia and platelet count is essential. In this case though patient reported no fever since second day of introduction of Sepia, patient’s platelet count was observed closely till it reached the normal range.

CASE – 2

PRELIMINARY INFORMATION

Name- Mr. D.S  Age- 24 years Sex- Male Education- 4^th standard

Occupation- welding machine worker, Marital status- married since 5 months

History:Patient came with complaints of fever with rigors on the 25/9/09. Along with fever complained of pain in limbs, backache and headache. There was an afebrile period for a day followed by fever with rigors again. Later on 6^th day developed nausea and vomiting. Please refer to table below for details. Throughout patient showed irregular fever patterns.

LOCATION	SENSATION	MODALITY	CONCOMITANT
General – Since 5 days             On first day Intermittent	Started from pain in limbs3, later started having fever with mild chilliness.  Backache 2 headache3   Fever with rigors3 Took Allopathic treatment with general practitioners.	< movement3 > pressure2 < night3         > covering3	Weakness3– could not get up and go to work
On 2nd and 3rd day	Asymptomatic
On 4th and 5th day	Fever with rigors again Bodyache3& headache3	< Jarring3 > pressure2	Thirstlessness3 during fever  Bitter taste3
	No fixed pattern of fever
On 6th day i.e. on the day of reporting   Stomach   Abdomen	Fever increased, chilliness3 Bodyache3, headache3 Nausea3 with retching & vomiting of ingesta not better after eating. Mild pain	< Jarring3 > pressure2	Bitter taste3

ON EXAMINATION FINDINGS-

G.C:		Fair, No pallor, icterus, edema, cyanosis, no lymphadenopathy
Tongue:		Clean, moist
Temp:		101.4OF
Pulse:		88/min
BP:		120/80mmHg
RS:		Clear
CVS:		S1S2 heard
PA:		Soft, recti tender +, Liver 1 finger palpable, Spleen 1Finger Palpable
Back:		lumbar para-spinal tenderness+           ROM full
	INVESTIGATIONS DONE ON 25/9/09		INVESTIGATIONS DONE ON 26/9/09
	CBC- Hb- 13.2, TLC- 4,000, N:50  L:40  E:08  M:02 ESR- 20 Platelet count- 1,65,000 PS for MP- negative		CBC- Hb- 13.8,  WBC- 4,000, N:55  L:38  E:05 M:02 Platelet count- 1,52,000 S. Total Bilirubin- 1.6 S. Direct Bilirubin- 1 SGOT- 77 SGPT-42.7 Widal test- negative PS for MP- negative MP antigen- Negative Urine routine- NAD DENGUE IgM- Positive DENGUE IgG- Positive

FINAL DIAGNOSIS:   Dengue fever

TOTALITY OF SYMPTOMS-

1. Thirst less fever during
2. < Jar³
3. > pressure²
4. Extremity pain fever during³
5. Weakness fever during³
6. Backache fever during³
7. Headache fever during
8. Taste bitter

DIFFERENTIAL REMEDIES:-

Drug		Materia Medica
China		Prodromal : nervous excitement, anxiety, headache, nausea, irritability
		Chill: Chill followed by thirst, wants to wrap himself warmly, chill begins in the breast.
		Heat: without thirst, fiery red face with congestion of head, other parts chilly
		Sweat: with thirst, drenching profuse, debilitating
		Apyrexia: debility, restlessness, anemia, edema
		Headache and weakness as concomitants.
		Fever patterns are clear and well defined
Nux.Vomica		Fever with prominent gastro-bilious symptoms
		Chill: preceded or accompanied by blueness of fingernails
		Chill with yawning & aching in limbs and back
		Chill not relieved by covering or external heat
		Thirst less during fever
		Low backache during heat
		Worse Pressure
		Weakness is not a prominent concomitant.
Nat Mur		Useful in inveterate and badly treated cases of fever
		Chill: 10 – 11 am, begins in small of back or feet
		Chill with thirst and generalized aches and pains
		Heat: high fever with throbbing headache, increased thirst,
		Fever blisters around lips
		Sweat: debilitating , relieves headache
		Marked periodicity
Sepia		Irregular Fevers
		Marked Chilliness
			Worse Jarring
			Better Pressure
			Profound Prostration
			Nausea at smell and sight of food
			Nausea not better by eating
			Thirst less during fever

Treatment:

SEPIA 200 1 DOSE WAS GIVEN ON 26/9/09

If one refers to reportorial sheet all remedies seem closely indicated. Except for natrum all other remedies considered are thirstless during heat. Nux has worse jarring but has worse pressure too, which is opposite of what patient presents. Natrum mur and China have well defined patterns of fever with regular paroxysms. Nux , China and Natrum have significant headaches but, with differing modalities.

Sepia covers generals of irregular pattern of fever, general modalities, and general sensation of weakness, thirstlessness and modalities of nausea. Hence, qualitatively sepia has better coverage of the case.

FOLLOW UPS:-

Date	Follow up	Platelet Count& Ix	Action
26/9/09	Fever & chilliness-better, Appetite SQ, thirst -improving, General sense of wellbeing present  Max Temp- 102.8OF	1,52,000	Placebo
27/9/09	Most of the complaints SQ in the morning but better by the evening. Max Temp- 98.6OF	Not done	Placebo
28/9/09	Itching of the palms+, no eruptions. Diarrhea 4 times/ day. Max Temp- 99OF	1,48,000	Placebo
29/9/09	Sleepless, app and thirst reduced, weakness and tiredness3, taste bitter, Afebrile all throughout	1,75,000	Placebo
30/9/09	Generals – much better,Particulars – better by 60-70% Afebrile	—	Placebo
1/10/09	Patient comfortable, moving around in the ward, all symptoms better Afebrile	—	Placebo
2/10/09	Completely better. Patient Discharged	—	Placebo

The patient was discharged on 2/10/09 and was called for a follow up after 4 days.

After 4 days patient was well and had no fever, but had some weakness which was better than before and he had started attending work. Patient was started on constitutional medicine after fever settled down.

DISCUSSION:

Repertory is a tool of great help but, has its limitation. Quantitative aggregation presented by repertory software needs qualitative analysis. In this case Sepia does not come up in first five remedies, yet on qualitative studies in Materia Medica stands up prominently. Meticulous differentiation of remedies based on Materia Medica is brings down errors in prescribing.

CASE – 3

PRELIMINARY INFORMATION

Mrs. V.P.J AGE: 35 years  SEX: Female Married since 14 years Housewife

DATE OF CASE TAKING: 15/9/09

Patient presented with low grade fever partially treated with allopathic medicines. Patient was not better hence came for homoeopathic treatment. Entire course of the illness was mild, insidious and slow. Patient did not complain of chills right from day one. She had headache, dullness with no desire to work, thirstlessness and bitter taste in mouth. Headache was severe led to weeping spells.

 DAY – 1

LOCATION	SENSATION	MODALITY	CONCOMITANT
General Since 3 days Sudden onset     Head-forehead and generalmuscles and soft tissues,legs   Stomach Since the last 2 days 2-3 / day Skin since 1 day Ext mainly upper	Fever initially low grade, later high grade with heat S. No chiils or rigors No sweating   Partial betterment with medicines prescribed by general practitioners. But, fever persists     Pain3- aching     Nausea 3 Vomiting of ingested food and water  Appetite reduced  Reddish rash, occasional itching, no burning	< noise2 > Binding head3     < eating3 < drinking2	DULLNESS3 – No desire to work WEEPING3 PAIN WITH Thirstlessness3 Taste bitter3

Past History – Fever 9-10 years back,? Koch’s

Family History – Hypertension in both parents

OBSERVATIONS MADE OF PATIENT’S BEHAVIOUR-

• Patient was a quiet lady who spoke little and appeared to be mild
• Patient was always accompanied by someone for the follow up.
• She was afraid when spoken to about admission and the diagnosis
• She timidly followed everything told to her by the team of physicians and her husband.

GENERAL EXAMINATION-

• GC:  Fair, Mild pallor +
• Weight:      49 Kg
• TEMP:       2⁰F
• Pulse:         98/min
• BP: 120/80 mmHg
• Tongue:      Moist white coated
• Skin: Macular erythematous rash on the upper and lower extremities, 1-2 petechiae, not palpable, non-tender, blanching + on pressure

SYSTEMIC EXAMINATION-

• S- Clear C.V.S- S1S2 heard
• A- soft, non-tender, L 1F, S 2F
• ENT- NAD
• Oral Cavity – Fordyce’s spots +

INVESTIGATIONS –

Hb- 13, WBC- 4,200    N:68 L:26E:4M:2,  ESR- 18

Platelet count- 78,000

Ps for MP- Absent

Actions on Day 1.

• Patient advised admission for observation and investigations.
• Patient refused admission.
• Patient asked to follow up daily and sos.
• Prescription- placebo

DAY – 2

Bleeding PV started, Profuse, dark red, LMP- 15 days ago    ? Menses early, ?hemorrhage  Rash- same

Mild feverishness in evening, temperature not measured by patient.

No improvement in app and thirst

No other complaints

PROBABLE CLINICAL DIAGNOSIS- Dengue fever

REASONS–

• Sudden onset of fever with severe intense headache and myalgia.
• The appearance of rash at the de-effervescence of fever with its characteristic pattern of initial macular to later purpuric type are characteristic of dengue fever.
• A low leucocyte count.
• Falling platelets with appearance of bleeding is also more suggestive of a dengue infection.

ON EXAMINATION FINDINGS-

Mild icterus +, No pallor

T- 98

RS, CVS- Nad

PA- L2fp, S3fp

Skin- petechial spots + over the arms, blanching on pressure, non-palpable, erythematous macules developing over the abdomen and back

PLATELET COUNT- 50,000 DENGUE IgM-positive,  IgG- positive FINAL DIAGNOSIS- Dengue fever with thrombocytopenia.

DAY – 3

PV bleeding persisted

Mild fever

Mild nausea, no other complaints

ON EXAMINATION-

Rash same, Purpuric spots on the lower extremities and very few over the abdomen.

Case taking of the chronic totality done to know the deep acting CONSTITUTIONAL REMEDY as well as the probable ACUTE REMEDY in relationship with the constitutional remedy.

Acute Totality:

1.       Dullness fever during 2.       Weeping pain due to 3.       Thirstlessness 4.       Nausea < eating3 5.       Head pain > binding the head3

6.       Bitter taste3 7.       Nausea < drinking2 8.       Head pain < noise2 9.       Menses profuse 10.   Menses dark red

CHRONIC TOTALITY

1.   Sensitive3 reprimands to 2.       Weeping tendency3 3.       Mildness3 4.       Timidity3 5.       Aversion milk3 6.       Aversion sour3

7.       Aversion sweet2 8.       Hunger agg3 9.       Thermals- HOT 10.   Menses dark3 11.   Menses offensive3 12.   Menses staining3 13.   Head pain2 exposure to sun due to

REMEDY:

PULSATILLA was indicated in the acute phase and also as the constitutional remedy.

SUSCEPTIBILITY

Criteria	Assessment	Reasons
Tissue Susceptibility	Moderate	Pace- slow, presenting in declining phase of fever Pathology- acute fever with thrombocytopenia Characteristics- many, mental characteristic symptom +, physical gen +, particular++
Sensitivity and Reactivity	High	Presence of characteristic mental as well as physical general symptoms in the fever episode as well as, at dispositional level
Pathology	Moderate	Functional reversible
Miasm	Dominant– Sycotic Fundamental– sycotic	Slow insidious onset, mild intensity yet prolong symptoms. Affection of the blood and RES with reduction of the platelet count and bleeding.
Vitality	Good	Vitals stable,

Susceptibility of the patient indicated only moderate deviation from state of health, hence single dose of constitutional remedy should suffice. Pulsatilla was the deep acting constitutional force in the case. Patient had a sensitive and reactive system hence, PULSATILLA 200 single dose was given on 17/9/09.

FOLLOW UPS:-

DATE	GENERALS	PLATELET COUNT	ACTION
18/9/09	App and thirst improved,No fever, body ache Rash reduced, Headache mild,PV bleeding reduced	58,000	Placebo
19/9/09	App and thirst further improved, energy levels better Rash improved, purpuric spots SQ, erythema reducing, bleeding reduced	62,000	Placebo
20/9/09	Better Purpuric spots also fading, no erythema, bleeding stopped	1,68,000	Placebo
22/9/09	Improved Only mild headache  Rash- only 1-2 purpurae seen	1,68,000	Placebo
29/9/09	No symptoms	2,35,000	Placebo

DISCUSSION:-

Case presented during de effervescence of the episode. Onset duration and progress clearly showed a slow mild, and insidious pace of illness. Thou patient did not have high grade fever lady was weeping due to headaches and also had other concomitants like drowsiness. Complete history was sought to obtain constitutional data. Constitutional data helps plan the treatment based on remedy relationships.

In this case constitutional remedy Pulsatilla itself covered the fever totality. Susceptibility assessment did not show any gross deviations from state of health as illness was in declining phase. Hence single stimulation was adequate for the case to sail through.

Key decision making points were stage of disease, pace and progress of symptoms, state of susceptibility and confirmation of acute and chronic totality coverage by Pulsatilla.

CASE – 4

PRELIMINARY INFORMATION

Name: R.C.N.  Age:  25 yrs, Sex:  Male, Religion: Hindu Education: student          D.O.A: 8-09-2004

Patient presented with high grade fever sever chilliness and body pains since 2 days. He had travelled to an endemic area a few days ago, also had ice cream in the journey. Since the fever he had low appetite, bitter taste,thirstlessness and headache. Body ache was extremely severe associated with restlessness. Whole body was sore, patient was unable to lie down in one position for more than a minute.

LOCATION	SENSATION	MODALITY	CONCOMITANT
Since 2 days   BLOOD & RES   SUDDEN	Chilliness with fever Fever in range of 104° F 105° F Severe Chilliness Severe Body Pains   Intense restless3 due to intense soreness of body Unable to lie in one position even for a minute but finds it difficult to move due to intense weakness	A/F- Had lot of Ice-cream 2 days back	Taste bitter App low Thirst- reduced Headache

H/O- Having traveled to endemic area 2 days ago.

On Examination-key findings

Toxic look

T- 105 ⁰F

Tonsils – Enlarged ++, Congested ++, Pus pocket ++

Abdomen- Liver not palpable, Spleen 2 cm

Differential diagnosis.

	Tonsillitis		Malaria		Dengue
  	Ailments from ice cream. Fever Tonsils enlarged, congested and with pus pockets	  	High grade fever with chilliness. Malaise and headache. Spleen 2 cm.	  	H/o visit to Dengue endemic area Abrupt onset of fever. Malaise, headache, backache.
					Spleen 2 cm.
					Toxic look.

INVESTIGATIONS:

8-9-04

Hb- 15 , TLC- 4,800/cmm. N-66, L-27, E-04, M-03, Platelet- adequate.  SGOT- 16.6       SGPT- 44.7S.Bil. – 0.58Direct- 0.39

Malarial Parasite – Not Detected

Widal : O- 1:30  H – 1: 30

Totality of symptoms:- 1.Ailment from ice cream.

2. Restlessness due to intense soreness and aching of body parts lied upon
3. Feel too weak to move in bed.
4. Fever with rapid prostration.
5. Thirst decreased during fever.
6. High-grade fever with toxic state.
7. Painless inflammation of tonsils.

Remedy differentiation:

BAPTISIA	ARS ALB	ARNICA	GELSEMIUM
Restlessness due to intense soreness and aching of body parts lied upon Toxicity Thirstlessness Painless throat	Mentally restless Physically exhausted. Thirsty – Drinks little and often	Intense soreness and aching of body parts lied. Thirsty during chill	Drowsiness is more marked  Bodyache thirstlessness

POSOLOGY:

Susceptibility	High	Sudden, abrupt onset Rapid pace Functional changes Characteristic symptoms	Potency – 200 Repetition – 3 doses
Sensitivity	High	Characteristic symptoms

REMEDY SELECTION: Baptisia 200 three doses 08.09.04.

FOLLOW UPS:-

8-09-04	After first dose Soreness decreased+ ,feeling better. Fever range104 F – 103 F After second dose Body ache decreased+fever range same. After third dose Weakness++Body ache++ Restlessness++ ,Fever102 F – 99 F
9-09-04	Asymptomatic
10-09-04	Asymptomatic
11-09-04	Purpuric rash, Sub-Conjunctival Hemorrhage, TLC 4200, Platelet count 90,000/cmm
12-09-04	Patient Asymptomatic ,TLC – 4600, Platelet count – 62,000/cmm
13-09-04	Asymptomatic, DENGUE IgM- 95.7 PANBIO units Platelet count 64,000/cmm
15-09-04	Patient Asymptomatic, Platelet count – 94,000/cmm
16-09-04	Patient Asymptomatic, Platelet count – 1,52,000/cmm

DISCUSSION

Diagnosis in this case was inconclusive for first 3 days, though had suspicion of Dengue and Malaria, but because prescribing characteristics were present in the case homoeopathic treatment could be started even before conclusive diagnosis was arrived at. This is one advantage of using homoeopathy in early stage of diseases, even before classical pathological symptoms develops, because homoeopathic treatment is patient specific and not disease specific. However this doesn’t undermine importance of diagnosis for the homoeopathic physician. Diagnosis helpedto do follow up investigations, to anticipate complications, to understand natural course of disease visa vis course of disease in this specific case after homoeopathic treatment.

IMPACT OF TREAMENT:

	NATURAL COURSE		CASE
••• • •	Abrupt onset 3-4 days duration of first phase Biphasic-saddleback pattern –2  to several weeks Sequel with distress Complications- shock, death	•••• •	Abrupt onset First phase –duration of 1 day. Biphasic –saddleback pattern – aborted No Sequel. No complications.

CONCLUSIONS:

• Homoeopathic treatment helps in cutting short the clinical course of disease, reduction of distress of patient, prevention of complications & cutting short the convalescence in Dengue.
• Meticulous homoeopathic case taking during Dengue fever focusing on; onset, duration and progress of each symptom, fever pattern & concomitants during different stages is essential.
• Carefully elicited symptoms and systematic recording in LSMC format as suggested by Boenninghausen helps in analysis, of common symptoms from individualizing characteristics.
• Assessment of individuals susceptibility based on pace of disease, stage of illness, presence of homeopathic characteristics help in deciding the potency and repetition schedule. In Dengue, rarely is multiple dose repetition essential unless clearly indicated by severely deviated state of susceptibility like in DHF or DHS.
• Close follow up of dengue patient is essential. Mere sense of wellbeing, absence or reduction of fever should not be relied upon. Dengue is known for relapses and kickback fevers.Objective signs like platelet count, purpuric rash and active bleeding should be observed closely.
• After patient is afebrile for 48 hours or during convalescence, the deep acting constitutional remedy should be prescribed to prevent relapse.