A Case Study on Successful Ayurvedic Management of a Rare Case of Reiter's Syndrome.

Reiter's syndrome is a clinical syndrome of arthritis, urethritis, conjunctivitis, and mucocutaneous lesions. Skin and mucosal involvement is observed in about 10% of the cases. A 34-year-old male was brought in severe condition. He had red colored foul smelling maculopapular skin lesions all over body, swollen and painful knee and shoulder joints. History revealed that he was suffering from Reiter's syndrome since 2003. He used to get admitted between the months of February and May every year due to aggravation of symptoms. Every time he was treated with systemic antibiotics, corticosteroids, immunosuppressants and non-steroidal anti-inflammatory drugs. He was successfully treated with external application and internal medication with tikta (bitter) and kaṣāya (astringent) drugs. He got significant relief in skin lesions as well as joint pain and his quality of life was markedly improved. This case study demonstrates that Reiter's syndrome can be well managed with Ayurvedic medicines.

Introduction

The clinical syndrome of arthritis, urethritis, conjunctivitis and mucocutaneous lesions is commonly known as Reiter syndrome. It is a multisystem disorder triggered by genitourinary or enteric infection. The classic triad, namely urethritis, arthritis and conjunctivitis presents in only one-third of patients and the tetrad, with the addition of the mucocutaneous findings of balanitis and keratoderma blennorrhagica is seen rarely.[12]

Case Report

A 34 year old man was brought by his relatives to the OPD of Kayachikitsa in the month of April 2011 in a severe condition [Figures 1–3]. Clinical examination revealed red colored foul smelling maculo-papular lesions all over body including scalp, nails, palms, soles. There was also swelling of both the knee and shoulder joints and was unable to walk due to severe pain. He had also restricted movements of both shoulders. Previous history revealed that he was suffering from above illness since 2003. The symptoms used to get aggravated very fast in a very short period in the month of February to May of every year so much so that every time he had to be admitted for treatment where he was treated with systemic antibiotics, corticosteroids, immunosuppressants and non-steroidal anti-inflammatory drugs. In spite of continuous medication, his condition was deteriorating. He was admitted in Kayachikitsa ward. On examination, his prakṛti (body constitution) was pitta-kaphaja. His agni bala (Digestive power) and Sharir bala (physique) was avara (poor). No specific etiological factor (occupation related or life style related) was found in history. The laboratory studies showed the following: hemoglobin 11.4 g/dl, leukocytes 6400/cu mm, neutrophils 68%, lymphocytes 26%, Eosinophils 01%, Monocytes 01%, ESR 96 mm/h. The urine analysis showed no albumin, pus cells, epithelial cells or RBCs.

Figure 1

Skin lesions of legs before treatment

Figure 3

Skin lesions of palms before treatment

Skin lesions of hands before treatment

Considering the history, clinical examination and investigations, following treatment was given [Table 1].

Table 1

Treatment plan

There was gradual improvement in the skin lesions within eight days [Figures 4 and 5]. The scales started shedding and Papular lesions converted into macules. Itching and burning sensation also decreased. Svedana (sudation) of both knees and shoulder was helpful in relieving pain and restricted movements.

Figure 4

Skin lesions of legs on 15th day of treatment

Figure 5

Skin lesions of Rt. shin on 15th day of treatment

Discussion

It was difficult to correlate Reiter’s syndrome with any one of the different Kuṣṭha rogas (skin diseases) described in Ayurveda. Some of the features of Kaphaja and Pittaja visarpa (one of the skin disorders) were found in this patient. The treatment was decided on the basis of predominance of doṣa and dhātu (~body tissues) involvement. The symptoms indicated vitiation of pitta and kapha doṣa and rasa and rakta dhātu. Treatment was planned according to treatment principles governing vitiation of Raktavāha srotas (~macro and microchannels of blood).

Triphalā and Nimbapatra (leaves of Azadirachta indica) were used to made decoction for the cleansing of skin lesions because Triphalā is anti-inflammatory, astringent and Neem is an antiseptic. These were helpful in shedding of the scales of skin and preventing secondary infection. The Cikitsā Sthāna of the Suśruta Saṃhitā recommends Triphalā among medicines that are good for purifying a wound.[10] Mṛdu virecana (Mild purgation) was given with Harītakī cūrṇa which proved helpful for koṣṭha śuddhi (~bowel cleaning). In Reiter’s syndrome, there is involvement of nails and joints. It is because of this that Pañcatikta ghṛta guggulu was selected. It is a combination of drugs having Tikta Rasa (bitter taste) dominance. Tikta Rasa is commonly used in skin diseases and as a vehicle to deliver medicines at the level of Asthi dhātu (~bony tissue). Guggulu is a proven anti-inflammatory agent.[11]

Gandhaka Rasāyana is a Sulphur based preparation. It is considered as a Rasāyana (rejuvenator) which promotes positive health and vigor, retards aging process and increases longevity in individuals by increasing immunity in the body, thus increasing resistance against the factors causing ailments. It is indicated in kuṣṭha (skin disorders).[12]

Mahāmañjiṣṭhādi Kvātha is described as Rakta śodhaka (~ remover of blood impurity), āmapācaka and viṣahara (detoxifier).

Aśvagandhā cūrṇa was used as an anti-anxiety drug because the patient was in stress due to chronic illness. Aśvagandhā has been used as a Rasāyana. It has a significant anti-stress adaptogenic effect.[13] It is also proven for its anti-inflammatory and antioxidant properties.[1415]

Karañja oil was used due to its Kaṇḍughna (anti-itching) and kṛmighna (anti-infective) property. It is commonly used in different skin diseases.[1617] It is also cost effective.

Guḍūcī ghanavaṭi was continuously used for one month. It has been used in Ayurvedic preparations for the treatment of various ailments throughout the centuries. It is used as a rasāyana to improve the immune system and body resistance against infections.[18] After completion of two months treatment, patient was apparently well. In the Next year (2012), he again had skin lesions but the intensity was not severe. He responded well to Pañcatiktaghṛta guggulu and Mahāmañjiṣṭhādi Kvātha with the previous dose for one month. From the year 2013 to 2016, patient was advised Guḍūcī Ghana 500 mg twice a day from the month of January to April as a preventive measure. He got significant relief in skin lesions as well as joint pain and his quality of life was markedly improved [Figures 6–8]. Patient is still on regular follow up and free from Arthritis and cutaneous lesions.

Figure 6

Legs after completion of treatment

Figure 8

Palms after completion of treatment

Hands after completion of treatment

Conclusion

This case study shows that Reiter’s syndrome can be successfully managed with Ayurvedic intervention. It is supportive for further research in Reiter syndrome and other autoimmune dermatological disorders.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.