gullian barre syndrome in ayurveda a case presentation

1. 1

2. CASE PRESENTATION
Moksha B.M.
2nd year PG Scholar
Dept., of PG studies in Kayachikitsa
SKAMCH&RC
BENGALURU

3. • Name : M. Nivetha
• Age : 7 Years
• Sex : Female
• Religion : Hindu
• Socio economic status : Middle class
• Education status : I std
• Date of admission :23/08/16 11 A.M
• Date of discharge :14/09/16 3 P.M
3

4. • Ward : 4th floor General ward
• Source of history : Patient’s parents
• Consultant doctor : Dr. Sridhar
• O.P No : D25470
• I.P. No : 3611/16
• Case taken on : 24th August 2016
• Address : # 8, Mevasandivam
village, Denkanikotta
Taluk, Tamilnadu.
• Phone no : 9942264557
4

5.  C/O Balakshaya & shoola in both lower limbs.
 Unable to get up from sitting position or supine
position.
 Not able to stand or walk.
 Balakshaya in both upper limbs, not able to hold
objects.
since 1 month (28/07/2016)
5

6. The child was apparently normal till 27/07/2016. On the
day of 28/7/16, when the mother tried to wake up the
child in the morning she noticed Balakshaya in both the
lower limbs and that the child couldn’t move her lower
limbs and also couldn’t get up from the bed. She helped
the child to get up but the child couldn’t stand or walk.
The child also complained of shoola in both lower limbs.
So they took her to nearby Lakshmi Hospital in Hosur. 6

7. She was admitted and investigations were done. Nerve
Conduction study was done and a probable diagnosis of
? Acute Inflammatory Demyelinating Polyneuropathy
was done and was referred to a higher centre for further
treatment. The child was taken to St. John’s Hospital
but no treatment was done there and was referred to
Narayana Hrudayalaya. She was admitted from 1/8/16
to 4/8/16 in Narayana Hrudayalaya. The child’s parents
didn’t notice any improvement and was discharged on
request. Also the mother noticed weakness in the
7

8. B/L upper limbs as the child was not able to hold any
objects.
By the suggestion of their relative, came to the OPD of
SKAMCH&RC for further treatment on 23rd August
2016.
There was no H/O Bowel/ Bladder incontinence, no H/O
trauma.
8

9. H/O
Fever for around 10 days in June 2016. (? Viral fever
– was treated on OPD basis)
Fever 10 days back for a day (before the onset of
presenting complaints) and subsided with treatment in a
local hospital.
9

10. In Narayana Hrudayalaya (from1/8/16 to 4/8/16)
• IvIg 2 gm/kg in 2 divided doses
• Syp.Zincovit 5 ml BD
• Syp.Shelcal 5 ml BD
• Syp.Paracetamol 5 ml (250 mg) QID
10

11. 7 yrs
10 yrs
11

12. • All developmental milestones achieved normally.
• All vaccinations done as per the immunization
schedule.
• Diet : Mixed, Non veg
once in a week (chicken, fish)
• Appetite : Reduced
• Sleep : Good
• Bowel : once/day (regular)
• Micturition : 5-7 times/day
12

13. 13

14. • Jatatah: Sadharana
• Samvardhitah: Sadharana
• Vyadhitah: Sadharana
14

15.  Naadi-80 bpm
 Mootra- 5-7times a day.
 Mala- Once/day/ regular
 Jihwa- lipta
 Shabda- Prakrita
 Sparsha–Anushnasheeta
 Drik- Prakrita
 Aakriti - Madhyama
15

16. • Prakriti :- Vata Kapha
• Saara :- Madhyama
• Samhanana: Madhyama
• Pramana : Madhyama Ht:1.05 m , Wt: 16 kg
• Saatmya : Madhyama
• Satva : Pravara
• Aahara Shakti :
Abhyavaharana Shakti : Madhyama
Jarana Shakti : Madhyama
• Vyayama Shakti : Madhyama
• Vaya : Baala
16

17. Patient is conscious, alert, oriented to time, place and
Person.
• Built : Moderate
• Nourishment : Moderate
• Pallor : Absent.
• Cyanosis : Absent.
• Nail : Normal
• Icterus : Absent
• Oedema : Absent
• Lymphadenopathy : Absent.
17

18. Vikriti :- Pravara
Hetu:- ?Agantuja
Dosha:- Vata , Kapha pradhana tridosha
Dushya:- Rasa, rakta, mamsa, meda, snayu,
kandara
Desha:- Sadharana
Bala:- Pravara
Kaala:- Varsha
Prakriti:- Vata kapha
18

19. • Temperature: 98.6 degree F
• Pulse : 80 bpm
• Resp Rate: 24/minute.
• Tongue : coated.
• Height : 1.05 m
• Weight : 16 Kg
• BMI : 14.54 ( 5 th percentile)
19

20. Per Abdomen Examination
Inspection –
Scaphoid
Umbilicus – centrally placed, Inverted
 Auscultation - Bowel sounds heard
 Palpation –
Soft, No tenderness.
No organomegaly
 Percussion – Tympanic
20

21. 21
• Respiratory system
Inspection –
Shape of chest –B/L symmetrical
Chest movements- Symmetrical
Respiratory rate-24/min
Palpation - Trachea - Centrally placed
Chest Expansion - Symmetrical
TVF - Normal
Percussion - B/L Resonant
Auscultation - B/L NVBS heard

22. Cardiovascular System Examination
Inspection - No distended blood vessels
over chest and neck
Palpation - Apex beat felt
Auscultation - S1, S2 Heard
No murmurs
22

23.  CENTRAL NERVOUS SYSTEM
1. HMF
Consciousness - Conscious
Orientation to - Time, place, person- Intact
Memory - Recent - Not affected
Remote - Not affected
Intelligence - Intact
Hallucination & Delusion - Absent
Speech disturbance - Absent
Handedness - Right
23

24. Cranial Nerve Examination
CRANIAL
NERVES
LEFT SIDE RIGHT SIDE
CN I- Olfactory
a) Smell
sensation
Intact Intact
CN II- Optic
a)Visual acuity
b)Visual field
c)Light reflex
Not affected
Not affected
Normal
Not affected
Not affected
Normal
24

25. CN III Occulomotor Nerve
CN IV Trochlear Nerve
CN VI Abducens Nerve
A) (Pupil- Position, Size,
Shape, Symmetry)
B) Eye ball Movements
Normal
Normal
Normal
Normal
25

26. 26
CN V Trigeminal Nerve
A) Sensory –Touch, pain
and pressure sensation
B) Motor -
a) Clenching of teeth
b) Jaw movement against
resistance
c) Jaw jerk
d) Corneal reflex
Intact
Possible
Possible
Normal
present
Intact
Possible
Possible
present

27. 2
7
CN VII Facial
Nerve
a)Forehead frowning
b) Eyebrow raising
c) Eye closure
d) Teeth showing
e) Blowing of cheek
f) Nasolabial fold
Possible
Possible
Possible
No deviation of
angle of mouth
Possible
Equal on both
sides
Possible
Possible
Possible
No deviation of
angle of mouth
Possible

28. CN VIII Vestibulo
Cochlear Nerve
a) Rhinne’s test
b) Weber’s test
AC>BC
Equal on both sides,
No lateralisation
AC present,
BC absent
28

29. 29
CN IX, CN X
Glossopharyngeal
and Vagus nerve
a) Position of uvula
b)Taste sensation
c) Gag reflex
Centrally placed
Intact
Normal

30. 30
CN XI Accessory Nerve
a) Shrugging the
shoulder
b) Neck movement
Not Possible
against resistance
Possible against
resistance
Not Possible
against
resistance
Possible against
resistance
CN XII
Hypoglossal Nerve
a) Protrusion of tongue
b) Tongue movements
Possible
Possible

31. Motor system
Muscle Bulk Right (in cms ) Left (in cms)
Upper limb
Biceps 14.5 14
Forearm 12.5 12
Lower limb
Mid Thigh 23.5 24
Calf 16.5 16.5
31

32. Muscle tone
Right hand - Hypotonic
Left hand - Hypotonic
Right leg - Hypotonic
Left leg - Hypotonic
Muscle strength Rt Lt
a)Elbow flexion 3/5 3/5
extension 3/5 3/5
b)Wrist flexion 3/5 3/5
extension 3/5 3/5
32

33. Rt Lt
c) Finger abduction 3/5 3/5
d)Opposition of thumb 3/5 3/5
e) Test of grip
Palmar grip- Moderate (tends to drop objects)
Pincer grip- Moderate
Lower limb
Hip -adduction 0/5 0/5
-abduction 0/5 0/5
-flexion 0/5 0/5
-extension 0/5 0/5
33

34. Rt Lt
Knee -flexion 0/5 0/5
-extension 0/5 0/5
Ankle -dorsiflexion 0/5 0/5
-plantarflexion 0/5 0/5
Foot drop
34

35. DEEP TENDON REFLEX Left Right
Biceps jerk - -
Triceps jerk - -
Supinator jerk - -
Knee jerk - -
Ankle jerk - -
Babinski sign - No response
35

36.  Gait - Not elicited as patient is unable to walk (foot drop)
 Co ordination
Upper limb
• Dysdiadokinesia- absent
• Finger to nose test - Possible
Lower limb
• Heel shin test- Not Possible
• Rhomberg’s sign- couldn’t be elicited.
36

37. SENSORY SYSTEM
• Superficial
a) Touch - Intact
b) Temperature - Intact
c) Pain - Intact
• Deep
a) Vibration sense- Intact
b) Joint position sense- Intact
37

38. • Cortical
a) One point localization - Intact
b) Two point discrimination - Intact
c) Stereognosis - Present
d) Graphesthesia - Present
38

39. LAB INVESTIGATIONS

40. ON 1 AUG 2016
Complete Blood count
Haemoglobin : 12.8 g/dl
Red blood cell count : 5.02 million / microliter
PCV : 39.0 %
MCV : 77.7 fl
MCH : 25.6 pg
MCHC : 32.9 g/L
RDW : 12.5 %
40

41. Platelet count : 439 Thous/ microliter
Total count : 11.9 Thous/ microliter
Differential count :
Neutrophils : 53.0 %
Lymphocytes : 37.9 %
Monocytes : 6.2 %
Eosinophils : 2.6%
Basophils : 0.3%
41

42. RENAL FUNCTION TEST
Serum Creatinine : 0.4 mg /dl
Blood Urea Nitrogen : 9 mg/ dl
Sodium :141 mmol/L
Potassium : 4.1 mmol/L
Chloride : 106 mmol/L
Calcium : 9.9 mg/dl
Magnesium : 2.39 mg/dl
42

43. Uric acid : 2.9 mg /dl
Phosphorus : 5.7 mg / dl
Random blood sugar : 78 mg / dl
Creatine kinase (CK/CPK) : 85 IU/L
Nerve conduction study : ?AIDP
43

44. 44

45. Nidana – ? Agantuja
Purvaroopa - Not able to elicit
Roopa – Balakshaya and shoola in B/L Lower
limbs and Balakshaya in B/L upper limbs, Not
able to walk and not able to hold objects.
45

46. Nidana - ?
Agantuja
Dosha
vaishamya
Agnimandya
Formation of Ama
Circulating in Rasavaha srotas
Vishama Jwara
? Tritiyaka jwara
? Mithyahara vihara/
? Vishamat upachara
Leena
doshavastha
46

47. Kaphavruta
vyana-
Gati sanga
Vata prakopa
? Doshaja
marmabhigata
? Kukundara
marmabhigata-
chestopaghata
Pangu
C/O Balakshya in B/L lower limbs and upper
limbs, pain in both lower limbs, not able to
walk, not able to hold objects
47

48. Dosha – Vata kapha pradhana tridosha
Dushya – Rasa, rakta, mamsa, meda, snayu, kandara
Srotas – Rasavaha, raktavaha, mamsavaha, medovaha
Sroto dushti - Sanga
Agni – Jatharagni, Dhatwagni
Ama - Jatharagni and Dhatwagni mandya janya ama
48

49. Udbhavasthana – Amashaya, Pakwashaya
Sancharasthana – rasayani
Vyaktasthana – Shakha
Adhishtana – Shakha
Rogamarga- Madhyama
Sadhya-Asadhyata – Kricchra Sadhya
49

50. • Pangu
• Pakshavadha
• Tritiyaka jwara- Trika grahi
• Kaphavrita Vyanavata
• Kukundhara Marmabhighata
50

51. Disease Inclusion criteria Exclusion criteria
Pakshavadha Chesta nivrutti Either vama or
dakshina bhaga
involved
Pangu Balakshaya in both
the jangha
Tritiyaka jwara Trika grahi
Kaphavrita Vyanavata Gati sanga
Kukundhara
Marmabhighata
Chestopaghata
51

52. • Transverse Myelitis
• Myahestani Gravis
• Poliomyelitis
• Vasculitic neuropathy
• Periodic paralysis
• Benign acute childhood myositis
• Inclusion body myositis
• Guillian barre syndrome - ? AIDP
52

53. Disease Reason for Inclusion Reason for Exclusion
Transverse Myelitis Asymmetric motor or
sensory loss usually
involving lower
extremities.
•Early bowel/bladder
dysfunction with
persistent incontinence
and segmental
radicular pain
•On Examination-
UMN signs like
hyperreflexia, +ve
Babinski
Myasthenia Gravis •Weakness in the
limbs
•No bladder
dysfunction
•Excess fatigability
•Variation of
symptoms through the
day.
•Reflexes-preserved53

54. Disease Reason for Inclusion Reason for
Exclusion
Poliomyelitis •Muscle weakness/
paralysis of lower
limbs
•Flaccid type
•Asymmetrical
distribution since
only some muscles
are affected.
•Always preceded by
fever and headache.
•Improvement sets in
towards end of first
week with subsequent
wasting of muscles
and contractures,
54

55. Disease Reason for Inclusion Reason for
Exclusion
Periodic paralysis •Weakness of legs and
arms.
•Commonly occurs
after sleep or rest.
• Episodic- occurs on
and off.
•Normal strength
between the attacks.
Vasculitic neuropathy • Painful asymmetric
presentation of
muscle weakness
• Sphincter
dysfunction
•Respiratory paralysis
55

56. Disease Reason for Inclusion Reason for
Exclusion
Benign acute
childhood myositis
•Sudden onset of leg
pain(mostly calf
region) and weakness
of the lower limbs
with walking
difficulty.
•H/O recent fever
•Self limiting process
•Increased Creatinine
kinase levels
following viral
infection
Inclusion body
myositis
•Weakness of the both
upper and lower
limbs
• Prominent muscle
wasting
56

57. Disease Reason for Inclusion Reason for
Exclusion
Guillian barre
syndrome
• Progressive
weakness in both
arms and legs over
hours to days
• Relative symmetry
of symptoms
• Areflexia
•Triggered by
antecedent
viral/bacterial
infection
57

58. • Pangu (The underlying samprapti to be analysed –
considering Trikagrahi jwara, Kaphavrita vyana,
kukundara marmabhighta – doshaja )
• Guillian barre syndrome
58

60. DATE TREATMENT GIVEN OBSERVATIONS
23/08/ 16
to
29/08/16
1. Sarvanga Parisheka with
Dashamoola quatha for 7 days
2. Guduchi churna ksheerapaka - 25
ml BD
½ tsp powder +milk 25 ml + water
100 ml boil and reduce to 25 ml,
filter and add sugar to taste.
3.Tab.Amlaparimala 1 tab BD
Jihwa- liptata
At admission- Not
able to turn
sidewards on
bed, or get up.
Not able to stand
or walk
60

61. DATE TREATMENT GIVEN OBSERVATIONS
30/08/ 16
to
14/09/16
1. Sarvanga mrudu Abhyanga with
Balashwagandha taila followed by
Shashtika shali pinda sweda for 16
days
2. Matra Basti with Mahakalyanaka
ghrita – 25 ml for 8 days
3. Guduchi churna ksheerapaka 25
ml BD
4. Tab.Samshamani Vati 1 tab TID
5. Tab.Amlaparimala 1 tab BD
At- discharge-
Able to stand with
support and walk
with support for
20-30 steps.
61

62. • Guduchi Ksheerapaka 25 ml BD
• Tab.Ekangaveera rasa- 10 tabs
• Ashwagandha Churna- 50 gms
• Cap.Palsineuron- 10 caps
½ tsp churna + 1 tsp Mahakalyanaka ghrita TID
• Tab. Samshamani vati 1 TID A/F
• Balashwagandha taila for local application
Again readmitted on 19/9/16.
62

63. DATE TREATMENT GIVEN OBSERVATIONS
19/09/ 16
to
26/09/16
1. Sarvanga Abhyanga with Bala
ashwagandha taila followed by Patra
Pinda Sweda for day
2. Tab Ekangaveer rasa (10 ) +
Ashwagandha choorna (50 gm) +
Cap Palsineuron (10) - ½ tsp
powder + 1tsp Mahakalyanka Ghrita
–BD (A/F)
3. Tab Samshamani Vati – TID
(A/F)
At admission-
Able to stand with
support and walk
with support for
20-30 steps
63

64. DATE TREATMENT GIVEN OBSERVAT
IONS
4. Guduchi ksheerapaka - BD (B/F)
(½ tsp powder +milk 25 ml + water 100 ml boil and reduce
to 25 ml filter and add sugar to taste.)
5. Syp.Nirocil 1tsp – 0-1tsp (B/F)
6. Rasnadi choorna - mix little powder with
warm water and apply to forehead
7. Physiotherapy
8. Matra basti with Bala ashwagandha taila-
25 ml for 8 days (from 24/9/16)
64

65. DATE TREATMENT GIVEN OBSERVATIONS
27/ 09 /16
to 4/10/16
Treatment from 1- 8 contd.
9. Marmani gulika lepa to left
foot
H/O Slip and fall
during walking on
26/9/16.
C/O pain while
walking
O/E- Mild edema,
Tenderness over
lateral aspect of left
foot
on 27/9/16- Able to
stand without
support and walk
without support- 1
round
X ray of left foot-
Normal
65

66. DATE TREATMENT GIVEN OBSERVATION
S
5 / 10 / 16 1. Tab Ekangveer rasa (10 ) +
Ashwagandha choorna (50 gm) +
Cap Palsineuron (10) -
½ tsp powder + 1tsp Mahakalyanka
Ghrita –BD (A/F)
2. Tab Samshamani Vati – TID
(A/F)
3.Syp Nirocil 1tsp – 0-1tsp (B/F)
4. Marmani gulika lepa to left foot
5. Physiotherapy
C/O pain while
walking- reduced
O/E- No
Tenderness
Able to stand
without support
for about 15
minutes
Able to walk
without support
about 2 rounds
66

67. IMPROVEMENTS SEEN
PARAMETERS I ADMISSION II ADMISSION
HUGHES GBS
DISABILITY
SCALE
At admission- 4/6
At discharge- 3/6
At admission- 3/6
At discharge- 2/6
On examination •CN XI- shrugging
shoulders- not possible with
resistance
•Muscle tone in B/L UL-
Normotonic
•Muscle strength in B/L
elbow and wrist- 3/5
•CN XI- shrugging
shoulders- possible with
resistance
•Muscle tone in B/L UL-
Normotonic
•Muscle strength in B/L
elbow and wrist- 4/5
67

68. PARAM
ETERS
I ADMISSION II ADMISSION
•Palmar grip- Moderate (tends to
drop objects)
•Pincer grip- moderate
•Muscle strength in B/L LL
Hip -adduction 0/5
0/5
-abduction 0/5
0/5
-flexion 0/5
0/5
-extension 0/5
0/5
•Palmar grip- good
•Pincer grip- good
• Muscle strength in B/L LL
Hip -adduction 1/5
1/5
-abduction 2/5
2/5
-flexion 1/5
1/5
-extension 1/5
1/5
68

69. PARAMETERS I ADMISSION II ADMISSION
Knee -flexion 0/5
0/5
-extension 0/5
0/5
Ankle -dorsiflexion 0/5
0/5
-plantarflexion 0/5
0/5
• Gait- could not be elicited as
the child couldn’t walk- foot
drop
Knee -flexion
3/5 3/5
-extension
2/5 2/5
Ankle -dorsiflexion
0/5 0/5
-plantarflexion
0/5 0/5
• Gait- Steppage gait
69

70. PARAMETERS I ADMISSION II ADMISSION
At admission- Not able to get
up from sitting or supine
position, not able to walk.
At discharge- Able to stand
with support and walk with
support for about 20-30 steps.
At admission- Able to
stand with support and
walk with support for
20-30 steps
At discharge- Able to
walk without support-
about 2 rounds
Able to stand without
support for about 15
minutes
70

71. • Guduchi Ksheerapaka 25 ml BD
• Tab.Ekangaveera rasa- 10 tabs
• Ashwagandha Churna- 50 gms
• Cap.Palsineuron- 10 caps
½ tsp churna + 1 tsp Mahakalyanaka ghrita TID
• Tab. Samshamani vati 1 TID A/F
• Syp. Appetite 5 ml TID
• Balashwagandha taila for local application
Review in OPD after 1 month.
71

72. THANK YOU
72