SARS IN AYURVEDA A BRIEF PRESENTATION

1. SARS- AYURVEDA AND NATURE
CURE

3. SEVERE ACUTE RESPIRATORY
SYNDROME
• 1st major global epidemic of 21st
century.
• Pandemic potential.
• Potential Bio-weapon (CDC).
• Communicable viral respiratory
infection.
• Caused by a novel corona virus.

4. TIMELINE
• Initial cases in Nov. 2002 in Guangdong Province, South
China (atypical pneumonia)
• Feb 11. 2003 ministry reports 305 cases and 5 deaths.
• Feb 26 -1st notified by Dr Carlo Urbani to WHO HQ.
• Feb 28- 1st introduction to Hongkong.
• March 12 Global Alert.
• March 15 WHO Emergency Travel Advisory.
• March 21 CDC published a preliminary clinical
description of SARS

5. Up to June 2003
Sick, Deaths & No. recovered
No. Recovered (77%)
Deaths (9%)
Probable Cases (14%)
Ultimately 8422
cases identified by
WHO in 28
countries of Asia
Europe & North
America
~ 90% in
Hongkong
Source WHO

6. DISTRIBUTION
• Worldwide
• Epidemic (once) in
South China , Hongkong
• Laboratory acquired
cases
• Sporadic cases in China
2004

7. UP TO APRIL 03

8. AS PER JUNE 2003

10. EPIDEMIOLOGY
 SARS – CoV
 Zoonotic infection
 Originally from
Himalayan Palm Civet &
Raccoon dog
Palm civet
Raccoon

11. TRANSMISSION
• Direct/ Indirect contact
of mucous membranes
• Fomites
• Aerosol transmission
rarely
• Faecal-oral route

12. SECONDARY ATTACKS
• 2-4 cases on an average
• “Super-spreaders” infect
about 10 -40 cases
• Average rate – 1:3
• Children < 12 yrs of age not
likely to transmit
• No mother – infant
transmission
INFECTIVITY
• No transmission prior to
onset of symptoms
• Maximum efficient
transmission during 2nd
week of illness
• Peak virus excretion on 10th
day of illness
• No infectivity 10 days after
fever resolution

13. VIROLOGY
• SARS Associated CoV
• Ancient split – off from
group 2 Coronaviridae
• Large enveloped single
stranded RNA Virus
• Club shaped surface
projections
• 100-150 nm in diameter
• Survive in dry air 3-24 h but
easily killed by UV (sun light
sensitive)
SARS CoV UNDER
ELECTRON MICROSCOPE

14. • S (Spike) major antigen,
receptor binding, cell
fusion.
• E (Envelope assoctd
protein.
• M (Membrane)
transmembrane
budding
• N (Nucleocapsid)
phosphoprotein
SARS CoV GENOME

15. PATHOGENESIS
VIRAL REPLICATION PHASE
• Progressive increase in viral
load
• Specific antibody
appearance coincide with
peak viral replication
IMMUNOLOGIC PHASE
• Decline in viral load
• Cytokine- mediated
immune response
• Tissue injury
INCUBATION PERIOD
4-6 DAYS

16. PULMONARY PATHOLOGY
 Hyaline membrane
formation
 Desquamation of
pneumocytes in the
alveolar space
 Interstitial infiltrate of
lymphocytes and
mononuclear cells
 Viral particles in
pneumocytes

17. CLINICAL FINDINGS
(90%)
(52%)
(30%)
Chills/rigors (71 %)
Diarrhoea (25 %)

18. CLINICAL COURSE
Adults
• Triphasic clinical pattern
 Onset
Fever, cough, chills, myalgia,
malaise, headache
 Ist week end
Recurrence of fever
Dyspnoea, Diarrhoea,
Hypoxaemia
 3rd phase (20%)
ARDS & respiratory failure
Children & Teenagers
 Children <12yr – mild non
specific
• <5 days duration
• Minority develops LRTI
 Teenagers
• Intermediate severity
• Hypoxaemia & respiratory
distress in 10- 20 %
• ⅓ cases ventilatory
support

19. WHO CASE DEFINITION
SUSPECT CASE (after nov1st
2002)
 High fever (38°c )
Cough /breathing difficulty
10 days prior to onset
– h/o close contact with a
suspect /probable SARS case
– h/o travel to SARS affected
area
– h/o residing in SARS affected
area
 Death due to an
unexplained acute
respiratory disease but no
autopsy done with h/o
• -do-
PROBABLE CASE
 Suspect case with
radiographic evidence
 Suspect case with autopsy
findings
 Excluded if any alternate
diagnosis

20. LABORATORY FINDINGS
• Lymphopenia (50% of adult cases) (90% of children)
• TWBC - normal/slightly low
• Neutropenia
• Thrombocytopenia (progression stage)
• Prolonged activated partial thromboplastin
time
• Incr. alanine aminotransferase
• Incr. lactate dehydrogenase
• Incr. creatine kinase

21. RADIOGRAPHY
Normal x-ray CXR at presentation

22. • Small unilateral patchy
shadowing (beginning)
• Multiple bilateral
generalised subtle
haziness with interstitial
infiltrates (1-2 days) (70%)
• Areas of consolidation in
peryphery and lower lung
fields

23. DIAGNOSIS
 Serologic testing (ELISA, IFA)
• IgM Detection (not detected until 10
days of onset)
• 4 fold rise in IgG titre
• Seroconversion from –ve to +ve (delayed
up to 4 weeks)
 RT-PCR (repeated sampling till peak viral
load)
– Nasopharyngeal aspirates
– Blood or serum
– Stool
 Isolation of the virus in cell culture

24. DIFFERENTIAL DIAGNOSIS
• Atypical pneumonia (mycoplasma) (tracheo-
bronchitis)
• Influenza (myxovirus) (spasmodic cough)
• Parainfluenza (paramyxovirus) (crouping)
• RSV Infection (oedema of peribronchial region)
(mucous plugs)

25. PROGNOSIS
10-17 % fatality rate in the 2003 epidemic
• Estimated case fatality rate
• <1 % in < 20 yrs of age
• >50 % in >65 yrs of age
• Comorbidities being risk factors
• CVD , Diabetes, Hepatitis

26. COMPLICATIONS
• Reduced peak oxygen consumption
• Mild restrictive/ obstructive pattern on PFT
• Thinning of hair 2-3 months after disease
onset
• Osteonecrosis due to corticosteroid use

27. TREATMENT
• Primarily supportive
• Bronchodialators discouraged due to
aerosolization of virus
• Psychological support on isolation
• Use of antivirals & immunomodulatory
measures remain inconclusive (poor invitro activity)
• Ribavirin + corticosteroids IV brought some
clinical improvement

28. ANTIVIRALS
• Glycyrrhicin induces
nitric oxide synthase in
vero cells that viral
replication is inhibited
• Similar antiviral
property for aescin and
reserpine.

29. PREVENTION & CONTROL

30. • Effective vaccine not yet available
• Epidemic containment (combined efforts)
• Emergency operating centres
• Institutional support in quarantine and
legislation
• Travel alert
• Exit screening of travellers
• Protection for health care workers
• Disinfection

31. AYURVEDIC PERSPECTIVE
• Aganthu jwara
• Dosha analysis : kapha vata predominant
sannipata
• Dooshya : kapha sthanas
• Dhatukshaya to be considered

32. Symptoms of SARS
• Chills and rigors
• Fever
• Malaise
• Headache
• Myalgias
• Cough
• Diarrhoea
Vata sleshmolbana manda pitta
sannipata jwara
• Seeta jwara
• Parswabhigraha
• Soola
• Cough
• Asveda
• Tandra
• Swasa leading to death.
(cha, chi)

33. CIKITSA
• Deepana pachana cikitsa.
• Svedana specially indicated in
respiratory symptoms.
• Use of katu, ushna madhura dravya
• Jwara cikitsa protocol
• Pranayama as a restorative therapy

34. Some formulations
• Balajeerakadi kwatham (oxygen saturation)
• Dasamoolakatuthrayam (vasa svasaghna)
• Elakanadi kashaya
• Indukantha kashaya (immune enhancers)
• Pathyakusthumbaradi (myalgias )
• Amruthaprasha ghrutha (tissue injury)
• Indukantha ghrutha
• Chyavanaprasa
• Dasamoola hareetaki (complications)
• Vyoshadi vataka (local inflammation)

35. NATUROPATHIC MANAGEMENT
 General
• Fruit/ vegetable juice 50- 50 diluted with
water (3-5 days)
• Warm water enema daily
• Fever 3 meals a day of fresh juicy fruits
• Lemon juice in salads
• Spices, condiments, coffee, alcohol, over
boiled milk etc must be avoided
 Specific
• ½ tsp long pepper+ 2 tsp honey+1/2 tsp
ginger juice
• Tulsi decoction
• Garlic juice nasal administration
• 1 tsp turmeric powder in acup of warm milk
3 times a day

36. • If cough
• Honey with grape juice
• Paste of skin removed
almond + 20 gm butter
and sugar twice daily
• Roasted and powdered
root of turmeric

37. CONCLUSION
• Acute contagious disease.
• Can pose threat any time anywhere!
• Strict isolation is to be ensured.
• Managing cases at once diagnosed minimizes
fatality.
• Areas of research wide opened at a herbal
remedy.
• Can be effectively managed by any system of
medicine if attended promptly.