A Case of Idiopathic Thrombocytopenia
A female patient, age of 18 years, came to see me with a main complaint of low platelet count. She has been diagnosed as suffering from idiopathic thrombocytopenia (ITP).
All her complaints started in June of 2007, when she experienced severe menorrhagia, with her menses lasting for more than 15 days. She was extremely weak and prostrated. She was relieved temporarily by allopathic medicine; however the next cycle was worse, with her flow continuing for more than a month. The prostration was even greater than the previous episode, and after about twenty days of blood flow she started with fever and chills, and collapsed with weakness.
On investigations, her hemoglobin level had dropped to 3.3 gm/dL and her platelet count was merely 14,000 per cubic mm (normal range is 150,000 – 440,000 per cubic mm). She had to be hospitalized and was given an emergency blood transfusion. She was put on hormonal tablets to control her flow. Due to her alarming condition, doctors thought that she might have secondary myeloid dysplasia. However, it was ruled out and finally she was diagnosed as having ITP with septicemia. She was treated with steroids. Since that time she has regularly complained of menorrhagia and large ecchymotic patches on her body, for which she has been put on high doses of steroids for about 4-5 months each year for the past four years, during which time her platelet count has widely fluctuated.
Her platelet count had decreased from 20,000 (August, 2011) to around 8,000 per cubic mm (September 9, 2011), hence she was immediately started on the steroid Omnacortil, 60 mg daily. When she consulted us on 23rd September 2011, her platelet count was 640,000 per cubic mm, so her steroid dosage was reduced to Omnacortil 20mg daily.
Besides this complaint, she has had severe headache since 2007, with pain mainly in the vertex, usually brought on by sun exposure, due to which she avoids being in the sun. She has dysmenorrhoea, with pain in lower abdomen, better bending or flexing forwards, with inability to lie straight. She also complains of constipation – she has to strain at stool every day. She continues to have a lot of weakness.
When asked about her nature, she says that she is generally a calm person, and family-oriented. However, she also gets angry easily when someone does not listen to her. She says that the anger comes suddenly and goes quickly, and that in her anger she does not like the person with whom she is angry and does not want to talk to them. Most of her anger is towards her brother, sister and mother.
- She is easily affected by noise, which irritates her; sudden noise also startles her. She says, “If someone screams or shouts at me, I can’t bear it – my ear drum feels as if it will burst.”
- She further narrates, “Occasionally I fear that someone is holding my hand or someone has held me, I can’t change my position; I can’t speak; I get scared. As if my all the organs of my body are being held tight and I can’t move at all. It feels tight, as if someone is holding me.”
- Her mother says that she talks in her sleep and calls out to her mother for help.
- She has fear of robbers and ghosts. She cannot stay alone. She says, “I get bored. I feel somebody should always be there with me.” She feels insecure when alone. After seeing scary movies or other frightening things she cannot sleep and wants the company of her family members.
- She gets frightful dreams that someone from her family is drowning. She says, “I feel like screaming; I feel someone should come and save them. I get scared.”
- She narrates an incident in which she witnessed a friend slip under water. She was the only one who saw it happen. She screamed and called for help, and her friend was saved. Since then her fear of drowning is very strong.
- The patient tells us that she likes to be covered, and she perspires mostly on her scalp.
- Most of you will be surprised to find this title of ‘case analysis’ here at this juncture of the case – does that mean that the case is over, or is it just the analysis of the case up to this point? Is this data sufficient to make a logical analysis and draw a conclusion??
- I would definitely say, yes! The case is complete enough to understand and to come to remedy.
- The key lies in listening most carefully. What may have sounded like a mere narration of the patient’s symptoms and her nature is actually the key to understanding the whole case. The simple, nonchalant talk of the person in front of us is nothing but the very description of the main symptoms on which we need to prescribe, if heard carefully. And for me, the patient had said everything about herself in this very meager data.
Though describing herself as calm, the patient gets irritated and angry very easily, especially from noise. And it is interesting to see that she is generally angry with her family members, despite describing herself as family-oriented.
When we look at these symptoms in reportorial language we get:
- Irritability from noise
- Quarrelsome with family
- Company desire for, alone agg.
The other most characteristic symptom which gives the idea of this remedy is its quarrelsome tendency toward the people on whom she is dependent, and with whom she is most closely associated, which is very beautifully illustrated in the rubric:
- Company, desires for, yet treats them outrageously
Next we see her sensitivity to noise, which is so great that she startles from noise, even the slightest:
- Startling nose from
- Startling nose from, slightest
Further we see in her dreams and in sleep intense fear and anxiety, where she screams and shouts for help. We have the corresponding rubrics:
- Shrieking for aid
- Shrieking for help in sleep
Then she has intense fear of drowning, as in the incident with her friend, since which she remains scared. In such a situation where I do not find a direct rubric, I combine the related fear, dream, and delusion rubrics, as they all fall in the level of delusion. So here we can take:
- Dreams of drowning
Apart from this we also see in her a lot of fear and anxiety reflected at quite a few levels:
- of robbers and ghosts
- of being alone
- for her family members, who she sees drowning in her dreams
On repertorising in Mac Repertory we see the following results:
We come to the remedy Kali carbonicum.
Here, I would like you to refer Phatak’s Materia Medica, “Kali carbonicum”:
- Weakness caused by all potassium salts is more pronounced in this typical salt of the potassium group.
- Weakness; of the muscles; of heart; of the back; of limbs; weakness of intellect.
- Tendency to start, with aloud cry; when touched, even lightly esp. in the soles, which leads a thrill throughout the whole body.
- Debilitating states after miscarriage and labour.
- Easily startled; starts when touched esp. on feet; on dropping to sleep.
- Anxiety, with fear when alone.
- Very irritable.
- Hypersensitive to pain, noise, touch.
- Fear; of future; of ghosts; of death.
- Anxious about his own diseased condition.
- Quarrels with one’s bread and butter, with his family.
- Violent colicky pain, before menses, which are irritating and of pungent odour.
- Hemorrhages, after curetting, and all sorts of other treatment.
- Severe uterine spasms without appearance of menses, with feeling of heat and restlessness.
From the book, The Soul of Remedies, I would like to quote a few lines to demonstrate how exactly the remedy and the patient’s characteristics match:
- Company, desires for, yet treats them outrageously
This symptom combines three main components of Kali carbonicum. The first is the desire for company: she wants company and is dependent on it; she is aggravated when alone, must have support and always likes to be with people who support her. The second component is that she treats them outrageously, which means she always shows dissatisfaction with people on whom she is dependent. The third aspect is quarrelsomeness: when she is discontented she cannot keep quiet, she has to quarrel.
Hence we find in Phatak’s Materia Medica:
- Quarrels with his family and
- Quarrels with his bread and butter
Peculiar to Kali carbonicum is quarrelsomeness only with family and husband, and not so much with outsiders (except unfortunately with the physician).
When there are very characteristics symptoms forming a totality from which emerges a single remedy, then I would surely consider that remedy, and read it up thoroughly in the Materia medica. Then if the remedy picture and the patient picture correspond exactly, just like a key fitting into the lock, I would definitely prescribe that remedy to the patient.
I chose to give a medicine in the LM scale. The indication for an LM potency comes when the pathology is progressive, constant and continuous, and not episodic. As her condition was progressive, she needing more doses of steroid, with her subsequent platelet count dropping each time. The potency chosen is LM8 because her complaint, ITP, is an affection of immune system, and the symptoms in her case were at the level of delusion or dreams. Thus she required Kali carb LM 8.
Follow-up, June 20, 2012
- Her energy levels are much better. She is sleeping well. She has had no headaches, other than a mild heaviness on sun exposure. She has some weakness, but it is much better than previously.
- Her mood and her mental state are very good. Her anger and irritability are much reduced.
- She complains of constipation, urging to pass motion every two days, and having to strain.
- Her last menstrual period was May 18, 2012, which lasted three days. The flow was scanty. Abdominal pain was felt only on the second day of menses, and the intensity was less than previously. Thus there is a great improvement in her dysmenorrhoea, and the duration and intensity of menstrual flow are also much better.
- She reports having dreams of family, of her normal routine, and of traveling, and her dreams give her a good feeling. There have been no scary dreams.
In general, all of her complaints are much better. The only remaining problems are weakness from unaccustomed amounts of walking, and constipation.
Prescription: Kali carbonicum LM8
Follow-up, October 20, 2012
- The patient feels much better overall. Her platelet count was 378,000 per cubic mm (done 2 days back). She is very happy that her count is rising slowly despite being off steroids.
- She still gets headaches when exposed to sun, but the intensity of these is slightly better, and the frequency has reduced to a great extent.
- She no longer has constipation; she passes stools very easily every day, no longer having to strain.
- Her last menses lasted for four days. The flow was moderate and she had dysmenorrhoea only on the second day, which was bearable.
- She reports that she stopped getting ecchymotic patches a long while back.
Her energy levels are very good these days, and she is doing well in her studies. She says that her anger and irritability are almost non-existent now and she has very good relations with her family members. Overall she says that she is better by more than 60%.
Prescription: Kali carbonicum LM 8
The patient’s mother also suffered from the same complaint, and she also started taking treatment at ‘the other song’.
Summary of the patient’s platelet count:
|Date||Platelet count(per cubic mm)||Normal range(per cubic mm)||Steroid||Homoeopathic treatment|
|20 08 11||20, 000||150,000 – 450,000||No steroid||—|
|09 09 11||8, 000||150,000 – 450,000||Steroid: Omnacortil 60 mg||—|
|23 09 11||604, 000||150,000 – 450,000||Steroid: Omnacortil 20 mg||Kali carb 0/8 from 2409 11.|
|21 10 11||455, 100||150,000 – 450,000||10mg Omancortil every alternate day||Kali carb 0/8|
|23 11 11||209, 000||150,000 – 450,000||5mg Omnacortil every alternate day||Kali carb 0/8|
|10 12 12||287, 000||150,000 – 450,000||Discontinued steroids||Kali carb 0/8|
|26 12 11||129, 200||150,000 – 450,000||Took steroid for 15 days on alternate days, 10 mg, then discontinued on 26.01.12||Kali carb 0/8|
|26 01 12||320, 000||150,000 – 450,000||Off steroids||Kali carb 0/8|
|25 02 12||329, 000||150,000 – 450,000||Off steroids||Kali carb 0/8|
|15 05 12||102, 000||150,000 – 450,000||Off steroids||Kali carb 0/8|
|01 06 12||148,400||150,000 – 450,000||Off steroids||Kali carb 0/8|
|20 08 12||200, 000||150,000 – 450,000||Off steroids||Kali carb 0/8|
|12 09 12||200, 000||150,000 – 450,000||Off steroids||Kali carb 0/8|
|18 10 12||378, 000||150,000 – 450,000||Off steroids||Kali carb 0/8|
Understanding and conclusion
On looking into the scope of treatment of ITP, conventional medicine has limited options to treat this condition, the main line of treatment being glucocorticoids and IV Ig (iintravenous immunoglobulin). The other lines of treatment include steroid use, immunosuppressive drugs and splenectomy, which may be undesirable because of their associated complications. For long-term steroid use, complications include osteoporosis, glaucoma, cataracts, loss of muscle mass, and an increased risk of infection. For immunosuppressive therapy and splenectomy, risks include worsening immunosuppression and infection or sepsis. (https://emedicine.medscape.com/article/779545-medication)
The patient had already been on steroids for the past four years. Would it have been humane to subject this young girl to so many complications, adding to the already present disease symptoms? But then, what alternative does this condition have? Homoeopathy proved to be the answer for this case. A simple gentle mode of treatment; free of any complications, which helped her holistically, at both the physical and mental levels. Astonishing results in such cases instill faith in patients as well as in the Homoeopath, reinstating ones faith in Homoeopathy time and again.
Then arises the question, what makes it possible to achieve such results consistently? For this, the Homoeopath has to be very sharp in taking down the symptoms and should be able to intelligently understand and integrate what the patient wants to convey while he or she is narrating the story or the drama of his life.
In this case, the rubrics are beautifully demonstrated, for example, ‘Company, desire for, yet treats them outrageously’. This can only be understood by reading between the lines of patient’s narration and then comprehensively integrating this understanding. What was striking in this case were the symptoms, which came up prominently in a short case history.
What is needed is the flexibility to approach each case as it demands. Just as in Aphorism 83 of The Organon of Medicine, Hahnemann writes “This individualizing examination of a case of disease, for which I shall only give in this place general directions, of which the practitioner will bear in mind only what is applicable for each individual case, demands of the physician nothing but freedom from prejudice and sound senses, attention in observing and fidelity in tracing the picture of the disease..” Here Hahnemann clearly states that there cannot be a fixed approach to understanding cases. Every case will differ in its analysis and evaluation on the basis of the data collected during the case examination of the patient.
Mastering the different approaches and applying what the case demands is the key to success. And after a few years of experience, one will see that all the approaches beautifully merge into one, giving the same result – the remedy which fits the patient like a key fitting into a lock.
This flexibility will give consistent results and instill huge confidence in Homoeopaths, providing greater motivation to practice this beautiful healing science for the betterment of humankind.
By Dr. Rajan Sankaran | October 6, 2015