Homoeopathic management of targeted haemarthroses in inhibitor positive haemophiliac: A case report

 

Omkar Kumat ¹, Dr. Tapas Kundu ², Gulfisha Mirza ³, Rita Kundu ⁴

 

¹ Communication Consultant, Homoeopathy in Haemophilia, C/O Sakha the Centre of Research and Charity, Upnagar, Nashik, Maharashtra, India

² Principal Investigator, Homoeopathy in Haemophilia, C/O Sakha the Centre of Research and Charity, Upnagar, Nashik, Maharashtra, India

³ Research Associate, Homoeopathy in Haemophilia, C/O Sakha the Centre of Research and Charity, Upnagar, Nashik, Maharashtra, India

⁴ Coordinator, Homoeopathy in Haemophilia, C/O Sakha the Centre of Research and Charity, Upnagar, Nashik, Maharashtra, India

 

1. INTRODUCTION

Bleeding episodes in muskulokeletal system is very common in haemophilia.  About 80% occur within the joints mainly elbows, knees and ankles Rodríguez-Merchán (2019). When the haemorrhage persists or recurrent bleeds occur, intra-articular blood causes apoptosis of the chondrocytes. The synovial membrane usually hypertrophies as it reabsorbs blood, leading to accumalation of blood into joints. This a vicious cycle of chronic synovitis leads to joint destruction and classical haemophilic arthropathy, the involvement of target joint Valentino et al. (2012). Replacement of missing coagulation factors is usually the standard management in prevention and treatment of haemarthroses. Repeated exposure to replacement therapy leads to development of inhibitors against factor VIII (FVIII) or factor IX (FIX) in haemophilia patients. Haemarthroses is one of the most common complications in haemophilia and has major clinical and economic consequences Minno et al. (2010). About one-third of patients, following treatment with factor concentrates, usually develop an antibody (inhibitor) to that particular factor, making it inactive.This makes the patient more prone and at risk for life-threatening bleeding Wight & Paisley (2003).

 

2. Case Presentation

A pre-diagnosed case of severe haemophilia A and inhibitor positive presented on 24/01/2020 with left knee swelling on slightest trauma or strain.

Patient had vertigo since 2 days with restlessness due to pain. Aggravation-flexed knees, Amolieration-cold fomentation

Figure 1

Figure 1 Target joint - Lt. Knee

 

Right knee joint=33cm

Left knee joint =39.5 cm

Past history Swelling of left knee joint intermittently since 2 years

Genetic and family history maternal grandfather had haemophilia A

 

Local examination

Swelling with effusion

Leading to flexion and extension loss of left knee

Gait-limping

Walking, Stairs climbing, Running are not within normal limits according to global gait score (HJHS)

 

General examination-

Thirst-thirstless

All other general feature were within normal limits

 

Mind

Loquacious

Not serious about his studies

 

Miasmatic analysis-Syco-syphillitic

 

3. Assessment with scales

Table 1

Table 1 Hemophilia Joint Health Score Before Treatment - Summary Score Sheet Morfini et al. (2007)
	Left Knee		Right Knee
Swelling	3	NE	0	NE
Duration (swelling)	1	NE	0	NE
Muscle Atrophy	0	NE	0	NE
Crepitus on motion	1	NE	0	NE
Flexion Loss	3	NE	0	NE
Extension Loss	3	NE	0	NE
Joint Total	15		0

 

Sum of Joint Totals -15

Global Gait Score - 4                           

HJHS Total Score =19

 

 

4. Rubrics and Remedial analysis

Figure 2

Figure 2 Repertorial Totality

 

Rx,

1)     Apis Mel 30,5 doses 24 hourly in sacchrum lactis.

2)     Placebo in 30 number globules, 2 drachm bottle to be taken 4 pills BD.

Table 2

Table 2 Follow Up Chart
Date	Symptoms	Justification and Image	Medicine
03/04/2021	The patient was lost to follow up for almost an year due COVID-19 restrictions. When he returned his left knee swelling was almost the same.   Right knee joint=34cm Left knee joint =39.5 cm	Figure 3 Repertorial Sheet	Apis Mellifica 30 in saclac powder 3 doses 24 hourly   Placebo in 30 number globules,2 drachm bottle to be taken 4 pills BD
14/06/2021	Partial relief     Right knee joint=34cm Left knee joint =37cm	Figure 4 Repertorial Sheet	Phytolacca Decandra 30 in saclac powder 3 doses 24 hourly   Placebo in 30 number globules,2 drachm bottle to be taken 4 pills BD
18/07/2021	Right knee joint=34.5 cm Left knee joint =38 cm	Figure 5 Repertorial Sheet	Strontium Carbonicum 30 in saclac powder 3 doses 24 hourly   Placebo in 30 number globules,2 drachm bottle to be taken 4 pills BD
03/9/2021	Swelling of left knee increased since 2days. Earlier the swelling had reduced to and flexion increased. Right knee joint-35.5 Left Knee joint-37.5cm	Figure 6 Repertorial Sheet	Clemitis Erecta 30 in saclac powder 3 doses 24 hourly   Placebo in 30 number globules,2 drachm bottle to be taken 4 pills BD
20/11/2021	Right knee joint=36.5 Left knee joint =36.5	Figure 7 Left Knee Measurement Figure 8 Right Knee Measurement Figure 9 Both the Knees (Normal)	Sulphur 0/1 ,3 doses 24 hourly.   Placebo in 30 number globules,2 drachm bottle to be taken 4 pills BD
11/04/2022	Target joint completely resolved. No recurrence of bleeding since last 6 months.	Figure 10 Follow Up After 6 Months	Placebo in 30 number globules,2 drachm bottle to be taken 4 pills BD

 

Table 3

Table 3  Hemophilia Joint Health Score After Treatment - Summary Score Sheet-14
	Left Knee		Right Knee
Swelling	0	NE	0	NE
Duration (swelling)	0	NE	0	NE
Muscle Atrophy	0	NE	0	NE
Crepitus on motion	0	NE	0	NE
Flexion Loss	0	NE	0	NE
Extension Loss	0	NE	0	NE
Joint Pain	0	NE	0	NE
Strength	0	NE	0	NE
Joint Total	0		0

 

Sum of Joint Totals -0

+        = Global Gait Score 0  

HJHS Total Score =0

 

 

5. Discussion

Haemarthroses, that is intra-articular haemorrhages are a frequent finding usually observed in patients with haemophilia Rodriguez-Merchan et al. (2011), Buzzard & Beeton (2008), Buzzard & Jones (1988).  The extravasation of blood into the joint is the most important event that leads to development of haemophilic arthropathy Hermans et al. (2011), Lafeber et al. (2008), Roosendaal et al. (2008). The functional prognosis becomes very poor once arthropathy develops Nilsson et al. (1992). Long-term prophylaxis aimed in order to establish factor levels over 1 IU dL, if started at an early age, prevents the onset of chronic haemophilic arthropathy Roosendaal et al. (2008). However, after the replacement therapy about 10% and 30% of patients with severe haemophilia A and 2–5% of patients with severe haemophilia B usually develop anti FVIII and anti FIX antibodies respectively Rodriguez-Merchan et al. (2003) When present, these inhibitors inactivate the biological activity of infused FVIII or FIX, making the patient refractory to treatment Morfini et al. (2007), Lamba et al. (2020). Haemophilic arthropathy along with inhibitors is quite a challenge.

This case presents homoeopathic management of case of chronic haemarthroses in haemophilia inhibitor. Left knee joint over the period of two years was found to be the target joint. Rest all joints were normal functionally and anatomically. This target joint swelling had completely hampered the routine of the patient. As the left leg had flexion and extension loss to severe degree even daily chores seemed difficult. Walking, climbing stairs, running was obscured. When the patient presented at Homoeopathy in haemophilia research centre, he was already diagnosed with inhibitor. The case was thoroughly analysed. Left knee joint was severely swollen (Figure 1) with effusion. After a thorough case taking Apis mellifica 30 was prescribed. Later on, due to COVID-19 pandemic the patient was lost to follow up. Over the time recurrent haemorrhages had caused chronic haemophilic arthropathy in

over left knee. Apis mellifica, strontium carb and phytolacca were prescribed (Table 2) with moderate changes in the patient. Each medicine though brought down the swelling to moderate degree, but recurrence of swelling at target joint was the concern and hence it was changed time to time. Fresh anamnesis was done and typical symptom of aggravation during full moon and new moon was noticed. New totality was formed (Figure 6) and Clematis Erecta was prescribed. This brought about the desired results and the swelling was completely resolved. Both the knees measured equal and were normal functionally and anatomically. After the pathology had resolved, sulphur 0/1 which was found to be constitutional was prescribed to inhibit the recurrence of swelling. For next 6 months regular follow, up was taken. No episodes of recurrence of bleeding at target joint were seen.

The syco-syphillitic changes that had occured in target joint were completely reversed. The joint health was evaluated using Hemophilia joint health assassment score (HJHS). The difference of before and after treatment using HJHS score was tested with paired t-test. The two-tailed P value equals 0.0009 
By conventional criteria, this difference is considered to be extremely statistically significant. Modified Naranjo criteria for homoeopathy, casual attribution (MONARCH) St-Louis et al. (2022) inventory was used to assess curative response of the case. The score of MONARCH is 10. Reporting of the case strictly adheres to HOM-CASE-CARE Van Haselen (2016) guidelines.

 

6. Conclusion

Haemarthroses was effectively managed in a diagnosed inhibitor positive Haemophiliac with homoeopathic Intervention.

 

7. Declaration of Patient Consent

The authors testify that they have obtained proper patient and parents’ consent in written format from the patient. The patient has given consent for clinical information and images for the sake of scientific interest and publication of data.

 

8. Patients perspective

The case being a paediatric case, mothers perspective was taken. According to her slightest trauma frequently caused swelling in left knee joint. Homoeopathic treatment reduced frequency and reversed the hemophilic arthropathy. It has brought his sons routine back to normal.

 

CONFLICT OF INTERESTS

None. 

 

ACKNOWLEDGMENTS

None.

 

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