[Severe lead poisoning caused by ayurvedic medicine]. / Schwere Bleivergiftung durch ayurvedisches Heilmittel.

HISTORY: We report the case of a young patient who presented to our emergency department with reduced general condition, anemia, and crampy abdominal pain. A previous inpatient workup including abdominal imaging and bone marrow aspiration had not yielded a diagnosis. On inquiry, the patient reported oral ingestion of an Ayurvedic remedy over the course of one month. FINDINGS: 24-year-old circulatory stable patient in reduced general condition with gray skin coloration and a dark gingival margin. Laboratory testing revealed an increase in transaminases and normocytic anemia. A peripheral blood smear showed basophilic stippling of the erythrocytes. Significantly elevated lead levels were detected in the patient's blood and hair. Toxic lead levels were detected in the ingested preparation. DIAGNOSIS: Severe lead poisoning caused by self-medication with an Ayurvedic remedy. Analysis revealed a daily oral lead load of 136 times the maximum permissible dose. THERAPY AND COURSE: By means of chelation therapy, the blood lead levels were significantly reduced, and there was a complete regression of the complaints as well as a normalization of the laboratory findings. CONCLUSION: Lead has toxic effects on all organ systems of the body and is stored in the bone for decades. Symptoms of poisoning are nonspecific; a thorough history and generous indication for measuring lead levels are helpful for the diagnosis.

A systematic review of clinical and laboratory findings of lead poisoning: lessons from case reports.

Lead is one of the most toxic heavy metals in the environment. The present review aimed to highlight hazardous pollution sources, management, and review symptoms of lead poisonings in various parts of the world. The present study summarized the information available from case reports and case series studies from 2009 to March 2020 on the lead pollution sources and clinical symptoms. All are along with detoxification methods in infants, children, and adults. Our literature compilation includes results from 126 studies on lead poisoning. We found that traditional medication, occupational exposure, and substance abuse are as common as previously reported sources of lead exposure for children and adults. Ayurvedic medications and gunshot wounds have been identified as the most common source of exposure in the United States. However, opium and occupational exposure to the batteries were primarily seen in Iran and India. Furthermore, neurological, gastrointestinal, and hematological disorders were the most frequently occurring symptoms in lead-poisoned patients. As for therapeutic strategies, our findings confirm the safety and efficacy of chelating agents, even for infants. Our results suggest that treatment with chelating agents combined with the prevention of environmental exposure may be an excellent strategy to reduce the rate of lead poisoning. Besides, more clinical studies and long-term follow-ups are necessary to address all questions about lead poisoning management.

Case series and review of Ayurvedic medication induced liver injury.

BACKGROUND: Complementary and alternative medicine use among Americans is prevalent. Originating in India, Ayurvedic medicine use in the United States has grown 57% since 2002. CAM accounts for a significant proportion of drug induced liver injury in India and China, but there have been only three reports of drug induced liver injury from Ayurvedic medications in the U.S. We report three cases of suspected Ayurvedic medication associated liver injury seen at a Southern California community hospital and review literature of Ayurvedic medication induced liver injury. CASE PRESENTATIONS: Three patients presented with acute hepatocellular injury and jaundice after taking Ayurvedic supplements for 90-120 days. First patient took Giloy Kwath consisting solely of Tinospora cordifolia. Second patient took Manjishthadi Kwatham and Aragwadhi Kwatham, which contained 52 and 10 individual plant extracts, respectively. Third patient took Kanchnar Guggulu, containing 10 individual plant extracts. Aminotransferase activities decreased 50% in < 30 days and all 3 patients made a full recovery. Roussel Uclaf Causality Assessment Method (RUCAM) scores were 7-8, indicating probable causality. These products all contained ingredients in other Ayurvedic and traditional Chinese medicines with previously reported associations with drug induced liver injury. CONCLUSIONS: These patients highlight the risk of drug induced liver injury from Ayurvedic medications and the complexity of determining causality. There is a need for a platform like LiverTox.gov to catalog Ayurvedic ingredients causing liver damage.

Vajra Bhasma, Ayurvedic medicine: a rare and unusual cause of Lyell's syndrome and its successful management.

Toxic epidermolysis necrosis (TEN) or Lyell syndrome is a potentially life-threatening immunological adverse skin disease, which mostly occurs secondary to the intake of an offending drug. It commonly manifests as a widespread exfoliating bullous lesion in skin and mucous membrane mimicking superficial burns and may result in hypovolemic and/or septic shock. Authors report an unusual case of Lyell's syndrome in a 42-year-old woman, secondary to the intake of Ayurveda medicine 'Vajra Bhasma' (Diamond Ash) prescribed by an Ayurveda physician for treatment of her trigeminal neuralgia. After 8th day of continuous medication intake, she had prodromal illness and rapidly developing exfoliative skin lesion extended over 80% of total body surface area, breathing difficulty, dizziness and anuria. The case was successfully managed by timely diagnosis, adequate hydration and administration of immunoglobulins. After 17 days, the skin epithelium regenerated, and she improved clinically with some depigmented lesions at discharge, which were normalised without any sequel during her further follow-up visits in hospital. Identification and withdrawal of the suspected drug, adequate resuscitation and early immunoglobulin administration are critical in management of TEN.

Efficacy and safety of two Ayurvedic dosage forms for allergic rhinitis: Study protocol for an open-label randomized controlled trial.

BACKGROUND: Allergic rhinitis (AR) is an immune response of the nasal mucosa to airborne allergens and involves nasal congestion, watery nasal discharge, itching of the nose, and sneezing. The symptoms of allergic rhinitis may significantly affect a patient's quality of life and can be associated with conditions such as fatigue, headache, cognitive impairment, and sleep disturbances. Various complementary and alternative medicine treatments have been used for this condition in clinical practice. The Ayurveda system of medicine is the most common complementary medicine system practiced in Sri Lanka. The aim of this study is to examine the efficacy and safety of a decoction used in traditional Ayurveda for allergic rhinitis and its ready- to-use freeze dried formulation in comparison to an antihistamine over a period of 4 weeks on relief of symptoms in allergic rhinitis. STUDY DESIGN: This is a three-arm, open-label, non-inferiority, randomized controlled clinical trial enrolling patients with AR. Tamalakyadi decoction containing 12 ingredients (TMD12), used in traditional Ayurveda and its freeze-dried formulation are the test products. The efficacy and safety of the two Ayurvedic dosage forms will be tested against the antihistamine loratadine. Patients with symptoms of AR will be allocated randomly into the three arms after a 1-week run-in period and the medications will be given orally for 28 days. Total Nasal symptom Score (TNSS) of the patients will be used as the primary efficacy endpoint. TNSS will be recorded and compared between the three arms prior to visit 1, at the end of 28 days, and end of the first and second months of follow-up. Symptom scores of daytime nasal symptoms, night time nasal symptoms, non-nasal symptoms and health-related quality of life questionnaire are used as secondary end points. DISCUSSION: This clinical trial will be able to provide evidence-based scientific data on Ayurvedic dosage form, TMD12, and the freeze-dried formulation in the treatment of allergic rhinitis. This trial is expected to develop capacity to scientifically evaluate various Ayurvedic treatments that are claimed to have efficacy in treatment of various disease conditions. TRIAL REGISTRATION: ISRCTN18149439 (6 May 2019).

Ocular chemical burns from accidental exposure to topical dermatological medicinal agent.

We report a case of accidental ocular chemical injury by self-medication with a single application of a topical ayurvedic medication containing salicylic acid, phenol, and tincture iodine, which is being used in developing countries for treatment of various dermatological conditions.

Ayurveda metallic-mineral 'Bhasma'-associated severe liver injury.

Ayurveda Bhasma is a metallic-mineral preparation homogenised with herbal juices or decoctions and modified with heat treatment to apparently detoxify the heavy metals. It is widely recommended for the treatment of many disease conditions by practitioners of complementary and alternative medicine in the absence of good quality clinical trial evidence on its safety and efficacy. Heavy metal-induced liver injury is widely reported in the literature, and heavy metal adulteration of non-Bhasma-related Ayurveda and herbal products has been well described. We report a patient who developed severe liver injury requiring listing for liver transplantation for improved survival, after consumption of Bhasma for dyspepsia. This case describes the first documented case and toxicology analysis of Ayurveda Bhasma associated with severe drug-induced liver injury. Physicians must be alert regarding patient's use of supposedly safe Ayurveda Bhasma that may promote acute severe liver injury in the absence of other known aetiologies.

Clinical outcomes, histopathological patterns, and chemical analysis of Ayurveda and herbal medicine associated with severe liver injury-A single-center experience from southern India.

INTRODUCTION: Ayurvedic and herbal medicines (AHM) are known to cause varying degrees of drug-induced liver injury (DILI). Clinical, biochemical, histological spectrum and outcomes of AHM linked to severe DILI are not well studied. METHODS: Out of 1440 liver disease patients, 94 were found to have a severe liver injury and associated AHM intake. Thirty-three patients were suspected to have AHM-DILI on Roussel Uclaf Causality Assessment Scoring Method. Forty-seven and 30 of retrieved AHM samples were analyzed for heavy metals and hepatotoxic volatile organic compounds (hVOCs), respectively. Eleven patients ingested AHM from unregistered traditional healers (UTH). Clinicopathological outcomes were analyzed in 27 patients (who underwent liver biopsy) and outcomes with respect to chemical analyses were studied in 33 patients. RESULTS: Males predominated (70.4%) with mean age 46.9±15.8 years. Mean follow up was 119.2±81.4 days. The median duration of drug intake was 28 days (10 - 84). Five patients died (18.5%). Hepatic encephalopathy, hypoalbuminemia, and hepatic necrosis were significantly associated with mortality (p < 0.005). Arsenic and mercury ingestion was significantly associated with death (p < 0.005). hVOCs were detected in more than 70% of samples. AHM intake from UTH was associated with higher mortality. CONCLUSION: Adequate regulation and scrutiny regarding AHM use among the general population is an unmet need. Early liver biopsy after clinical identification of at-risk patients can expedite definitive treatment with a liver transplant.

Topical ayurvedic ointment-induced chemical injury presenting as bilateral acute keratitis.

A 40-years-old female patient was referred to the cornea clinic as a probable case of bilateral keratitis. The patient had a history of headache followed by acute onset of redness, pain and discharge from both eyes for 15 days. The patient was diagnosed as bilateral keratitis by the first contact physician and was started on topical antibiotics, cycloplegics and lubricating eye-drops. At presentation, both eyes had visual acuity of perception of light, conjunctival congestion, limbal blanching, diffuse corneal oedema and epithelial defect. A detailed history revealed application of Vicks VapoRub [topical ayurvedic analgesic which contains (per 100 g of product) menthol (2.82 g), camphor (5.25 g) and eucalyptol (1.49 mL) and excipients include thymol (0.1 g), turpentine oil (5.57 mL), nutmeg oil (0.54 mL), cedar wood oil and petrolatum)] on the forehead and eyelids for headache several times over 2-3 days before the onset. The patient further confirmed the accidental application of the ointment in the eyes. A provisional diagnosis of acute chemical injury with Vicks VapoRub was made and treatment with topical antibiotic, cycloplegic, steroid, lubricant and vitamin C was started. On follow-up, both eyes showed gradual resolution of corneal oedema and epithelial defect. Visual acuity improved in the left eye to 6/60 with no change in right eye due to corneal haze.

Ayurvedic plumbism.

Ayurveda is a traditional medicine native to India but is used in many parts of the world as an alternative or adjunct to standard medicine. Preparation can involve incorporation of heavy metals, including lead. We report the case of a 64-year-old man presenting with malaise, abdominal pain, anaemia and very high lead levels. He was found to be taking ayurvedic medicines to help his diabetic control. Analysis of the ayurvedic medications showed several with very high lead content. Following treatment with an oral chelating agent, the patient's symptoms and blood abnormalities resolved. This case highlights the need to be aware of potentially toxic alternative medications patients take and the efficacy of oral treatment choices in lead poisoning.