A Case of Tubercular Lymphadenitis

Case of Dr Rajesh Bhogale submitted for Organon Club study group.

Mr S.A
Age 32yo
Computer Engineer
Married, wife 28, 1 son 3 yo.

Chief Complaint:

Location	Sensation/pathology	Causation, modalities	Concomitants
Cervical Lymph node R side	Enlarged gland	Removed surgically because size was large
Since May ‘98	Weakness
Sept’98	Biopsy: chronic inflammation	Antibiotics
May’99	Relapse, 2-3 glands
R side	Diagnosis: tubercular lymphadenitis	Antibiotic treatment for TB for 3 months
	Tuberculin test +ve
Aug ’99 early	Size reduced, weight ­
Aug ’99 later	Size ­	Anti tubercular treatment
	Fever, Weakness, bodyache
Nov ‘99	Size normal, W=66kg
20 Jan 2000	Size ­		Thirst no change
RHS	Fever, WEAKNESS
Within 3 days	Pus formation
	Could not move neck

Associated complaints:

Location	Sensation/pathology	Causation, modalities	Concomitants
RS	SNEEZING
NOSE	60-70 sneezes
Mucous membranes 3-4 days before gland developed	No nasal discharge

Family History:

Diabetes paternal grandmother
Paralysis paternal grandfather

Patient as a person:

Appearance: Bald, prematurely aged
Perspiration: general ++. Partial: Palms, SOLES. Perspiration staining whitish. Odor socks OFFENSIVE
Aversions: Sweets.
Cravings: HIGHLY SEASONED FOODS
Thermals: C4H meaning very sensitive to cold++
Rum < vomit++

Mental State:

Pt was wearing simple dress, greeted physician with a good smile. There was an offensive smell to his body which could be smelt immediately on entering the room. Father started withdrawing from daily family chores early for religious reasons, just gave money to mother. Mother is spendthrift type and allowed sharing with her own brothers. Mother was therefore told to leave the house by father and remained away for 4 years.

Family matters were looked after by paternal grandmother who had great values and passed them on to her grandchildren. Patient regards this as very formative period, “Golden period” of his life. Mother came back after 4 years and continued the free spending on luxurious items and her brothers. Pt took side of grandmother, was in blacklist of mother and decided goal of life clearly of completing graduation. Was average student but managed through earnest work and high motivation/will/drive to achieve good position associated with some jealousy from peers. Great conflict between his wife and his mother which was great source of strain for the couple only sustainable with support of grandmother. So it was a great grief for them to lose her when she passed away in ’98. Is now fighting battles alone. This battle within family plus within company against rivalry.

Objective examination:

Afebrile.
Pulse: 70
BP: 120/80
Vertical ridges nails.
Tongue: flabby.
Weight: 69kg
Cervical nodes: on RHS 2 swollen
Pus seen oozing, redness+, warmth+

Objectives

1. Perceiving the TOTALITY peeping through the sufferings of the person.
2. Learning the importance of APPROACH in homoeopathic practice.
3. Experiencing the dos and don'ts while treating a case of Tuberculosis.

Directives

1. Classify all the data critically and select a suitable approach for the case.
2. Present your understanding of psycho-dynamic and psycho-somatic co-relations.
3. State your choice of the remedy with differentiation.
4. Give your total problem definition and resolution mainly focusing on the aspect of posology.

Recommended readings

Text book of medicine by Harrison &/or Udani - Tubercular Lymphadenitis
Basic Pathology by Stanley L. Robbins - Tuberculosis

SOLUTION:

Clinico-pathological & miasmatic correlations

If one takes a close look at the case then one finds that the prominent affection coming up in adverse circumstances (physical as well as mental) involves reticulo-endothelial system a more specifically cervical lymph nodes. Now lymph nodes can present with acute infective lymphadenitis or chronic non-specific lymphadenitis or various other pathologies. In this case the pathology that has evolved gradually is tubercular or scrofulous. Only right side has been involved. The location & the pathology become the hallmark of this system. This is where Boger’s point of view becomes very important. He emphasizes the points like:

Time dimension
Tissue affinities (region, area, tissue, organ, system)
Along with pathological and strong physical generals.

Thus the focus remains on the evolution of disease from miasmatic point of view & from functional to structural phase. Evolution of disease implies origin, pace or tempo, direction, extent, manner, evolution, acme and devolution or decline.

In this patient, one can understand the evolution of tubercular miasm and also perceive its intensity or the dominance, at least when the patient comes for homoeopathic treatment. Weakness evolving from one mark intensity to three-mark intensity & change in pathology of glands itself from simple inflammation to suppuration become strong markers for understanding tubercular miasm along with other points. This understanding would also have therapeutic implications & we can see that with this rate & direction of the pathology, sinus formation may take place if disease is not taken care of at this juncture.

Psychodynamic and psychosomatic correlations

The grandmother was an important model during the formative years: she had straightforward values and principles. During childhood patient identified strongly with her. For this man also hard working nature and conscientiousness are marked attributes. The mother seems more interested in material things. The father has taken less interest in family dynamics. Largely the patient is able to deal with this conflict constructively: he is able to complete bachelor Engineering with determination and attracts the jealousy at work through his hard work. The spendthrift mother and incooperative working colleague do not fit in with this man’s basic disposition. With the death of the grandmother he loses the moral support for these struggles. From this moment onwards he fights his battles alone. The irritability, vexation become suppressed and this conflict between self and surrounding (family and work) at present manifests as tubercular lymphadenitis.

This mental picture plus offensiveness of perspiration completes a totality suggesting SILICA as the constitutional remedy.

Posology

Susceptibility / Sensitivity is still in moderate zone
Pace – gradual
Characteristics ++
Immunity - still in fighting zone.
Reactivity ++
Pathology - Structural reversible

These parameters allowed planning the treatment as described below.

Management

Silica 30 7HS was started on 28-1-00
Then it was made 30 BD from 3-3-00 to 6-5-00
Tub was given twice; on 8^th April and 14^th April.
Silica 200 was given from 6-5-00 to 27-5-00. After that patient was kept on PLACEBO.

ESR came down to normal. Weight when checked last was 71 Kg. A Physician (MD) was consulted for the need of biopsy of lymph node. His opinion was that since there are no glands, hardly 2-3 % mass available, so we can’t go for biopsy and considering clinical improvement patient doesn’t need it at all.

Retrospective analysis suggests that SILICA 200 could have been given earlier instead of 30 BD so that the course of the whole disease could have been aborted earlier, say within 2 months.

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