Personalized ayurvedic approach involving Sadyo Vamana in COVID-19 management: A case report

Sars Cov-2 has emerged as a global threat worldwide. At present, India is the second worsely-hit nation by COVID-19. Since it is a novel virus, there is no specific treatment strategy available at present. A mild symptomatic case of COVID-19 was managed through Ayurvedic intervention involving a personalized approach based on his Prakruti. He was prescribed Vamana Karma followed by Vyaghryadi Kashaya as an oral drug for fifteen days. The patient recovered well clinically, the disease progression to a more severe stage was not observed and the patient tested negative for COVID on the 17th day. In this report, the patient was of Kapha predominant Prakruti and his strength was good so he was prescribed Vamana Karma. Ayurveda advocates patient management by incorporating personal physical and mental attributes classified as Doshas. The promising results in the present case study indicate that a personalized approach involving Ayurveda in such cases can be helpful for a better prognosis.


Introduction
The rapid spread of SARS Cov-2 or COVID-19 almost brought the world to a standstill and emerged as one of the biggest threats for the health and economy across the globe. It stands as a challenge to the medical fraternity as a whole. Currently, India stands as the second most severely affected country. The numbers are expected to worsen in near future due to the rapid exponentiation of the virus. So far, no specific cure has been devised. However, vaccination drive is in progress throughout the world.
The clinical features of COVID-19 share a resemblance with the features of Jwara [1] and Dushta Pratishyaya (Chi.26/109) [1] mentioned in Ayurveda classics, especially having a preponderance of Kapha Dosha (~Biohumour). If the patient is having good strength and Kapha Dosha is predominant then Vamana can be opted as a choice of treatment (Chi.3/146) [1]. Hence, Ayurveda intervention, involving a personalized approach based on Prakruti (~nature based on of physical and mental attributes) of patient was planned for a COVID-19 patient. Vamana Karma (Panchakarma treatment which includes induced emesis) was followed by oral drugs (~decoction of Vyaghryadi Kashaya) was planned after obtaining informed consent from the patient under a planned protocol. This prakruti based assessment and management in COVID-19 through Ayurveda makes this a unique case. The same is being presented in this case report.

Patient information
A 33 years old male with moderate physical strength and good Satva (~will power) tested positive for COVID -19. The patient was of Kapha predominant Prakruti (predominant humor was Kapha), had normal bowel habits. He was working as a banker in a government sector bank at Lucknow, India, which made him susceptible for a probable exposure to the Corona virus.

Clinical findings
He presented with following symptoms loss of sense of smell, congestion in the nasal region, heaviness in the head, sore throat, and fever (Table 2).

Diagnostic assessment
After one day of contracting the symptoms, he got tested for novel Corona virus infection through Real-Time PCR, which is considered as gold standard investigation for COVID-19. The patient tested positive for it.

Therapeutic intervention
The patient chose to be under home isolation as the symptoms were mild and was started Ayurvedic medications for the same. Sadyo Vamana (~immediate induced emesis) was planned for him ( Table 1) followed by Ayurvedic drugs for a duration of fifteen days followed by repeat test.

Instructions for the patient
Before beginning the treatment, the patient was advised to make the following preparations to ensure easy commencement.
1. To consume milk with jaggery the night before Vamana. 2. To sleep early on the previous night and have 6-7 hours of sleep. 3. To wake up early in the morning for Vamana. 4. To prepare warm milk about 1 L, Yashtimadhu phanta (concoction) 2 L and Lavanodaka (saline water) 2 L early in the morning, in separate utensils. 5. He was informed about the procedure in detail, the complications which can take place during the procedure, and informed consent was obtained for Vamana.
6. To carry a pulse oximeter and a digital blood pressure machine for their measurements during and after the procedure.
Vamana was commenced at 6 am in the morning. Due to the infectious nature of the disease, the procedure was conducted through video calling. The patient was advised to take all necessary arrangements, like utensils, glasses for intake of Yashtimadhu concoction (prepared from 50 g of licorice powder in 1 L warm water) and Lavanodaka (lukewarm saline water prepared with rock salt), and a tub for collection of vomitus. He was asked to sit on a comfortable chair of knee height.
Regular monitoring of Oxygen level and pulse rate during the procedure was done using a pulse oximeter. Firstly, he was asked to drink milk up to maximum capacity (Akanthapurana). This was vomited out after taking about 800 ml (four glasses of milk each measuring about 200 ml). 800 ml of milk was enough a quantity to induce emesis. There was no specific emetic drug used in this procedure. All the drugs used were to support emesis. After this, he was administered a Yashtimadhu concoction of about 800 ml which was also vomited out easily. Thereafter, the patient was administered Lavanodaka (saline water) about 900 ml twice which also resulted in two bouts of vomiting. In the earlier two bouts, vomitus was more viscid and had more mucus relatively than the last two bouts. In between the bouts of vomiting, pulse and oxygen levels were repeatedly measured (Table 1). In between two Vegas, a period of rest was advised along with deep breathing for about a minute to regulate the heart rate to normal which normally elevates after each Vega during Vamana. The numbers of Vegas (forceful expulsion of vomitus) present was four. The procedure was discontinued when symptoms such as feeling of lightness in abdominal and thoracic regions, and lightheadedness were reported by the patient. The patient also reported a sensation of bitter taste which could be considered as a feature of Pittanta Vamana, so the treatment was discontinued at that point considering the presence of adequate features resembling markers of endpoint for Vamana Karma.
On the basis of number of Vegas present, patient was advised to follow Samsarjana Krama [2] (specific dietary regimen) for three  [2]. Rice gruel was advised for evening diet on the day of Vamana. Next day he consumed semi liquid rice gruel in afternoon and soup prepared from green gram in evening (Si.2/13) [2]. Semi solid food in the form of semi solid meal prepared from rice and green gram was consumed on third day. After third day, patient was allowed to consume green vegetables and other light and easily digestible food. He was advised to completely refrain from cold water intake, curd, and, refrigerated, processed and fast food items. From the second day of Vamana, the patient was advised to take Vyaghryadi Kashaya [3] in a dose of 50 ml empty stomach, twice daily for a period of ten days.

Timeline
The whole case is being summarized in a tabular form involving initiation of symptoms, their progression, the clinical management and the recovery phase including clearance of symptoms and gradually returning to the normal routine after testing negative for RTPCR ( Table 2).

Outcome
Immediately after Vamana, the patient reported improvement in nasal congestion and heaviness in the head. There was a feeling of general well-being and lightness in the abdomen after Vamana. Fever was not reported the next day. The appetite also improved significantly after Samsarjana Krama. No complications were reported by the patient after Vamana or Samsarjana.
Almost all the symptoms were resolved gradually within a period of 7 days except for the sense of smell. Recovery in sense of smell was reported by the patient on the 13th day. During the period of treatment, the patient was following strict isolation and physical distancing from other family members.
Complete recovery in symptoms was observed on the 13th day from the initiation of symptoms. The patient tested negative for Corona virus in the RTPCR test on the 17th day.

Follow up
Follow-up was taken twice, first after one month of treatment and then again after one year. He stayed healthy without suffering from any known complications of Covid-19 infection like weakness or decreased immunity. There was no history of any other infection reported by the patient even during the second wave of the pandemic which was rather severe in India.
The probable samprapti (~pathogenesis) of the disease involves abhishangaja jwara (Chi. 26/109) [1] wherein after contracting the infection, the site of Kapha dosha i.e urah Pradesh (~the thoracic region) is affected which leads to Kapha prakopa (~aggravation). This leads to pranavaha srotasa avarodha (~obstruction of respiratory tract), Mandagni (~diminished digestive calibre) and swedavaha srotasa avrodha (~obstruction of sweat channels). This eventually leads to obstruction of pranavaha and rasavaha srotasa, ultimately causing symptoms like fever, nasal congestion, loss of sense of smell, sore throat and other respiratory symptoms like breathlessness and difficulty in breathing when disease progresses.
The rationale for Vamana in the management is elimination of excessive Kapha dosha adequately and Vyaghryadi kashaya as shamana of the remnant Kapha along with suppression of the deranged Vayu.
Langhana is the choice of treatment in Ayurveda (Chi. 1/1) [3] which incorporates four types of Shodhana [4] (~purification therapies) among which Vamana is also included. Considering the Kapha predominance in Prakruti of the patient and in the clinical features presented, Vamana seemed to be the most appropriate intervention. Vamana was planned and prior to its execution, the patient was councelled regarding the procedure. Due to the aggravated state of biohumours, Snehapana (intake of unctuous substance like Ghee or oil which is being done before classical Vamana Karma) was not done. The patient was advised to take milk with jaggery on the night before.
Shunthi (Zingiber officinale Roscoe) is one of the most potent drugs for Ama Pachana (~digestion of undigested food material). It is useful in headaches, abdominal pain and has digestive and carminative actions [8] It is also useful in a cold, hoarse voice and is a good appetizer. Recent studies have reported its antiinflammatory effects [9].
Pippali (Piper longum L.) was used in the form of fine powder in a dose of 500 mg with the Kashaya. It is known to act as a bio enhancer, increases the bio-availability of drugs by several folds, due to the presence of piperine [10]. The action of Pippali is the alleviation of Kapha and Vata which was the prime cause of pathology [11].
Dysosmia (altered smell perception) and dysgeusia (altered perception of taste) are common features of COVID-19 infection. There have been various studies suggesting the Corona virus' effects on the CNS [12]. Routes intended for CNS infection are peripheral Trigeminal or Olfactory nerves following intranasal inoculation. The observations from studies on rodents indicate that these viruses cause demyelination and stimulate T cell-mediated autoimmune reactions against CNS antigens producing the curious question about relationship of Corona viruses and neurological infections in humans [13].
The absence of sensation of smell could be due to deranged Prana Vayu (Su.12/8) [4]. Avarana (~superimposition) of Kapha over Vayu leads to improper functioning of Prana Vayu, which could be the reason for the lack of sensation of smell. Through Vamana and Vyaghryadi Kashaya, removal of this avarana was the study objective as it would be able to help resuming normal functioning of Vayu.

Significance of Langhana and Vamana
Langhana is the basic modality of treatment in any morbidity having a predominance of Kapha Dosha, for correction of Agni. Considering the disease manifestation as Nava-Jwara and Pratishyaya, the primary objective of treatment was the restoration of deranged Agni (digestive fire). Vamana was planned instead of other Langhana procedures, owing to the condition of Nava jwara and considering the disease as amashaya samuttha vyadhi (~having disease origin in the upper abdominal region). Besides, the sites which are chiefly affected are amashaya and urah pradesh (after infection, lungs are the chief site of infection). Therefore, Vamana was the ideal treatment choice for providing shodhana of kapha leading to minimized complications and minimum progression of disease.
Vamana is one of the principle Shodhana procedures that provides Langhana (Si.6/23) [2] as well as correction of Agni by eliminating excessive Kapha Dosha from Amashaya. This elimination of excessive Kapha Dosha by Vamana enables the removal of cover of Kapha over Agni thus ensuring proper repairing of the impaired digestive fire (Si. 6/22) [2]. However, immediately after Vamana, there is a general condition of Agnimandya (~temporary deterioration of digestive caliber) hence regular diet is not advised to the patient immediately. Agni has to be gradually raised to normal status. For this, a specific diet regimen known as Samsarjana Krama is planned to ensure gradual improvement of digestive fire (Si. 1/13) [2]. Peya (rice gruel) was administered to the patient on the day of Vamana in the evening. It has the properties of improving Agni (Su. 27/250) [4] (~digestive caliber). Vilepi was given on the second day morning followed by Yusha (prepared from green gram) in the evening. The fourth diet advised was semi-solid prepared from green gram and rice. This specific diet pattern helped in gradually improving the appetite of the patient and by the time Samsarjana was completed most of the prominent symptoms were resolved.
Vyaghryadi Kashaya intake also helped in maintaining Agni and ensured that the results obtained after Vamana did not relapse. Clinically, more improvement was noticed as the days passed by. None of the symptoms worsened during the course of treatment.

Probable mode of action of Vamana Karma
Vamana or induced medicated emesis is indicated for the elimination of Dosha through the oral cavity which is the nearest route for Dosha located in the thoracic and the upper abdominal regions. In conditions like fever, rhinitis, and morbidities involving the upper respiratory tract, it is stated that excessive morbid humors (Doshas) are located in the upper abdominal region and Vyaghryadi Kashaya 50 ml was prescribed twice daily for 10 days Garlic 1 gm was advised with warm water once a day for ten days. Saline Gargling was advised twice daily for ten days, Steam inhalation advised for ten days twice daily Regular Warm water intake was advised for ten days 8 to 12 Afebrile, temperature 97.  [14].
To induce vomiting, local and central stimulation is required. Local stimulation is caused by abdominal distention which tends to recoil with force resulting in forceful elimination of abdominal contents. Central stimulation is done by stimulating the chemoreceptor trigger zone by administration of certain drugs like Madanaphala (Randia dumetarom lam.). Drugs like Yashtimadhu (Glycerrhiza glabra Linn.) and Lavanodaka are administered in larger quantities to achieve sufficient abdominal distension followed by recoil resulting into forceful ejection of abdominal contents in the form of vomiting or emesis. Here the drugs procured were mild instigating peripheral stimulation and producing adequate abdominal distension. This led to adequate elimination of Kapha from the upper gastrointestinal tract.
In this study, Yashtimadhu and Lavanodaka were used which are stated to help induce vomiting. Yashtimadhu has a soothing action on the throat therefore there are minimal chances of erosion during vomiting and hence minimizing any chances of bleeding. It has been mentioned under Vamanopaga Mahakashaya (drugs supporting emesis). Lavanodaka has been opted because of its mucolytic actions and here it was used to liquefy and remove excessive Kapha (Su. 26/13) [4] or mucous and eliminate it through oral route by vomiting. This removal of Kapha through Vamana helps in repairing digestive fire as excessive Kapha impedes it [15].

Limitations and special precautions
Vamana is a major Panchakarma procedure conducted with diligent observation and timely monitoring of vital parameters to avoid any complications due to vomiting. Patient was infected with COVID-19 and hence it was unsafe to conduct the procedure in person. Therefore the procedure was carried out through video conferencing, explaining him each and every step before and during the treatment. Regular monitoring of the vital parameters of the patient was conducted. A mild form of Vamana Karma was planned instead of going for a rigorous one. It was especially important to avoid any severe complications as the patient was not present in person for the procedure.
In classical Vamana Karma, Snehapaana (oil or ghee) is administered to the patient for about three to seven days depending on the Prakruti, nature of disease, and Koshtha (nature of abdomen). This is done to saturate the body with Sneha and accumulate the Dosha (toxins), most of which are fat-soluble. After a day of massage and steam fomentation, Vamana is conducted in a controlled manner by administration of drugs that have been advocated as inducers of emesis. In this study, Snehapana was not conducted as it was a sub-acute condition featuring symptoms like fever and nasal congestion, wherein Snehapana is contraindicated. Keeping these things in consideration, immediate Vamana was planned for the patient.

Significance of this study
Ayurveda has always emphasized on the personalized approach to a patient wherein along with the Vikruti (~clinical manifestation of the disease), Prakruti of the patient is also very important in any treatment (Vi. 8/94) [15] It is stated that each individual is different and has different physical and mental attributes. Response to particular morbidity would be different in every individual. This gives importance to the individual's physical and mental traits according to which the management of each individual varies as per his Prakruti. Therefore if a prior understanding of these attributes is ensured and treatment is planned as per these considerations, the prognosis could be much better. In this case report, patient was having Kapha predominant Prakruti, Vamana was planned for him and it yielded significant improvement in results. Along with the clinical manifestations of a disease, Desha (~place), Kala (~season) and patients' Prakruti should also be given adequate importance while planning a management protocol (Vi.8/95) [15].
This management protocol yielded effective results in this patient by controlling the symptomatic reprogression of the disease to severe stages, thereby minimizing the chances of progression of infection to complications. This also helped in providing effective control over the probability of further spread to other family members thereby restricting the community spread as well. This can be a significant finding for control of COVID-19 pandemic, which has a rapid transition time. Future case studies may include sadyo Vamana in Covid-19 management in the patients with good strength and Satva, which may lead to minimum complications and better prognosis.

Conclusion
The outcome of this case study is encouraging enough to conduct more work on COVID-19 involving Ayurveda and specifically considering the personalized approach for patients. The most significant finding in this study was an early resolution of all the major symptoms and negative RTPCR detection. This was also important because symptoms did not progress to severe stages and patient's family members were not infected through him because of his early recovery thus restricting any community spread. This is important to pave the way to a more specific prakruti based approach to morbidity which Ayurveda has emphasized upon.

Informed consent
Written informed consent was provided by the patient.

Sources of funding
None.

Conflict of interest
None.