Placebo For Drug Induced Erythema Nodosum

A 31 years old non-hypertensive, non-diabetic gentleman, a Homoeopath by profession, was shifted at Shaad homoeopathic hospital from another center on 12/7/2010 for complaints of –

1. Fever since 12 days
2. Skin rash since 9 days
3. Chest pain since 3 days

Fever was continuous to remittent, not associated with chill or rigor. History of mild headache with nausea was present. No history of bowel or bladder alteration, abdominal pain, cough, altered sensorium or bleeding from any natural orifices.

History of consumption of tablet Sulphadoxine + Pyrimethamine on the 3^rd day of fever. After 24 hours of taking the tablet, he developed red, papular, tender, indurated lesions over both lower limbs up to mid thigh. He was hospitalized at the local hospital near-by and was diagnosed by a dermatologist, to have “Erythema Nodosum” of ?Drug Induced or ?Infective etiology. An empirical course of antibiotics for Typhoid Fever was prescribed

1. Tablet Ceftriaxone (4^th generation Cephalosporin - antibiotic)
2. Tablet Ofloxacin (antibiotic)
3. Injection Falcigo (anti-malarial)

The following was his investigatory profile (as mentioned in his Discharge card)

1. Hb 15.8 gm/dl
2. DC 4700 /mm cu
3. N63%, L18%, M11%, E8%
4. ESR 34 mm @ 1st hour
5. PS for MP – Negative
6. Widal – Negative
7. Typhi card (Rapid IgM) – Negative
8. Leptospirosis IgM - Negative
9. Montoux - Negative
10. Tuberculosis by PCR – Negative
11. Serum Ferritin – 771.3 (upto 400 Normal)
12. X-Ray chest – Right Hilar Lymphadenopathy. Rest was Normal
13. Skin Biopsy – Leucocytoclastic Vasculitis

After 5 days of therapy, no response. Fever and rash persisted. Skin lesions more inflamed with cellulitis and pedal edema. Patient also started developing chest pain – dull, stitching type localized to the anterior past of chest. ECG – sinus tachycardia, rest within normal limits.

In addition to the above-mentioned drugs, the patient was started on (NSAID) Tablet Indomethacin and (Steroid) tablet Prednisolone 20 mg twice a day. Rash reduced but fever persisted; hence the patient opted for homoeopathy.

When patient came to us, he had

Fever – moderate grade, intermittent,

Skin rash - red, papular, tender, over both lower limbs up to mid thigh with swelling

Chest pain – left anterior chest, stitching type

Chilly, Appetite diminished. No specific desires / aversions. Thirst profuse for small quantities, Urine/ stool/ sweat and sleep – normal

State of Disposition – calm, answered logically and spontaneously. Memory of recent and past events was good. Liked company.

On Examination

Moderate Built

Conscious, co-operative, comfortable in lying and sitting posture

Weight -67 Kg

Febrile – 102 deg F

Pulse- regular, 100/min, good volume, non-collapsing, synchronous

BP – 130/84 mm Hg Right upper arm in sitting posture

Respiration Quiet

Pallor +, No icterus, No cyanosis or clubbing

JVP- not raised. Edema feet ++

No stiffness of cervical muscles or neck rigidity

Ears / Nose / Throat – Normal

Spine / Joints - normal

Heart Sounds-pure, no gallop or murmur

Respiratory System- Air entry was equal on both sides. No adventitious sounds.

Abdomen – Soft, Non tender. Liver or Spleen - not palpable. Kidney’s not ballotable. Intestinal sounds heard in all 4 quadrants. Hernial orifices – normal

Skin - erythematous tender papules on bilateral lower extremities, from dorsum of feet to mid thigh with swelling.

Investigations on admission

• Hb 15.3 gm/dl
• Total Leucocyte Count 3200 /mm cu
• Neutrophils = 78%, Lymphocytes =18%, Monocytes = 2%, Eosinophils = 2%
• ESR 45 mm @ 1^st hour
• Urine Routine - Normal
• PS for MP – Negative
• Widal – Negative
• Malaria Antigen – Negative
• Plasmodium (LDH) optimal Test - Negative
• Blood Urea – 26 mg/dl
• Serum Creatinine – 0.9 mg/dl
• Serum S.G.P.T – 31mg/dl
• Blood Sugar (Random) – 112 mg/dl
• Serum Antinuclear Antibody - Negative
• Rheumatoid Arthritis (RA) Factor – Negative
• Serum HIV, HBsAg and HCV – Negative
• Ultrasonography Whole Abdomen – Normal
• 2D Echocardiogram – Normal
• CAT scan of Thorax with Contrast - Multiple
  Mediastinal Nodes
• Bactec Blood Culture Negative

All antibiotics, NSAIDs and Steroids were stopped and case was repertorized with Kent’s Repertory

1. Generalities, cold, general aggravation, in
2. Stomach, Thirst profuse
3. Fever hectic
4. Fever intermittent
5. Extremities, legs, eruptions, red
6. Extremities, legs, eruptions, painful
7. Chest pain, left side
8. Chest pain, stitching

Potential Drugs – Arsenic alb, Arsenic iod, Iodum, Kali arsenicum, Phosphorus, Sulphur, Sepia, Silica, Tuberculinum

12/7 SL 12 doses / 4 hourly

13/7 Fever 99 deg in eve x 1 hour warm water sponging

Pulse- regular, 78/min, BP-120/74 SL continue

Edema feet + but less

Heart Sounds-pure, Chest clear

Red papules on both lower limbs.

Non tender and reduced number

14/7 No fever. Eruptions less SL 3 times / day

15/7 No fever. Appetite normal SL 2 times / day

Eruptions only on the dorsum

No limb edema

16/7 Patient discharged. No Fever.

Eruptions only on the dorsum

No itching, redness or pain

No edema.

ESR 11mm@1^st hour

Hb- 15.8g/dL.

Discussion – There were several points against the drugs arrived after repertorization -

1. Arsenic album – the state of disposition was very calm and the patient did not have much fatigue in spite of the grave pathology. This is contrary to the great fearful, restless and exhaustive temperament of the horse’s remedy. The hectic febrile state of Arsenic is accompanied with coldness in spots, chilliness, profuse sweat, thirst and intense exhaustion. This was not so in our patient. Arsenic eruptions are dry, papular blue or black. Ulcers have a bloody offensive discharge. Poisoned wounds. None of this was seen in our patient.
2. Arsenic iodatum – It has dry skin with marked exfoliation of large scales, leaving a raw exuding surface along with lymphadenopathy quite unlike the eruptions seen in our patient. The fever is accompanied with drenching night sweats. But in the present case, sweating is not a marked feature at all. Chilliness and intense thirst are the only favorable points.
3. Iodium – It has hectic fever, profuse sweating, with restlessness or stupor. The skin is hot, dry, and dirty with itching nodosities. Excepting the last word, none of the symptoms were present in our patient. Also Iodium has ravenous hunger, intense thirst and is one of the hottest remedy. Mentally too, it has great dejection, intolerably cross and restless with tendency to weep.
4. Kali Arsenicosum- mentally this remedy has got great nervousness, hypochondriasis, anxiety, leading to panic attacks. The skin is dry, scaly with numerous small nodules under the skin. There is intolerable itching worse from warmth, walking and undressing. None of the symptoms matched those with our patient.
5. Phosphorus- the fever is accompanied with profuse perspiration and intense chilliness. Likewise the Phosphorus skin presents with ecchymosis, purpura hemorrhagia and bleeding wounds. Mentally the patient has fearfulness clairvoyance, restlessness loss of memory and hypersensitivity to external impressions. This remedial picture was way away from our patient.
6. Sepia- Sepia skin has wine colored spots, ringworm, cracks and fissures and sweaty feet. The fever is accompanied with profuse hot sweat, weakness, shivering and chilliness. In the repertory, in the chapter of Fever, there is a rubric “Changing paroxysms, homoeopathic potencies after” in which the medicine Sepia is indicated. Apart from this similar symptom, none of the symptoms of the remedy matched with the patient.
7. Sulphur- A decidedly hot remedy, the sulphur skin is unhealthy, dry scaly with the tendency to suppuration. Skin disorders after local medications. Itching aggravated from warmth, fever is in the form of frequent flashes of heat with general throbbing between scapulae and sweating on single parts. Temperamentally the patient is dull, absent minded and forgetful. Barring the thermal state a few of the remedy symptoms matched with those of the patient.
8. Silica – without doubt silica is chilly, has a suppurative disposition and coppery spots on skin. Hectic fever with profuse sweat is present. In the febrile stage the patient is anxious with fixed ideas, hopelessness but still retains the mental acuteness. Again many of the symptoms of the drug and patient mismatched.
9. Tuberculinum- Temperamentally the patient is very restless, fearfull, irritable, confused and depressed. There may be fits of violent temper and desire for movement. Fever is remittent with profuse sweat, loquacity and chilliness. Again the symptoms are farfetched as compared to patient.

Now the following questions came to our mind

- Both – fever and skin eruptions are eliminations of the
activated miasm. Should we treat them in the first place? As it is the patient
is haemodynamically stable and no clear cut picture of any remedy is available. So why not wait and watch.

- Is the pathology that grave since all the
investigations were within normal limits

- Do the rubrics need to be changed?

- Whether the Repertory needs to be changed?

- Should we ignore the mental state and only concentrate
on the fever and eruptions?

- Should we take the rubric “Ailment from Bad effects of
Drugs” i.e. drug reaction and administer Nux Vom or Sepia like drugs?

- Why not think of some lesser used remedies that have
not come up in the reportorial chart?

- Is it wise to use a Nosode?

- Can we empirically give drugs like Pyrogen or Apis or
Belladonna or Bufo and reduce the septic state?

In fine – Our patience with dealing with the patient did pay off, although the idea of a referred homoeopathic doctor being admitted in our hospital and being given only Placebo was quite alarming. Since we could not get a clear picture of any drug that came out in repertorization, we decided to wait and watch instead of engaging in over–zealous treatment. On follow-up, the patient reported complete disappearance of the nodules and no febrile episodes. The possibility of myocardiitis as a possible cause of chest pain was ruled out in the beginning. It was only a part of generalized myalgia which ultimately disappeared with disappearance of fever.

He joined his duties after a week of discharge from the hospital. Retrospectively, in our search for a nosological entity, only the pathologist and the radiologist had a D-day in this patient, otherwise, nature took care of the miasmatic disturbance on its own…..So sometimes Placebo works wonders too.

[Note – For reasons of Privacy, the name of the patient and the photograph of the lesions on admission and discharge are kept confidential since the patient has denied permission for publication]