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Case Study

Tuberculosis Pericardial Effusion
Dr Adil Chimthanawala
'Puls / Avena-s / Kali-iod / Aur-met

One patient consulted me on 13/10/99 for his close friend, 32, diagnosed at PGI an Superspecialty Hospital Nagpur, as Pulmonary tuberculosis- Lt Pleural Effusion with Pericardial Effusion.

His Complaints

  1. Fever, moderate grade, with chills, night sweats+, thirst scanty.
  2. Chest pains left precordium - stabbing, radiating to the front < each breath, cough with fatigue.
  3. Dyspnoea (N Y H A Gr III) < ascending stairs with palpitations.
  4. Cough with mucus expectoration < lying down. No haemoptysis.

It all started 2 months ago with gradually increasing intensity. Investigated at G M C Nagpur and put on AKT (2SHRZ + 6 HR). In 2 wks he developed erythematous, macular, itchy rash on both the lower extremities and trunk. Steroids and anti-histaminics gave no relief. On stopping treatment on his own, rash subsided in 10 days. Again admitted to PGI and Superspecialty Hospital for severe respiratory symptoms, diagnosed as Tuberculosis Pericardial Effusion and restarted on AKT. During this time he approached us.

O/E Conscious, emaciated, febrile, Pulse -reg 110/min, low vol, RR -24/min BP- 100/60 Pallor ++ No Icterus/Cyanosis/ Clubbing, No S/O CCF
P/A - liver/spleen - NP. No E/o Ascites. Sounds in all 4 quads.
CVS - Apex not palpable. HS ½ - muffled. No pericardial rub.
RS - Trachea shift to right. Air entry - absent- infra axillary. Crepts - left infra scapular.
O/I-BLOOD: Hb 8.2 gm%, TLC 11,800/cumm, Lymphocytosis, ESR 46 mm.
B. Urea 28 mg%, S. Creatinine 1.4 mg %, LFT - N, RA Factor - Negative
X-ray chest PA - Lt Pleural Effusion with mid zone consolidation, Cardiomegaly
USG abd - N
ECG - Global T inversion with low voltage complexes with sinus tachycardia.
2D ECHO - Mild Pericardial effusion, dilated LV, good systolic function.
LVEF - 72%, No RWMA, Valves normal, Aorta N, No Intracardiac clot/mass

Life Story: The patient's sister told us the life story: Sir, ours is a poor family of 7 members- My parents, 2 brothers and their wives and me. My father is suffering from paralysis (Rt) since 12 years. My this brother (patient) has worked hard throughout his life since 17 years of age. He is a mechanic. He has spent every paise of his earnings on our father's medication and on our studies. But since my younger brother married last year, our family has got disturbed. . Practically every other day there are quarrels. My 2nd brother has changed after his marriage, which ultimately ended in his living separately. Since then, my this brother has become sad and despondent. He has even stopped going to work and now has developed this disease!

Complaints: He has slight burning and increased frequency of urination. His thirst is less and gets 2-3 loose motions especially before going to bed and after tea.

During the conversation, the patient lamented on his frustrations. For him life had become a burden. He said "I wish I would die, rather than make others suffer due to my sickness". I asked how he feels about his brother's attitude. He said, although as a brother I think he is right, but whenever I think of the incident, I feel hurt."

He said "I am better when I sleep in our verandah, which has a cool breeze. As such my sleep is sound, but at times, I get fearful dreams of people stealing from my house." His sister added that basically, he is mentally strong and full of hope. He got angry whenever anyone failed to perform his or her duties. She said "Even with our poor condition, our brother did too much, but still feels guilty of not doing enough.

P/H - Rec attacks of Bronchitis < winter, CSOM - Lt ear (7-13 yrs age)
F/H - Fa - HT with Rt. Hemiparesis, Mo - Ulcerative colitis

Planning and Programming and Follow-Up



Puls 200 TDS x 1d
Avena-s Q 10 dr BD
Omit Anti-TB drugs


Febrile, emaciated, Pulse - 100/m, regRR-22/m BP - 100/64. Pallor ++RS-Trachea shift to Rt, Lt Infrascapular crepts +, Lt Pl effusion+ CVS- apex not palp, HS soft, No rub / gallopCNS/ Abd NAD

Puls 200 TDS x 1d
Avena-s Q 10 dr BD


Dyspnoea+, Fever Less, cough with expectoration ++

Puls 1M 3 d HSSL x 3 days


No fever, Dyspnoea+++, Cough++P-100/m BP - 110/70RS - Lt Infra-scapular crepts lessLt pleural effusion +

Kali-iod 30 fract doses x 3d
Omit Puls Ct Avena-s Q


Patient feeling better. Dyspnoea reduced Cough with expectoration+, vitals stableCrepts reduced. Pl effusion+

SL X 10 Days
Ct Avena-s Q 10 dr BD



Kali-iod 200 3 d x 1 day
SL x 10 days Omit Avena-s



Aurum-met 1M 1d
Avena-s Q 10 dr TDS x 1 mnth


Much better, depression >>, chest pain less. No dyspnoea, vitals stable. Chest clear. HS pure, ECG/ECHO - No fresh changes

SL 1 TDS x 1 mth


No complaints

Tub-b 1 M /1dose


No complaints - follow up+

Sac lac ct

Discussion for the Remedy Selection

  1. Puls was given as a short acting remedy for evening rise of fever with chills, less thirst an desire for open air. Cough with mucous expectoration < lying down and night. Kent says Puls is very useful in Catarrhal Phthisis -Kent MM pg 757
  2. Avena-sativa was used to tone up the patient's vitality. In my experience, this works well in cases with gross pathology where they do not react well to other medicines.
  3. Kali-iod given on the basis of pleural effusion, intense cough and dyspnoea with palpitaition < warm room, > exertion > open air. Chill with fever < night. It follows well after Puls, See Hering GS Vol IV pg 433
  4. Aurum-met on TOTALITY OF THE CASE: Chilly, generals < after cold an winters. Basically pt is strong and capable of lot of hard work. He is rigid on himself but soft on others. Aur fits the totality of the case Feeling of self-condemnation, worthlessness, loathing of life, dreams of robbers, palpitations, P/H of obstinate otorrhoea. Kent says that here the pts fundamental love of living is perverted with horrible depression of spirit, self condemnation and continual self-reproach and self-criticism. A constant looking into the self, magnifying the feeling that he has neglected his duties- Kent MM pg 165. Strong desire for open air. Heart affection, with resultant palpitation, chest pain, dyspnoea, < ascending stairs, exertion and better open air, finally ending in hopelessness and despair.
  5. Tuberculinum has been giving as the indicated Nosode on the basis of pathological changes an F/H ulcerative colitis and Hemiplagia.
  6. [Editor adds her own understanding of Aurum: A very strong sense of duty- this is the crux of the Aurum. Inspite of personal hardships he will do what is right. Even after doing all he possibly could, he feels he did not do enough. But he does not apply the same yardstick to his brother who completely shirked his duty. Pt forgives him, but does not forgive himself. Is very hard on himself, even to the point of going into depression. Here the link between organs and mental state is graphically established. Heart and depression= Aur. Lungs and optimism = Kali. In that sense the prescription of Kali-iod was pathological and ad-hoc and very far from the patient's totality. It could have been avoided]