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Case Study

Trinitrotoluene Battles Hypoproliferative Anaemia
Dr Adil Chimthanawala
'China / Carcinosin

Ms F A aged 16yrs, a student of Std X, approached us on 11/11/99 with the complaints of

  1. Gradually progressive weakness, dizziness, palpitation and breathlessness < on slight exertion (NYHA Gr III) - 2 1/2 months.
  2. Low grade, continuous fever, No chills or rigors.
  3. Occ Cramps in the calves < on walking

Persistent pain at the popliteal fossa (Back of knees) < night.
She had difficulty in getting sleep and has no taste even for tea (which was initially one of her favorite drinks but now despises it).

All these complaints started 5 momths ago with the onset of high-grade remittent fever accompanied with chills and rigors. Took certain Antibiotics/Antimalarials (details not known), 4 days after which, she developed bleeding gums and a generalised erythematous to purple rash.

She was hospitalised, (Hb-4gm%, PS-anisopoikilocytosis +++, Thrombocytopaenia, Neutropenia).
Blood transfusion given with IV supplements. 7 such Blood Transfusion till date. Rash subsided within 18-20 days, but rest of her symptoms continued. Still on symptomatic drugs.

Basically a shy, reserved girl who is very sensitive, apprehensive, nervous and weeps easily. Very fastidious in her day-to-day work.

Thermals - chilly patient
Appetite - decreased. Desires - salt, milk, eggs. Aversion - coffee, tea.
Thirst - average
Urine -8-10 times /24 hrs, occ burning +
Stool - Well formed, semisolid, 1 to 2 days. No blood, mucus, worms.
Perspiration - average
Menses - started 14 yrs, reg 3/30 days, bright red, Occ Leucorrhoea +. Now, since 4 months, reg 1/35-40 days, scanty, pains ++.
Sleep - 6-61/2 hrs, alert, sleeps on abdomen, with body completely covered. Restless, knee chest position.
Dreams - of her disease, swimming in high seas/oceans. Hairfall ++, Dandruff +

Past H/O - Pneumonia at 5 1/2 months age, Pin worms at age of 5 -12 yrs. Filliform warts, Lt finger, cauterised 2 yrs ago.

Family H/O - Father - DM on antidiabetics. PGM - Ca breast: died

Pt as a person: Loves music, dancing, singing, reading.Pt was hospitalised for investigations and replacement therapy,
O/E GC - not satisfactory,
conscious, restless, warm,
P- regular, 120/min, slow, weak,
Resp - laboured, 28/min,
BP- 90/60 mm Hg, Oedema feet +, JVP Not Raised,
No cyanosis / clubbing, Pallor +++, No lymphadenopathy
Skin pale, purpuric spots on extremities +.
RS - Trachea central, Air entry = Both sides, Vesicular BS,
Bilateral scattered ronchi ++,
CVS -apex = Lt 5th ICS, inside the midclavicular line, HS1/2 muffled,
Short systolic murmur parasternal -4,5th ICS (Gr II/VI). No S3 gallop.
P/A -Soft, Nontender, Liver-Just palp, Spleen/ Kidneys - Not palpable, No e/o ascites.

Diagnoses: Severe Anaemia? Haemolytic? Drug induced?





9.10 AM


Propped up. 
O2inhalation @4L/min. Blood 2 units Input/output, TPR, BP charting; Blood for investigations

China 30 4 hrly


Pt better, Restlessness/Dyspnoea.
P-100/min, BP -100/60, CVS - No S3 gallop, 
O2 inhalation SOS. Short systolic murmur
parasternal RS-B/l Ronchi + 
Blood-Hb=5.2gm%, PS- anisopoikilocytosis, teardrop RBC's, Howell-Jolly bodies+, Thrombocytopaenia, Neutropaenia. hypolobulated neutrophils, No parasites. 
MCV=90fL, Retic count=0%, 
TC -3200/cumm, DC-P14%, L70%,E4%,M12%,B0%,S.Na 122mEq/L. S.K=3.8 mEq/L. B S (R)=68mg%, 
S.Bil T=0.6mg/dL, D=0.2mg/dL,I=0.4mg/dL, BUN=28mg%, S.Creat=1.9mg%, S.SGPT 30U/L, S.Albumin=3.8gm/d
Urine (R)-NAD, Stool for occult blood = Negative; ECG - Sinus Tachy, QTc -0.40secs. Otherwise WNL


China 30 TDS
O2 inhalation SOS

12/11/99 8.AM

Pt settled and slept well . 
Fever cont. Cramps in calves > Rest. Palpitation >
BP-110/70 mmHg, P-90/min, reg, 
Bone marrow- for Histopath. Xray Chest PA = NAD; USG abdo:Mild Hepatomegaly. No Splenomegaly.


China 30 BD


Pt C/o Breathlessness & palpitation since early morning ;Min sleep, restlessness. P-reg 120/min, P100/64mmHg, RS-B/L Ronchi Infrascapular, increased. 
Bone marrow - S/o Myelofibrosis: dyserythropoetic changes with ringed sideroblasts, defective haemoglobinisation,with Nuclear cytoplasmic asynchrony, micromegakaryocytosis, with hyposegmented and hypogranulated polymorphs


O2 inhalation,SOS


Pt much better. Urine/stool/sleep Normal.
Vitals stable. Breathlessness/ Restlessness, palpitations decreased. RS=B/L Ronchi decreased. Short systolic murmur parasternal +


Ct. all


Pt discharged on request- to report after a wk




Pt better in all respects. Hb-6.4gm%, Retic count-1%, TC=4,800/cumm, C=P30%,L64%,M6%,E0%.


TNT 6 TDS ct


Pt better. No breathlessness, palpitation, dizziness, cramps. No fever. Sleep sound, Pt had a sense of well being. P-84/min, reg. BP-120/74mmHg.
RS-clear, No hepatomegaly, 
HS pure. No murmurs. HB=7gm%, PS-normocytic, hypochromic RBC's, Occ tear drop cells. TC 5,600/cumm, Platelets Normal,MCV-88fL.


Carcinosin 200 1D
TNT 6 TDS ct for 1 week


Pt started attending school from past 1 week. Better in all respects. Menses 3/30 days, flow increased, dysmenorrhoea less. Appetite/Sleep Normal.

Progressing well. Preparing for Board Exams in 2001.

Omit TNT.
Sac-lac x 2 mnths


  1. Myelofibrosis comes under the spectrum of Hypoproliferative anaemias, generally caused due to exposure to radiation, Chemicals and Drugs or in genetic disorders as Downs syndrome, Neurofibrosis etc. Leukemia’s, Lymphomas and Tuberculosis do lead to this disorder.
  2. Miasmatically, this is a Drug Miasm. An incurable disease. Fibrosis indicates an end stage of Tubercular Miasm.
  3. China was given for extreme pallor. PCF.
  4. Trinitrotoluene (TNT) was thought of as a pathological prescription on the basis of Bone Marrow report. The Severe anaemia and its effects as Breathlessness, dizziness, restlessness, insomnia, cramps, tendency to Hemorrhages under the skin, etc did show good results.
  5. Carcinosin - a multipolycrest was given on the basis of Drug disease, Family/Past/Personal History and Mental generalities.
  6. Prognosis - with no infections till date, and seeing the progress of the patient, it can be concluded that prognosis is fairly good.