CASE PRESENTATION
ANU MARIAM VARGHESE
2ND YEAR PG SCHOLAR
DEPARTMENT OF AGADATANTRA
GAVC, TVM

A 34 year female patient came to our OPD with complaints of the
alleged bite (unknown ) on 02/09/2021 which happens 8 days back.
Site : Medial aspect of left arm just above elbow
C/0
• Bite mark which is ulcerated.
• Greenish discoloration over bite site with black spot .
• Reddish painful swelling over surrounding area.
O/E She was conscious , oriented and afebrile.

History of bite
• According to the patient, bite may occurred on 23rd August while she was
handling with some creepers on her garden. She also was busy with cleaning her
house on the same day.
• She felt an itchy sensation over whole body but ignored.
• They have seen a green snake around their house before, as well as centipedes
inside house.
• Next day she saw two bite marks on medial aspect of left arm above elbow
which became a small pinpoint water filled bubble on 2nd day.
• On 4th day her whole upper arm became oedematous with severe pain and one
bite mark seems a purplish colour with reddish surrounding area and the bubble
bursts out , while the other mark remains the same.

• Went to nearby allopathic hospital, they initially doubted as snake
bite, given medications and advised 3 days dressing.
• By then swelling and pain of whole upper arm reduced
considerably but persists over surrounding area of bite mark.
• Next day she came to our OPD for further management , the area
appears slightly necrosed , bite mark seems a black colour with
erythema and swelling.
No k/h/o DM, HTN, DLP, Thyroid disorders

Treatment history of present illness
Took allopathic medications
Mg Sulphate – ointment for wound dressing for 3 days
T. Chymotrypsine – 1-1-1 A/F
• Took blood tests and was normal ( alleged, reports not available )

Personal history
• Mixed diet with good appetite
• Bowel regular and micturition is within normal limits
• Sleep good
• Addictions, Habits nil
• Allergic towards analgesics and most of wound healing
medications, identified followed delivery.
• Mode of work : 10-5pm office work
• Exercise poor

General examination
• Temperature : 36.3⁰ C
• Pulse rate : 76 / min , right radial, volume full
• Body weight-75 kg
Systemic examination
All others are found to be normal

INSPECTION
• A single small ulcer present on medial aspect of left upper arm 10cm above elbow.
• Margin – Irregular , rounded nearly .5 cm diameter
• Edge – Raised and beaded edge
• Floor –Slough present
• Base –Underlying soft tissue
• Skin around ulcer is hyper pigmented.
• Started slight necrosis
PALPATION
Tenderness : present , grade 1
Warmth absent

DASHAVIDHA PAREEKSHA
Dushyam : Dosham - Vatam, Pittam , kapham
Dhatu -Raktam
Desham : Deham - Vama Bahu
: Bhumi - Jangala sadaranam
Balam : Rogam - Madhyamam
Rogi - Madhyamam
Kalam : Ritu - Varsham
Vyadhyavastha- Navam

Analam : Samam
Prakruthi : Vatakaphajam
Vaya : Madhyamam
Satwam : Madhyamam
Satmyam : Shadrasa satmyam
Aharam : Jarana shakti- Madhyamam
Abyavaharana shakti- Madhyamam

ASHTASTHANA PAREEKSHA
• Nadi - Sadaranam
• Mutram - Anavilam
• Malam - Susamhatam
• Jihwa - Anupalepatwam
• Shabdam - Spashtam
• Sparsham - Anushna sheetam
• Drik - Anavilam
• Akriti - Madyamam

Laboratory investigations
Done on 28/08/2021
Reports not available
Alleged normal

• Visha bheda- Jangama
Jangama Vishabhedam
a. Place of bite : At her house
b. Time of bite : Afternoon
c. Time elapsed between time of bite and arrival : 8 days
d. Part of body affected : Medial aspect of left arm above elbow
e. Nature of bite : 2 bite marks present initially, one became
ulcerated later with slight necrosis. Erythematous swelling present
on surrounding area.

Signs and symptoms
a. Samanya lakshana : Ruk, Todam, Ragam, Pakam, Sopham
b. Vega lakshana : Not found
c. Anubandha upadrava : Kotham, Vranam
d. Rishta lakshana : Nil

VISHA SAMPRAPTI
Here the nidana is Aganthuja , therefore we can assume a
raktadushti from it ( Ref : Aganthuja jwaram – Tatra abhighajate
vato prayam raktam pradhooshayan Cha.Chi 1st chapter ) also the
guna of visha causing this bite also cause sthanika doshadushti and
raktadushti , thus manifesting the symptoms.
The guna may affected are Theeksha (prayeena avara) Ushna, -------
----Pitta kopa, Ushna Sookshma guna -------Raktakopa, Rooksha
guna -------Vatakopha.

DOSHA AND VIKRUTA LAKSHANA :
Vatam - Ruk, Todam, Syava varnatha
Pittam - Raga, Paka, Kotha
Kapham - Sopha
DOOSHYA AND VIKRUTHA LAKSHANA :
Raktam - Pidaka
SROTAS AND VIKRUTHA LASKHANA
Raktavaha srotas - Pidaka

VYADHI ADHISHTANAM - Twak
VYADHI MARGAM - Bahyam
DIAGNOSIS
a) Provisional : Keeta visham
b) Differential : Sarpa visham : As the patient didn’t see the snake
and the vega lakshanas were not found
c) Actual : Satapati damsam : The symptoms presented by the
patient was pain, swelling and redness, as she didn’t notice any
insect , from the clinical presentation we assumed it as a centipede
bite.

Treatment :
Chaturvimshati upakrama
Shamana chikitsa - Oushadam, Lepa

Details of treatment :
DATE OBSERVATION MEDICINE
02/09/2021
13/09/2021
Erythematous painful swelling on
medial aspect of upperarm just
above elbow
Bite mark slightly necrosed with a
blackish spot at centre
Swelling reduces , wound not
healed fully, greenish discoloration
subsided
•Patoladigana kashayam-90ml-bd-6am,
6pm-before food
•T. Vilwadi 1-0-1 with kashayam
•Sigrupunarnavadi lepam – for external
application and dhara
•Continue kashayam and gulika
•Triphala kashayam –kshalanam
•Jathyadi ghritham – External application

Pathya :
Ahara - laghu ahara preferably peya for few days, mudga yoosham,
mudgam, saindavam .
Vihara - visramam
Apathya
Ahara : Dadhi, guda, payas, tilam, masham, katu amla and lavana
ahara, abisyandhi ahara, matsyam,mamsam
Vihara : Divaswapnam

Adviceondischarge
• Mahatiktaka ghritham - 10 g bd for 5 days
• After that virechanam with Avipathy choornam 20g with honey
For sheshadoshasamanam
• T. Dooshivishaari 1 tds for 2 weeks

THANK YOU