Key Messages :
1. Vamana is effective in the hypothyroid patients with Joints pain.
2. There may be some relation between thyroid hormone replacement therapy and the musculoskeletal related symptoms, Bone metabolism.
Hypothyroidism is a common endocrine disorder that mainly affects women in middle and old age . Hypothyroidism is characterized by the slowing of mental and motor activity, depression, constipation, cold intolerance, menorrhagia, stiff muscles, carpal tunnel syndrome, sleep apnea, dry hair and skin, weight gain, snoring and a hoarse voice.  Less common symptoms involve the heart, muscles, Joints, and blood . Joints pain as the presenting symptom of hypothyroidism has only been reported once before.  Here, we present an unusual case of hypothyroidism on thyroxin treatment from three years presenting with Joints pain which is relieved by AyurvedicPanchkarma i.e. Vamana (Emesis).
Case Description :
A female,36-year-old, presented to the clinic with Joints pain- Both Knees, shoulders and wrists, and body ache since one year. On further questioning, it was revealed that there had been episodes of Joints pain, mild fever, snoring, sleep apnea, mild dysphagia. Her past medical history was normal except PUO episode four yearsback. Clinical examination, including the central nervous system, was normal apart from a slightly puffy face. Her thyroid gland was not palpable. An otolaryngeal examination revealed no local cause for her problem. There was no abnormality in movement of tongue or pharyngeal/palate muscles. A further neurological examination did not show any abnormality. Routine thyroid function tests showed thyroxinlevel
<4mg/dl (normal 4.5-12.0mg/dl), thyroid stimulating hormone level21.46 mIU/ml (normal 0.30-5.5mIU/ml). A complete blood count film was consistent with iron deficiency, hemoglobin level9.5 grams (normal 11-16 grams). In Other biochemical abnormalities, her RA test shows negative results, high serum cholesterol level - 225.70mg% (normal 125-200mg %), and HighLDL cholesterol -151.24mg% (normal 0.5-1.7 mg %). The Electro cardio-gram (ECG) was normal.
Based on these findings, hypothyroidism was diagnosed. In the light of the patient's diagnosis, a second history was taken which showed that she suffered from other symptoms of hypothyroidism such as, dry skin, generalized weakness, excessive sleeping, hoarse voice, and menorrhagia. All of these symptoms were neither reported nor elicited. She is already on thyroxin treatment from three years. Initially she got relief for dry skin, generalized weakness, excessive sleeping. But since one year she got symptoms like Joints pain, Pin prick sensation in both eyes, Redness in inner side of eyelids of eyes, hoarse voice, depression, constipation etc.
I decided to give Vamana(Emesis) Panchkarma tothe patient in this situation. Because Vamana Karma is consider as best line of purification procedure for Jatrurdhwavyadhi(above clavicle bone Diseases) and Kaphaja disorders.Vamana is highly beneficial for volunteers of Kapha and Kapha-Pitta constitution and patients suffering from KaphaRog and associated Pitta Rog or diseases originating or settled in the place of Kapha.Vamana is a procedure in which Doshas (waste products or toxins) are eliminated through upper channels i.e. mouth
Vamana was given as follows, forDeepana,Pachana,TrikatuChurna 3 grams twice daily with warm water before food for two days. ForSnehapana, Mahatiktaghruta starting from 30 ml up to 150 ml i.e. in 5 days administered. In the Pradhana karma (Main Procedure), Vamaka yoga (Emetic drug)was prepared by the fine powder of Madanaphala 4 grams, Yastimadhu 3 grams, Vacha 2 grams, Saindhavalavana 1 gram, Madhu (honey)10 ml. Yashtimadhuphanta and Saindhavajala given as Vamanaopagayogas to the patient.In the Paschat karma, Dhoomapanawas given.After this, Samsarjanakrama followed for 5 days.Vamana procedure was done as per Granthokta procedure (Ayurvedic classical Books). Diet and Life style advised as per AyurvedicDincharya(Daily Regimen) to the patient.
After completion of Vamana main procedure, immediately after 20 min, her Joints pain relieved up to 20% and she felt relaxed, reduced heaviness. After next follow up visit her Joints pain, Pin prick sensation in both eyes, redness in inner side of eyelids of both eyes, depression, constipation, was relieved near about 50 %. And the thyroid function tests showed thyroxin level of 10.6mg/dl (normal 4.5-12.0mg/dl), thyroid stimulating hormone level5.2mIU/ml(normal 0.30-5.5 mIU/ml).
Her thyroxin hormonal dose was also tapered with the help of her Endocrinologist in the next visit.
Next thyroid function tests showed thyroxinlevel 10.04pmol/L (normal 4.5-12.0 mg/dl), thyroid stimulating hormone level 2.38mIU/ml (normal 0.30-5.00 mIU/ml).
There maybe some relation between thyroid hormone replacement therapy and the musculoskeletal related symptoms, Bone metabolism, or arthropathy.
There was considerable relief in symptoms of the hypothyroid patient by Vamana procedure in the above case. So we can say that Vamana is effective in the hypothyroid patients with Joints pain, and also in patients who are taking thyroid replacement therapy.
Joints pain may be caused by Autoimmune diseases such as rheumatoid arthritis and lupus, Bursitis, Gout Infections caused by a virus, Rheumatic fever, Osteoarthritis, Osteomyelitis etc.. The second may be attributable to congenital, traumatic, inflammatory, tumors. These causes were unlikely in this patient, because she showed no associated clinical features of these diseases besides the normal neurological examination and investigations. Other causes such as congenital or acquired storage disorders such as amyloidosis and such endocrine disorders as acromegaly were not found. The most likely cause for the Joints pain in this patient was hypothyroidism. This was supported by the abnormal thyroid functions and other associated symptoms.
Iron deficiency anemia in this patient was due to menorrhagia, which is one of the characteristic features of the disease.  Hyperlipidemia may also be due to hypothyroidism, a known association. 
Clinical implication of the presented patient was Joints pain. Body ache may be the presenting symptoms of hypothyroidism, even if other symptoms had been present for a long time. There is a high prevalence of bone loss in patients with subclinical hypothyroidism treated with exogenous thyroxin . Thyroid hormones are essential for growth and development during childhood and for the maintenance of bone in adulthood .In children with hypothyroidism one sees stunted growth with epiphyseal dysgenesis and delayed skeletal maturation while in adults the phases of bone renewal are prolonged with reduced osteoblast activity and increased cortical bone thickness .Hypothyroidism as the cause of Joints pain was confirmed with the discovery of additional symptoms in the patient's history. Vamana is not indicated for joint pain in routine line of treatment. In this case, Patient had history of thyroid before joints pain. Vamana Karma is considered as best line of treatment/procedure for Jatrurdwavyadhi (above clavicle bone Diseases).Thyroid disease can be subtitled under Jatrurdwavyadhi so it was decided to do vamana. Prompt recovery of Joints pain is expected after Panchkarma (Vamana) therapy. And there was considerable relief in the symptoms of hypothyroid patient by Vamana procedure in the above case. So we can say that Vamana is effective in the hypothyroid patients with Joints pain and also in patients who are taking thyroid replacement therapy.It felt the need of conducting further research in this field.
*Sr.Consultant,RRA PodarAyurved Cancer Research Institute, Under CCRAS, Department of AYUSH, Mumbai.
** Consulting Ayurveda Physician, Arogyadham, Thane, Mumbai
We sincerely appreciate the guidance in Ayurveda during Postgraduate Period by Dr.N.M. Kamat, Ex-Principal & HOD of Kayachikitsa Department, Sion Ayurved college, Sion, Mumbai and guidance in modern aspects including need of work through Ayurveda in Endocrinology by Dr. Shashank Joshi, Endocrinologist, Lilavati Hospital, Bandra, Mumbai.
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