Dr. Mahesh Gupta

Diagnosis of Visarpa in clinical practice is very controversial. Visarpa is an extreme form of viral and spread in similar to that of cobra venom.  If not attended properly readily inflict as death.   Hence Visarpa is known as extreme form of atyayika roga. 

Visarpa is an infectious disease caused by Nita group (Harpes group) of viruses this classification made according to afflicting chemical, physical, and serological criteria. Herpes simplex 1, Herpes simplex 2, Herpes zoster, Vericella zoster, Vericella, Cytomogalo virus and secondary infection to streptococcus pyogenes (Hemolytic streptococci of group A)  80 types of streptococcus pyogenes  are have been recognized so far.  Parisarpana is due to these infections having lot of similarities in clinical condition of Visarpa.  Visarpa is caused by chardi vega dharana janya udavartha and also caused due to wounds fractures, crush injuries, cutting of immature part affliction by banda and fall the deranged and vitiated vatadi doshas get aggravated and there by afflicted the twak mamsa and rakta speedily gives rise to a sort of shifting elevated shotha marked by the characteristic symptoms any of them involved in the samprapthi this swelling tends to extend all over the body.  This disease is called Visarpa from the fact of extending or shifting character.

Clinical features:

• Vatika Visarpana:  The patient has same type of constitutional features as in vataja fever, inflammation, twitching, pins and needles, tearing sensation pain on movement, horripilation (Ah. Ni. 13/47).
• Giddiness, davathu (burning sensation in eyes), thirst, pricking pain, malaise, cramps, tremors, fever, tamaksvasa, kasa, pain in bones and joints and their dislocation, shivering, anorexia, indigestion, cloudiness of the eyes, lacrimation and a feeling as if ants are crawling over the body.
• The space through which the Visarpa spreads becomes grayish or pinkish in colour and oedematous. The space become excessively affected with pricking pain, breaking  pain, colic pain, expansion, contraction and tingling and throbbing sensation if not treated, space become accumulated with instantaneous cracking, pustules which are small in size and pink/grayish in colour and secretion of liquid which is thin, transparent small quantity.
• Arrest of voiding of flatus, urine and stool.
• The patient feels comfortable with ingredients having opposite attribute to vata.

Paittika Visarpam :

The pittaja Visarpa is rapidly spreading in character, deep red in color and the patient presents with constitutional features of pittaja fever (Ah.Ni 13/48)

The discolouration of the affected part will be haridra, harita, nila, krisnam, etc., with sravam.  The space, in which this spreads, becomes coppery, green, yellow, blue, black, or red coloured. The space becomes full of pustules, which are excessively swollen and associated with excessive burning sensation and breaking pain.  The exudates from these pustules have the colours like those of pustules.  The pustules get suppurated very quickly.  Factors described to cause pitta Visarpa are not homologatory to such a patient. 

Kaphaja Visarpa:  The kaphaja Visarpa patient presents with the same constitutional feature as in care of kaphaja jvara.There is numbness, stiffness, heaviness and less pain the body.  The space, in which Visarpa spreads, becomes oedematous, pale yellow, not very red and unctuous.  The pustules in this space get suppurated very late, they become chronic, they appear in large number, the skin over these pustules get covered with sticky material and these pustule are either white or pale yellow in colour.  When there is eruption of these pustules then exudates which is white, slimy, fibrous, dense, knotty and unctuous.  After the eruption of these pustules, the space is covered with ulcer which is deep seated, stable, surrounded by the capillary network, unctuous and covered with many skin scabs.  The ulcer continues to stay for long time.The upper part of the body (urdhva bhagam) becomes afflicted with the ulcer of the above mentioned symptoms, because the upper part of the body is the abode of kapha

Sannipatika Visarpa:

The sannipatika type of visarpa is caused by the all-etiological factors, the signs and symptoms described in respect of each of the vatadi verities Visarpa.  It pervades all the dhatus (tvak, lasika, rakta, mamsa). It spreads instantaneously and is incurable in nature.

Agni Visarpa: 

In this type vata and pitta simultaneously aggravated because of their respective causative factor, gain strength from each other and spread over the body along with burning sensation, which is called agneya visarpa.  Fever, vomiting, attacks of swooning diarrhea, thirst, dizziness, splitting pain in regional glands, diminished digestive power, respiratory distress and anorexia, the patient feels as if the whole body is covered with burning charcoal, all those sites where the Visarpa spreads, get quickly studded with blister as after with thermal burn and appears blackish, bluish or reddish like an extinguished charcoal.

On account of fast spreading tendency, it quickly pervades into the vital areas (marmas) as result of which vata becomes overwhelmingly powerful and gives rise to pain all over the body, loss of consciousness, sleeplessness, dyspnoea and hiccough. The patient who has reached this stage does not find any relief by any measures. He remains restless and attempts to lie down on the ground or sit or adopt any other posture resulting in extreme agony, mental confusion and bodily inactivity and finally results in death.

Kardama Visarpa: 

The disease generally spread in slow speed in the amasaya and gets localized there.  The space, in which this type of Visarpa spreads, becomes as if studded with eruption of red, yellow and pale yellow colour.   The space looks muddy, black, dirty and unctuous and it is excessively hot, heavy with dull pain, oedema and deep-seated suppuration.   These eruptions are free from exudations and become sloughy very quickly. The skin and muscle tissue over these eruption are shriveled, sticky and suppurated.  The pain over this space is less and it appears gradually.  By rubbing, these eruptions get cracked and when pressed sticky and purified muscle tissue comes out of these eruptions.  In the space at the bottom of this eruption (after taking out the slough), one can visualize vessels and ligaments and smells like cadaveric as emitted from this space.  The patient loses consciousness and memory.

Granthi Visarpa:

It is one of the Visarpa involving vata and kapha as main vitiated dosa.  Intake of sthira, guru, kathina, madhura, sita, snigdha, abishyandi, Lack of exercise, Habitually avoiding administration of elimination therapy (panchkarma therapies) at the appropriate time.  The channels of circulation of vayu get obstructed by the aggravated kapha (which causes further aggravation of vata). Both these vitiated dosas get excessively aggravated and vitiate dusyas giving rise to Visarpa.

Aggravatd vata, in turn, causes splitting of cough into several parts gradually giving rise to a series of granthis (grandular enlargements) in the abodes of kapha (ura: pradesa). These enlarged glands get suppurated very slowly and is difficult to cure.

In a person having excess of blood (aggravated vata and kapha) vitiate the blood giving rise to a series of glandular enlargements located in vessel, ligaments (or nerves), muscles and skin. These enlarged glands are extremely painful; some of them might be big in size and shape and some are red in colour.

Complication of Visarpa:

All types of Visarpa usually have following complications: fever, diarrhea, vomiting, tearing of the skin, muscle fatigue, anorexia, and indigestion.

Based on dosa dominance: (C.Ci.21/42):

Single dosa involvement:   vatika, pittaja, kaphaja, Visarpa types are curable.

Double dosa involvement; agniVisarpa (vatapittaja) and kardamaVisarpa (kaphapittaja) can be alleviated by the habitual use of general therapeutic measures (to counteract the respective etiological factors) only when the vital organs (like heart) are not afflicted and there is no softening of vessels, ligaments and muscle tissue. If not properly treated. Any one of these two may cause instant death like snake poison.

Granthi Visarpa is treatable only when it is without any complications otherwise difficult to treat.

Three dosas involvement: Sannipatika type of Visarpa is incurable because it pervades all the tissue elements, it spreads instantaneously and its treatment involves mutually contractor therapeutic measures.

Differential Diagnosis:  

Positive and complete findings are the tools to arrive at a definite diagnosis, to estimate the prognosis and to adopt appropriate line of treatment for the disease. Studying the various stages of the disease and the consequential changes can make a correct diagnosis.

Seven dhatus and tridosa are involved in the pathogenesis of Visarpa and kustha (a group of obstinate skin diseases).  In spite of the identify of these seven elements there is difference between these two diseases in as much as Visarpa is characterized by its spreading nature, and kustha by its chronic condition. Visarpa should also be differentiated from diseases in which rakta, lasika, tvak, mamsa are vitiated i.e. from kushtan, vidhradhi, visphota, apaci.

Other:

• When are aggravated pitta together with rakta spreads within the skin, it causes red swelling which known as Visarpa
• When the aggravated pitta is located in tvak (skin) and rakta, this will also causes red swelling which known as pidika (vesicle).
• When the aggravated pita gets dried up in combination with rakta, this causes skin diseases like tilaka (black moles), vyanga (red moles) and nilika (blue moles) (C.su. 18/23-25).
• In Visarpa inflammation is without swelling (annunat sotha) while arbuda, granthi, vidhadhi have swelling (sotha).
• In Visarpa clinical diagnosis is based on dosa dominance and morphological feature therefore they should be differentiated from kushtha with similar dosa dominance.

Nita group of viruses with Visarpa:

Visarpa is an inflammatory disease some types of Visarpa are due to the Nita group of virus classified made according to affecting chemical, physical and serological criteria.

• Herpes simplex 1
• Herpes simplex 2
• Herpes zoster,
• Vericella zoster
• Vericella
• Cytomogalo virus are comes under this group

It is having particle size 100-200µ nucleic acid DNA, type of symmetry cubic number of cap so meters 162 sensitive, Family-Herpes viridae, genomic type – DSDNA

Vericella zoster, herpes simplex – 1 Herpes simplex – 2 are concerned with skin eruption system.

Cytomegalovirus and epsein barr virus are concerned with hematopoietic disorder.

And also some of the Visarpa are due streptococcus pyogenes (hemolytic streptococci of group A). These streptococci pyogenes (Hemolytic streptococci of Group A) are I. Gram positive cocci, these are spherical or oval in shape, 0.5 to 1.0 in diameter, arranged in chains. They are important human photogenes, causing pyogenic infections with a characteristic tendency to spread. These may be sub divided into types based on the protein (MTR) antigens present on the cell surface. About 80 types of streptocci pyogenes have been recognised so far.

Even though the parisarpana is due to sara and chala guna of vata property any our acharyas are not enumerate the vataja Chikitsa, instead of that they explained the krimihara Chikitsa. Visahara Chikitsa. It indicates that the parisarpana is may be due to microbial infection spreding. The nature of spreading and the cliniical present of Nita group of virus and streptococcal pyeogene (group A,B,C) and Visarpa are one the same.

Visarpa is an infection disease which spreads from place to place quickly involving the raktha twacha mamsa snayu and lasika, having painful Visarpa on the twacha leads on to suppurating tumors, gangrene and multilation of the body. It has been identified with several discuss like erysipelas, cellulities, herpes zoster, moist gangrene, eczema erpitivum, chicken pox, herpes labials, herpes simplex, acute myeloid leukemia, acute lymphoid leukemia, carcinoma of stomach. Some kind of dermatitis etc., by modern scholors.

Herpes simplex

Herpes simplex occurs naturally only in man. There are two types of herpes simplex virus, herpes simplex virus 2. There are different modes of visaprana or prisarpana are seen herpes simplex are transmission occurs by close contact and may be venereal in genital herpes after contact, the virus probably enters the tissue through defects in the skin and mucus membranes. There is then phase of local multiplication with cell to cell spread and local lymph nodes are involved. The virus can also travel along with the nerve fibers and may be able to reach CNS in man. In general primary infections are localized. The avakasho Visarpa anusarpayatin of vataja Visarpa shows as that of typical herpes lesion, they are thin walled humiliated vesicles that rapidly becomes pustules and scabs and heal without scaring. In the vataja Visarpa davahuhu indicates the morbidity presenting chakshuradi indrayas like commonest site herpes simplex is the eyes, face on the cheeks, chin, around the mouth or on the forehead. Lesions may also appear on the buttocks as napkin rash an occupational variety of cutanious herpes is the herpetic whitlow.

Eczema herpectium is a generalized eruption caused by herpes infection in children suffering from eczema. Vagbhata Visarpa mainly straps from the affected area with wide spread ulceration. A clinically indistinguishable picture in also produced by vaccine virus infection both designated kaposis karicelliform eruption.

Herpes virus simiae (B virus)

Herpes virus simiae infects monkey in the same manner that herpes simplex infexts in man, herpes virus simiae is similar to herpes simplex properties. The disease in man is usually fatal. The rare patients who survive have serious neurological sequelae.

Vericella – Zoster virus

Mode of spread: Very rapidly whole body is sprinkled with live charcol

In pathology of agni Visarpa aggravated the vata and pitta simultaneous aggreavated with each other. These doshas shows effect in all over the body within a short period of time along with burning sensation. The incubation period of V-Z virus is 14-16 days, prodromal symptoms are minimal. These include mild favour malaise and impaired appetite as that of agni Visarpa. These rashes appear on the first day.

Management:

Samanya Chikitsa with clinical interpretation:-

Chikitsa sutra : - “Langanam ullekanam shaste tikta nam cha sevanam” ||(cha, chi)

Langana:-

One who fit for the langana, langana pachana, dashava sechanaand accourding to ama which is particular stana, rogabala, rogibala and also as per the doshas. The different langana therapies are to be adopted. Langana causes vata vruddi, jataragni vardana, amarpachana in the Visarpa patient. The adoption of different types of langana reduces the jwara, swayathu, angamardu etc lakshanas of Visarpa and by the langana therapy, avakasho Visarpa anusarpati have the lakshanas like svayathu, paka, kleda are also reduces. Langan is a therapy  which has the natural auto ammune power enhancing property in the body which helps in fight aginest the Nita group of virus (herpes viruses) and streptococci pyogenes infection which reduces the symptoms up to som extents.

Langana Tiktakam Cha Sevanam

Compounds with a tikta rasa pradana may reflexly increases the flow of gastric juice in the stomach acts as ama pacana and also having the Visarpa hara property. So our acharya highlighted the lagana Chikista with tikta dravya is ideal one. The drugs having the properties like langana-Visarpahara tikta rasa pradanya are to selected. E.g guduchi, musta, patola, nimbi, ushira, kirata tikta, nishi and katuki. In the purvarupa and amavasta of the Visarpa. These dravyas can be adopted as a front the treatment along with the peya mandadi ahara dravyas which are used for langana  as well as the kwatadi oushadis.

Langana Rukshana

Other acharyas also enlighten about langana rukshana. In the purvaropa Chikitsa langana followed by rukshana  or rukshana rupi langana chikitsa should be carried out so, the drugs having the properties like langana rukshana Visarpa hara are to be selected example, trivruth, musta, nimba, patola, kiratatikta, chandana, amalaki,  usheera, lodra, draksha, shunti, katuki.

Ullekana chikitsa in Visarpa:-

Ullekanam iti vamanam (chakrapani)

The ama which is present in pithastana and kaphastana vamana should be conducted.  If Visarpa is caused by rather kapha or pitha or both kapha and pitha.  Then vamana should  be conducted.  Kardama Visarpa should be treated by quickly by administration of vamana.

Sneha pana:

1) Mahatiktaka ghruta,   2)   Trayamana ghruta

Vamana yogas:

• Madana, maduka, nimba, vatsaka patra kwata, 
• Madana patola, pippali, nimba should be made into kwata and used.

Vamanopaka dravya:

• nimba,  musta, patola kwata (C.S)
• Patoladi phanta (A.S)

In pitha pradana Visarpa after the vamana virechana should be administer.

Virechana:

In both dosha dushta Visarpa and initial stage virechana should be selected

Sneha pana:

The medicated ghruta for sneha parartha should be administered which are having purgation property, otherwise which causes the paka of the twak, mamsa, rakta.  After ama pachana sneha pana should be administered with tikta rasa pradana ghrutas.

1. Triphala ghruta  2. Traya mana ghruta

The virechana yogas: 

Trivruth, draksha, triphala, trayamana  (A.S)

Trivruth churna should be boiled by adding ghruta or ksheera and administered with warm water or mrudvika swarasa.   Similarly boiled with trayamana (C.S) in kardama Visarpa for producing virechana should be made to drink trivruth churna along with either ghruta ksheera draksha rasa or ushna jala.  If pitha is aggravated greatly should drink milk boiled with trayamana. 

Mode of action of virechana in Visarpa: 

The main action of Visarpa dravya is adobaga hara. The vitiated pitha dosha is alleviated and expelled out through the mechanism of virechana so, the disease process is arrested.  The virechana dravya spreads through the body at cellular level due to its pharmacological action. Ushna and theekshna properties of virechana drugs produces chetana of dosha durshya sambanda, which are already soften due to snehamsha of shodananga snehapana.  Thus, liquid doshas are dragged towards to koshta due to the predominance of pruthvi and jalamahabhoota present in virechana kalpa.

Rakta mokshana in Visarpa:

Rakta mokshana should be administered as a front line treatment because of rakta dusti is the main factor of pathogenesis in Visarpa.  According to predominance of doshas associated with rakta, different methods of rakta mokshana should be conducted.  If dushta rakta associated with vata then avasechana should be done with the shrunga yantra.  If dushta rakta is associated with kapha alabu karma should be administered.  If Rakta dusti with is assocated with pitha jalauka charana should be administered.  Rakta  mokshana acts as auto immune enhancing property.  So, develop the resistance against the Nita group of virus and strepto coccus pyogenes.  Jaluka is having haparin which climes to exert some anti inflammatory activity and wound healing property.

Tiktanam cha sevanam:

Tikta dravya having the dosha prashamana, thrushna prashamana sheeta ruksha lagu and vidagda pitha hara property.  So, recipies which are dominant of tikta dravya pecifies the vitiation of rakta and pitha, which are the main causative factor for Visarpa.  The role of ama is cause in Visarpa is most important.  Due to the deepana pachana rukshana langana property of tikta dravya are acts as avapachana in Visarpa. tikta dravya which acts as samprapti vigatana with the property of tawk in mamsa sthira karana which gives stability immunity and also increases brachaka pitta.  If we administered the virechana and other shodana therapies from the tikta dravya. Visarpa is mainly due to Nita group of virus and strepto coccus pyogenes. The Use of  tikta dravya by internally and externally which acts against these microbes due to the krimi hara property.  Due to the vishagna property of tikta dravya acts as the anti dote for virus and toxins produced by these infetion. 

Shamana Yogas:  

• Kasisadi ghruta for external application tid.
• Balaguduchyadi kashaya (anubhutha yoga) 15 ml. bid, before food.  (In clinically experienced that balguduchyadi kashaya 15 ml per every one hour once Visarpa in initial stage relived that symptoms and lesions.  Within 3 days).
• Panchatikta guggulu ghruta without ballataka 10 ml with milk twice a day after food.
• Triphala churna 1 tea spoon with hot water at bed time.  
• Kustagna vati (anubhutha yoga): 1 tablet bid after food.

Some special clinical case presentation:

Case 1

Patient name kousar bai w/o panduranga aged 34 years, complaining of blisters, shopha, vrana, shula, Kunapa Gandhi, jwara, daha, kandu, srava, avkasho visarpa anusarpayathi lakshanas in the vrana since 3 days , these lakshanas are transferred through the while paper collection in garbage. This case simmilor to previous one. Vikruthi taha pariksha shows due to herpes virus similes (B virus).

In this condition kapha, vatha dosha dusti takes place, rasa, raktha, mamsa,  thwak, lasikadi dhatus, mamsa vaha srotas, rasa vaha srotas, lasika vaha srotas are involved. This shows the sroto dusthi lakshanas are sanga, vimarga gamana and athi pravruthi.  There are no abnormalities seen in the mala and general examination. Laboratory investigations done. Due to these lakshanas as per our acharya this disease can be diagnosed as agni Visarpa.  Through the modern perspective which is originated from the Herpes simplex B virus or Herpes simile. It is one of the daruna, kasta sadya vyadi.

Case 2

Patient name govinda aged 32 years complaining of blisters as a avakasho visarpa anusarpa yathi with full of water, pain, daha over the neck, unable to flex the neck & unable to sit properly, since 8 days. She undergone allopathic & fockler treatment but not relived. There family members concluded that he daid within 3 days. This condition is diagnosed as vericella pittaja visarpa.

Case 3

Patient name hruthik aged 4 years complaining of blisters as a avakasho visarpa anusarpa yathi with full of water, pain, daha over the pennies since 2 days.  This condition is diagnosed as Herpes genitals Vataja Visarpa.