SM Arif Zaidi Faculty of Unani Medicine, Jamia Hamdard, New Delhi, India

Key words Diabetic wound; Gangrene; Hirudotherapy; Non-healing ulcer; Unani medicine

Correspondence to

Dr SMA Zaidi

Faculty of Unani Medicine

Jamia Hamdard

Hamdard Nagar

New Delhi 110062 India

E-mail: arifzaidi13@gmail.com

Unani treatment and leech therapy saved the diabetic foot of a patient from amputation. Int Wound J 2014; doi: 10.1111/iwj.12285

Abstract Every 30 seconds, a lower limb amputation is carried out due to diabetes throughout the world. The mortality rate due to diabetic foot gangrene is just next to that of cancer. As tissue death cannot be reversed, surgical removal of the affected tissue (debridement) or amputation of the limb is the only treatment option left when gangrene has advanced. The present case study illustrates an option to treat poorly healing diabetic wounds with Unani medicine (blood purifier and deobstruent) besides hirudotherapy. The study was performed on a 60-year-old woman suffering from diabetic foot (on the left) grade 5 and facing the prospect of imminent amputation. The patient was having severe pain (80 mm on a 100 mm visual analogue scale) in the gangrenous foot and foul-smelling with necrosed areas. Wound dressing was done with unripe papaya as it has a very good role in clearing necrotising area and hirudotherapy was also used in poorly healing wounds. The pain score decreased to 0–10 mm on a 100 mm visual analogue scale within 20 days and no further pain relieving medication was required. Over a time interval of nearly 3⋅5 months, necrotic areas disappeared and the wound was completely healed.

A 60-year-old woman suffering with diabetic foot grade 5 on the left leg was admitted under my care on 2nd April 2013. The patient was having severe pain (80 mm on a 100 mm visual analogue scale) in the gangrenous foot and foul-smell. She was taking amoxicillin and clavulanate 625 mg thrice in a day, and painkiller tramadol injection 100 mg twice in a day besides insulin. She was not able to walk and consideration of below knee amputation as a first line alternative and immediate minor toe amputation was advised by a plastic surgeon attached to the Indraprastha Apollo Hospital, New Delhi. At the time of admission, her vital signs were stable and laboratory parameters were as follows: haemoglobin (Hb) 7⋅0 g%, white blood cells (WBC) 9900/μL, neutrophils 60%, lymphocytes 32%, eosinophils 7%, red blood cells (RBC) 3⋅03 mill/cum, packed cell volume (PCV) 25⋅3%, platelets 5⋅9 lakhs/cumm. Blood sugar(PP) 216 mg%, serum bilirubin 0⋅6 mg/dl, serum glutamic oxaloacetic transaminase (SGOT) 580 IU/l, serum glutamic-pyruvic transaminase (SGPT) 380 IU/l, serum alkaline phosphatase 863 IU/l, total cholesterol 122 mg/dl, serum triglyceride 101 mg/dl, blood urea 29 mg/dl, serum creatinine 1⋅2 mg/dl, serum uric acid 6⋅5 mg/dl, HbA1c 8⋅4%, bleeding time 1:15 minutes and clotting time 5:30 minutes.

Arterial Doppler examination showed mild to moderate atherosclerotic changes in main arteries with moderate involvement of peripheral arteries. The amoxicillin and clavulanate were discontinued immediately after admission. Blood sugar was kept under control by insulin injection. The patient was kept on Musaffiyat (blood purifier) decoction of Rosa damascene Mill (1), Azadirrachta indica A. Juss (2), Sphaeranthus indicus Linn (3), Swertia chirata Buch. Ham. (4), Tephrosea purpurea (5), Zizyphus jujube Linn (6) medicine, which have antiseptic, antibacterial properties and Mufatteh Sudud (deobstruent and vasodilator) decoction of roots of Apium graveolens Linn, Cymbopogon jwarancusa schult, Foeniculum vulgare Mill, and Cichorium intubus besides leech therapy (7). On the next day of admission, four leeches were applied around the gangrenous area of left foot. Pain was substantially reduced after 7 days (40 mm on a 100 mm visual analogue scale) and painkiller injection was stopped and patient was put on oral painkillers (Figure 1). On the seventh day, four leeches were applied after minimal debridement and extraction of slough. The wound was washed with A. indica water (leaves of A. indica boiled in plain water) and sterile dressing with meshed unripe fruit of Carica papaya Linn was applied on a daily basis. On the 15th day, the wound showed signs of further improvement and the pain disappeared. Simultaneously, the smell also reduced and the painkillers were stopped. After 3 weeks from date of admission, five leeches were again applied and the same treatment was continued. The wound showed signs of improvement and the smell reduced drastically. The dressing was continued daily besides minimal debridement as and when required. Laboratory parameters taken after 1 month are as follows: Hb 8⋅1 g%, total leucocyte count (TLC) 11 800/cm, neutrophils (N) 58%, lymphocytes (L) 32% eosinophils (E) 08%, monocytes (Mo) 2%, platelets 4⋅96 lakhs, mean corpuscular volume (MCV) 78⋅5 fL, mean corpuscular hb (MCHB) 23⋅1 Pg, mean corpuscular hemoglobin concentration (MCHbC) 29⋅5 g/dl, HbA1c 5⋅2%.

Thereafter, leech therapy was repeated every 15 days on completion of 1 month. Continuous improvement was observed in wound healing and the smell disappeared. Two months later, the patient was asked to walk for 5–15 minutes daily. On completion of 2⋅5 months, her Hb was 9⋅3g% and platelet count 3⋅04 lakhs. The Doppler examination repeated after 2⋅5 months shows mild atherosclerotic changes.

On completion of 3 months, the patient was asked to walk freely. The wound was completely healed and free from any deformity and pain after 3⋅5 months. The patient was discharged from the hospital (Figure 2). At the time of discharge, her Hb was 9⋅6 g%, TLC 600/cm3, N52, L38, E08, Mo2, RBC 3⋅96 mill/cum, PCV 32⋅4%, platelets 2⋅69 lakhs/cumm, MCV 80⋅8 fL, MCH 27⋅5 Pg, MCHC 32⋅3 g/dl and ESR 28 mm/hours.

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