Case presentation
A 35-year-old Caucasian man, residing in an urban area, with right laterality was admitted to our Neurology department in April 2022.
He was diagnosed with SM in October 2021 according to the latest criteria from the WHO. Bone marrow biopsy showed multifocal, dense infiltrates of mast cells (≥15 mast cells in aggregates) positive for c-Kit CD 117. Serum basal tryptase measurements were positive. At the time of diagnosis, complete blood count did not show anaemia, thrombocytopenia, leukopenia or leucocytosis and abdominal ultrasound was normal. Treatment with multikinase inhibitor Midostaurin 200mg/day was initiated.
In April 2022 the patient was admitted to the Emergency Department for 3 subnitrate generalized tonic-clonic seizures associated with urine incontinence, after a period of sleep deprivation and consumption of neurostimulator drinks. His vital signs showed tachycardia with a heart rate of 96 beats/minute, blood pressure of 85/60 mmHg, oxygen saturation level of 85%, and temperature of 36 degrees Celsius. The patient was unresponsive to first and second-level antiepileptic drugs, with a tendency to vascular collapse. Considering the worsening of the clinical condition, he was sedated with Thiopental and intubated, receiving mechanical ventilation and high doses of inotropic medication due to persistent hypotension. Laboratory values at admission showed elevated liver enzymes, mild hyponatremia, and hypokalaemia, mild normocytic normochromic anemia, and high serum creatine kinase levels. Head computed tomography angiography showed no signs of cerebral hemorrhage, stroke, or other abnormalities.
The patient developed a high temperature, 24 hours before admission, for which a lumbar puncture was performed, an emergency MRI (Magnetic Resonance Imaging) with gadolinium and empiric antimicrobial therapy with Ceftriaxone 4 grams/day and Clindamycin 2,7 grams/day was initiated. The results of the lumbar puncture were within normal limits (negative results for multiplex panel) and the brain MRI revealed pansinusitis and bilateral mastoiditis. Considering the MRI images, the otorhinolaryngologist performed an otoscopy and established the diagnosis of right suppurating otitis media, for which he drained the secretions with a favourable result at the 48-hour reassessment. After 5 days of admission, it is decided to safely extubate the patient with a slowly favourable evolution, the patient being later transferred to the Neurology department.
The neurological examination showed the following: normal level of alertness, pyramidal tract signs characterized by tetraparesis with a score of 4/5 at lower limbs and 3/5 at upper limbs (on the MRC—Modified Research Council scale). The psychological examination revealed mild cognitive dysfunction (MMSE- Mini-Mental State Examination 24/30), executive dysfunction, and behavioural disinhibition. Immediately after the patient was admitted to the Neurology department, he became unstable and presented with decreased oxygen saturation and hypotension. He was transferred to the Intensive Care Unit (ICU) and after 3 days, he was transferred back to the Neurology department.
One hour after the patient was admitted to the Neurology department, he presented with a sudden change in general condition, dyspnoea, severe diffuse headache without loss of consciousness, decreased oxygen saturation (up to 55% in ambient air), hypotension (70/40mmHg) and tachycardia. During the episode of decompensation, the patient insisted that we do not say anything to his mother about the worsening of his clinical condition and wanted to draw up the will, but still he was not afraid of death. Therefore, in association with the medical treatment comprising of inotropic medication, oxygen therapy with increased flow on a simple mask, corticotherapy and antihistamines, he also received a homeopathic remedy: Carbo Vegetabilis 30 CH 5 granules every 5 minutes (for 20 minutes). The patient’s general condition improved.
During hospitalization, the patient repeatedly expressed his wish to sue the hematologist who prescribed Midostaurin. Upon talking to his father, we found out that the patient has a highly reactive and compulsive personality and a low tolerance for injustice. Taking this into account, the patient was prescribed Causticum 30 CH seven granules administered sublingually daily, for one month. During and after hospitalization, the patient was treated with conventional therapy and a series of individualized homeopathic remedies, as it is presented in Table 2.
Considering the low tolerance of the patient to the treatment with Midostaurin (nausea, vomiting, abdominal pain, hepatocytolysis), upon the recommendation of the hematologist, the therapy was stopped. He was discharged with a diagnosis of severe SM with repetitive vasomotor collapses and generalized tonic-clonic seizures.