by Alakananda Devi (Alakananda Ma), M.B., B.S. (Lond.)
Intestinal parasites, known in Ayurveda as krumi, are troublesome, widespread and often poorly understood. In this article we will consider the types of parasite commonly found, who may be affected, how to make the diagnosis, how this condition may be managed Ayurvedically and how it may affect other aspects of Ayurvedic treatment.
Perhaps the most common parasite affecting people in the US at this time is giardia lamblia, a flagellate protozoon which can give rise to giardiasis. Giardia can exist in a hardy, dormant cyst form which can survive for long periods of time in soil or water, becoming active and reproducing once it enters the host body. It can affect both humans and animals and can be readily transmitted between species. Much more virulent, though less common in this country, is endamoeba histolytica. This is a simple nucleated cell which can invade the colon through secreting histolytic enzymes which destroy tissue. Amoebiasis is a cause of considerable death and disease worldwide. Like giardia, e. histolytica can survive outside the body in a cyst form which becomes active when ingested. It relative, endamoeba hartmanii, can cause sublinical infection in susceptible individuals. Blastocystis hominis is a common microscopic parasite that can survive in the body for years and is thought to give rise to troublesome symptoms of blastocystosis in certain individuals.
People in many walks of life may be affected by giardaisis. Young children can pass the disease around in day-care centres, resulting in many a diaper filled with runny green diarrhoea. Cats can contract the disease from eating infected mice, while dogs who run and play outdoors may also develop giardiasis. Humans who live in close contact with their pets and deal with their animal's faeces may expose themselves to infection unless they practice strict hygiene. Backpackers present the classic case of giardiasis, also known as beaver dam fever. By drinking out of infected streams, which may appear crystal clear, they can ruin a holiday by developing watery diarrhoea. Of course, they also contaminate the situation further for other backpackers. Elk, deer and beaver are now carriers of giardia. Since elk live on top of the continental divide in summer, one can never hike high enough to reach an uncontaminated area. Wells in rural or mountain areas may be contaminated by giardia and city water supplies are also suspect. Sushi eaters are at risk since it is very unwise to consume raw fish in a world where raw sewage is discharged into the oceans. Salads eaten at chain restaurants where prep cooks are poorly paid and have little education may also be a source of infection. And of course, travel overseas in third world countries increase the risk of water borne giardiasis.
Amoebiasis is most commonly seen in world travellers, although I have one patient who apparently developed amoebic liver disease from the city water supply in a mountain town in Colorado. E. Histolytica is widespread in India, Mexico, Latin America, Africa and South East Asia. Travellers returning from these countries with intestinal symptoms or low energy should be taken very seriously, since amoebiasis is such a dangerous illness. It is worth noting in this connexion that both amoeba and giardia can remain in the body for years in the dormant cyst form, hidden in lakes in the hepatic parenchyma or in folds in the intestines. Whenever a stressor tips the host parasite balance in their favour, they can reactivate and cause a fresh outbreak of symptoms. Thus individuals who have ever had amoebiasis should be taken very seriously whenever they complain of symptoms. The milder parasites such as blastocystis are spread by similar situations. In cases of parasitic disease, all members of the family, human, feline or canine, can spread the infection to one another, so all should be considered at risk.
Although the clinical diagnosis of parasitic disease may be elusive, the experienced practitioner will soon recognize classic and familiar story lines. Often the client has had vague symptoms for so long that they are accustomed to them and do not identify them as a problem. Instead, they will point to small complaints that are indeed incidental effects of the ama resulting from parasitic disease. Some classic "presenting complaint lines" include, "I am sorry to trouble you, Doctor, when there are others who are so much sicker, but I have dandruff and toenail fungus." Or, "I really don't have any complaints, I was just curious about Ayurveda" (Personally I would not spend that much money out of sheer curiosity). Or "I just don't seem to be eating right/I need guidance about what to eat." Once these typical opening gambits are heard, I would ask a series of questions pertinent to intestinal parasites.
"How is your digestion?" "Fine" (I put that in quote marks because I don't believe it.) "Do you suffer from gas or bloating?" "All the time." (Puzzled look: implication being "Doesn't everyone?) "Are your stools regular?" "Yes, as long as I eat prunes every day." (Constipation can be a symptom of chronic intestinal parasites) Or, "Yes, very regular. I go at least three times a day." (Malabsorption could also be a symptom.) "What tastes do you crave?" "Chips and salsa." (Due to low agni, a client with parasites often craves spicy food.) Or, "Chocolate." (This may be a symptom of low energy.) "Do you feel tired when you wake in the morning?" "Do you feel like napping in the afternoon?" "Are you doing as well in school/work as you expect to?" (Poor motivation arises from parasite -caused ama.) "How is your mental clarity?" (Brain fog also results from parasite-caused ama.)
Specific symptoms relating to amoebiasis in particular include waking in the morning due to a strong urge to pass stool, having a strong urge to defecate immediately after eating, emotional lability and unexplained fatigue. Specific symptoms that may relate to giardiasis include upper abdominal bloating and burping. This occurs because giardia can affect the upper digestive tract. Alternating constipation and diarrhoea or episodic diarrhoea can also be common symptoms of any parasitic infection. Less obvious symptoms of parasites include eczema, adult acne and arthritic pain. It is important always to consider whether krumi plays a part in the samprapti of any condition affecting rasa dhatu.
If the client answered 'yes' to many if not all of these questions, by now I'm confident of what I will see when I proceed to physical examination. Typical findings on the nails include marked vertical ridging, missing moons and white dots. Red, puffy nail beds often point to an overgrowth of candida albicans, a common accompaniment of intestinal parasites. Candida flourishes in the ama caused by parasites. Parasites create ama and ama is a breeding ground for yeasts and parasites, thus setting up a vicious cycle.
On the tongue I will expect to see a thick, greasy coating with small shaved areas towards the rear. Tooth marks may indicate swelling of the tongue due to malabsorption. Women in particular may appear anaemic, with pale conjunctiva.
On the face, take note of a bluish, pinched area on either side between the bridge of the nose and the orbits of the eyes. In the pulse, note a weak spleen pulse and colon pulse and a weak rasa dhatu. Agni type may be tikshnagni, visham or mandagni. The person who craves chips and salsa may have mandagni, the one with gas, bloating and constipation has classic vishamagni, and the one with diarrhoea and insatiable appetite has tikshnagni and an excess of the sour and liquid properties of pitta.
Laboratory diagnosis may help or confuse the situation. While a positive stool test can confirm your findings, a negative stool test tells little more than the absence of parasites in that particular stool specimen. Stool diagnosis may be critical before placing someone on strong medication such as Flagyl, but is not so essential for the Ayurvedic approach. If the clinical diagnostic signs and symptoms are present, it is fine to use anti-krumi herbs, which are also generally beneficial for the digestion. When the client gets well on the anti-krumi regimen, this confirms your diagnosis.
In the case of intestinal parasites, prevention is the better part of cure. In order for the herbs to be effective, you must be confident the client is not re-infecting themselves. Provide counselling about hygiene and keeping pets away from the pillow and eating areas, as well as about safe drinking water and selecting cooked food in restaurants. Water purifiers should be used in the mountains and on trips overseas. It is also important to provide more specific Ayurvedic advice on how to prevent build up of ama by emphasising proper food combining and meal spacing. Diet should be freshly prepared and should not include heavy, ama-causing foods such as deep fried items, hard cheeses and milk.
In terms of herbs, Vidanga is of course the star in this situation, famous for its effectiveness against all types of worms and parasites. Due to its hot energy and pungent vipak, Vidanga should be carefully combined in a formula suitable for prakruti and vikruti. It will also be more effective used with synergistic herbs such as Turmeric, which has strong anti-parasitical and anti-yeast actions, and Chitrak, which will kindle agni and burn parasite-related ama. In a pitta individual one could choose Guduchi to balance pitta and mitigate the hot effect of Vidanga. In a kapha person one could use Punarnava, which as well as balancing kapha will have anti-parasitical activity in its own right, and Trikatu, which will kindle agni, burn ama and have synergistic anti-parasitical effects. Mahasudarshan is very anti-parasitical as well as helping balance tikshnagni and sweet cravings. It is valuable in both pitta and kapha. In a vata person we could select Hingvastak as an excellent remedy for vishamagni which is also anti-parasitical. Herbal formulae for krumi are best given before meals for maximum effect upon the colon. Honey may be a good anupan as it is anti-parasitical in its own right. However, when a yeast/Candida overgrowth is suspected, it may be better to use Aloe Vera as the anupan, since any sweet item can exacerbate a yeast overgrowth.
There are some special considerations to be aware of when treating krumi. Whereas normally one expects a client to improve steadily once they start taking herbs, where krumi is concerned this is not always the case. Often, untoward symptoms may arise, including digestive upset, low grade fever, flu-like symptoms, body aches, joint pain, dizziness, ringing in the ears and increased fatigue. Typically the client will complain that the herbs are disagreeing with them. In fact, what they are experiencing is typical die-off reaction. I usually explain that the unwanted symptoms are caused not by the herbs but by the dead parasite bodies. Most people are quite willing to appreciate that this shows that the herbs are working. The best remedy for the die-off reaction is Sat Isabgol, half a teaspoon at bed-time mixed in warm water. The Isabgol will pull the dead parasite matter out of the system, thus mitigating the symptoms. Usually the die-off symptoms occur in waves, punctuated by periods where the client feels better than ever. The worst die-off reactions occur when there is a massive yeast overgrowth, as yeasts are much more numerous than the parasites, being an overgrowth rather than an infection.
When krumi infection is suspected, it must be dealt with before proceeding to other stages of the treatment plan. If the anti-krumi formula is based around a dosha pratyanika herb (a herb that will be antagonistic to the excess dosha), then one can proceed with balancing dosha as well as treating parasites. Panchakarma is best done after the parasitic infection has been addressed, which may take from one to three months.
Another important treatment consideration, which cannot be over-emphasised-- treat the whole family. The family pets can be treated for parasites by their vet and the human family members can each take an Ayurvedic formula tailored to their own prakruti and vikruti.
Few things are as rewarding as to assist someone in feeling well and fulfilling their potential. By understanding the causes, symptoms and Ayurvedic treatment of intestinal parasites, we can greatly improve wellbeing, even in those who scarcely knew they were sick.
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Alakananda Devi (Alakananda Ma) is director of Alandi Ayurvedic Clinic in Boulder, Colorado, and principal teacher of Alandi School of Ayurveda, a traditional ayurvedic school and apprenticeship program. She can be reached at 303-786-7437 or by email at: email@example.com.