by Anthony Capobianco, DO
[This paper was originally presented at the Annual Meeting of the Homeopathic Medical Society of the State of NewYork, New York City, NY, April 2004, and appeared in the American Journal of Homeopathic Medicine, Vol. 95 No. 2, in Summer 2005.]
Abstract: This article consists of a discussion of a novel and, homeopathically-speaking, non-classical approach, developed by AU Ramakrishnan, for the treatment of Streptococcal pharyngitis. The method is based upon a large body of clinical experience in the treatment of both Streptococcal illness and the carrier state of the bacillus. Said method employs exclusively the remedies Sulphur and Streptococcinum in frequent repetition (of liquid dilutions).
Keywords: streptococcal infections, a protocol for treatment of; streptococcal pharyngitis, a protocol for treatment of; Sulphur, streptococcal infections, in the treatment of; Streptococcinum, streptococcal infections, in the treatment of
[See Editor's Note at the conclusion of this article.]
“The physician’s highest calling, his only calling, is to make sick people healthy — to heal, as it is termed.”(1)
– Dr. Samuel Christian Hahnemann
When speaking of Streptococcal pharyngitis, homeopathic books usually backpedal, advising allopathic management, presumably due to the therapeutic difficulty and potential seriousness of the condition. Given the longstanding record of success with other serious infections, and even the most advanced autoimmune and degenerative end-stage illnesses, including neoplasia, it seemed plausible to this writer that Strep throat could also consistently and exclusively be treated homeopathically. Clinical experience has yielded an approach one might consider with regard to a pharyngeal Strep infection or carrier state. Because of a consistent pattern of favorable results, it appears, preliminarily at least, that many patients stand to benefit from this approach.
From his landmark book on a homeopathic treatment of cancer, and allied conditions due to allopathic cancer therapies, Dr. Ramakrishnan justifies the use of specifics in certain instances, stating that
“… in acute ailments and highly specific types of illnesses (such as cases of poison ivy, chickenpox, high fevers, or influenza) a limited number of medicines appear to work best, regardless of personality type. These are called “specific remedies,” in that they address the specific disease itself rather than the patient’s complex of physical, mental, and emotional symptoms.”(2)
Although not as serious as cancer, it could be argued that Strep pharyngitis warrants a similar increased tempo and range in prescribing. This would be because of a brief window of opportunity for correct treatment coupled with the potential severity of pathology in vital organs, affording a narrow margin for error. This might also be seen as justified, due to the inconsistency of results when solely using well-indicated acute remedies prescribed on physical, mental and emotional symptoms. [Editor's Note: Said inconsistency of results must obviously be critically dependent upon the skills of the prescriber and the available signs and symptoms of the patients at hand. Surely, many cases of Streptococcal pharyngitis are most ably handled with the classical homeopathic approach.] Another way of saying this could be that “because of the severity and in many cases urgency of this condition, the individuality of the patient must yield to the ‘specificity’ of the disease itself.”(3) Also relevant is that “one [may be] dealing with a measurable pathology and not with subtle imbalances of the body’s energies, and therefore less subtle methods of prescribing are required.”(4)
Group A Streptococci is responsible for about 19% of all upper respiratory tract infections, but the incidence varies according to clinical setting.(5) Streptococcal pharyngitis is seasonal in nature with the highest prevalence during the winter and early spring. The highest incidence is found in crowded populations such as military bases and in school-aged children, and evenly distributed between males and females.(6) The incubation period for Group streptococcal pharyngitis is two to four days, followed by abrupt onset of sore throat, malaise, fever and headache.
The “classic syndrome,” including temperature elevation, tender tonsillar lymph nodes (at angle of jaw), and grayish-white exudate on the tonsils occurs in less than ten percent of cases of strep pharyngitis and may occur in other types of pharyngitis as well (hence, the presence of all three “Strep predictors”— exudate, adenopathy and fever — are actually not very predictive at all. (7)). Importantly, cough and rhinorrhea are not usually present with Strep throat. The only clinical feature specific for group A Strep infection is a rarely occurring “sandpaper” textured, scarlatinaform rash (scarlet fever), characterized by a diffuse red blush appearing on the trunk early on, which spreads centrifugally and blanches with pressure. A week later the skin desquamates in large sheets, particularly over the palms and soles. The diagnosis of streptococcal pharyngitis requires a quick strep antigen test, throat culture, or both, because clinical findings are usually not specific.(8)
The majority of the approximately two dozen patients treated this way were initially diagnosed, followed and re-checked with the help of the Quidel In Line® Strep A test. This test was primarily used because the sensitivity is reportedly 92% and the specificity 99%, and overall agreement between Sheep Blood Agar (SBA) culture and QuickVue® was stated to be 96%.(9) In addition, a follow-up retesting method that yields rapid results helps determine the need for potential homeopathic remedy changes during the course of treatment. Occasionally, SBA culture would be ordered or requested by parents to validate the rapid anti-Strep antibody test. As many as ten percent of throat cultures are falsely negative;(10) therefore it is recommended to obtain two swabs from each patient if using this method as a primary or secondary method of supporting the diagnosis. Some argue that rapid Strep tests render the throat culture obsolete.
Strep carriers have positive cultures but do not have Streptococcal pharyngitis by any other criteria (clinical findings, antibody titer rises, or risk of acute rheumatic fever; therefore, in one sense, these cultures might be considered by an allopath to be “false positives”). Also, probably fewer than half of those diagnosed with Strep throat (clinically and with culture) are at risk for acute rheumatic fever.(11) However, all are considered worthy of treatment because a susceptibility to harbor the pathogens exists in carriers.
In adults over the age of fifteen without a prior history of acute rheumatic fever (ARF), first episodes of ARF are extremely rare (as in the case of Strep pharyngitis. ARF most often occurs in children; the peak age-related incidence is between 5 and 15 years (12)). The allopathic goals for treatment of Strep throat in such adults are for amelioration of symptoms, the prevention of local suppurative complications, and the prevention of spread. Early antibiotic dosing in the first two days is required for symptomatic relief (the duration and severity being perhaps only modestly reduced with early antimicrobial therapy); in untreated patients, fever, malaise, and sore throat are self-limited, abating in three to five days.(13) Therefore, patients fifteen years of age and older might not be limited to a window of opportunity for homeopathic treatment that younger patients at risk of ARF are considered to be. (A one week, or so, pediatric working window for homeopathic treatment is based upon some evidence that antibiotics most effectively prevent ARF if prescribed within ten days of the onset of pharyngitis.(14) Elsewhere it has been said that “in patients being treated (allopathically) to prevent the occurrence of ARF, therapy within seven days of onset of pharyngitis is sufficient. The mean latent period of ARF is nineteen days, with a range of one to five weeks.”(15)) Also, since symptoms alone, which abate relatively quickly, can mislead one into a false sense of security, intercurrent laboratory testing during the course of homeopathic treatment, if at all possible, is recommended.
To this author’s knowledge, all patients with an active infection or in a carrier state were successfully treated when two homeopathic medicines were prescribed aggressively. Of these, two female children required two courses of treatment (a review of their immediate family histories suggested evidence of sycosis).These were a combination of homeopathic Sulphur and Streptococcal nosode, administered simultaneously (to increase compliance). Many times a “fall back” prescription of Sulphur 1M and Streptococcinum 200C was administered anywhere from every ten to twenty minutes to one-half to one hour (dry pellets diluted in a four ounce medicine or larger spring water bottle, succussed ten times before each dose, with instructions to keep refilling the bottle with water), while awake, for at least two to three days, then four times per day after negative re-testing at two to three days, usually for a total of seven days, or so (with an upper limit of ten days, if needed). The consistent response to both of these remedies suggests that this prescription reflects a remedy for the genus epidemicus (as per discussion in paragraph number 241 in Hahnemann’s sixth edition of the Organon of Medicine) for Group A beta hemolytic Strep pharyngitis, tonsillitis or pharyngotonsillitis. The results obtained with both remedies also suggest that addressing the disease on two levels constitutes a stronger method of attack.
With an extended periodicity of occurrence over the course of years, beyond a seasonal peak incidence within a single year, Strep susceptibility might even be viewed in terms of a larger “season.” Indeed, a cyclic pattern of disease incidence involving decades has appeared in scientific literature.(17) In addition, epidemiologic observations suggest the organism itself has the capacity for increased virulence.(18)
Follow-up of the patients so treated to date have not presented any signs or symptoms, cardiac, renal or otherwise, to suggest that the prescription acts in a suppressive way. It is encouraging to note that when asked the question if suppression occurred from the use of homeopathic medicines, Dean Crothers, MD stated “yes, but rarely,” basing his reply on two cases amidst thousands of patient visits.(19) On the other hand, repercussions of allopathic suppression are everyday observations in homeopathic practice.
Interestingly, Sankaran describes the main feeling of Sulphur as that of being “scorned, suppressed, put down, criticized … made to feel humiliated, his pride hurt … embarrassment. There is a constant effort, a struggle to come up again … to be someone, to know something, to earn respect … The struggle is for ego and honor … The effort and the feeling are both psoric .. .” (20) It’s almost as if the staging area of conflict for the verbally unsophisticated child with a domineering, hyper-critical parent or teacher, perhaps, takes place right in the throat (anatomical junction between mind and body). In a wider sense, Whitmont discussed Sulphur as symbolizing the basic polarity and conflict of the soul as it embraces and is torn between spirit and matter. (21) Sulphur has been called the “common denominator” and has the most symptoms of all remedies proved.(22)
A reference to Streptococcal infections and Sulphur appeared in Grandegeorge’s recent discussion of a Sulphur case of Streptococcal erythema of the legs. (Elsewhere in his insightful book, The Spirit of Homeopathic Medicines, he cites the remedy Ailanthus glandulosa for Strep throat/scarlet fever and states that Aurum metallicum [thematically, "Transgressing the Law of the Father"] children are extremely sensitive to hemolytic streptococcal infections.) With Sulphur, one might consider Hahnemann’s “king of antipsorics,” the universal sickness, or Kent’s equating of psora to the sinful state of mankind,(23) affecting all of humanity. This could offer a clue as to the justification of its common use; a lesson epitomized by the well-known story of the early twentieth century homeopath, whose entire pharmacy consisted of Sulphur. It is also interesting that Whitmont mentioned “Strep Intestinal nosode” to be considered in addition to Tuberculinum, when Sulphur fails to act; that is, when the seemingly indicated remedy does not work. (24)
The usual method of administering the second dose when the remedy exhausts its action is not employed since time is of the essence, there being little room for error (the bulk of the treatment involving lay dispensing) and frequent repetition is apparently required. If a remedy reflecting a constitutional state is discernable (e.g.; Mercurius solubilis, Pyrogenium), it may be given intercurrently, in alternation with the two simultaneously administered Strep remedies. Begin a one week course, or so, of homeopathic treatment immediately following a positive quick Strep test (read at 5 minutes with a timer — a positive generates any shade of red, even a faint light pink color (a “low positive”), in addition to a blue control line). There is some evidence that antibiotics most effectively prevent acute rheumatic fever if prescribed within ten days of the onset of pharyngitis, justifying the initiation of antibiotics, in allopathic circles, if the patient has had symptoms that initially began seven (or more) days earlier.(25) This one week (with a ten day upper limit) working window underscores the importance of an immediate patient encounter, in conjunction with a rapid lab test, to confirm the presence of Strep for suspicious sore throats. This is so that homeopathic treatment can begin as soon as possible since the physician can lose up to a few days due to uninformed caretakers or children minimizing symptoms out of office visit fear.
An approach that is a synthesis between frequent remedy administration of the remedies on a regulated (not “as needed”) basis, and an intensified “wait and watch” follow-up regimen, is suggested. Therefore, repeat the physical exam and laboratory testing in two to three days (successful homeopathic treatment should withstand the scrutiny of objective laboratory follow-up.(26)), especially if symptoms are the same or worse. (If compliance to follow-up is unlikely and antibiotic intake is imminent, one might consider forestalling this in order to allow homeopathy to work by writing a prescription for antibiotics to be dated for, and filled three days after the onset of pharyngitis associated with a positive Strep test. These might be started at that time if the frequency, intensity and duration of the symptoms, and/or the follow-up appearance of the pharynx, according to home caregiver flashlight inspection, remains unchanged or becomes worse, despite aggressive homeopathic treatment.) However, by day two or three the patient, regardless of age, usually subjectively feels better and objectively appears less toxic or acutely ill.
If the day two to three repeat testing is negative, one can begin to allow dosing at intervals of four times a day for the remainder of the week. If positive (rare), review compliance of the regimen with the patient’s caretaker; it might be necessary to reiterate the importance of frequent dosing or to change the remedy prescription for the remainder of the week.
On rare occasion, a medically oriented or otherwise competent parent has been entrusted with a quick Strep kit and instructions to allow re-testing after two or three days following lab confirmation and treatment of Strep, and to report on findings at that time. If a patient seems to not be improving at day two or three in terms of a positive or low positive test and/or a failure to experience a decrease in symptoms, including but not limited to fever, exudates and/or adenopathy, continuation of the original prescription to allow more time and/or dosing and re-testing at day seven is scheduled. In this instance, a patient may need more than two or three days of the initial very frequent non-prn dosing protocol, because of factors including patient or caretaker non-compliance. One might consider re-testing the patient at day 4, 5 or 6 to be able to change the dosing interval and/or remedy potencies, if necessary, before the week expires. If the patient is reliable and compliant, but not able to be re-tested at day two or three, re-testing at day seven or so, after the onset of the illness, can be performed.
The patient should try avoiding others during this week and should be free of fever or illness (preferably with a negative test) before contact with others (school, etc.). Consider examining, testing and treating all symptomatic people who have come into contact with documented cases of Strep or Strep carrier states. One can also re-test a patient already treated with this method at a future visit to confirm “for peace of mind” that Strep carriage did not become established.
What follows is a case illustrating the clinical application of the approach when a ten day upper limit course of treatment is opted for in light of an expiring seven day, “just to be on the safe side,” window of opportunity. M.K., a twelve year old, and daughter of an alcoholic father, presented to another physician complaining of “an earache,” fever, slight hoarseness and sore throat with difficulty swallowing for two days. She was found to have exudates on the left tonsil with a positive rapid Strep test. The mother refused to medicate, deciding to wait for consultation until my return from medical meetings. Four days later I was able to see her; at that time she had another positive rapid Strep test with an accompanying otitis externa on the right side and bilateral otitis media, as well. She was started on Sulphur 1M and Streptococcinum 200C every 15 minutes, while awake, with instructions to return for re-testing in 48 hours.
At this two day follow-up, now day six into her illness, she was again found to be positive on a second repeat rapid Strep test. A decision was made to treat for a total of ten days, the patient to continue taking the remedy mixture, now with the addition of Streptococcinum viridens 1M, the most commonly required back-up or remedy substitution, chosen. Five days later, on day eleven, she stated she was, and appeared to be, significantly improved, was re-tested once again and was found to be negative with the rapid Strep test. A year and a half later she presented with a right earache, this time found to have ipsilateral cerumen impaction with a red pharynx. A rapid Strep antigen test was performed and was negative. Eight months following this, fever with upper and middle respiratory signs and symptoms resulted in another rapid Strep testing which was negative; a clinical diagnosis of infectious mononucleosis was made. To date, three months later, she remains well.
One might consider this approach for all affected by Streptococcal infections; specifically, pharyngitis, scarlet fever and post-Streptococcal glomerulonephritis. One might also consider utilizing homeopathic Sulphur and Strep nosode, in cases of thyroid or inflammatory joint disease, following a history of antibiotic or antipyretic suppressed Strep throats with or without tonsil and adenoid (T&A) surgery, as well as other Strep-related syndromes (suppression sequelae), such as Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection — “PANDAS” (common manifestations being obsessive compulsive disorder and tics). A current case of a six year-old girl with the deeper beta-hemolytic strep skin infection, ecthyma, of approximately six months, recalcitrant to topical antibiotics, is clearly responding to the remedies. Lastly, third trimester Group B Streptococcal vaginitis might also benefit from this approach.
The salient risk of allopathic antibiotic suppression is worth mentioning, because of antibiotic resistance occurs at an alarming rate among all classes of mammalian pathogens.”(27) These considerations coupled with an opportunity to heal conflict of a profound and fundamental nature have prompted the writing of this paper. It is the aim of this preliminary article to offer the possibility for a consistently effective homeopathic approach to be considered for the benefit of patients of all ages with Strep pharyngitis.
About the Author: Anthony Capobianco, DO, has practiced homeopathy for twenty years on Long Island, NY. He is ever grateful for his teachers, especially, Dominic Masiello, DO, Dr. A.U. Ramakrishnan and Christopher Whitmont, MD.
[Editor's Note: The above article describes a method of treatment of strep throat employing two homeopathic remedies routinely, said method apparently verified by repeated clinical success. The peer review committee approved its publication with the consideration that this protocol could well provide therapeutic recourse in those cases of streptococcal pharyngitis failing to manifest adequate symptoms upon which to base an appropriate individualized homeopathic prescription, which, in the committee's view, remains a superior method of non-suppressive treatment, when achievable. Further, the author's recommendation of close follow-up of treatment results, both clinically and with laboratory testing, is encouraged.]
(1) Hahnemann, Samuel. Organon of Medicine, 6ed, trans. Kunzli, MD Jost, Naude, Alaine and Pendelton, Peter, J.P. Tarcher, Inc., Los Angeles, 1982, p.9.
(2) Coulter, Catherine R. and Ramakrishnan, MBBS, MF Hom. (London) A.U.A Homoeopathic Approach to Cancer, Quality Medical Publishing, Inc., St. Louis, Missouri, 2001, p.2.
(5) Lauer BA, Reller LB, and Mirrett S. Journal of Clinical Microbiology, 17:338-340, 1983.
(6) Wannamaker, LW. New England Journal of Medicine, 282: 23-31,78-85, 1970.
(7) Reilly, MD, Brendan M. Practical Strategies in Outpatient Medicine, 1ed, W.B. Saunders Co., Philadelphia, 1984, p.7.
(8) Barker, MD, Randol L., Burton, MD, John R, and Zieve, MD, Philip D. (ed.s) Principles of Ambulatory Medicine, 3d ed., Williams & Wilkins, Baltimore, 1991, p.308.
(9) OuickVue® insert, Quidel Corporation, San Diego, CA, August 2001.
(10) Reilly, MD, Brendan M. Practical Strategies in Outpatient Medicine, 2ed, W.B. Saunders Co., Philadelphia, 1991, p.7.
(11) Ibid., p.7.
(12) Braunwald,MD (ed), et al.Harrison’s Principles of Internal Medicine, McGraw-Hill Book Co., NY, 15ed, p.1341.
(13) Barker (et al), pp.308, 9.
(14) Cantanzaro, FJ et al. Symposium on rheumatic and rheumatic heart disease; The role of the streptococcus in the pathogenesis of rheumatic fever. Am J Med 17:749, 1954.
(15) Barker (et al), p. 309.
(16) Hahnemann, op cit., pp.67,8.
(17) Masiello, DO, Dominic. Personal communication, mid-1990’s.
(18) Braunwald, op. cit.
(19) Crothers, MD, Dean and Herscu, ND, DHANP, Paul. Homeopathic Suppression: A Forum, Journal of the American Institute of Homeopathy, Winter 1997-98,vol. 90, No.4, p.174.
(20) Sankaran, Rajan. The Soul of Remedies, led, Homeopathic Medical Publishers, Bombay, 1997, p.196.
(21) Whitmont, Edward C. Psyche and Substance: Essays on Homeopathy in the Light of Jungian Psychology, 2d ed, North Atlantic Books, Berkeley, CA, 1982, p. 77,78.
(22) The British Institute of Homeopathy, LTD., general diploma course material. 2003. 2003. 2003.
(23) Whitmont, Psyche and Substance, p.79.
(24) Whitmont, MD, Edward C. Level l Course in Homeopathy study group lecture, Sherman, Connecticut, 1995.
(25) Reilly, p. 78, 79.
(26) Masiello, DO, Dominic. Personal communication, mid-1990’s.
(27) Braunwald, op. cit., p.763.