Differential diagnosis of autism spectrum disorder

The core features of autism are difficulty in language and communication, difficulties in social interaction, restricted or repetitive behaviours, difficulties in multiple domains. For language and communication disorders they suffer a condition called echolalia or repetition of words and phrases that they hear or have heard. People may develop some language skills, but not at a normal level. For example, they may develop a strong vocabulary for a particular interest, but may not understand what they read. They may not respond to the speech of others or to their own names. They may speak in a high-pitched or sing-song voice, or use robot-like speech. They may also use stock phrases to start a conversation. They may use challenging behaviours instead of words or gestures to communicate. These language difficulties are often misunderstood for language disorders, speech sound disorders, social communication disorders, selective mutism, expressive language disorder, mixed expressive disorders.

Regarding the difficulties in social interaction, They may have difficulty communicating with others, and may repeat words they don’t understand. They may have difficulty understanding social cues and non-verbal communication. They may avoid eye contact during social interactions. They may have difficulty initiating and maintaining conversations, and responding to others attempts to interact. They may have sensory needs that make it difficult to focus on conversations, or make social situations overwhelming, they may find it difficult to socialize in groups. They may prefer structure and routine, and may find unstructured activities anxiety provoking, they may appear to be not paying attention to people around them, or to resent commands or actions. This can be misunderstood for attention defecit-hyperactivity disorder, anxiety disorders, particularly social anxiety disorders, major depptressive disorders, major depressive disorders, personality disorders ,social phobia.

Regarding restricted or repetitive behaviours , One of the hallmark features of an autism spectrum disorder is the presence of restrictive and repetitive behaviours (RRBs), interests, and activities. Individuals may engage in stereotyped and repetitive motor movements (e.g., hand flapping or lining up items) or speech (e.g., echolalia). They may have an insistence on sameness, such as needing to take the same route to school every day or requiring that activities be completed in exactly the same order each time. RRBs can be problematic when they interfere with the individual’s ability to engage in other activities (e.g., academics or leisure) and when they negatively impact social relationships. In addition, when some individuals are blocked from engaging in repetitive behaviour or if a change in routine is required, they may feel anxiety and engage in more severe problem behaviours, such as aggression, to gain access to the ritual or to discourage others from changing the routine. This can be often misunderstood for stereo typic movement disorder, obsessive compulsive disorder, tic disorders including torette syndrome.

Regarding difficulties in multiple domains intellectual disabilities, global developmental delay, reactive attachment disorder, childhood onset schizophrenia, traumatic brain injury, neuro behavioural disorder associated with prenatal alcohol exposure, genetic or metabolic syndromes.

 

MANAGEMENT OF VITILIGO

Process of treating vitiligo should be a slow and steady in steps. we should not forget the sloka “ver pare senthuram pare minjinakaal parpam senthuram pare”.firstly the medication should be purely herbal.the herbal treatment should contain anti oxidant herbs, anti biotic,  anti helminthic, immune system stabilizing herbs since it is a auto immune disorder, above all the treatment should be planned accordingly to eliminate the cause of the disease.

Some of the herbs with these properties are:

The root of aristalochia indica,Tribulus terrestris(photo helium property),matured inner bark of Thespesia populinea, plumbago indica(should be used after purifying), psoralea corylifolia(it can be used internally and externally), semecarpus anacardium(thetrankottai nei)its anti oxidant property cures vitiligo, terminalia bellerica(it reduces constipation and has antibiotic properties), nigella sativa(can be used internally and externally),decoction prepared from psoralea corylifolia and euphorbia nerrifolia should be given,gingko billoba a nervine tonic treats toxicity from neuro chemical transmitters), picrorhiza kurroa, zingiber officinale, ammi visnaga, milk thistle, Tribulus terrestris fruit powder, azadiracta indica again an anti biotic and anti helminthic, ammi majus.

Anti viral herbs like Phyllanthus niruri, glycyrrhiza glabra, tulsi, eclipta alba, emblica officinalis, rubia cordifolia, hemidesmus indicus, curcuma longa, berberis aristata, plumbago zeylanica, picrorrhiza kurroa.

Herbs to improve immune system shatavari(asparagus racemosus),ashwagandha(withania somnifera), bala (sida cordifolia), naagbala(grevia hirsuta), samudrashosh(argyreria speciosa) and along with it the herbo mineral preparation abhrak bhasma.

Oil massage with the following taila should be done-aragwadhya taila, chitrakadya taila,jyotishmadi taila, kusta kala nala taila, kushta rakshasha taila, laghu marichyadi taila, maha vajraka taila, manasiladya taila, visha taila. These are ayurvedic herbal based taila available in the online market.

In ayurveda there is a procedure called lepana applying paste prepared from herbal extraction and having sun bath. This process is called surya pada santhapam in ayurveda like ankollakadi lepa , avalgujadi lepa works well when applied with coconut oil, bakucyadi lepa, balyadi lepa,bhallatakadi lepa, bhringarajadi lepa, gandhakadi lepa, girikarnika yoga(a bath ritual with clitorea ternatea flower, graha dhumadi lepa (lepana with a carban based lepa),gunjadhi lepa(if bullae arises after sun bath they must be punctured by sterile needle, for last three days then kashayam made with ficus hispida,pterocarpus marsupium, callicarpa macrophylla, peusedanum graveolens, coleus vettiveroides and alkaline extract of butea monosperma(palasa kshara) along with an alchoholic preparation of jaggery called jaggery wine in ayurveda it is called as phanitha. Diet should be salt free and should contain buttermilk, gunjadi lepa, gunjadi lepa, gunjaphaladi lepa, katukalabvadi lepa, manasiladi lepa, maricadi lepa, pancanimbava lepa, pathyadi lepa, patrakadi lepa, putikadi lepa, talakadi lepa, vayasyadi lepa.these preparation are already available in ayurvedic market. These are nothing but Sanskrit names of pure herbal preparation. If we know the Sanskrit name of our Indian herbs we can be parichya(familiar)with the names given.

Along with this patent drugs like vit b12 tablets, folic acid and vitamin c tablets, melatonin to decrease the activity of dopamine, ashwagandha, omega fatty acids(fish oil tablets), arishtams like saribadyasava, mahamanjishtadhi kwadha, khadiradhi arishtam can cure vitiligo.In leucoderma patients wbc level will be increased due to the inflammatory process so anti inflammatory drugs are needed.

 

Vitiligo

Pathophysiology

Oxidative stress, specifically from hydrogen peroxide, in the setting of reduced cellular defence mechanism

Inherent functional defect of melanocytes

Reduction of melanocytes due to dysregulation of their survival and apoptosis

Toxicity from neuro chemical transmitters

Viruses eg: cytomegalovirus

Etoiology

Auto-immunity-Due to frequent associations with other auto immune diseases such as thyroiditis and type 1 diabetes, the presence of anti melanocyte antibodies and a response to immune suppressant therapy

Cytotoxicity- the possibility that metabolites formed during melanin synthesis may destroy melanocytes

Neural-chemical mediators released at nerve endings might destroy melanocytes or inhibit melanin production

Free radicals-excess free radicals might be toxic for melanocytes

Convergent- a combination of these theories.

Genetic- there appears to be several genes (such as NALPI) that cause an individual to be susceptible for developing vitiligo. what these genes control is yet to be determined

Triggering-it appears that some event must trigger the destruction of the pigment cells.There are many proposed triggers and they may not be the same for all vitiligo situations (such as sunburn, trauma, pregnancy etc)

Immune system can also be involved with the destruction of the pigment cells.That is why vitiligo is frequentely reffered to as an auto Immune disease.

Vitiligo is a condition in which the skin loses its pigment cells (melanocytes).this can result in discoloured patches in different areas of the body, including the skin, hair and mucous membranes. Patchy loss of skin colour, which usually first appears on the hands, face and areas areas around body openings and the genitals. Premature whitening or greying of the hair on your scalp, eyelashes, eyebrows or beard. Loss of colour in the tissues that line the inside of your mouth and nose (mucous membrane).

CLINICAL CRITERIA FOR CLASSIFICATION OF VITILIGO

In active stage v1 new lesions develops which are increasing in size but the border is ill defined.

Stable v2-no new lesions develop. Lesions are stationary in size border is hyperpigmented and well defined.

Improving v3-lesions starts to decrease in size, no new leisions developing. Border defined and signs of spontaneous repigmentation both (follicular and peripheral).

According to the area of spread:

Non segmental vitiligo(also known as bilateral vitiligo, vitiligo vulgaris,and generalized vitiligo)

This is the most common type of vitiligo and results in white patches appearing on both sides of the body. Colour loss comes in spurts over the course of one’s life, spreading and becoming more noticeable as time goes on.

Segmental vitiligo(also known as unilateral vitiligo)

The patches appears in one area of the body, such as one arm or one leg or along the course of nerves like that of herpes zoster(zosteri form is type)

ACCORDING TO THE PIGMENT LOSS

Localized-The vitiligo appears in just one or a couple of sports on the body.

Generalized-The patches of colour loss appear in many areas of the body.

Universal-This is a rare.Most of the original skin colour is gone.

Nutritional etiology

Defects in copper, protiens and vitamins in diet a scientists called Cunningham discovered

The skin of dark people contained more copper that that of white. Copper content was concentrated mainly in the epidermis, in vitro experiment demonstrated that the copper activated the oxidation of dopa by skin extracts containing dopa-oxidase. On the other hand addition of vitamin c neutralize the catalize effect of the copper.

Protien

Vitiligo is also considered as a genetically transmitted disorder. Studies have identified that NALPI, a protein coding gene that encodes a protein related to apoptosis, plays an important role in developing vitiligo.

Vit b12 and folic acid

Vit b12 inhibits the production of homocysteine, a homologue of amino acid cysteine. Homo cysteine down regulates the activity of tyrosinase, an enzyme responsible for melanin production as well as generates free radicals, leading to impaired melanin synthesis and destruction of melanocytes. In this whole process folic acid works in tandem with vit b12 as a methyl group donor.

Combination of vitb12, folic acid and sun exposure is a good strategy to regain the colour.

Supplementation of vit b12, folic acid and pantothenic acid removes white patches.

Vit A, C, E

These vitamins act as antioxidants and prevent epidermal oxidative stress, which is considered as a causative factor for premature destruction of melanocytes.

Vitamin d

Vitamin d increases the rate of melanogenesis by increasing the activity of tyrosinase. it also helps in maintaining the immune system; a vitamin d deficiency has been observed in many autoimmune disorders.

Beta carotene

Beta carotene is a precursor form of vitamin a with immense antioxidant activity. It plays a role in maintaining normal skin colour; moreover, skin deposition of dietary carotenoids provides photo protection for lightely pigmented skins. Vitamin A helps to normalize the appearance of pigmentation. It does so by normalising the activity of tyrosinase, an enzyme that plays a vital role in the production of melanin.