Focus on Ayurvedic Diet Resolves Persistent Severe Covid-19 Symptoms: Case Report

Abstract

Introduction

We report the successful management of a patient with persistent severe SARS-CoV-2 (covid-19) with poor prognosis, by using ayurvedic dietary guidelines and supporting herbal and herbomineral formulations.

Case presentation

After two ICU admissions and at the end of conventional care options for Covid-19 infection, this 71-year-old patient presented online with persistent severe shortness of breath (spO2 85% on room air and spO₂ 75% with minimal exertion), methylprednisolone dependence of 32 mg/day, and CT Severity Score of 23/25. Upon initiating specific ayurvedic dietary guidelines (āhāra) and supportive formulations to increase digestive metabolism and induce respiratory repair, the patient improved clinically (PCFS grade 4 to 2) within 3 weeks, and radiologically (CT severity 23/25 to 12/25) within 6 weeks.

Conclusion

Ayurveda provides valuable clinical algorithmic insights into the mechanism of hyperinflammatory surges and dysregulated host response that characterize not only Covid-19 but also most infectious diseases. Ayurveda posits that diet incompatible with the individual’s current metabolic state is the key element in inflammatory host response, providing detailed dietary guidelines, and tools that syncretize using a whole systems approach.

Introduction

The scourge of the worst modern global health crisis, due to SARS CoV-2 (Covid-19, Covid) infections since December 2019 has underscored the biomedical struggle to understand basic foundations of immune host response.^1,2 Despite unprecedented and desperate efforts from the science community, no mainstream intervention has yet consistently and successfully contained the infection or its later complications for severe or critically ill patients during recovery. Advances in understanding the dysregulated host response as the pathogenesis of septic shock evolved only by scrutinizing pathogens. Yet treatment protocols for strengthening and regulating host responses during complex infectious diseases remain frugal or minimal.

Persistent pneumonia in Covid patients with elevated inflammatory markers (CRP, ferritin, LDH and hyper-coagulability marker D-dimer) remains one of the most worrisome causes of mortality and long-term morbidity and poor prognosis for millions of affected patients converting to RT-PCR Covid-negative status. The formal demarcation of a post-Covid syndrome or delayed phase awaits definition. Terms such as Covid pneumonia, late-phase Covid, and post-Covid lung syndrome are used, but lack clear guidelines around delayed or persistent manifestation of clinical pneumonia requiring prolonged high-dose exogenous steroids and supplemental oxygen. The standard of care remains anti-microbials such as remdesivir, immunosuppressives, and oxygen, leading to patient exhaustion, depression, and long term sequelae of medications and disease, including acid reflux and dependence on a cascade of pharmaceutics to alleviate their side effects and related interventions.

Ayurvedic medicine utilizes a host-centric approach³ to most infections, in contrast to germ-centered protocols that overuse antimicrobials. It emphasizes the body’s natural responses around inflammation, prioritizing tools that realign natural immune responses at each step of imbalance. With clinically-accurate insights into potential causes of abnormal host responses, the concepts aama and agni highlight the importance of dietary alignment during any infection. Numerous tools for restoring normal metabolism track meaningful dynamic, whole-systems parameters of appetite, satiety, excretion, sleep, and happiness.

Case Presentation

A 71-year-old male retired administrator living in his native small town in south India presented via video consultation (day 0) with the aid of his family, with persistent severe shortness of breath (SOB) for the previous 80 days, worsening over 12 days, accompanied by generalized weakness, severe burning epigastric pain, constant hunger, and anxiety. He had been discharged to home from a local hospital 2 days earlier with grave prognosis due to unmanageable dyspnea. His goal was simply to live without life support.

The family reported a history of intermittent fever and dry cough from mid-Jnly 2020 (day -90), for which he used symptom-based OTC medicines until progressive dyspnea & weakness became unmanageable at home. He was hospitalized in a local Covid-specific federal-mandated ICU (on day -82) with a SpO₂ of 83% on room air (RA) and tested positive (on day -80) via RT-PCR for SARS-CoV-2 (Covid-19) and remained in acute care for 29 days due to respiratory distress. During this time, he received a full course of remdesivir for 10 days; ceftriaxone; doxycycline; methyl-prednisolone injections 40mg twice daily (BID); enoxaparin; and high-flow O₂ at 15 L/min. After gradual improvement, he was sent home with oral methylprednisolone 16mg BID with a plan to taper over 4 weeks and a calorie-dense diet. One week after the taper was completed (on day -15), the patient redeveloped SOB, cough, weakness with SpO₂ of 65% on RA and was emergently readmitted to the ICU (on day -12).

Rapid antigen testing preceding RT-PCR for SARS-CoV-2 were negative. HR-CT scans revealed extensive ground glass opacities consistent with pneumonia, with rapidly worsening CT Severity Score from 19/25 at readmission to 23/25 within the same week. Cardiac evaluation remained unremarkable.

In the ICU, he was managed with favipiravir, faropenem, perfenidone, and anticoagulants. Two attempts for convalescent plasma were planned but could not be arranged. He required high-flow oxygen continuously. Restarting of methylprednisolone at 125 mg daily was prescribed. Concomitant fungal and bacterial infections were investigated before beginning steroids. With only marginal improvement even on high-flow oxygen and parenteral 80mg steroids daily, he was discharged after 10 days (on day -2) for home care with a grave prognosis by the pulmonologist, receiving prescriptions for home oxygen and continuous oral steroid methylprednisolone 32mg OD, apixaban, perfenidone, and pantoprazole to manage the complications of high-steroid use.

Prior to this episode, he had no respiratory illness, a premorbid BMI of 24.7, and a past medical history of hypertension managed well on amlodipine and atenolol. He also had well-managed type 2 diabetes mellitus using metformin 500 mg BID, along with injections of biphasic fast- and longer-acting insulins 15 U once daily. He is a former smoker who quit 30 years ago and has a history of occasional ethanol use 1-2 times per month. Residing with his extended family, many of whom are physicians, he was in his usual state of health prior to this illness.

Presenting Concerns

Through online consultation with the aid of physician-relatives, the patient appeared emaciated and in mild distress, unable to speak freely. His presenting concern was dyspnea both at rest and with minimal exertion, persistent weakness, burning epigastric pain, constant hunger, and anxiety.

His heart rate was 102/min, blood pressure was 130/70 in sitting position, and his respiratory rate was 32/min. His fasting blood sugar was 150 mg/dL and his post-lunch fingerstick blood sugar level was 280 mg/dL, as summarized in the longitudinal laboratory findings. The patient breathed fairly comfortably with an spO₂ of 96% on 2 L/min of supplemental oxygen which rapidly declined to spO₂ 89% on room air. With minimal exertion of walking to his bathroom 12 steps away, his spO₂ plummeted to 75%.

The biomedical assessment was (1) persistent severe SARS-CoV2 pneumonia, presently antigen negative, (2) steroid dependence, (3) acid peptic disease, (4) situational and steroid-related anxiety with preserved insight.

After his vital signs and emergent biomedical parameters were measured (day 0), the patient’s family requested Ayurvedic clinical interventions and management, due to lack of conventional medical options. Evaluation was shifted to ayurvedic clinical diagnosis and an integrated plan with ayurvedic emphasis.

The ayurvedic assessment was (1) dhatugata jwara (fever running throughout the tissues, non-localized fever, body-wide inflammation), (2) aama-avastha (unassimilated food intermediates)⁴ and toxins throughout the tissues), (3) vataja shwaasa (breathing difficulties focused on dry-rough nature), and (4) amlapitta (heartburn due to hyperacid production among the digestive enzymes in the central cauldron of the gut).

Because the manōbala (mental strength and inherent happiness level) of the patient was high despite his anxiety, and he was well-supported by family helpers willing to participate fully with suggested interventions, he was treated quickly using multiple simultaneous interventions that are usually integrated sequentially over months.

On initial examination (day 0), his tongue was severely coated with exudate. As he continued methylprednisolone 32 mg BID) with plans for gradual tapering, his hyperacidity engaged him in 14 food intake episodes daily and pantoprazole. He resumed insulin for glycemic control with regular blood sugar monitoring and apixaban 2.5g BID.

Therapeutic Interventions and Treatment

Ayurvedic interventions from inception focused on gut function while aiming for respiratory repair to quell all medical issues. His food intake was restructured to <6 episodes per day. He was requested to attentively intake amounts according to his appetite, and to record all times of food/beverage intake. He was strictly advised to avoid saturated fats, particularly milk, curd (cow yogurt), and half-cooked eggs; raw or uncooked food items, especially fresh fruits; dry fruits and nuts; mucilaginous fruits or vegetables such as banana, avocado, colocasia root; and foods with high fiber or heavy root vegetables that are difficult to digest.

His diet for phase 1 was prescribed as unprocessed rice- and wheat-based carbohydrate-rich foods adapting the ayurvedic prescriptive manda-peya (cooked dilutions of rice gruel), alongside green gram soup known as mudga dal, and coriander-based puree soups. Due to his alarming weight loss over 80 days (65kg on day -80 vs. 57kg on day 0), he was prescribed meat broth-based soups as per ayurvedic rehabilitation recommendations; he chose four well-cooked egg whites daily. His beverage and cooking water was a stock of clean water boiled with coriander seeds; this was switched after 5 days to a polyherbal powder mix shadanga paniyam for drinking and for cooking all foods.

By day 11, when he had recovered significantly, his diet was shifted to reintroduce foods (phase 2) such as lighter preparations such as idly (rice-batter cakes), (moori) rice puffs, as long as they were accompanied by bioavailability-enhancing moist preparations of the legume moong, in dahl or sambaar.

The recovery (phase 3) and replenishment (phase 4) known as rasayana included reinforcement of food intake three times daily with no snacks, and continued refrain from raw foods and from meals with highly heterogeneous components requiring distinct digestive chemical functions. These customs are known to most Indians due to integration into traditional ancient cultural norms.

Of note, pure unprocessed grass-fed cow milk was reintroduced as a powerful remedy for vata-pitta shamana to support recovery and repair only after the patient’s heaviness resolved in late November, six weeks after treatment started. This served as a marker for the end of inflammation and a turn toward rejuvenation of the traumatized tissues. Attempted conversion from water decoction to milk-based decoction (milk = ksheera, decoction = kashayam) on day 18, during the same period that steroids were quickly tapered, resulted in increasing cough, pedal edema, and a sudden increased CRP from 0.94 (baseline <6) to 26.6. It indicated that the body was not ready for digesting the slimy heaviness of milk. Reversion to water-based decoction from day 25 until day 36 was required and reinforced the dietary guideline to avoid milk when inflammation is present in the body.

Herbs were used to support digestive functions to enhance processing and expulsion of toxins stuck in the vata (flows of the body) and pranavahasrotas (breath channel, respiratory tract). These included the most common ayurvedic remedy for vata, known as dashamula in decoction form, mineral supplements to aid the replenishing of cofactors in lung enzymes, the metabolism-optimizing polyherbal known as shadanga paniya churna, and several potent immune modulators, shown in table 3. Only after the patient was stabilized, cleansed of toxins, and assessed, phase 3 began using the rejuvenating herb ashwagandha, along with a gold preparation to enhance immune function, lung repair, and a polyherbal-infused ghee to fortify the gut, respiratory and body tissues.

Table 3.

Ayurvedic Diet-Supporting Herbs

	Effect on agni	Dosage and timing (sevana kāla)	Type of preparation / kalpana	Chief ingredients	Effect on dosha	Possible pharmacodynamics
dashamul kashāya	agni-deepana & destroys vishama-agni	7 gm soaked powder & then boiled down to half, approx.125ml water up to half i,e, 50-75 ml, prepare fresh, twice daily.	sukshma churnam (fine powder)	roots (mula) of 10 (dasha) plants -bilwa, syonaka, agnimantha, gambhari, patala, brahati, kantakari, prsnaparni, shalaparni, gokshura	vata-kapha shamana, somewhat pitta shamana, jwarahara, rasayana	ama-pachana, vata-shamana, correlated to anti-inflammatory, thus pain-reducing
jaya mangala rasa	agni-deepana maricha makes it laghu, dhatugata jwarahara, rasayana	125 mg twice daily in kashayam	kharaliya ras (bhasmabased poly-herbal formulation)	7 metals, one for each dhatu; bhavana with 3 dravyas for 3 doshas	tridosha shamana	gold is considered antimicrobial, antipyretic, antiinflammatory
shwasa kasa chintamani rasa4	agni-deepana	125 mg PO BD	kharaliya ras (bhasmabased poly-herbal formulation)	Suvarna Bhasma, Shuddha Parad, Shuddha Gandhak, Suvarnamakshik Bhasma, Abhraka Bhasma, Loha	predominantly vata and pitta shamana, with some kapha hara	Increases digestive fire, enhances repair of respiratory tissues
sahasraputa abhraka bhasma5	agni-deepana	100 mg with few drops of honey plus 6 drops of ghee, once daily	bhasma (calx)	Calcium-aluminum-magnesium-silicate K(Mg,Fe) 3AlSi 3O10(F,OH)2	tridosha shamana	Minerals replenish coenzymes needed for lung function and repair
guduchi ghana vati	agni-deepana, amapachana, dhatuagni deepana,	500 mg 2 tab thrice daily	ghana vati - tablets, rasakriya	guduchi (Tinospora cordifolia)	tridosha shamana, jwarahara, rasayana	antimicrobial, immune-modulator, antiinflammatory,
shadanga pāniya	agni-deepana & dāha shamana, trsna shamana, ama-pachana	amount boiled in 64x volume of water for drinking and cooking	herbal coarse powder	6 ingredients - musta (Cyperus rotundus), parpataka (Fumaria indica), ushira (Vetiveria zizanioides), chandana (Santalum album), hrivena (Pavonia odorata), (dried Zingiber officinalis) shunthi, ambu-H2O 64 parts, boiled to reduce to half, solids filtered	pitta-kapha shamana	anti-inflammatory, esp for ama with pitta, anti pyretic, used in hyperthermia, mala-shuddhi kara, kostha-shodhana, will affect the microbiome

Abbreviations: Dasha-mula kashāya, standard 10-root decoction, cited in text Caraka Samhita; jayamangala rasa, systemic inflammation reducer, anti-microbial; shwasa-kasa chintamani rasa, has respiratory repair and anti-fibrotic components; sahasra-puta abhraka bhasma, 1000-times incinerated bhasma of black mica, cited in text Bhaisajya Ratnavali; guduchi ghana vati, concentrated decoction poured over guduchi powder to make tablets; shadanga pāniya, herbal powder that improves digestive enzymes, does ama-pachana, daha-prasamana.

Dashamula is made in modern times from bilva fruit (Aegle marmelos), shyonaka root (Oroxylum indicum), agnimantha root (Premna integrifolia), gambhari root (Gmelina arborea), patala root (Stereospermum suaveolens); brhati (Solanum indicum), kantakari (Solanum xanthocarpum), prshnaparni (Uraria picta), shalaparni (Desmodium gangeticum), gokshura fruit (Tribulus terrestris)

Patient adherence to diet and medicinal herb schedules and doses was assessed by periodic online video and telephone conversations with patient and family members providing care. Regular herbal prescription refills also confirmed that the patient was adherent to medicinal herbs and that the herbs were tolerated very well both clinically and biochemically.

At the last follow-up visit on day 101, the patient was asymptomatic, had an spO₂ of 98% on room air, had resumed activities of daily living (ADLs) independently, was able to walk 20 minutes, and climb two flights of stairs with no discomfort. He reported no epigastric burning, and had resumed regular sleep, with no anxiety. The Ayurveda prescription was given based on attention to constitutional symptoms of sleep quality, cough, shortness of breath, and return to ADLs.

Pulmonologist and radiologist evaluations on day 36 of the 2D-echo, NTproBNP, TSH, creatinine, and albumin final labs and scans were normal, despite earlier prognoses. His outside physicians declared that the improvements were likely due to life-saving high steroid doses, and advised salt restriction with judicious fluid intake dictated by thirst as their only prescription.

Discussion

Persistent inflammation with or without hypercoagulability, even after the virus is cleared by the host’s defense, underlies the pathophysiology of this very common syndrome, causing extensive mortality and morbidity worldwide during this pandemic. While it is the hallmark of most persistently sick patients, the mechanism of the host response is still poorly understood in conventional medicine, and steroids with their wide variety of side effects including immunosuppression, remain the only therapeutic option during emergent crises.

Ayurveda emphasizes a host-centric approach after millennia of clinical experience with infections and provides insight positing the aamashaya (upper gastrointestinal tract and liver) as the main locus of pathophysiology. Ayurveda advises that the mismatch between food intake [aahara] and metabolic/digestive mechanisms [agni] is the main process leading to inflammatory cascades.⁵

The intake of specific foods by a person suffering from chronic or acute infection and infection-induced metabolic sluggishness or dyspepsia produces partly-digested material in the gut [aama] and occupies metabolic catalysts, furthering maldigestion. Foods deemed heavy or difficult-to-engulf [guru]⁶ usually contain: (1) highly-saturated fats as in curd-yogurt, milk, eggs and meat; (2) high-fiber foods, especially highly-processed multi-grain preparations; (3) oil-heavy seeds and nuts; (4) mucilaginous foods such as banana, avocado, and colocasia; (5) raw fruits that require multiple enzymatic processes; and (6) foods deep-fried, especially in processed refined seed oils.

Heavy-to-digest foods require more metabolic manipulation and energy inputs to extract energy, transform, and assimilate the nutrients into the blood. Stranded partially-processed intermediates (aama) are not completely assimilated as their foreign non-self immunologic state of outside food substance is not tagged with appropriate antigens, known as vivecheti, to allow transformation into the self-state that allows assimilation into the host [muncheti]. This process of converting non-self food into self-building blocks, requires efficient action in the host metabolism/digestive system [agni].

Dysfunctional or incomplete conversion results in the production of intermediates that behave as non-self in the body, producing inflammation and auto-immunity.⁷ Dysfunction is signaled by symptoms of anorexia, nausea, dysgeusia, or vomiting in the patient, seen in many infected and inflammatory states. During states where the immune system is preoccupied outside the gut, it is unable to complete the job in the gut of identifying non-self molecules egressing into blood and must battle the non-self molecules deposited in tissues around the body, manifesting as clinical symptoms of different diseases.

Hence Ayurveda advises management of illness by reducing overload on the gut’s capacity to integrate food. Heavy diets are replaced with judicious fasting [langhana] to reduce mass,⁸ alongside herbs scheduled to stimulate digestive mechanisms [agni-deepana] while facilitating metabolism and excretion [aama-paachana] of partially-digested foods. Herbs are delivered through processed water and seasoned food. Food, called agrya, that is the best physiologically is based on nourishment into the human tissues and ease of digestion, not on energy measurements external to the human body such as calories or anti-oxidant ORAC values, bioavailability, biochemical moieties, data from animals with obviously different digestive systems, or theoretical constructs. Clinicians with extensive experience have compiled these recommendations over thousands of years with genetically varied humans, as seen in ancient vedic texts.

Foods of choice for strength-compromised patients include simple non-binding starch preparations such as rice gruel variations of dilution in water, known as manda, peya, vilepi, kanji; ground wheat berry-based preparations such as semolina; yavagu, wheat, barley, or rice gruel boiled in 6x water; alongside mudga, green split gram beans that are to be easily-absorbed proteins; and non-vegetarian soup broths with seasonings of ginger, pepper, rock salt, and cumin that allow the altered gut the extremely vital rest it requires for agni to recover.

1. To prove the agni-aama theory, each exact protocol is guided by the appetite of the patient, individualizing food content, quantity, and timing around clinical symptoms: if anorexia with nausea or vomiting → fasting [upavasa] with no solid food for 6-8 hours

2. if minimal appetite → gruels of non-binding starches, preferably rice or wheat

3. if mild appetite → thin, hot porridges of rice made with spice-boiled water [yavagu]

4. if appetite is normal → soft, moist diet of rice/wheat, green gram or non-vegetarian soups for protein, and no fat/fried/fruit/fiber

This patients post-infective inflammation became persistent when he started consuming multiple eggs and fats to ‘boost his nutrition and immunity‘ as advised by his physician at hospital discharge, though they are difficult to digest. In addition, he used food to mollify the continued dyspepsia and artificially-augmented appetite from months of corticosteroids. Upon gradually withdrawing the specific food items fat/fried/fruit/fiber, and by restricting food intake times to give the gut the additional processing time it required, aama was reduced and reversal of respiratory distress was achieved. Complete fasting was avoided in this patient in view of his overall depleted state since day -80, and the patient showed a steady improvement using the ayurveda food theory. Moreover, he reduced his need for steroids completely after 4 weeks. Repair of damaged tissues was addressed in the final phase of treatment using regeneratives called rasayana^9-11 and was evidenced by functional improvement, CT Severity Score, and laboratory testing.

Conclusion

Perhaps the way to understand the pathophysiology of severe covid and post-covid lung syndromes and their management is to focus more on dietary inputs during the infection, optimized to the particular patient’s metabolic and digestive capability, as manifest by the appetite, gut signals, and outputs. Imbalanced gut signals portend immune dysfunction and abnormal inflammatory response due to production of unassimilated intermediates or aama. Optimizing digestive function can reverse the course of severe inflammation-accompanied persistent disease.

This case study suggests that host inflammatory response can be modified using principles described in Ayurveda to skillfully stimulate and optimize metabolism (agni-deepana), eliminating specific foods that are energy-intensive to assimilate, such as fats, fruits, fish, and fiber, use of fasting, and prescribing foods that contribute harmoniously to metabolic algorithms. These include cooked water processed with digestion-stimulating herbs, formulations that metabolize [aama pachana] partially processed intermediates that obstruct the channels of the body where key immune information flows. Diet plays a central role in causation and management of abnormal host response.

This case highlights the potency of Ayurveda dietary guidelines to intervene on inflammatory host dysregulation, according to integrative understanding of gut metabolism as the fulcrum of all immune dysregulation and host defense oversight. Correction of dysregulation according to simple ayurvedic principles while utilizing herbal medications to hasten resurrection of metabolic function in the gut, is an important means to reverse severe pathophysiology in various infections as well as in auto-immunity.

Figure 1.

Timeline

Figure 2a.

Day -1

Figure 2b.

Day 36

Table 1.

Patient Data and Timeline

Day	day -94 to -83	day -82 to -53	day -52 to -22	day -21 to day -13	day -12 to day -2	day 0	day 3	day 11
Date	20 Jul - 31 Jul	01 Aug - 30 Aug	31 Aug - 30 Sep	01 Oct - 09 Oct	10 Oct - 20 Oct	22 Oct	25-Oct	03 Nov
Main events	first symptoms	first inpatient/COVID-ICU admission	in home management		second inpatient/ICU admission	iniitial video consultation for ayurveda management	phone check-in with family for herbs arrival and food adherence
COVID testing + symptoms + management		severe SOB, bedridden	mild cough, no fever, no sore throat		Rapid antigen (-) RT-PCR (-), dry cough +, increasing weakness, afebrile, received Fabiflu x 9days	Weakness++, severely restricted movement due to SOB, apixaban 2.5mg BID		RT PCR (-) stop fabiflu, continue apixaban 5mg OD
SOB and QoL	independent, able to perform ADLs	severe SOB	moderate-mild SOB, Initially needed 10L/min O2 at home, gradually weaned	on room air	severe SOB, bedridden, disturbed sleep due to ICU	severe SOB on minimal exertion	disturbed sleep due to burning in gut	SOB moderate, Subjectively much better
steroid use		methyl prednisolone inj 40mg BD,	methyl prednisolone po 16 BD, Apixaban, d/c steroids on 9/30 for 10d	off steroids	needed to restart steroids 10/10, IV 80mg BD	methyl prednisolone po 16mg BD, Anxiety++
Vitals						Temp:98.6 PR:--/min
spO2 + supplemental oxygen use		spO2 83% on RA, high flow O2 -15L/ min	continuous O2 4-5L/min		spO2 65-70% on RA, high flow O2 >15L O2/ min	spO2 83-85% on RA >75-80%/min after minimal exertion spO2 96% on 2L/min, requiring all day		spO2 96% on RA 85% after 3min walk, use of intermittent 2 L/min O2 through day
GI symptoms						severe epigastric burning +++ appetite++ bitter taste, dysgeusia++
Tongue coating						Tongue coated+++, bilateral on periphery		Tongue: no coating
Blood Glucose		8/2-62U, 38 short-acting + 24 intermediate-acting			Random BS: 171	FBS: 150 PLBS: 290
Diet Management						Advised light diet, eat as per appetite, avoid fats, raw diet, dry fruits and high fibre diet. water boiled with shadanga paniyam for drinking and cooking
pharmaceutical drugs		faropenem, remdesivir x 10 days, enoxaparin, various antibiotics, pantoprazole, vit d, zinc, vit c			pirfenedone, favipiravir, apixaban, pantoprazole, antibiotics	Pirfenex 1BD Pantodac 1BD	pantoprazole 40mg OD reduce Medrol to 16+8 taper and stop over 15days	Stop Pirfenex and farapenem, pantoprazole 40mg OD reduce Medrol to 16+8 taper and stop over 15days
ayurvedic digestive support drugs				10/15 - Hb-11.1 TLC- 11840 P-86, L-10, E-1 M-2, PL-3.18		Dashamoolam KSC BD, jayamangal ras BD, Swasakasa Chintamani BD, Abhraka bhasma OD, Guduchi ghana vati 2BD		add Suvarna sootasekhara ras 1BD continue all others
food intake episodes /day						14
CBP		hgb-11.5						Hb-11.8 TLC- 9800 P-77, L-17, E-1 M-3, PL-1.75
CRP					CRP-25.96(<5)			CRP-0.94(<6)
D-Dimer		<200 WNL			D-DIMER:- 1130			D-DIMER:- 262
ferritin					Ferritin: >2000
IL-6					IL6-412
LDH					LDH-578
PCTQ					PCTQ- 1.03			PCTQ- 1.03
LFT		LFT- 0.5/19-ALT/27-AST/3.7-ALB/3.2-GLOB			LFT- 1.1/54/37/29/3.3/3			LFT-0.47/55/18/20/3.3/1.8 TSB: / 0.47
Creatinine		Creatinine-1.4			Creatinine-0.76	10/28 - Creatinine-0.87 NT Pro BNP: 59.3(<450) Sodium: 146 K+: 5.1 TSH 1.22
Tropononin - 1		NEGATIVE			Troponin I (-)
		HIV -, HbSAg -
2D-echo					2D-Echo: Normal
HR-CT chest					HRCT CO-RADS 4, CT severity 19/25	HRCT: CO-RADS 5 CT Severity 23/25

Day	day 18	day 31	day 36	day 49	day 102
Date	10 Nov	23 Nov	28 Nov	11 Dec 2020	04 Feb 2021
Main events
COVID testing + symptoms + management	mild weakness, no cough	mild dry cough+	very mild cough, discontinue all other pharmaceuticals
SOB and QoL	mild SOB, insomnia+ (lack of sleep), mild weakness, subjectively overall better able to perform all ADLs	No SOB, Sleep improved (getting up only once), able to perform all ADLs, and walk for 3-4min	No SOB, Subjectively much better sleeps most of night undisturbed.		continues to perform all ADLs can walk 4 km daily
steroid use	c/o pedal edema
Vitals	PR: 90/min	PR:109/min->112/min	PR:98->100/min
spO2 + supplemental oxygen use	spO2: 96% on RA 92% after 3min walk, use of intermittent O2 after exertion for <2 hr/day	spO2: 96%->91% on RA after 4min walk, d/c supplemental O2 Requiring oxygen only 1-2hrs a day	spO2: 96% on RA ->91% after 6min walk. completely d/c O2
GI symptoms	meal appetite increased Epigastric burning++	hunger controlled, epigastric burning +	epigastric burning absent
Tongue coating	Tongue coated+only on periphery	Tongue: no coating
Blood Glucose		10 U + 10U		FBS: 90 PLBS: 120 23 Dec - insulin stopped	FBS: 110 PLBS: 130 no insulin
Diet Management
pharmaceutical drugs	Continue pantodac OD Reduce to apixaban 2.5mg OD reduce to Medrol 8+4 Taper over 1week to full stop.	day 6 off steroids, on vit B-complex injection on alternate days	discontinued pantodac and all other pharmaceuticals
ayurvedic digestive support drugs	Dashamoolam KSC boiled with milk (ksheera kashayam) Ashwagandha ghana vati 2tab HS	Continue course	Dashamoolam ksc with milk OD after dinner Shwasakasa Chintamani 1 OD, abhraka bhasma once daily, guduchi ghanavati 2OD, Suvarna sootasekhara ras 1 OD, Ashwagandha ghanavati 2HS	vidaryadi ghritam
food intake episodes /day	5		3
CBP		Hb-11.9 TLC- 6800 P-70, L-20, E-6 M-4, PL-1.77
CRP		CRP-26.6(<6)	CRP: 11.7 (<6)	3.9.baseline6.0	CRP: 1.2 on 12/16
D-Dimer	D-Dimer: 262	D-DIMER:- 370		D-DIMER: 160
ferritin
IL-6
LDH
PCTQ
LFT
Creatinine
Tropononin - 1
		ECG: sinus tachy cardia WNL
2D-echo	2D Echo- good LVRV Function, Grade 1 dyastolic dysfunction, EF: 58%, No RWNA
HR-CT chest			HR-CT chest: CT Severity 12/25

Table 2.

The patient’s diet report, as given by family member. Movement to a 3-meal daily schedule with 12 hours of no oral intake accompanied health changes post-covid.

Times	Day -1 (21Oct)	Day 11	Day 31	Day 36
6 AM	Tea with milk = sugar + almonds + 4 egg whites			1 glass milk with pippali Dec 11 milk w decoction
7:30 AM	4 Idli + coconut chutney
8:30 AM	pongal (rice with green gram)	BF: 3 egg whites + idly or dosa	BF: idly	Breakfast: Idly
10:30 AM	milk + protein powder (Ensure™)	Vegetable soup	soup
11:30 AM	oats/raagi-sorghum—malt + fruits (high fbre millets)		moongdal/ murmura (pufed rice)
12:30-1:00 PM	L: rice + toor dal + cow yogurt	L: rice + curry + rasam (shadanga paniyam)	L: rice + curry + rasam	Lunch: rice + dal + curry + rasam
3:30 PM	Fruits + oats
4:30 PM	tea with milk +biscuits	Soup/ dosa	4:00 : soup
6:30 PM	Fruits (apple, orange, guava)		6:00p : moongdal + murmura (pufed rice)
7:30-8:00 PM	D: rice + toor dal + curry + curd	D: rice + curry + rasam	D: rice + curry+ rasam	Dinner: rice + dal + curry + rasam
10:30 PM	250ml hot packet milk	upma/roti	(all cooked with shadanga paniyam)
12:30 PM	curd rice

Biographies

Uma Shankar Prasad Adluri, MBBS, MD, DNB, BAMS, MPhil, is a critical care-trained internist at Sunshine Hospitals in Secunderabad, India, and an ayurvedic physician at SIVAS Health & Research Institute in Hyderabad, India.

Bhaswati Bhattacharya, MPH, MD, PhD, AD, is a family and preventive medicine-trained physician serving as Clinical Assistant Professor in the Dept of Medicine at Weill Cornell Medical College, New York, working globally as a Fulbright Specialist in Public Health, and an Ayurvedic scientist. Both practice integrative medicine.