Chinese Medicine Traveller

The patient flew from Wuhan to Hainan on January 24th, 2020. After arriving at Haikou, he went directly to his home in Ding An county for isolation and observation. After developing a fever, he was immediately hospitalized in Hainan’s Provincial People’s Hospital. A chest CT revealed “exudative changes in both lungs”. The first, second, and fourth viral nucleic acid tests were negative, and the third test was mildly positive. After receiving anti-infectious treatment and not presenting with fever he was discharged. The fever recurred on January 31st, and he came to our hospital for isolation and observation.

After admission, he suffered from continuous fever, his temperature began to rise in the afternoon, the lowest temperature was 37.4°C and the highest was 39.2°C. On February 3rd, the patient still had a fever and his symptoms did not improve.

 

Symptoms: Continuous high fever, each antipyretic medication caused profuse sweating, aversion to cold after sweating, four limb soreness and weakness, diffused bone pains and headache, dry mouth, strong thirst for warm drinks, no bitter taste, cough with scant white sticky phlegm, throat itching after coughing, poor sleep, poor appetite, BM every 1-2 days, scant yellow urine, slightly dark red tongue with thick yellow greasy coating. The pulse could not be palpated due to quarantine regulations.

 

Chest CT analysis:

Thorax is symmetrical bilaterally. Multiple high density flake shaped spots and stripe shaped shadows can be seen below the pleura of both lungs, the lower lung lobes are prominent, with unclear margins, lung vein texture is normal, with no abnormal distribution. Normal trachea and bronchus morphology. No obvious masses or enlarged lymph nodes in the mediastinum. No pleural cavity effusion or thickening was observed bilaterally. Confirmed severe infection of both lungs.

 

Jing Fang Diagnosis: Tai yang Tai yin Yang ming concurrent syndrome with severe body fluid depletion.

Analysis:

Tai yang syndrome: Each antipyretic medication caused profuse sweating, aversion to cold after sweating, four limb soreness and weakness, diffused bone pains and headache.

Yang ming deficiency syndrome: Dry mouth, strong thirst, scant yellow urine.

Yang ming damp heat syndrome: Sticky phlegm, BM every 1-2 days, throat itching after coughing, tongue with thick yellow greasy coating.

Yang ming excess syndrome: Continuous high fever, slightly dark red tongue.

Tai yin syndrome: Thirst for warm drinks, no bitter taste, cough with scant white phlegm, poor sleep, poor appetite.

 

Pathogenesis: Pathogenic dampness transforming into heat, which stagnated in the lungs and stomach leading to a heat stasis and hindering lung and stomach functions.

 

Classical references:

Shang Han Lun, clause 26 states: “After giving Gui Zhi Tang, there is profuse sweating, severe vexation and incessant thirst, with surging and large pulses; Bai Hu Jia Ren Shen Tang governs.” This clause discusses a patient with depleted body fluids, internal excessive and deficient Yang ming syndromes.

Shang Han Lun, clause 168 states: “Shang han syndromes, if after applying the vomiting and purging [methods], the syndrome does not resolve in 7 or 8 days, there is heat binding in the interior, with heat sensations in the exterior and interior, constant aversion to wind, severe thirst, dryness of the surface of the tongue with vexation, desire to drink numerous sheng (200ml) of water; Bai Hu Jia Ren Shen Tang governs.”

Shang Han Lun, clause 162 states: “After purgation was applied, Gui Zhi Tang cannot be given. If there is sweating and panting without severe heat; Ma Huang Xing Ren Shi Gao Gan Cao Tang can be given.”

Shang Han Lun, clause 62 states: “After sweat promotion, there are body aches and deep, slow pulses; Gui Zhi Jia Shao Yao Sheng Jiang Ge Yi Liang Ren Shen San Liang Xin Jia Tang governs.”

 

From the understanding of these Shang Han Lun clauses, Dr. Wang combined the 3 formulas with Da Yuan Yin (Reach the Membrane Source Decoction) from the Wen Bing school. This formula was added to expel internal turbid phlegm in the upper and middle, clear heat, expel toxic dampness and nourish blood. Wu You ke (吴又可) states: “Bing lang can transform and disperse dampness, expel pathogens, treat diarrhea and dysentery, while treating southern epidemics, (zhang qi); Hou po breaks stasis and nodules; Cao guo is acrid and vigorously moves qi and strongly expels pathogens, These three medicinals work together to expel the pathogens from the internal membranes. This is where the name of the formula comes from. Heat injures body fluids, Zhi mu is added to nourish yin [fluids]; heat also injures the ying qi, Bai shao is added to harmonize the blood, Huang qin clears dry heat, and Gan cao harmonizes the middle; these last four medicinals harmonize the formula.”

 

“Early stage Wen yi (Epidemic diseases), first there will aversion to cold followed by heat sensations, in the following days there will be heat sensations without aversion to cold. The early stage will last 2-3 days, the pulses are not floating or deep and rapid. There will be heat sensations day and night, which will be more severe at dusk, with headaches and body aches. At this time, the pathogen is pressing in front of the spine and behind the intestines, even though there are headache and body aches, this is caused by pathogenic heat floating outwards to the channel, this can not be mistaken for a Shang han external syndrome, using medicinals such as Ma huang and Gui zhi to promote sweating. This pathogen is not in the channel, sweat promotion will damage the exterior qi, and the heat will not resolve. Purgation method is also inappropriate, the pathogen is not in the interior, promoting purgation will damage stomach qi, increasing the thirst. Da Yuan Yin is appropriate.”

 

Formula Patterns:

FP 1: Ma Xing Shi Gan Tang (SHL) Tai yang Yang ming syndrome

FP 2: Xin Jia Tang (SHL) Tai yang Tai yin syndrome

FP 3: Da Yuan Yin (Wen Yi Lun- Treatise on Warm Epidemics) Yang ming syndrome

 

Dosages: Zhi ma huang 5g, Xing ren 10g, Sheng shi gao 45g, Sheng gan cao 6g, Bing lang 15g, Hou po 10g, Cao guo 10g, Zhi mu 10g, Bai shao 10g, Huang qin 10g, Dang shen 15g, Gui zhi 10g, Sheng jiang 15g, Da zao 20g. 14 medicinals

 

On February 3rd afternoon, the patient half a dose of the formula in granules, reporting that his throat felt better as soon as he drank the formula, he did not take antipyretic drugs again and his temperature gradually decreased.

The next morning his temperature was measured at 37.2°C, which was the lowest since he was admitted to the hospital, in the afternoon it measured at 37.4°C, reporting reduction of symptoms and his vitality improved greatly. His tongue coating was less thick and greasy.

Since the patient tested positive with the pneumonia Novel Coronavirus, he was transferred to Hainan’s Provincial People's Hospital for further treatment in isolation.