Case History: Acute Rhinitis

Case History: Acute Rhinitis

September 27, 2013

Case Study on Allergic Rhinitis

Cara Frank, Dipl. OM., L.OM.

The following case study is an excerpt from a chapter on my forthcoming book on case studies of Ear Eye Nose and Throat Disorders to be published by Peoples Medical Publishing House. I’m currently preparing to lecture on rhinitis and sinusitis for the 2014 Southwest Symposium in Austin, Texas. The case history is from China. The commentary is mine. I hope that you will enjoy it.

CASE STUDY:

Female, 34 years old. Initial Visit: April 14, 2007.

Chief Complaints: Itchy nose, clear nasal discharge and continuous recurrent sneezing over 2 years.

History: Since the winter of 2004, the patient had experienced an itchy nose with profuse clear and watery nasal discharge, nasal congestion and paroxysmal sneezing (3-10 sneezes in a cluster). Symptoms were aggravated during menstruation. The patient had been diagnosed with allergic rhinitis by many hospitals and was taking Loratadine, Cetirizine and Burker Sodium to relieve the symptoms.

Signs and Symptoms: Severe itchy nose with nonstop clear nasal discharge, constant sneezing, and a stuffy nasal cavity. Accompanying symptoms included sweating easily, cold extremities, soreness in the knees and lower back and frequent night urination. Bowel movements were normal. The tongue was pale with a moist white coating. The pulse was thin.

History: Unremarkable.

Physical Examination: Pale face, thin and weak body type with good posture, BP 110/70mmHg.

Special Examination: Bilateral mucous inside the nasal cavities were smooth and swollen with pale white color and a large amount of watery discharge; bilateral enlarged inferior turbinate.

Laboratory Examination: Allergen tests: dust mites (++); pollen mites (++); Lilac Flower (+++); open epicutaneous test (+). Positive comparison test: histamine (+).

Diagnostic Analysis

The patient’s weak defensive surface, loose empty interstices and sweating indicate lung qi deficiency. Her pale face, thin and weak body type, cold extremities, soreness in the knees and lower back, frequent urination and aversion to cold indicate kidney yang deficiency. Yang deficiency is indicated by the following: dysfunction of transportation and fluid retention that results in clear watery nasal discharge; pale white nasal mucous; a sweating, pale tongue body with white moist fur and a thin pulse.

Yang qi arises in the morning. When it is weak, wind-cold pathogens can easily invade the body. During menstrual bleeding, women’s source qi is flowing outward; therefore, qi and blood become empty, weakening the immune system. As a result, the symptoms of allergic rhinitis are often worse in the morning and are exacerbated during menses.

The location of this disease is the nose. It belongs to the pattern of kidney yang deficiency.

Diagnosis

WM Diagnosis: Allergic rhinitis

TCM Diagnosis: Allergic rhinitis due to kidney yang deficiency

Clinical Treatment

The main patterns associated with allergic rhinitis are deficiency and cold. The root etiology of this case was yang deficiency and it was triggered by external wind cold invasion. Treatment should focus on warming the yang, benefiting qi, raising the clear and unblocking the orifice.

Treatment Principles: Warm the yang, Supplement qi, raise the clear and unblock the orifice.

Formula: Modified Shèn Qì Wán (Kidney Qi Pill)

[肾气丸加减]

附子

fù zĭ

3g

Radix Aconiti Lateralis Praeparata

肉桂

ròu guì

3g

Cortex Cinnamomi

熟地黄

shú dì huáng

30g

Radix Rehmanniae Praeparata

山药

shān yào

10g

Rhizoma Dioscoreae

山茱萸

shān zhú yú

10g

Fructus Corni

泽泻

zé xiè

10g

Rhizoma Alismatis

茯苓

fú líng

10g

Poria

牡丹皮

mŭ dān pĭ

10g

Cortex Moutan

黄芪

huáng qí

20g

Radix Astragali

白术

bái zhú

10g

Rhizoma Atractylodis Macrocephalae

防风

fáng fēng

10g

Radix Saposhnikoviae

乌梅

wū méi

10g

Fructus Mume

升麻

shēng má

9g

Rhizoma Cimicifugae

细辛

xì xīn

3g

Radix et Rhizoma Asari

甘草

gān căo

3g

Radix et Rhizoma Glycyrrhizae

 <strong>Formula Analysis</strong></p><p>
   The <em>Yellow Emperor’s Inner Classic</em> states that when treating patients with a weak body type the principle of warming the qi should be applied.</p><p>
 <em>Fù z</em><em>ĭ</em>and <em>ròu guì </em>open the yang, warm the channels and tonify the kidney yang.</p><p>
 <em>Huáng qí </em>supplements the three burners and strengthens the protective qi. Combining it with <em>fáng </em><em>fēng</em>and <em>bái zhú </em>strengthens the spleen, benefits the lungs, stabilizes the surface and stops sweating.</p><p>
 <em>Shēng má </em>raises the clear yang and guides the clear yang qi upwards to the nasal orifice.</p><p>
 <em>Xì xīn </em>is acrid and warm and has a traveling nature that internally supports <em>fù z</em><em>ĭ</em>to supplement yang.</p><p>
 <em>Shú dì, shān yào </em>and <em>shān zhū yú </em>supplement liver and kidney.</p><p>
 <em>Dān pí, zé xiè a</em>nd <em>fú líng </em>disinhibit water and percolate dampness. They combine with the supplementing medicinals to reduce their sticky nature.</p><p>
 <em>Wū méi </em>has the function of astringing nasal discharge. It eliminates wind and stops nasal itching and discharge when combined with <em>fáng fēng </em>and <em>gān căo</em>.</p><p>
 <strong>Acupuncture</strong></p><p>
   Main Points: LI 20 (<em>yíng xiāng</em>), EX-HN 3 (<em>yìng tang</em>), GB 20 (<em>fēng chí</em>), DU 16 (<em>fēng fŭ</em>) and ST 36 (<em>zú sān l</em><em>ĭ</em>).</p><p>
   Supplementary Points: DU 23 (<em>shàng xīng</em>), LI 4 (<em>hé gŭ), </em>LI 19 (<em>kŏu hé liáo</em>), UB 13 (<em>fèi shū), </em>UB 23 (<em>shèn shū</em>), UB 20 (<em>pí shū</em>), SP 6 (<em>sān yīn jiāo</em>).</p><p>
   Method:<strong></strong>Select 1-2 main and supplementary points each time. Needles should be retained for 20 minutes after obtaining needle sensation, once per day, 10 times as one course of treatment.</p><p>
   Techniques: Supplementing technique.</p><p>
 <strong>Follow Up</strong></p><p>
   After 14 packs of herbs, most of the symptoms were reduced.  The morning onset of the condition improved, with decreased nasal discharge, sweating and night urination. The patient’s cold extremities and soreness in the knees and lower back also improved. The tongue body was pink with white coating and the pulse was slow. The itching sensation in the nose remained.</p><p>
   The improvement of the patient’s symptoms indicated that the herbal treatment was successful. However, the yang qi was still deficient and kidney essence had not recovered. The same herbal treatment was continued for another 42 packs.  After that, all nasal symptoms had disappeared and the systemic symptoms all improved. The patient was then given <em>Shèn Qì Wán </em>(Kidney Qi Pill) and <em>Bŭ Zhōng Yì Qì Tāng </em>(Center-Supplementing and Qi-Boosting Decoction) to regulate the body and consolidate the treatment. She was also advised to pay attention to her life-style.  At the follow-up visit 6 months later, the patient’s only symptoms were a mild, clear nasal discharge in the morning and an intermittently stuffy nose.</p><p>
 <strong>COMMENTARY AND DISCUSSION </strong><strong></strong></p><p>
     This slender case history offers a snapshot of the relationship of yang and <em>wei</em>. The lungs rule the skin and open into the nose, thus all diseases of the nose and of surface weakness must be treated through the lungs. The lungs will function robustly when all the organs that support them are in top form.</p><p>
 <em>Wei </em>qi is an expression of yang qi.<em> Wei</em> qi flows on the outermost layer of the body, spreading in a vaporous way across the body to defend it from external pathogenic influences by regulating the opening and closing of the pores as well body warmth and sweating. This dynamic function is at the end of a supply chain of qi production and transformation. Each aspect of qi transformation pivots from one organ to the next in an interactive way.</p><p>
   It can be said that the root of <em>wei</em> qi is in the lower jiao, the source is in the middle jiao, and its function is in the upper jiao. The kidneys are the root of source and essence. Their qi warms the spleen, which then distills the pure qi from food, which is then differentiated into <em>ying</em> and <em>wei. </em></p><p>
   One of the most striking features of this case is that the patient’s allergies worsen when she menstruates. The author earlier in this chapter discusses the mechanism of source qi leading to wei qi deficiency. This serves as a cautionary red flag for practitioners to be mindful to inquire whether the rhinitis is a) cyclic in nature and b) for women, coordinates with menstruation in any way.</p><p>
    Another pattern seen with symptoms that recur cyclically is <em>Shaoyang</em> disorders. A classic modification of <em>Xiăo Chái Hú Tāng </em>(Minor Bupleurum Decoction) combines it with <em>Sì Wù Tāng</em> (Four Substances Decoction) to create the formula <em>Chái Hú Sì Wù Tāng </em>(Bupleurum Four Substances Decoction). The formula treats <em>shaoyang-jueyin </em>warp disorders. Symptoms include fever and chills with menstruation or catching colds during menses, which may be accompanied by signs of blood deficiency with blood stasis.</p><p>
   In this case, the patient exhibits none of the heat symptoms associated with a <em>shaoyang</em> pattern; her pattern is purely one of qi and yang deficiency. This deficiency is expressed as kidney yang vacuity, which is the root of yang and <em>wei</em> qi defensive energy. Even the time of day in which the patient’s symptoms are exacerbated (morning and evening) is significant for this case. The entire presentation is rooted in tracking the movement of yang in the body and in time, and correcting the mechanisms.  Compared to a <em>shaoyang</em> disorder, this case exhibits no signs of heat, latent heat, or congested heat in the lungs or even constitutionally.</p><p>
     Since the main symptoms are deficiency and cold with root yang deficiency, the focus of the formula is to warm the yang, benefit qi, raise the clear and unblock the orifices. The surface is loose and needs tightening and consolidating, which is achieved in two ways: 1) by tonifying the qi to tonify the wei qi and 2) by using sour medicinals to stabilize the surface and prevent leakage.</p><p>
     The formula is focused on the root treatment by using a modified<em> Shèn Qì Wán Jiā Jiăn</em> (Kidney Qi Pill). The actions of the medicinals are described above; however, there are other relationships between the medicinals that help to flesh out our understanding of the formula.</p><p>
 <em>Fù z</em><em>ĭ</em><em>, ròu guì, fú líng, bái zhú</em> and<em> huáng qí </em>are used together in <em>Gù Zhēn Tāng</em> (Stabilize the True Decoction), which strengthens the spleen, warms the kidneys and dispels cold after prolonged diarrhea and vomiting.</p><p>
 <em>Fù z</em><em>ĭ</em>and<em> xì xīn</em> warm the kidney yang and dispel exterior cold. This is an interior, exterior replete pattern is best represented by the formula <em>Má Huáng Fù Z</em><em>ĭ</em><em> Xì Xīn Tāng</em> (Ephedra, Aconite and Asarum Decoction). The pair is used with <em>wū méi</em> in <em>Wū Méi Wán </em>(Mume Pill).</p><p>
 <em>Shēng má </em>not only acts as an envoy, directing the formula to the nose, but its inclusion in the formula references <em>Bŭ Zhōng Yì Qì Tāng</em> (Center-Supplementing and Qi-Boosting Decoction) when paired with <em>huáng qí</em> and <em>bái zhú.</em></p><p>
 <em>Huáng qí</em> and<em> ròu guì </em>are the warming, tonifying modifiers of <em>Bā Zhēn Tāng </em>(Eight-Gem Decoction) used to create <em>Shí Quán Dà Bŭ Tāng</em> (Perfect Major Supplementation Decoction). This formula also includes <em>shú dì huáng, fú líng, bái zhú</em> and <em>gān căo. </em></p><p>
   Finally, <em>xì xīn </em>and <em>fú líng</em>, alsoteamed up in <em>Lìng Gān Wŭ Wèi Jiāng Xīn Tāng</em> (Poria, Licorice, Schizandra, Ginger and Asarum Decoction), warm the lungs and transform congested fluids.</p><p>
Cara Frank, L.OM. was raised by in a health food store in Brooklyn NY. When she was 8 she cartwheeled 5 miles from Greenwich Village through Soho and Chinatown and across the Brooklyn Bridge.</p><p>
For over 30 years she has had the same crazy passion for Chinese medicine.</p><p>
At 17 she had her first acupuncture treatment. At 20 she enrolled in acupuncture school. 1n 1998 she went to China to study where she fell deeply in love with herbs and has never recovered.</p><p>
Cara is the founder of Six Fishes Healing Arts in Philadelphia. She is the president of China Herb Company and she is the Academic Director of the Department of Chinese Herbology at the Won Institute of Graduate Studies. You can read her <a href="http://sixfishes.com.php54-1.ord1-1.websitetestlink.com/about/staff/cara-frank">bio</a> or schedule an <a href="http://sixfishes.com.php54-1.ord1-1.websitetestlink.com/contact">appointment.</a></p><p>
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