Fever, Loss Of Smell And Severe Cough: A Case Study

This is a case study of 69 y.o female suffered from fever, loss of smell and severe cough for 8 days. She took Lianhua Qingwei capsules but her symptoms and fever did not resolve until she was prescribed a Qi boosting and Dampness expelling Chinese patent medications. Her fever went down the next day and all her symptoms resolved within 8 days after she started a new prescription.

69 y.o female, usually healthy, no medication

Chief Complaint: loss of smell, fever with chills and shivering. Headache and heavy sensation, no appetite, severe cough, O2 saturation- 98% for 4 days. On a first day patient had a loose stool, but after that it become normal. From the day one, patients took Lianhua Qinwen four capsules four times a day. Some research shows positive effect of Lianhua Qingwen capsules on coronavirus patients¹. China’s National Health Commission and State Administration of Traditional Chinese Medicine also included  this pattern medication in the  Diagnosis and Treatment Protocol for C-19 (Trial Version 7)².

Component of the formula: Forsythia suspensa (Thunb.) Vahl. (Lianqiao), Lonicera japonica Thunb. (Jinyinhua), Ephedra sinica Stapf (Mahuang), Armeniacae Amarum Semen (Kuxingren), Gypsum Fibrosuum (Shigao), Isatis tinctoria L. (Banlangen), Dryopteridis Crassirhizomatis Rhizoma (Mianmaguanzhong), Houttuynia cordata Thunb. (Yuxingcao), Pogostemon cablin (Blanco) Benth. (Guanghuoxiang), Rheum palmatum L. (Dahuang), Rhodiola rosea Linn. (Hongjingtian), Mentha haplocalyx Briq. (Bohe), Glycyrrhiza uralensis Fisch. (Gancao)

The action: expel heat-toxins, disperse the Lungs and release the exterior. Indications: cold, flu, sore throat, and fever.

Even though patient took Lianhua Qingwen for four days she did not feel improvement. She decided to contact me for online consultation.

1^st consultation. Dec 31. 2020. Chief complain: fever- 37.8 Celsius ( 100.04 °F), loss of smell, headache and heavy sensation to the head, chills and severe shivering once fever goes up. Severe dry, non productive cough that is worse if patient talks. Poor appetite. No sore throat.

Tongue: Pale, swollen, dry, fissured in the middle. Only a very small аrea to the RT and LT sides of the root shows a greasy and thick coating.

Case analysis: As per patient’s symptoms it was clear that disease belongs to a category of Li qi 戾气 (Perverse qi), Li qi 疠气 (Pestilential qi)⁴ or “mountain forest toxic qi” and does not belong to category of 6 regular pathogenic factors in TCM⁵. The correct treatment of the current epidemics described in “The Lantern”. Volume 17 No.2a by Dr. Jin Zhao and Chris Flanagan³ and should be based on “ Hou Po Xia Ling Tang’’ and “Da Yuan Yin” variation. 

Symptoms analysis: severe chills and shivering in this case are not due to “external” pathogenic factor, but rather due to blockage of the Yang Qi by damp-toxin lodged in the internal layers. Severe dry cough is due to obstruction of the Lung Qi and disrupting descending mechanism of Lungs. Her fever rises in the evening – this is also indication of the Damp-toxin pathogen⁵.

“ In the early stages of a warm epidemic (溫疫 wēn yí) there is

first chills and then fever; ……. Fever will

continue day and night, but the evening will be worse with

headaches and body aches”.⁶

The tongue in this case had only a small area covered by sticky and thick coating. In general her tongue was pale, swollen and dry with the “prolapsed middle and lower part”² . In this case it does not indicates Yin deficiency but rather deficiency of Spleen and Kid Yang and inability of the clear Yang to rise  and distribute fluids. The loss of appetite is the only symptom that can support this statement in this case.

Loss of smell- blockage of the “orifices” by damp-toxin. 

Treatment strategy: Boost the Spleen Qi and rise the Yang Qi, disperse damp-toxin and disseminate the Lung. However due to New Year holidays the Chinese pharmacy was closed until January 4^th. The only thing that could be done in this case is just to continue Lianhua Qinwen capsules with the same dosage.  Patient also found  Ginseng capsules at home and recommended to add it to her treatment.

Jan1-Jan 4^th. Patient’s fever is still high – 38,2-38,5C (100.8-101,3) with spikes in the evening. Chills, body aches reduced to some degree but still present. There is no appetite and poor intake, loss of smell and taste.

Diet recommendations: avoid sugar in any forms. It was found that the structure of the Novel coronavirus spikes covered by glycan- a layer of sugar-like coating, that helps to virus penetrate into cells undetected⁸. Patient confirms that due to holidays she consumed candies daily and she feels significantly worse.

Jan 4^th. Patient took : Bu Zhong Yi Qi Wan 8 pills 3 times a day,  Xiang Sha Yang Wei Wan 4 pills x 3 times a day, Huo Xiang Zhen Qi Wan 4 pills x 3 times a day. This evening fever -37.5, Sat O2-98%

Jan 5^th . General blood test. WBC  3.91* (4.50 – 11.00 x10⁹/L), neutrophiles 44.0% ( 48.0 – 78.0%), lymphocytes 40.4* % (19.0 – 37.0%). Fever 37.0 C, the sense of smell started to come back. Cough is still strong but become more productive.

Jan 6^th. No fever. The sense of taste is completely back, there is a minor improvement in a sense of smell. Appetite without change. Treatment: Bu Zhong Yi Qi Wan 14 pills x 3 times a day, Xiang Sha Yang Wei Wan 3 pills x 3 times a day, Mu Xiang Shun Qi Wan 3 pills x 3 times a day. Stop Huo Xiang Zhen Qi Wan

Jan 7. No fever. Cough become more productive but is still strong. No appetite, smell without change. Treatment: Pi Qi Wan ( Bai Zhu,Chen Pi, Fu Ling,Gan Cao,Shen Qu,Mai Ya,Ren Shen ,Shan Yao, Shan Zha, Ze Xie, Lian Zi) 1 bolus x 3 times a day , Er Chen wan 8 pills x 3 times a day

Jan 9^th. No fever, cough has reduced significantly, appetite is better, no improvement in sense of smell yet. Treatment: Add huo xiang Zheng Qi Wan 4 pills x 3 times a day

Jan 11^th. Patient reports that her sense of smell is almost back to normal. Appetite is normal. Minor cough but patient feels improvement every day. Suggested to continue Bu Zhong Yi Qi Wan  to boost her immunity for few days and then stop all the treatment.

In this case study of a 69 y.o female  with classical symptoms of coronavirus infection – loss of smell, fever and severe dry cough lasting for more than a week , I implemented a strategy to eliminate  Damp- Toxin simultaneously with supporting the Spleen Qi and Rising Yang. Despite  Lianhua Qinwen capsules that patient took  from the very first day, it did not show any improvement. On the contrary, her fever went down the next day after she started treatment based on her proper TCM differential diagnosis. There are few important key points that attention should be drawn to :

1. Guideline of Clinical Practice on COVID-19 in China widely support Ma Huang based formulas such as Qing Fei Pai Du Tang, or Lianhua Qinwen capsules⁹. Although, multiple clinical and laboratory studies shows anti-viral effect of these remedies^9-10, the correct treatment should be based on “Wen Yi Lun” and “Wen Bing Xue“ strategies as described in “The Lantern”-The journal of Chinese medicine by Jin Zhao and other authors.  The symptoms of chills, body aches and dry cough are not due to external pathogenic factor, but rather due to pathogenic Damp-toxin lodged in the internal layers- such as GI tract or Mo Yuan ( interstitial space)  and blocking distribution of the Yang Qi and disturbing descending Lung’s mechanism. In this case 69 y.o lady took Lianhua Qinwen capsules for 8 days without resolution of her symptoms. Adding Ginseng to support her Zhen Qi also did not help.
2. In warm-epidemics the tongue coating suppose to be white, thick and greasy or putrid³.  In this case, however there is only a small area of the thick coating found on the root of the tongue. Instead, her tongue was pale, swollen, dry and fissured. Although many practitioners can mistakenly assume that this is Yin deficiency pattern, but in fact, this is not. In this case the color and the tongue texture (pale and swollen) are indicators of the Spleen And Kidney Yang Vacuity. Uneven distribution of the tongue coating and dryness are sign of the failure of the clear Yang to rise and to bring fluids up. Fissured tongue in this case also does not indicates  Yin deficiency, but rather Deficiency of the Middle jiao  or Phlegm/ dampness rooted in collaterals ( chronic problem)
3. In my previous case study of the 48 y.o male with viral pneumonia and as well as in  this case blood results show declining of the leukocytes and neutrophils- the natural body defense cells. Most likely, the Damp-Toxin  aggressively damages Zhen Qi or body immune system, especially if the course of the disease lasts more than a week or even less in some cases.  Bu Zhong Yi Qi wan or other Qi boosting herbs should be added to the treatment plan as soon as any Qi deficiency signs are shown or if the disease lasts more than a week or even earlier.
4. Due to the fact that Sars-CoV-2’s spikes are covered with sugar -like substances, called glycans, it allows the virus to pass immune cells undetected. Therefore the diet is very important and patient should avoid sugar in any forms, especially monosaccharides, include glucose, fructose, and galactose. Due to holidays season, patient consumed candies and her symptoms and fever got worse.

References:

1. Li LC, Zhang ZH, Zhou WC, et al. Lianhua Qingwen prescription for Coronavirus disease 2019 (COVID-19) treatment: Advances and prospects. Biomed Pharmacother. 2020;130:110641. doi:10.1016/j.biopha.2020.110641
2. Wei, Pei-Fang Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 7), Chinese Medical Journal: May 5, 2020 – Volume 133 – Issue 9 – p 1087-1095 doi: 10.1097/CM9.0000000000000819
3. Dr Jin Zhao, Chris Flanagan. Approaching covid-19 as damp toxin. The Lantern. Volume 17 No.2a Online issue March 2020 ISSN 1449-2717
4. Exploring Novel Corona virus Pneumonia- A Wen Bing Epidemic Disease. By: Keren Zelicha. By: Keren Zelicha. https://www.sinimed.co.il/en/internal_medicine/exploring-novel-coronavirus-pneumonia-a-wen-bing-epidemic-disease/
5. Bowei Qin, Boping Wu .Qin Bo-Wei’s 56 Treatment Methods: Writing Precise Prescriptions.  Translated by Jason Blalack Paperback – Eastland Press, 2011
6. “Early stages of a warm epidemic From the Treatise on Warm Epidemics by Wu Youke, 1640. Wen Yi Lun 溫疫論 by Wú Youxíng 吳有性 (aka 吳又可 Wú Yòukě)”. Translation by Steve Clavey. The Lantern. Volume 17 No.2a Online issue March 2020 ISSN 1449-2717
7. Modern Tongue Diagnostics in Chinese Medicine by Hong Chun Yin. 2018 ISBN 1717777058 (ISBN13: 9781717777058
8. UC San Diego News Center. Sugar-Coating Disguise Allows for Coronavirus Infection. By Jorge Salazar and Cynthia Dillon. Jun 18, 2020
9. Zhong LLD, Lam WC, Yang W, Chan KW, Sze SCW, Miao J, Yung KKL, Bian Z, Wong VT. Potential Targets for Treatment of Coronavirus Disease 2019 (COVID-19): A Review of Qing-Fei-Pai-Du-Tang and Its Major Herbs. Am J Chin Med. 2020;48(5):1051-1071. doi: 10.1142/S0192415X20500512. PMID: 32668969.
10. Zheng S, Baak JP, Li S, Xiao W, Ren H, Yang H, Gan Y, Wen C. Network pharmacology analysis of the therapeutic mechanisms of the traditional Chinese herbal formula Lian Hua Qing Wen in Corona virus disease 2019 (COVID-19), gives fundamental support to the clinical use of LHQW. Phytomedicine. 2020 Dec;79:153336. doi: 10.1016/j.phymed.2020.153336. Epub 2020 Sep 6. PMID: 32949888; PMCID: PMC7474845.