How do we treat Covid-19 with Chinese Medicine?

This is a question posed on my recent Chinese Herbal Medicine course.  I’m posting my answer to show the sort of thinking that goes into how we choose a herbal formula in Chinese Medicine.  There are many different herbs and formulae that can be chosen for Covid-19.  A formula is a decoction of herbs that work together to treat a specific pattern.  We go by the presenting signs and symptoms rather than the diagnosis of Covid-19.  We treat yin and yang, hot and cold, and so on rather than a medical diagnosis.

So the question for the essay was:

Using the knowledge learnt in this module, analyse the case below and prescribe the herbs accordingly. Please choose one question to answer:

Case study one: 56 year old female has a cough, shortness of breath and has had a body fever for 7 days.

The patient tested COVID-19 positive about 7 days ago. She has a body temperature ranging from 37.6-39.5°C, normally with the temperature getting higher in afternoon. She has taken some medicine to help the body temperature, but the cough and breathlessness are getting worse. She is also suffering from extreme fatigue, slight thirst, and poor appetite. She sweats when she takes paracetamol, otherwise she does not sweat.

From a picture she provided via email, she has a flushed face and looks tired. The tongue is red and plump, and the edges of the tongue are full and smooth. The coating of the tongue is thin, and the upper half of the tongue appears furless.

Differentiation of Symptoms and Signs in a case of Covid-19.

Obstruction of Lung Qi “impairs the descending of Lung Qi and it causes cough and breathlessness” (Maciocia, 2015).

A body fever of 7 days is an acute fever.  Acute fever is defined as one of no more than 7 – 10 days’ duration; if it persists beyond 14 days it is considered chronic.  The traditional designation of acute fever is ‘external damage’ (wài shāng fā rè).  Fever of this type is typically analysed according to the guidelines laid down in classical texts that deal with external pathogenic invasion (Discussion of Cold Induced Disorders – Shang Han Lun; Discussion of Warm Heat Pathogen Disorders – Wen Re Lun).  (Maclean, 2018)

According to W.H.O., Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus.

Most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment. However, some will become seriously ill and require medical attention. Older people and those with underlying medical conditions like cardiovascular disease, diabetes, chronic respiratory disease, or cancer are more likely to develop serious illness.

(Organisation, 2022)

Our patient has fever, cough and fatigue which are common symptoms, as well as shortness of breath which is a serious symptom. (Organisation, 2022)

The fever, which varies from 37.6 – 39.5 °C, is a moderate to nearly very high fever.  According to Maclean et al:

• Very High Fever of 40° C can indicate severe disease. The patient’s resistance is strong and the struggle fierce, but yin and fluids may be damaged to the point of collapse.  Our patient is within half of a degree of this at times, which for a 56-year-old is a very high fever, and she may already be yin deficient as she will be menopausal.
• Moderate Fever of 37.2 – 39°C may indicate a mild or early stage of an infectious process, or the muted response of weak anti-pathogenic qi in a compromised, very young or elderly individual. (Maclean, 2018)

The patient’s temperature is higher in the afternoon which may, or may not, suggest that there is some yin deficiency.

Her temperature tells us that she is suffering from an invasion of Heat.  There are no chills, so the Heat is internal.  We know she has an external invasion by a pathogenic factor as she tested positive for Covid-19. Continuous fever with no chills or aversion to cold are experienced when a pathogen has broached the surface defences of the body and entered the interior: the qi level, yang ming, nutritive or blood levels.  The battle between the pathogen and normal qi is at its zenith, reflected in the vigour of the fever.  (Maclean, 2018)

Fatigue is normal when there is a fever as the body’s energies are all directed at fighting the pathogen, but it could also be a sign that the heat is depleting fluids, blood, and or yin.

The patient has slight thirst. There is thirst at the qi level.  This is very pronounced at the Yang Ming level, but our patient’s symptoms are more indicative of Lung Heat – as discussed below.

Poor appetite is normal when there is a fever and suggests Heat is disturbing the normal qi mechanism of the stomach.

She sweats when she takes paracetamol, otherwise she does not sweat.  Qi level heat in the Lungs is characterised by sweating in the early stages, less so as fluids are damaged.  There may be night sweats.  (Maclean, 2018)

In Chinese medicine paracetamol is described as having a cold temperature.  (Chen, 2022)  Cold medicinals may clear heat (Yang, 2010). Qi level heat can quickly deplete fluids, especially if there is pre-existing yin deficiency (Maclean, 2018).  I think in this situation the paracetamol is clearing heat and moving the patient away from the level of nutritive and blood levels and more towards the upper part of the qi level.

The tongue is red and plump which suggests there is heat and Phlegm (Maciocia, 2015).  The edges of the tongue are full and smooth, which suggests a full condition of the lungs. (Lungs at the front of the tongue, liver and gallbladder slightly further back.  There are no other signs of liver or gallbladder pathology) (Maciocia, 2015).  The coating is thin, so no significant signs of Damp.  The upper half appears furless with suggests a fluid and yin deficiency (Maciocia, 2015).

Flushed face suggests Heat (yin deficient heat if just on the cheeks)

Qi Level

In warm disease level the first level is the protective, or wei qi level.  Wind-Heat manifests as fever, chills and aversion to cold.

The qi level lies between the surface and the deep yin organs.  It is here that the body mounts its most robust defence against invading pathogens.  The fever and potential for damage is at their zenith.  In terms of depth, the qi level corresponds primarily to the more superficial and exposed organ systems: the Lungs, Spleen, Stomach, and Intestines.  Qi-level pathology reflects the presence of a heat pathogen affecting these organ systems and their related tissues, so in addition to the fever, respiratory, gastrointestinal, skin and muscle symptoms are seen.  In this case we are seeing lung issues which suggest Heat in the Lungs.  The clinical features according to Maclean et al are:

• Continuous moderate to high fever with sensation of heat in the chest and hacking unproductive cough.
• Sweating in the early stages, less so as fluids are damaged; possible night sweats
• Dry mouth and thirst
• Tongue is red or with a red tip and a dry, yellow coat.

With respect to our patient

1. we don’t know if the cough is dry or productive. A variant of Heat in the Lungs is Phlegm-Heat in the lungs – where the cough is more productive.  The swollen tongue suggests Phlegm is present(Maciocia, 2015)
2. There is probably no yellow coat because of damage to body fluids. Heat at the nutritive level is the later and critical stage of an acute febrile disease.  The clinical manifestations are fever that worsens at night, severe irritability, restlessness, delirium and indistinct erythema and purpura.  The tongue body is deep red without a coating; the pulse is thready and rapid. (Yang, 2010)

So, to conclude, the patient has a pathogen at the Qi level causing Heat in the Lungs and stomach; almost certainly Phlegm-Heat in the Lungs.  But there is also damage to fluids moving the patient towards the Nutritive and Blood level.

Treatment strategy.

Clear Heat from the Lungs and Stomach, restore the spreading and descending function of the lung, resolve phlegm, increase the body fluids and yin.

Treatment to clear heat at the Qi Level should use sweet, salty, pungent, and cold herbs to clear the heat, reduce fire, protect the body fluids, and vent the heat to the Defensive level and eliminate it.  (Yang, 2010)

For the heat at the Nutritive level herbs that are sweet, salty, bitter, and cold are used to reduce the fire and increase the body fluids and yin. (Yang, 2010)

Herbal Formula.

I am basing my formula on an herbal supplement created by Giovanni Maciocia (Maciocia, 2022) which he calls Clear Metal

 

Da Qing Ye  – Folium Isatidis                                                                           9g
Huang Qin  – Radix Scutellariae                                                                      6g
Lian Qiao –  Fructus Forsythiae                                                                       6g       

Ban Lan Gen  – Radix Isatidis                                                                          9g
Dan Zhu Ye –  Herba Lophateri                                                                       6g
Zhi Mu –  Rhizoma Anemarrhenae                                                                 6g
Jin Yin Hua –  Flos Lonicerae                                                                          6g
Yu Xing Cao –  Herba Houttuniae                                                                   15g
Sheng Di Huang  – Radix Rehmanniae recens                                             9g
Huang Lian –  Rhizoma Coptidis                                                                      6g
Chuan Bei Mu  – Bulbus Frittilariae cirrhosae                                             6g
Bai He  – Bulbus Lilii                                                                                             9g
Mao Dong Qing  – Radix Ilicis Pubescentis                                                    15g
Mu Dan Pi  – Cortex Moutan                                                                              6g

 

Decoct the herbs

Cover the herbs with water and gently boil for 20 minutes.  Strain, add another 200ml water, and cook for a further 20 minutes.  Mix the two decoctions and take twice a day.

Yu xing cao is added at the end and decocted for no more than 5 minutes. (Yang, 2010)

Pattern:

Invasion of Wind-Heat progressing rapidly into the Interior, with Lung and Stomach-Heat. Location of Heat at the Qi and Ying level. (Maciocia, 2022)

Action:

Release the Exterior, expel Wind-Heat, clear Lung-Heat at Qi Level, clear Ying, benefit fluids. (Maciocia, 2015)

Explanation:

This formula is for the sequelae of an external invasion of Wind. From the point of view of the 4 Levels, in the beginning stages of an external invasion of Wind, the pathogenic factor is at the Wei Level. If the Wind is not expelled, it penetrates into the Interior and it turns into Heat. As the pathogenic factor disrupts the function of the Stomach and Spleen, it often gives rise to Phlegm which then combines with Heat: this is the Qi Level. At the Qi Level, the tongue is red and has a thick-sticky yellow or brown coating.

Most people will recover at the Qi Level. If not, the Heat penetrates to a deeper level and it injures Yin: this is the 3rd or 4th level, i.e. Ying Level or Blood Level. At the Ying or Blood Level, the tongue is deep red and has no coating. (Maciocia, 2022)

• Huang Qin and Huang Lian resolve Dampness and clear Heat
• Jin Yin Hua, Lian Qiao, Da Qing Ye, Mao Dong Qing and Ban Lan Gen expel Toxic-Heat
• Zhu Ye, Yu Xing Cao and Zhi Mu clear Lung-Heat
• Chuan Bei Mu resolves Phlegm and restores the descending of Lung-Qi
• Sheng Di Huang and Bai He nourish fluids to protect from injury from Heat
• Mu Dan Pi clears Heat and cools Blood (Blood Level) (Maciocia, 2022)

Dà qīng yè is bitter, salty, very cold and enters the Heart, Lung and Stomach.  It strongly cools heat toxin or pathogenic heat in both the qi and blood levels. (Bensky, 2015)

Huáng qín, is bitter, cold.  It cools heat and dries dampness and is often used with huáng lián, which is also bitter and cold and cools heat, drains fire and dries dampness.  (Bensky, 2015)

Ban lan gen drains heat, resolves fire toxicity, cools the blood and benefits the throat. (Bensky, 2015)

Dan zhu ye, (often used instead of bamboo leaf) is sweet, cold and bland and leaches dampness and facilitates urination and treats irritability associated with heat. (Bensky, 2015)

Zhi mu, is bitter, sweet, and cold and clears fire and nourishes the yin of the lungs, stomach and kidneys and is a very important part of this formula. (Bensky, 2015)

Jin yin hua, honeysuckle flower, disperses heat, resolves toxicity, cools the blood, stops bleeding (if charred). Often used with huang qin and huang lian for unremitting high fever.

(Bensky, 2015)

Yu Xing Cao – clears Lung Heat (Bensky, 2015)

Sheng di Huang enriches the yin, cools the blood, and clears heat. (Bensky, 2015)

Chuan bei mu cools, moistens, directs the lung qi and heart fire downward to transform phlegm, alleviate cough, relieve constraint, and disperse clumped phlegm-heat (Bensky, 2015)

Bai he moistens the lungs, clears heat and stops cough and is especially useful when lung heat has injured the yin.

(Bensky, 2015)

Mao dong qing invigorates the blood, clears heat, resolves toxicity and stops coughs. (Bensky, 2015)

Mu dan pi clears heat and cools the blood for heat entering the blood level during a warm-heat pathogen disease. (Bensky, 2015)

Bibliography

Bensky, 2015. Chinese Herbal Medicine, Formulas and Strategies. 2nd ed. s.l.:Eastland Press.

Chen, D., 2022. Herbal Medicine Course. s.l., Phoenix Academy, Acupuncture & Herbal Medicine.

Maciocia, G., 2015. The Foundations of Chinese Medicine, a Comprehensive Text. 3rd ed. s.l.:Elsevier.

Maciocia, G., 2022. Giovanni Maciocia. [Online]
Available at: https://suwenpress.co.uk/product/clear-metal/
[Accessed Sunday February 2022].

Maclean, L. B. T., 2018. Clinical Handbook of Internal Medicine. 2nd ed. Seattle: Eastland Press.

Organisation, W. H., 2022. Coronavirus Diseased (Covid-19). [Online]
Available at: https://www.who.int/health-topics/coronavirus#tab=tab_1
[Accessed 23 February 2022].

Yang, Y., 2010. Chinese Herbal Medicines, Comparisons and Characteristics. 2nd ed. s.l.:Elsevier.

For a discussion of whether acupuncture can help with Long Covid please see this post