Allergic Rhinitis Case Report

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1 Allergic Rhinitis Case Report (A) Diagnoses of Diseases and Patterns Pattern/Syndrome Differentiation Analysis Allergic rhinitis is due to an invasion of External Wind Cold or Heat (exopathogens) with an underlying Lung Qi deficiency that in some cases is further complicated by the deficiency of the Spleen or Kidney. 1. Lung Qi Deficiency Deficiency of the lungs can be attributed to genetics, chronic lung disease, and excessive or insufficient exercise. The Lung Qi is further affected by emotions of grief or sadness. The persons with deficient Lung Qi can also suffer from a deficiency of Defensive Qi (Wei Qi) and thus be susceptible to External Wind (exopathogens). Typical symptoms include physical and mental fatigue, apathy, sweating with minimal exertion, and an inclination to catch colds. 2. Spleen Qi Deficiency The functioning of the Spleen is impaired by over-thinking, poor eating habits, and the consumption of foods that contribute to dampness and phlegm within the body. Foods that can aggravate the digestive system are greasy, fried, spicy and cold foods, as well as sweets, dairy products and alcohol. Strong fumes such as cigarette smoke can also irritate the nasal passages and contribute to more nasal congestion. 3. Kidney Deficiency A deficiency of the Kidneys may be due to hereditary conditions, chronic illness, aging, overwork, and sudden fright. In cases where the condition is genetic, allergic conditions often begin during childhood. Since the Kidneys are the source of all Qi (Primordial Qi) within the body, a deficiency of the Kidneys can also disrupt the functioning of the Lung's Defensive Qi (which comes from Primordial Qi). This condition frequently occurs in persons who also have a condition of asthma or eczema, and can arise from one of the earlier syndromes discussed. [1]-[5] Research Findings: 1. Study of Maciocia Allergic rhinitis is due to an antigen-antibody reaction in the nasal mucosa. If the antigens responsible are only pollen particles then it causes seasonal allergic rhinitis (hay fever). If the antigens are dust, house-dust mites faecal matter, fungal spores and animal dander, it causes perennial allergic rhinitis. Allergic rhinitis develops as a result of the interaction between the inhaled allergen and adjacent molecules of IgE antibodies. These adhere to the surface of the mast cells which line the nasal epithelium with the first exposure to the offending allergen. After the first exposure, the mast cells are primed, i.e. high levels of IgE antibodies adhere to their surface. With subsequent exposure to allergens, the IgE antibodies provoke an "explosion" in the mast cells with the massive release of histamine. Histamine itself causes an increase in permeability of the epithelium allowing allergens to reach IgE-primed mast cells. Sneezing results from overstimulation of the afferent nerve endings and starts within minutes of the allergens entering the nose. This is followed by a greatly increased nasal secretion and eventually nasal blockage about minutes after contact with the allergen. [6] 1

2 [figure 1] Antigen-antibody reaction in allergic rhinitis [7] 2. Thick and Sticky Nasal Discharge It is accompanied by nasal obstruction and loss of the sense of smell. Etiology and Pathogenesis Occurrence of thick and sticky nasal discharge is related to the attack of pathogenic factors on the lung which has its specific body opening in the nose. Exogenous wind cold may transform into heat. Sometimes, the lung is directly attacked by wind heat. Both may lead to dysfunction of the lung and invasion of the pathogenic factors upon the nose through the upper respiratory tract. Differentiation [Main manifestations] Nasal obstruction, loss of the sense of smell, yellow fetid nasal discharge, thick and sticky, accompanied by cough, dull pain in the forehead, rapid pulse, reddened tongue with thin, white and sticky coating. [Analysis] Pathogenic heat accumulated in the lung impedes the descending of the lung Qi, then pathogenic heat rushes up to the nose, causing nasal obstruction. Pathogenic heat consumes the body fluid and changes it into phlegm and mucus, so there is turbid and fetid nasal discharge. Cough results from adverse flow of the lung Qi. When extreme heat in the lung and stomach further disturbs the upper orifices, pain with distension occurs in the forehead. Reddened tongue and rapid pulse are signs of pathogenic heat in the lung. Treatment [Method] Points of the Hand-Taiyin and Hand-Yangming Meridians are selected as the principal points to smooth the flow of the lung Qi and expel pathogenic wind heat by applying the reducing method. [Prescription] Liegue (LU 7), Yingxiang (LI 20), Bitong (Extra), Hegu (LI 4), YIntang (Extra). [Explanation] Liegue (LU 7) smooths the flow of the lung Qi and eliminates the pathogenic wind. The Hand-Yangming Meridian is exteriorly-interiorly related to the Hand-Taiyin Meridian, and travels by the sides of the nose. So Hegu (LI 4) and Yinxiang (LI 20) are selected to regulate the Qi circulation in the Hand-Yangming Meridian and to clear away the heat from the lung. Yintang (Extra) is close to the nose, and Bitong (Extra) is located at the sides of the nose. Both have the action of removing the obstruction and eliminating heat from the nose. Remarks This condition corresponds to chronic rhinitis and chronic nasosinusitis in modern medicine. [8] 3. According to Principles and Practice of Eastern Medicine ( 東醫寶鑑 ) that was published in 1613 in Korea and was recommended for inclusion in the Memory of the World Register as the Documentary Heritage of UNESCO in 2009, the pulse and the formulas of allergic rhinitis are as follows; 2

3 [Pulse Diagnosis] (1) If the left cun pulse is superficial (fu mai) and moderate (huan mai), it is invaded by wind. In this case, the nose is obstructed and the discharge comes out of the nose. (2) If the right cun pulse is superficial (fu mai) and surging (hong mai) as well as rapid (shu mai), the nose bleeds and the end of nose becomes reddish. [Formulas] (1) Turbid and fetid nasal discharge (Bi Yuan, 鼻淵 ) Hunag Lian Tong Sheng San( 黃連通聖散 ), Fan Feng Tang ( 防風湯 ), Cang Er San ( 蒼耳散 ), Jing Jie Lian Qiao Tang ( 荊芥連翹湯 ) (The heat in the gall bladder goes to the head and the turbid nasal discharge isn t stopped. In severe cases a nose bleed occurs.) (2) Clear nasal discharge (Bi Qiu, 鼻鼽 ) Chuan Jiao San ( 川椒散 ) (Clear discharge from nose attacked by External Wind) (3) Nasal obstruction (Bi Sai, 鼻塞 ) Gong Qigong San ( 芎藭散 ), Wen Fei Tang ( 溫肺湯 ), Wen Wei Tang ( 溫衛湯 ), Tong Qiao Tang ( 通竅湯 ), Chang Pu San ( 菖蒲散 ) (Lung is hurt by Wind Cold, and then fluids (Jinye) are not circulated well and spleen Qi is not distributed, so that we don t smell well.) [9] [Table] Formulas of Allergic Rhinitis Hunag Lian Tong Sheng San ( 黃連通聖散 ) Fan Feng Tang ( 防風湯 ) Cang Er San ( 蒼耳散 ) Jing Jie Lian Qiao Tang ( 荊芥連翹湯 ) Chuan Jiao San ( 川椒散 ) Gong Qigong San ( 芎藭散 ) Wen Fei Tang ( 溫肺湯 ) Wen Wei Tang ( 溫衛湯 ) Tong Qiao Tang ( 通竅湯 ) Chang Pu San ( 菖蒲散 ) Fang Feng Tong Sheng San ( 防風通聖散 ) + Hunag Lian, Bo He Ye (Hua Shi, Ji Gan Cao, Shi Gao, Huang Qi, Jie Geng, Fang Feng, Chuan Xiong, Dang Gui, Chi Shao, Da Huang, Ma Huang, Bo He, Lian Qiao, Mang Xiao, Jing Jie, Bai Zhu, Zhi Zi + Hunag Lian, Bo He Ye) Fang Feng, Huang Qin, Chuan Xiong, Mai Men Dong, Ji Gan Cao Bai Zhi, Xin Yi, Cang Er Zi, Bo He Jing Jie, Chai Hu, Chuan Xiong, Dang Gui, Sheng Di Huang, Chi Shao, Bai Zhi, Fang Feng, Bo He, Zhi Zi, Haung Qin, Jie Geng, Lian Qiao, Gan Cao Qian Cao, He Zi Rou, Gan Jiang, Gui Xin, Chuan Xiong, Xi Xin, Bai Zhu, Chuan Xiong, Bing Lang, Ma Huang, Rou Gui, Fang Ji, Mu Tong, Xi Xin, Bai Zhi, Shui Chang Pu, Mu Xiang, Qian Cao, Gan Cao, Sheng Jiang, Zi Su Ye Ma Huang, Huang Qi, Sheng Ma, Fang Feng, Ge Gen, Qiang Huo, Ji Gan Cao, Ding Xiang Dang Gui, Huang Qi, Cang Zhu, Sheng Ma, Zhi Mu, Chai Hu, Qiang Huo, Ren Shen, Fang Feng, Huang Bai, Bai Zhi, Huang Bai, Ze Xie, Gan Cao, Chen Pi, Qing Pi, Hunag Lian, Mu Xiang Fang Feng, Qiang Huo, Gao Ben, Sheng Ma, Ge Gen, Chuan Xiong, Cang Zhu, Bai Zhi, Ma Huang, Qian Cao, Xi Xin, Gan Cao, Sheng Jiang, Cong Bai Shui Chang Pu, Zao Jia 4. Studies of Two Korean Researchers The modern clinical study was done as a preliminary treatment for rhinitis with oriental medicine. Two Korean researchers analyzed 73 patients with sneezing, nasal discharge and nasal obstruction, who had visited Dept. of Internal Medicine Hospital of Oriental Medicine, Dong-Eui University ( 東醫大學校 ) from Jan. 1, 1993 to Dec. 31, The results were obtained as follows; (1) In the sex ratio, man was higher than woman as 2.31:1 and in age distributions, below 10 years of age was the top 30.14%. (2) In duration of history, over one year was the top 64.38%. (3) The most common symptoms were nasal discharge and nasal obstruction 94.52%. (4) In the frequency of treatments, the cooler season had more than the warmer season. (5) In the treatments of Medi-acupuncturist, most of acupuncture therapy was done less than 5 times and Jia Wei Xian Wu Tang ( 加味仙烏湯, 62.90%) was most used in prescriptions. And then Bu 3

4 Zhong Yi Qi Tang ( 補中益氣湯, 12.90%), Li Ze Tong Qi Tang ( 麗澤通氣湯, 4.84%), Jia Wei Er Chen Tang ( 加味二陣湯, 4.84%) in order of quantity. (6) In the case of applying to Jia Wei Xian Wu Tang, nasal discharge was the most relieved symptom. [10] 5. Allergic Rhinitis is also called Hypersensitive or Reactive Rhinitis, and Belongs to Nasal Sneezing ( 鼻嚔, Bi Ti). [Synopsis] There is a sensitive medical history of individual or family. The symptoms are as follows: paroxysmal and sneezing, running clear discharge from the nose, itching in the nose, nasal obstruction. In case of an outbreak in the nasal mucous membrane, a purple-gray swelling can occur in the nose. Otherwise the nose remains in a normal state. There is a lot of eosinophil in the nasal mucous. Skin tests and sensitivity tests assist in the diagnosis. [Diagnosis] Lung and Spleen Qi deficiency ( 肺脾氣虛證 ). [Treatment Principles] Strengthens the Spleen and tonifies Lung, Augment the Qi. [Formulas] Modification of Bu Zhong Yi Qi Tang ( 補中益氣湯 ) and Yu Ping Feng San ( 玉屛風散 ). [11] [Bu Zhong Yi Qi Tang] This is the most famous formula composed by Li Dong-Yuan ( 李東垣, also known as Li Gao) one of the four great masters of the Jin-Yuan era, who is widely regarded as the founder of the tonify the earth current ( 補土派 ) in TCM. [12] Western Differential Diagnosis: 1. Allergic rhinitis is a group of symptoms affecting the nose. These symptoms occur when you breathe in something you are allergic to, such as dust, animal dander, or pollen. Symptoms can also occur when you eat a food that you are allergic to. This article focuses on allergic rhinitis due to plant pollens. This type of allergic rhinitis is commonly called hay fever or seasonal allergy. (1) Causes An allergen is something that triggers an allergy. When a person with allergic rhinitis breathes in an allergen such as pollen, mold, animal dander, or dust, the body releases chemicals that cause allergy symptoms. Hay fever involves an allergic reaction to pollen. Plants that cause hay fever are trees, grasses, and weeds. Their pollen is carried by the wind. (Flower pollen is carried by insects and does not cause hay fever.) Types of plants that cause hay fever vary from person to person and from area to area. The amount of pollen in the air can affect whether hay fever symptoms develop. Ø Hot, dry, windy days are more likely to have a lot of pollen in the air. Ø On cool, damp, rainy days, most pollen is washed to the ground. Hay fever and allergies often run in families. If both of your parents have hay fever or other allergies, you are likely to have hay fever and allergies, too. The chance is higher if your mother has allergies. (2) Symptoms Symptoms that occur shortly after you come into contact with the substance you are allergic to may include: Ø Itchy nose, mouth, eyes, throat, skin, or any area Ø Problems with smell Ø Runny nose Ø Sneezing Ø Watery eyes Symptoms that may develop later include: Ø Stuffy nose (nasal congestion) Ø Coughing Ø Clogged ears and decreased sense of smell Ø Sore throat Ø Dark circles under the eyes 4

5 Ø Puffiness under the eyes Ø Fatigue and irritability Ø Headache (3) Exams and Tests The health care provider will perform a physical exam and ask about symptoms. You will be asked whether your symptoms vary by time of day or season, and exposure to pets or other allergens. Allergy testing may reveal the pollen or other substances that trigger your symptoms. Skin testing is the most common method of allergy testing. If your doctor determines you cannot have skin testing, special blood tests may help with the diagnosis. These tests, known as IgE RAST tests, can measure the levels of allergy-related substances. A complete blood count (CBC) test called the eosinophil count may also help diagnose allergies. [13] 2. The IgE Link and Allergy Shot Allergies depend on an IgE response that causes mast cells to release irritating and inflammatory chemicals that in turn cause airway inflammation and constriction. Western doctors can test for levels of IgE in the blood and skin, and indeed, this is one way that they determine if a person has allergies. Examining levels of IgE antibodies in the blood has also helped reveal the link between asthma and allergies. In one study published by the American Lung Association, western doctors found that children born to parents with high IgE levels were more likely to develop asthma. After looking at more than 1,000 children in Tuscon, Arizona, western doctors found that parents with the highest blood levels of IgE antibodies were most likely to have children with asthma; even those parents with only moderate levels of IgE antibodies were more likely to have children with asthma than those with low IgE levels. [14] [figure 2] Allergens lock on to receptors on mast cells, causing them to release chemicals that cause on asthma attack. [15] People with asthma and allergies may react to allergens because they lack parts of the immune system that turn off an IgE response. Western doctors believe there may be at least two parts of the immune system that do not adequately inhibit the effects of IgE in people with allergies and allergy-triggered asthma. Allergy shots are thought to work by boosting the immune system to better inhibit the effect of IgE. [16] 3. Hay Fever and Allergic Rhinitis When people think of allergies one of the most common images which comes to mind is hay fever. Western medically characterized as a form of allergic rhinitis (allergy plus inflammation of the nose) this condition is usually accompanied by sneezing, a runny nose, watery eyes, and, in some cases, fever. In hay fever, the nasal mucosa secretes a combination of mucus and a clear, watery fluid; conjunctival irritation leads to watery and itchy eyes; and sometimes there is ear pain along with the sensation of ear pressure. Overall, the afflicted person may experience fatigue, irritability, moodiness, 5

6 and headaches. Hay fever is marked by recurrence during the pollen seasons, primarily spring and summer. Another form of allergic rhinitis, called nonseasonal or perennial allergic rhinitis, occurs yearround and bears symptoms identical or hay fever. Whereas hay fever is thought to be caused by pollen, the perennial type is presumably due to other allergens such as foods, dusts, molds, and chemicals. The term hay fever originally described the feverish symptoms experienced during English hay harvests. In those days people thought the hay itself caused the fever. Eventually, it was learned that the symptoms were actually induced by pollen or grass or trees. For this reason, to the present day, it is still believed that hay fever is caused by pollen. However, this explanation is shortsighted, and only designates the superficial cause. If pollen were the true cause then everyone would develop hay fever. It is true that certain allergic antibody (IgE) and allergens (e.g., pollens) interact to elicit the hay fever response; but the real cause is that which leads to the susceptibility to hay fever, an overly yin, sticky blood quality localized in the respiratory tract and mucus membranes. The hay fever individual, like all allergy-prone people, is faced with an interesting set of decisions when the causative factors of his condition are revealed. If, for instance, a man in eastern Oregon is told by his western doctor that he is allergic to the pollen of the juniper and cedar trees, he may consider moving to an area free of these trees. However, if this man is a lumberjack, then he may also have to consider changing his occupation, since carrying along allergy drugs in the woods may prove too burdensome or impractical (lumberjacks must be able to maneuver about easily in tight places). More common is the case of a farmer or gardener with a severe allergy to grasses or weeds. These people may be compelled to change both their residence and their occupation if the condition is too inhibitory; and even when such adjustments are made, the relief from symptoms is almost always temporary. Because of their predisposition or susceptibility to allergy they will in all probability develop a new allergy they will in all probability develop a new allergic symptom when exposed to a new pollen, dust, or mold. At the extreme, there appears to be no alternative but to live in a completely sterile environment. [17] Western Medicine Disease Names: 1. Coryza vasomotoria (ICD-9 Codes 487.1) 2. Upper respiratory tract infection (ICD-9 Codes 487.1) 3. Exposure to stimulant (ICD-9 Codes 995.3) 4. Medicamentous rhinitis (ICD-9 Codes 487.1) 5. Non-allergic rhinitis with accompanied by eosinophilia (ICD-9 Codes 487.1) 6. Rhinitis due to beta agonist (ICD-9 Codes 477.9) TCM Patterns (Pattern/Syndrome Differentiation): 1. Lung cold, especially due to lung Qi deficiency 2. Spleen Qi deficiency 3. Kidney deficiency (P) Treatment Treatment Principle: 1. Strengthens spleen and tonifies lung, invigorates Qi and strongly augments the Qi, strengthens Wei Qi and expels wind 2. Strengthens Qi and dispels cold, warms and tonifies the kidney yang, expels wind and unblocks nasal passages Treatment Plan: 1. [Father] The patient needs to be treated with Acupuncture and Herbal Formulas for at least 3 months. 2. [Daughter] She needs to be treated with only Herbal Formulas (for at least 3 months) because that she is so young and is afraid of the needles. 6

7 Acupuncture Points: 1. Open nasal passages, disperse wind heat: LI Unblock nasal obstruction and remove rhinitis: Bitong 3. Resolve head heaviness and rhinorrhea, calm the spirit: Yintang 4. Unblock nasal passages, remove rhinitis and rhinorrhea: DU Expels wind and unblocks nasal passages: LU 7, LI 4 6. Remove rhinitis and rhinorrhea: Tung s points Simazhong(88.17, 駟馬中 ), Simashang(88.18, 駟馬上 ), Simaxia(88.19, 駟馬下 ) Herbal Prescription: Bulk: [Father] Modification of Bu Zhong Yi Qi Tang ( 補中益氣湯 ) and Yu Ping Feng San ( 玉屛風散 ) (Huang Qi 15g, Hong Shen 6g, Ji Gan Cao 6g, Bai Zhu 6g, Dang Gui 6g, Chen Pi 9g, Sheng Ma 3g, Chai Hu 3g, Fang Feng 6g, Yu Gen Pi 15g, Wu Jia Pi 20g, Xin Yi 10g, Cang Er Zi 6g, Xi Xin 3g, Gao Ben 6g, Bo He 4g, Mu Xiang 8g, Sha Ren 8g, Sheng Jiang 3 pcs, Da Zao 2 pcs) [Daughter] Modification of Bu Zhong Yi Qi Tand Chun Fang ( 補中益氣湯春方 ) (Huang Qi 3g, Hong Shen 3g, Bai Zhu 3g, Ji Gan Cao 3g, Dang Gui 3g, Chen Pi 2g, Sheng Ma 2g, Chai Hu 2g, Mai Men Dong 3g, Jing Jie 2g, Bo He 2g, Gan Jiang 2g, Xin Yi 2g, Chuan Xiong 2g, Mu Xiang 2g, Mai Ya 2g, Da Zao 1 pc) Recommendations/Nursing/Lifestyle Advice: 1. I recommended the improvement of indoor environment, exchange of indoor air, frequently cleaning of comforter and pillows, cleaning carpet, reducing contacts with material causing allergy (e.g., pollen), regular life style, frequently washing hands, etc. 2. [Father] Qi Gong exercise, stretching and running are recommended. And in order to strengthen his immune system, high quality probiotics (unit 50 billion or 75 billion) for at least 1 month was recommended to the patient. 3. [Daughter] She was recommended to change her room environments and to wash her face as soon as returns home from going out due to possible exposure to allergy-causing materials. Remarks: 1. [Father] He has visited me 5 times since Feb and his nasal obstruction symptoms has not improved much. However, he is suffering less from the rhinitis than last year. 2. [Daughter] She has visited me 6 times sinec Jan and her symptoms have improved a lot. She now rarely gets a runny nose and watery eyes. References: 1) Krapp, K., Longe, J.L. (editors) (2001), Gale Encyclopedia of Alternative Medicine (volume 1), Detroit, Gale Group. 2) Maciocia, Giovanni (1994), The practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs, Edinburgh, Churchill Livingstone, pp ) Maclean, W., Littleton, J. (1998), Clinical Handbook of Internal Medicine-the Treatment of Disease with Traditional Chinese Medicine (volume 1), Sydney, University of Western Sydney. 4) Phillips, S. Allergic Rhinitis and Acupuncture, Accessed from 5) Ying, Z.Z., De, J.H. (1997), Clinical Manual of Chinese Herbal Medicine and Acupuncture, New York, Churchill Livingstone. 7

8 6) Maciocia, Giovanni (2007), The practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs, Edinburgh, Churchill Livingstone, p ) Maciocia, Giovanni (2007), The practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs, Edinburgh, Churchill Livingstone, p ) Deng Liangyue, Gan Yijun,He Shubui, Ji Xiaoping, Li Yang, Wang Rufen, Wang Wenjing, Wang Xuetai, Xu Hengze, Xue Xiuling and Yuan Jiuling (2010), Chinese Acupuncture and Moxibustion 3 rd Editon, Foreingn Language Press, Beijing, p ) Heo, Jun (2005), Principles and Practice of Eastern Medicine ( 東醫寶鑑, Korean Language edition), Yeogang Publishing Co., Seoul, pp ) Lee, Seun-Yeon, Park, Dong-Ill (1995), A Clinical Study on the Patients with Rhinitis (The Journal of Korea Institution of Oriental Medicine), Korea Institution of Oriental Medicine, Seoul, pp ) Kim, Gap-Seong, Kim, Yun-Beom, Kim, Jang-Hyeon, Lee, Won-Cheol, Lim, Yang-Geun, Jeong, Chan-Gil (2001), Practical Eastern-Western Medicine Clinical Series (Korean Language edition, Volume 7 of 9), Jeong-Dam Publishing House, Seoul, pp ) Volker Scheid, Dan Bensky, Andrew Ellis, Randall Barolet (2009), Chines Herbal Medicnie Formulas & Strategies (2 nd edition), Eastland Press, Inc., Seattle, p ) 14) The American Lung Association Asthma Advisory Group with Norman H. Edelman, M.D. (1997), Family Guide to Asthma and Allergies, Life Time Media, Inc., pp ) The American Lung Association Asthma Advisory Group with Norman H. Edelman, M.D. (1997), Family Guide to Asthma and Allergies, Life Time Media, Inc., pp ) The American Lung Association Asthma Advisory Group with Norman H. Edelman, M.D. (1997), Family Guide to Asthma and Allergies, Life Time Media, Inc., pp ) Michio Kushi (1985), A Natural Approach Allergies, Japan Publications, Inc., Tokyo and New York, pp

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