68-year old woman with fever and cough for a week

1. A Case Presentation of TCM
Treatment in COVID-19
68-year old woman with fever and cough for a week
Presenter: Chu-Feng Wu M.D.

2. Patient Profile
Name: 汪o珍
Chart number: 4701OOOO
Age: 68 years old
Gender: Female
Occupation: Retired from bank
Residence: Taipei city, Taiwan
Date of admission: 2021/06/13 via ER

3. Chief Complaint
Fever and cough for a week

4. Present Illness
05/29 The ADL of the patient is totally independent and lives alone.
She had incidentally contacted with confirmed cases in the
local market.
She developed fever with cough. Mild chest tightness was
also mentioned.
06/08
06/11 She then went to 市聯醫仁愛院區 where her COVID-PCR was
positive and CT value was 15. Therefore, she was quarantined.
06/13 She was then transferred to our ER due to desaturation(SpO2:
93%).

5. LAB DATA and IMAGE at ER(6/13)
CXR showed mild RLL infiltration.
WBC 3200 CRP 1.15
Hb 12.4 ESR -
Plt 76000 CK 111
Na 137 Procalcitonin 0.07
K 3.3 LDH 244
GLU 111 Total bilirubin 0.38
HbA1c - albumin -
Crea 0.67 Ferritin 590.0
eGFR 88 Lactate -
ALT 23 Trop. I <0.010
INR 1.11 CKMB 13
PT 11.9 CA -
APTT 34.9 Urine WBCPUS 0-5
D-DIMER - Urine protein +/- (15mg/dL)

6. Past History
1. HTN under Diltiazem 60mg/day
2. Dyslipidemia under Pitavastatin 4mg/day
3. Depression under Zoloft 50mg/day

7. Personal history
• Alcohol / betel nuts/ Cigarettes
Denied
• Food allergy / Drug allergy :
Denied
• Travel/Occupation/Cluster/Contact :
Had been to local market on 5/29
• Drug history:
Listed in past history

8. Review of Systems
• GENERAL : no body weight gain, no fatigue, no weakness, fever(+), no poor appetite , no
chillness
• HEAD : no trauma , no headache , no dizziness ,no syncope
• EYES : no photophobia, no blurring, no diplopia, no dry eyes, no ptosis, no pain , no eyelid
swelling
• EARS : no tinnitus, no otalgia, no otorrhea, no vertigo, no hearing impairment
• NOSE : no epistaxis, no nasal obstruction, no sinus problems, no sense of smell loss, no
rhinorrhea
• MOUTH : no bleeding gums, no voice change, no pain over the oral cavity and tongue, no
ulcerations over buccal mucosa
• NECK : no pain over the neck , no neck stiffness
• SKIN : no rashes, no pruritus, no bruising, no dryness , no itching, no cyanosis, no atrophy
• RESPIRATORY : no chest pain, no night sweats, cough(+), shortness of breath, breathing
discomfort

9. Review of Systems
• CARDIOVASCULAR: no exertional dyspnea, palpitation, chest tightness, no syncope ,no
fainting, no peripheral swelling
• GASTROINTESTINAL: no heart burn, no nausea or vomiting, no diarrhea, no constipation,
no melena, no clay-color stool, no abdominal pain
• GENITOURINARY: no frequency, no dribbling, no urgency, no dysuria, no hematuria, no
nocturia, no incontinence, no discharge
• ENDOCRINE: no polyuria, no polydipsia, no tremor, no heat intolerance
• MUSCULOSKELETAL: no trauma, no myalgia, no tenderness, no morning joint stiffness, no
numbness, no joint swelling, no muscle soreness
• HEMATOLOGY: no bleeding tendency , no gum bleeding , no anemia , no easy bruising
• NEUROLOGY :no seizure, no numbness, no slurring speech, no drug and alcohol problems
• PSYCHIATRIC : sleep disturbance, anxiety, depressive mood, no mood swing, no
abnormal speech, no abnormal behavior, no thought disturbance

10. Physical Examinations(via ER)
Cardiovascular
Extremities
HEENT
General condition
68 y/o woman
Body height:163cm
Body weight:54kg
BMI: 20.3
-Symmetric expansion
-Rales sounds
Chest
Abdomen
-Muscle power:5/5/5/5
-pink conjunctiva
-anicteric sclera
-regular heart beats
-no murmur
-normoactive bowel sounds
-soft and flat
-no tenderness, rebounding pain
-Acute ill-looking
-E4V5M6

11. Hospital Course
Under the impression of COVID-19 related pneumonia, she was
admitted to our ward for further treatment.
06/13

12. Hospital Course
After admission, she was under room air initially with fair
saturation (97- 98%).Besides, intermittent fever and chest
tightness was complained.
• Supportive care was given  prone position was tried initially.
06/13
However, progressive dyspnea.
• Ventri-mask 40% was used for respiratory support.
06/16
laboratory data showed increased CRP level and chest plain
film showed progressive bilateral increased infiltration.
• Dorisone and Remdesivir were initiated along with
ceftriaxone as empirical antibiotics.
06/17 Her family asked for TCM consultation.

13. TCM Inspection
General appearance
• Poor spirit
• Pale face
• Prone position
• Medium body weight
Tongue feature
• Unavailable

14. TCM Auscultation and Olfaction
Auscultation
• Sputum-like sound
Olfaction
• Unavailable

15. TCM Inquiry
Symptom patterns
• Fever up to 39 degree Celsius and sweat a lot
• Short of breath with much sputum production
• Feel anxious and look at the oximeter frequently
• Palpitation
• Shallow sleep and easy to awake every hour
• Normal diet but diarrhea
• General weakness and soreness limbs
Menstrual status
• G1P1, menopaused at 49 year old

16. TCM Palpation
Pulse
• Unavailable
Tenderness
• Unavailable

17. TCM Syndrome Diagnosis
Lung-Qi dysfunction and Dampness-Heat
syndrome
ICD. 10: U07.1 COVID-19, virus identified.

18. TCM Treatment
Dispersing Lung-Qi to relieve asthma
• Qiang-huo 0.5g, Ge-gen 0.5g, Ma-huan 0.12g, Xing-ren 0.5g, Zi-wan
0.5g
Eliminating Dampness-Heat with aromatics
• Huo-xiang 0.5g, Sheng-jiang 0.5g, Ban-xia, Hou-po 0.5g
Others
• Ze-xie 0.5g, Chai-hu 0.5g, Huang-qin 0.5g, Xue-fu-zhu-yu-tang 0.5g

19. Hospital Course
High flow nasal cannula was used.
06/18
First prescription of Chinese medicine was given QID.
06/21
Her oygen demands decreased gradually, and nasal cannula
was tried in these days. Antibiotic was then shifted to oral
levofloxaxin.
06/25
Second prescription of Chinese medicine was given QID.
Follow-up laboratory data showed decreased CRP level. Besides,
we gradually tapered down the FiO2 supplied. Follow-up chest
plain film showed minimal improvement.
06/22
06/24
Due to elevated liver enzyme and CK level, pitavastatin was
discontinued.
06/27

20. Hospital Course
Third prescription of Chinese medicine was given QID.
06/28
She was no fever, smoothly breathing, vital signs stable, under
relatively stable condition, arrange discharge and OPD follow
up. Taken home last prescription of Chinese medicine.
07/07
Forth prescription of Chinese medicine was given QID.
Under ambient air. Repeated COVID PCR revealed positive(ct:35.56).
06/30
07/01
Rechecked covid PCR revealed positive(ct:33.61).
07/05
We also consulted psychiatrist for medication adjustment for
depression, added Lorazepam usage for anxiety state, R/O Panic
features. Now her mood has smooth, keep current treatment.

21. Sequential TCM Prescriptions
First prescription
• Qiang-huo 0.5g, Ge-gen 0.5g, Ma-huan 0.12g, Xing-ren 0.5g, Zi-wan 0.5g,
Huo-xiang 0.5g, Sheng-jiang 0.5g, Ban-xia, Hou-po 0.5g, Ze-xie 0.5g, Chai-
hu 0.5g, Huang-qin 0.5g, Xue-fu-zhu-yu-tang 0.5g
Second prescription
• FP add Ting-li seed 0.15g, remove Ge-gen 0.5g
Third prescription
• SP add Xiang-fu 0.5g, remove Qiang-huo 0.5g, Ze-xie 0.5g, Huo-xiang 0.5g
Sheng-jiang 0.5g
Forth and last prescription
• TP add Shi-chang-pu 0.33g, Yuan-zhi 0.33g, gui-zhi 0.25g, Fu-ling 0.33g

22. Discussion
TCM-base treatment in COVID-19 and
its sequel mental disorders

23. Theory from Chinese Medicine
Perspective
• Chinese medicine (CM) formulate treatment based on
symptom-based diagnosis
• COVID-19 patients with fever, dry cough, upper airway
congestion, shortness of breath are respiratory tract
infection-associated presentations,
• Patients co-presented with myalgia/arthralgia, anorexia,
gastrointestinal symptoms, thick greasy tongue fur, and
slippery pulse are further subclassified into dampness
subtype according to CM theory.

24. The pathogenesis of infectious
disease is correlated to the weather
• The weather in Wuhan in November was warmer than
expectation, reaching 27℃ and staying above 20℃ in
daytime during 1–16 November 2019. It sharply became
humid and cold since 24 November (18℃, 63% humidity)
reaching 4℃ and 89% humidity in daytime on 25
November until the end of November.
• The unusually warm temperature caused endogenous
stagnated heat in the human body, and the abrupt increase
in humidity and temperature drop increased the
susceptibility to exogenous cold-dampness.
• The timeline matched the outbreak started in late
November to early December.

25. The Internal Pathogenesis
• The core pathogenesis of COVID-19 is a dampness
pestilence caused by external cold-dampness distressing
lung and spleen, transforming to heat due to dysfunctional
qi activity and endogenous stagnated heat in CM theory.
• The corresponding treatment at the early stage should
target eliminating dampness and the strategy should focus
on eliminating dampness, releasing lungs and expelling
pathogenic factors, to shorten fever duration, relieve
symptoms, prevent disease progression, reduce mortality,
and assist rehabilitation.

26. The advantages of TCM in the
treatment of COVID-19
• Effective removal of the symptoms of suspected and
confirmed COVID-19, including fever, cough, shortness of
breath, fatigue, myalgia, nausea/vomiting or diarrhea, and
rhinorrhea (Hu et al., 2020; Xiao et al., 2020; Xin et al., 2020;
Zhao et al., 2020)
• Delaying the progression from mild and common to severe
and critical(Tian et al., 2020)

27. TCM herbal extracts or TCM-derived
Compounds with anti-HCoV Activity

28. Current recommended TCM

29. Inhibiting the spike
protein/ACE2
interaction, 3CL
protease activity,
viral plaque
formation, and
production of
cytokines
interleukin (IL)-6
and tumor necrosis
factor (TNF)-α
Mechanism

30. Stepwise Therapy by Stages
• By summarizing the clinical characteristics of patients with
COVID-19, academician Tong Xiaolin put forward the
theory of cold dampness epidemic and applied a series of
TCM drugs, such as Huoxiang Zhengqi Dropping Pills,
Lianhua Qingwen Granules, Hanshiyi Formula (HSYF), and
Tongzhi Granule, which were developed for different
stages, namely mild, moderate, severe, recovery stages, of
COVID-19(Zheng et al., 2021)
• COVID-19 Clinical Staging Guidelines in Taiwan:
https://www.nricm.edu.tw/p/406-1000-
6141,r11.php?Lang=zh-tw

31. Clinical Outcomes of 102 Cases
Letter to the Editor from Pharmacological Research
Traditional Chinese medicine for COVID-19 treatment
https://doi.org/10.1016/j.phrs.2020.104743

32. Ongoing TCM Clinical Trials for
Treatment of COVID-19
The Outcomes of
NRICM101 on SARS-
COV-2 (COVID-19)
Infection
ClinicalTrials.gov
Identifier:
NCT04664049

33. Treatment of mental disorders in
COVID-19 survivors
Ma K, Wang X, Feng S, et al. From the perspective of Traditional Chinese Medicine: Treatment of mental disorders in
COVID-19 survivors. Biomed Pharmacother. 2020;132:110810.

34. Treatment of mental disorders in
COVID-19 survivors
Ma K, Wang X, Feng S, et al. From the perspective of
Traditional Chinese Medicine: Treatment of mental
disorders in COVID-19 survivors. Biomed
Pharmacother. 2020;132:110810.

35. Take Home Messages
• CM has a good potential to complement the service need
as CM treatment relies on symptom-based diagnosis.
• Early reported benefits of CM included symptomatic relief,
shortening fever duration, reverting radiological changes,
and shortening hospital stay, similar to the SARS
management experience.
• Given the paucity of strongly evidence-based regimens, the
available data suggest that CM could be considered as an
adjunctive therapeutic option in the management of
COVID-19.

36. References
• Chan KW, Wong VT, Tang SCW. COVID-19: An Update on the Epidemiological,
Clinical, Preventive and Therapeutic Evidence and Guidelines of Integrative
Chinese-Western Medicine for the Management of 2019 Novel Coronavirus
Disease. Am J Chin Med. 2020;48(3):737-762.
• Sun QG, An XD, Xie P, et al. Traditional Chinese Medicine Decoctions Significantly
Reduce the Mortality in Severe and Critically Ill Patients with COVID-19: A
Retrospective Cohort Study. Am J Chin Med. 2021;49(5):1063-1092.
• Tsai KC, Huang YC, Liaw CC, et al. A traditional Chinese medicine formula
NRICM101 to target COVID-19 through multiple pathways: A bedside-to-bench
study. Biomed Pharmacother. 2021;133:111037.
• Ma K, Wang X, Feng S, et al. From the perspective of Traditional Chinese Medicine:
Treatment of mental disorders in COVID-19 survivors. Biomed Pharmacother.
2020;132:110810.
• https://www.nricm.edu.tw/p/406-1000-6141,r11.php?Lang=zh-tw

37. Thanks for your attention