A treatment for Henoch-Sch?nlein purpura based on Shaoyang Channels:a hypothesis and case report

Xing Cui,Rui-Rong Xu*,Kui Liu,Ya-Qin Luo

1Department of Hematology,Affiliated Hospital of Shandong University of Traditional Chinese Medicine,Jinan,China.

Abstract Henoch-Sch?nlein purpura(HSP)is an IgA-mediated vasculitis which is easy to relapse.A lot of patients have to use glucocorticoids,immunosuppressive drugs and other drugs which will bring sorts of serious side effects.Unfortunately,most of patients have to face the hurt of abdom inal pain,arthritis,purpuric rash and renal involvement again after relapse.We have used Xiaochaihu decoration which is a famous formula in Shanghanlun to cure most of patients,especially who with abdominal pain and purpuric rash.Due to the fact that this formula belongs to the Shaoyang Channels,interestingly,we find that these symptoms are located in regions close to the Shaoyang Channels.So that is the reason why Xiaochaihu decoration could work.

Key words:Henoch-Sch?nlein purpura,Xiaochaihu decoration,Shanghanlun,the Shaoyang Channels

Background

Henoch-Sch?nlein purpura(HSP)is an IgA-mediated vasculitis that presents with the common tetrad of abdominal pain,arthritis,purpuric rash and renal involvement.HSP is often preceded by an upper respiratory tract infection,with Group A beta-hemolytic streptococcus responsible for up to50%of the occurrences[1].Purpura occurs in all cases,joint pain and arthritis in 80%,and abdominal pain in 62%.Some cases involve gastrointestinal hemorrhage as a fourth criterion;this occurs in 33%of cases,and is sometimes due to intussusception.The purpura typically appears on the legs and buttocks,but may also be seen on the arms,face and trunk.The abdom inal pain is colicky in character,and may be accompanied by nausea,vom iting,constipation or diarrhea.The joints involved tend to be the ankles,knees,and elbows;the arthritis is nonerosive and hence causes no permanent deform ity[2].Forty percent of cases present the evidence of kidney involvement,mainly in the form of hematuria(blood in the urine),but only a 25%of these will have this in sufficient quantities to be noticeable without laboratory tests[3].The treatment of HSP remains mainly supportive,as the acute symptoms resolve spontaneously in the majority of patients.For more severe cases with serious complications of the disease,treatment commonly includes glucocorticoids,immunosuppressive drugs,and plasmapheresis[4].The use of glucocorticoids in the treatment of HSP remains anecdotal,as no prospective placebo controlled trials have been conducted[1].

Treatment in traditional Chinese medicine(TCM)and acupuncture is based on channels and collaterals,the principles of which were established 2,000 years ago in the Chinese medical treatise,Shanghanlun.The Shaoyang Channels include the Gallbladder Channel and San Jiao Channel.The Gallbladder Channel starts from the outer canthus proceeds to the side of the forehead and then to the back of the ear.The Gall Bladder channel has two branches that originate from the back of the ear:Branch1,enters the center of the ear,goes anterior to the ear,extends to the inner canthus,cheek,neck,and finally to the supraclavicular fossa.Branch 2,goes from the back of the ear to the neck,goes shoulder anterior to the San Jiao Channel and then posterior to San Jiao Channel,to eventually join the supraclavicular fossa.Branch 2 splits at the supraclavicular fossa.Branch 2a,proceeds to the chest,diaphragm,and then emerges under the sacrum,into the hip.Branch 2b goes from under the armpit,to the chest,and then to the hip.From the hip,it goes to the lateral leg/knee/malleolus,and the dorsum of the foot.Branch 2b splits again,into Branch 2c which goes to the 4 toes;and Branch 2d that goes to the big toe where it links with the liver channel.

The San Jiao Channel starts from the ring finger dorsum of the hand,goes between the radius and ulna,proceeds to the shoulder and then to the pericardium.From the pericardium the channel extends to the neck and then to the back of the ear.The San Jiao then splits into two.Branch 1 goes around the back of the ear and enters it,emerging in front of the ear and term inating at the outer canthus of the eye where it connects with the Gallbladder Channel and sends Qi to this meridian.Branch 2 of the San Jiao channel circles behind the ear,and goes to the cheek and then the inferior aspect of the eye.

Just like etiological treatment in modern medicine,TCM is based on the foundation that the blockage of flowin the meridian’s Qi can cause a number of diseases.According to TCM the appropriate medication is dependent on which region,in relation to the meridian,the symptoms originate from.

In HSP we find that all of these symptoms are located in regions close to the Shaoyang Channels.The physiological functions of the symptomatic regions are managed by Shaoyang Channels,just as the physiological functions are managed by organs according to modern medicine.For example,the purpura typically appears on the legs and buttocks,but may also be seen on the arms,and over most of the extensor limbs which are the regions of the Shaoyang Channels.Joint pain and abdominal pain are also influenced by the Shaoyang Channels.Most patients present symptoms such as alternate chills and fever,chest and hypochondriac discom fort and fullness,lack of appetite,vexation and susceptibility to vom iting.Other symptoms include:bitter taste in the mouth and dry throat,irritability,red tongue with yellow coating,and a wiry pulse.Some patients also have a history of allergic rhinitis/otitis media/cholecystitis.However,what causes the kidney damage?In TCM,the gallbladder in the Five Elements Property is wood,and kidney is water.The energy of wood is from water,that is,water generates wood.Taken another way,water is the mother of wood,so when wood is sick,it will involve his mother,water.So the development of diseases of the Gallbladder Channel will cause kidney damage.Therefore we propose that HSP is located throughout the Shaoyang Channels;with the skin,joints,kidneys and stomach involved.

We have an important formula,Xiaovhaihu Decoration,which can regulate the Shaoyang Channels according to Shanghanlun.It can regulate the flow of Qi in the Shaoyang Channels and help it in ascending and descending smoothly,and has been held in high esteem by TCM physicians through the ages.Xiaochaihu Decoration is composed of Chaihu(Bupleuri Radix),Huangqin(Scutellariae Radix),Banxia(Pinelliae Rhizoma),Gancao(Glycyrrhizae Radix Et Rhizoma),Dazao(Jujubae Fructus),Shengjiang(Zingiberis Rhizoma Recens),and Renshen(Ginseng Radix Et Rhizoma).In the clinic,the author prefers using the modified Xiaochaihu Decoration in the treatment of Henoch-Sch?nlein purpura,and observes good results.Recent studies also indicate that Chaihu(Bupleuri Radix)[5]and Renshen(Ginseng Radix Et Rhizoma)[6]can regulate the immune system.Considering that Henoch-Sch?nlein purpura is a form of immune disease,we think that Xiaochaihu Decoration can treat Henoch-Sch?nlein purpura by modulating the immune system.

Case presentation

This study was approved by the institutional review board of A ffiliated Hospital of Shandong University of Traditional Chinese Medicine(Shandong,China)and w ritten informed consent was obtained from every participant.

A 31-year-old male from Shan Dong Wei Fang,presented with fever and sore throat for 5 days.He had an erythematous,nonpruritic rash which progressed proximally from both feet to thighs and upper extrem ities including palms and soles.The rash was located all over the extensor limbs.Review of systems is unremarkable except pain in the right ear.His significant comorbidities include allergic asthma.On physical exam ination,there was pharyngeal erythema,petechiae on the soft palate,cervical lymphadenopathy,purpuric rash involving both upper and lower extrem ities with nonpitting pedal edema.There was no truncal involvement.Two days later,the patient developed abdom inal pain involving the right and left upper quadrant,which was constant,colicky in nature,8/10 in intensity,aggravated with meals and associated with watery stools.Laboratory tests showed leukocytosis(WBC:11,900/microL);Hb:15 g/dL;BUN:11 mg/dL;Urinalysis:no hematuria or proteinuria;ESR:48 mm/Hr;CRP:5.6 mg/dL;Antistreptolysin O titer:712 IU/L;C3:125 mg/dL;C4:11 mg/dL;ANA:Negative;EBV-VCA IgM:Negative;Anti-HAV IgM:Negative;HbsAg:Negative;Anti-HBc IgG:Negative;Mono spot test:Negative;c-ANCA:0.2 units;p-ANCA:0.2 units;Stool for occult blood:Negative.There was no evidence of epithelioid granuloma.Skin biopsy showed pustular leukocytoclastic fibrinoid vasculitis with microabscess.The patient was diagnosed with Henoch-Sch?nlein as per American College of Rheumatology,European League Against Rheumatism(EuLAR)and Pediatric Rheumatology Society(PReS)criteria.He was treated with Xiaochaihu Decoration for 5 days,and did not use any other agents such as glucocorticoids or immunosuppressive drugs.There was a resolution of his symptoms and a decrease in ESR and CRP.Treatment was continued for two weeks,and there was no evidence of recurrence on follow-up,six months later.

Consent

Written informed consent was obtained from the parent of our patient for publication of this case report.A copy of the w ritten consent is available for review by the Editor-in-Chief of this journal.