THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 18, Number 5, 2012, pp.

509512 Mary Ann Liebert, Inc. DOI: 10.1089/acm.2011.0292

Case Report

A Case of Unilateral Pleural Effusion Secondary to Congestive Heart Failure Successfully Treated with Traditional Chinese Herbal Formulas
1 Han-Dao Lee, MD, and Hsien-Hsueh Elley Chiu, MD1,2

Abstract

Objectives: A case is presented that illustrates the potential effect of traditional Chinese medicine (TCM) herbal formulas on treatment for unilateral pleural effusion secondary to congestive heart failure (CHF). Subject: A 79-year-old woman experienced episodic dyspnea with unilateral pleural effusion for 2 years. Thoracocentesis with pleural uid analysis revealed no infection, tuberculosis, or malignancy. She had received conventional treatment for CHF but the symptoms persisted. Therefore, she visited the authors TCM clinic for help. Interventions and outcome: This patient was treated with TCM herbal granules including Shengmaisan, Xiebaisan, and Tinglizi, 3 times a day for 4 weeks. The daily dosage was adjusted on the basis of the patients clinical response and her follow-up chest x-ray studies. After 8 months of treatment, her symptoms improved and the pleural effusion showed signicant regression. Conclusions: It is suggested that TCM herbal formulas could play an important role in preventing the progression of unilateral pleural effusion secondary to CHF, in case of poor response to conservative treatment. Additional studies about the mechanism of action of the medication involved are warranted.

Introduction

pleural effusion is the result of uid accumulation in the pleural space, which indicates the presence of pulmonary, pleural, or extrapulmonary disease.1 Although many different diseases may cause a pleural effusion, the most common causes in the United States are congestive heart failure (CHF), pneumonia, and cancer.2 The overall prevalence of heart failure in a population-based Rotterdam study was estimated at 3.9%, which increases rapidly with age.3 According to the guidelines of the European Society of Cardiology, heart failure is a pathophysiologic state with the following features: symptoms (e.g., shortness of breath or fatigue, at rest or during exercise, ankle swelling) and objective evidence of cardiac dysfunction.4 Increased interstitial uid in the lung due to elevated pulmonary capillary pressure leads to both pleural effusion and pulmonary edema, causing exertional breathlessness.5,6 Since CHF-related effusions are typically bilateral, thoracocentesis is indicated if effusion is seen unilaterally or has not responded to diuretic therapy.7 Approximately 75% of effusions due to CHF resolve within 48 hours after diuresis is begun.8 However, there are still some

cases that do not respond to conventional therapy or thoracocentesis. In the Chinese medicine concept, there are several strategies of treating refractory pleural effusion, including herbal formula, acupuncture, and food therapy. This case report deals with a patient who had unilateral pleural effusion secondary to CHF and who was successfully treated with Traditional Chinese medicine (TCM) herbal formulas over an 8-month follow-up period. Case Report A 79-year-old woman had been in good health until 2 years ago, when she started to have coughs and severe dyspnea on exertion. Her initial chest plain lm study showed unilateral pleural effusion on the right side. The pleural uid analysis after thoracocentesis revealed neither bacterial infection nor malignancy. Unilateral pleural effusion secondary to CHF was suspected. She was treated conservatively with diuretic pills and the symptoms subsided. However, the same situation recurred in March 2010. This time her chest plain lm study showed left-side pleural effusion. She repeated thoracocentesis 3 times for relief of

Division of Acupuncture and Chinese Traumatology, Departments of 1Traditional Chinese Medicine and 2Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.

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FIG. 1. Chest plain lms series. A. First visit to clinic. B. Three (3) months later. C. Six (6) months later. Unilateral pleural effusion on the left side gradually subsided after treatment with Traditional Chinese Medicine herbal formulas.

symptoms. Due to the symptoms persisting, she visited the TCM clinic for help on July 29, 2010. The patient had past history of asthma since childhood and cerebrovascular disease with a small infarct in 2003. Her current medication included aspirin (500 mg per day), rosuvastatin (10 mg per day), and asthma controller with Seretide evohaler (salmeterol/uticasone combination) and tiotropium inhaler. These modern medications had been used on a long-term basis by this patient. The patients chief complaint during her rst visit was of her recurrent dyspnea on exertion, cough, and dizziness. On physical examination, the patient had a pale-white appearance, and a wheezing breathing sound and deep-weak-ne pulse were noticed. Tongue diagnosis revealed ne texture, redness, dryness, and yellow coating. Initial chest radiography, on July 29, 2010, showed left-side pleural effusion, inltrations in bilateral lower part of the lungs, and mild-to-moderate cardiomegaly (Fig. 1A). The TCM diagnosis of the deciency of Heart Qi, accompanied by Lung Heat that consumes Yin, were concluded. The prescription of TCM herbal formulas included ingredients (Tables 1 and 2) administered daily in three separate doses. The herbal granules used were all prepared and

extracted by standard procedure in Taiwan Good Manufacturing Practice (GMP) Pharmaceutics. After 1 month of TCM treatment, the patients dyspnea was relieved and coughs became less frequent. To maintain the therapeutic effect, the original TCM formulas were continued but with a daily dosage decrease by one third, separated into twice per day. After 3 months of treatment, a follow-up chest plain lm study showed moderate regression of left-side pleural uids (Fig. 1B). The TCM formulas were adjusted to one third of the original daily dosage, being taken once per day. Her repeated chest plain lm study, on January 6, 2011, disclosed a sharper costophrenic angle on the left side (Fig. 1C). The patient returned to TCM clinics for monthly follow-up and received continuous TCM treatment until March 2011. She did not take any conventional diuretic medication during this 8-month treatment period. Her chest plain lm studies have been conducted monthly, which indicated no sign of recurrence of left-side pleural effusion. There was a continuous follow-up of the patient over the last year, and she was in stable health when this report was prepared. In addition, there were no obvious side-effects reported throughout the treatment period. Discussion The patient in this report was diagnosed with recurrent unilateral pleural effusion secondary to CHF. During March to June in 2010, she had been treated conservatively with diuretics and received thoracocentesis 3 times. Because there was no spontaneous regression of pleural uids, she chose alternative TCM treatment. In Taiwan, TCM doctors usually preferred to prescribe concentrated herbal granules with formulas plus a specic single herb according to the patients symptoms. The herbal granules were prepared with an all-raw herbal mixture cooked and concentrated following GMP standard process. Unlike ground herbal powders, the extract granules not only retain the same ingredients and the spirit of traditional herbal decoction, but also have been screened from pesticides

Table 1. Ingredients of Traditional Chinese Medicine Herbal Formula Chinese names Shengmaisan Renshen Maimendong Wuweizi Xiabaisan Sangbaipi Digupi Gancao Gengmi Tinglizi Scientic names Panax ginseng Radix ophiopogonis Schisandra chinensis 3 (4.5:4.5:2.25:6) Cortex mori Cortex lycii Radix glycyrrhizae Semen oryzae Lepidium apetalum willd Daily dosage (g)/ concentration ratio 3 (10:10:5)

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UNILATERAL PLEURAL EFFUSION TREATED WITH TCM Table 2. Function and Indication of Traditional Chinese Medicine Herbal Formula Chinese names Shengmaisan
          

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Function Tonify Qi Nourish Yin Stimulate pulse Prevent excessive sweating Clear Lung Heat Relieve asthma and cough Nourish the stomach Purge the lung Relieve asthma Promote water metabolism Disperse swelling

Indication Qi-Yin deciency in Heart failure, coronary artery disease, and chronic Pulmonary-Heart disease, with symptoms of profuse sweating, thirst, shortness of breath, dry cough, fatigue, palpitations, irregular heartbeats, dry mouth, red Tongue without much saliva, and a weak and thready pulse Lung heat has damaged Yin, causing cough, asthma, fever rising in the afternoon, thirst, spontaneous sweating, red lips and cheeks, facial edema, red Tongue, and rapid pulse. Asthma due to water retention in the lungs, water distention in the chest and ribs, cough due to the retention of phlegm and uid, pulmonary abscess

Xiabaisan Tinglizi

and heavy metals. In this way, it is much more convenient and efcient for the patient to take their medication than with previous methods. Shengmaisan is an old TCM herbal formula consisting of three raw herbal components: Panax ginseng, Radix ophiopogonis, and Schisandra chinensis. P. ginseng tonies Qi, R. ophiopogonis nourishes Yin, and S. chinensis astringes and invigorates Qi. This formula has long been used for treatment of Qi-Yin deciency due to consumption of Qi and Yin by heat. It is especially prescribed for patients with heart failure and ischemic heart disease.9 In the Cochrane library systemic review, the author suggested that Shengmaisan might be benecial for CHF compared to placebo or plus usual treatment compared to usual treatment alone.10 Xiebaisan is a TCM herbal formula made of four raw herbs: Cortex mori, Cortex lycii, Radix glycyrrhizae, and Semen oryzae. C. mori and C. lycii clear Lung Heat; R. glycyrrhizae and S. oryzae nourish the stomach. It has been used clinically to treat the common cold, asthma-like diseases, or any other condition associated with pulmonary inammation. In a previous study, Lee proved the hypothesis that Xiebaisan inhibited the inammatory process in lung tissue through suppression of the IjB signaling pathway.11 In the TCM theory, dyspnea on exertion, cough, and deepweak pulse relate to deciency of Heart and Lung Qi; dry-red Tongue and ne pulse reveal deciency of Yin. Shengmaisan is indicated for Qi-Yin deciency in heart failure. When it comes to the excessive and long-term uid accumulation in the Lungs, the authors believe Heat evil exists as a result of sputum production. Xiebaisan and Tinglizi both act to clear Lung Heat and purge retention of phlegm and uid from the Lungs. Due to the patient not receiving any diuretic pills during TCM treatment period, the therapeutic benets were conrmed by observing improvements of clinical symptoms and following up chest plain lm studies monthly. After 1-month treatment with Shengmaisan, Xiebaisan, and Tinglizi combination formulas, the patients exertional dyspnea and cough subsided, which was consistent with the regression of pleural uids. The dosage of the treatment formulas was then reduced without changing or adding a single herb. If the patient could maintain the therapeutic effect under low-dose treatment, the authors would consider completing the treatment course. This experience

suggested that TCM could act to prevent the progression of pleural effusions secondary to noninfectious causes: in this case, heart failure. Conclusions A patient diagnosed with unilateral pleural effusion secondary to CHF has been successfully treated with TCM herbal formulas alone for 8 months. Although the efcacy of TCM has not yet been proven in this case, the authors believe that Shengmaisan exerted its function on Heart Qi and Yin tonication over heart failure; Xiebaisan and Tinglizi act to clear Lung Heat and disperse phlegm resulting from pleural uids. TCM herbal formulas could play an alternative role in preventing the progression of pleural effusions, in case of poor response to conservative treatment. Further studies on a possible mechanism of action of the herbal medicine involved here are warranted. Disclosure Statement No nancial conicts exist. References
1. McGrath EE, Blades Z, Needham J, Anderson PB. A systematic approach to the investigation and diagnosis of a unilateral pleural effusion. Intern J Clin Pract 2009;63:1653 1659. 2. Light RW. Clinical practice. Pleural effusion. NEJM 2002;346: 19711977. 3. Mosterd A, Hoes AW, de Bruyne MC, et al. Prevalence of heart failure and left ventricular dysfunction in the general population: The Rotterdam study. Eur Heart J 1999;20:447 455. 4. Task Force for the Diagnosis and Treatment of Chronic Heart Failure, European Society of Cardiology: Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001;22:15271560. 5. Puri S, Baker BL, Oakley CM, et al. Increased alveolar/ capillary membrane resistance to gas transfer in patients with chronic heart failure. Br Heart J 1994;72:140144. 6. Porcel JM. Pleural effusions from congestive heart failure. Semin Respir Crit Care Med 2010;31:689697. 7. Porcel JM, Light RW. Diagnostic approach to pleural effusion in adults. Am Fam Physician 2006;73:12111220.

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8. Shinto RA, Light RW. Effects of diuresis on the characteristics of pleural uid in patients with congestive heart failure. Am J Med 1990;88:230234. 9. Chen SY, F Li. Tonics and astringents. In: A Clinical Guide to Chinese Herbs and Formulae. Churchill Livingston, 1993:75. 10. Zheng H, Chen Y, Chen J, et al. Shengmai (a traditional Chinese herbal medicine) for heart failure [Review]. Cochrane Library Syst Rev 2011;2:CD005052. 11. Lee KH, Yeh MH, Kao ST, et al. Xia-bai-san inhibits lipopolysaccharide-induced activation of intercellular adhesion molecule-1 and nuclear factor-kappa B in human lung cells. J Ethnopharmacol 2009;124:530538.

LEE AND CHIU Address correspondence to: Hsien-Hsueh Elley Chiu, MD Division of Acupuncture and Chinese Traumatology Department of Traditional Chinese Medicine Kaohsiung Chang Gung Memorial Hospital Chang Gung University College of Medicine No.123, Dapi Road, Niaosong District Kaohsiung City 83301 Taiwan E-mail: elley@adm.cgmh.org.tw

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