UCLA K30 Case Presentation

Malcolm Taw, MDUCLA Center for East West Medicine

Department of MedicineDavid Geffen School of Medicine, UCLA

July 25, 2007

CC: refractory chronic urticaria, daily SOB/wheezing from asthma

History of Present Illness:

41 year-old male with intermittent hives (2-5 mm) x 7 years.Urticaria got worse, became constant and occurred over his entirebody after he received steroid injections and took oral prednisone forDe Quervain’s tenosynovitis 5 months ago. Had swelling of his lipsfor which he received prior epinephrine injection. Dermatographismon scratch test was negative. No improvement despite being onhydroxyzine, zyrtec, benadryl, steroids and penicillin for presumederysipelas (Strep) infection. His symptoms worsened with stress (ieanger outbursts & planning for upcoming wedding) and hot weather.

Patient also had daily SOB/wheezing from asthma x several weeks.Was using Albuterol PRN (up to 8 puffs per day) to gain relief. Hadnot been prescribed steroid inhaler by PMD.

CC: refractory chronic urticaria, daily SOB/wheezing from asthma

History of Present Illness:

41 year-old male with intermittent hives (2-5 mm) x 7 years.Urticaria got worse, became constant and occurred over his entirebody after he received steroid injections and took oral prednisone forDe Quervain’s tenosynovitis 5 months ago. Had swelling of his lipsfor which he received prior epinephrine injection. Dermatographismon scratch test was negative. No improvement despite being onhydroxyzine, zyrtec, benadryl, steroids and penicillin for presumederysipelas (Strep) infection. His symptoms worsened with stress (ieanger outbursts & planning for upcoming wedding) and hot weather.

Patient also had daily SOB/wheezing from asthma x several weeks.Was using Albuterol PRN (up to 8 puffs per day) to gain relief. Hadnot been prescribed steroid inhaler by PMD.

Past Medical/Surgical History:Heatstroke x 2 episodesAsthmaIntermittent oral and esophageal blisterss/p tonsillectomyHistory of heavy EtoH useDe Quervain’s tenosynovitis

Medications: Hydroxyzine ATC, Zyrtec, Benadryl ATC &PRN, Albuterol PRN

Social History: He works at a tropical fish store where theclimate is kept warm and humid (approximately 80 degreeF)

Diet: He likes eating red meats, spicy foods, drinks EtoHand uses supplements for weight lifting

Tongue: red, especially at the tip with slight yellow coating

Past Medical/Surgical History:Heatstroke x 2 episodesAsthmaIntermittent oral and esophageal blisterss/p tonsillectomyHistory of heavy EtoH useDe Quervain’s tenosynovitis

Medications: Hydroxyzine ATC, Zyrtec, Benadryl ATC &PRN, Albuterol PRN

Social History: He works at a tropical fish store where theclimate is kept warm and humid (approximately 80 degreeF)

Diet: He likes eating red meats, spicy foods, drinks EtoHand uses supplements for weight lifting

Tongue: red, especially at the tip with slight yellow coating

Western Medicine diagnosis:

- Chronic Refractory Urticaria - Moderate to Severe Persistent Asthma

TCM diagnosis:Damp-HeatFire within Stomach/Large Intestine/Lung

Case Presentation

Greaves M, et al. Chronic Urticaria. J Am Acad Dermatol. 2002 May;46(5):645-57

Heat

HeatDampness

ColdCold

Arch Dermatol. 1998 Nov;134(11):1397-9.

Large Intestine-11 (LI-11)

Location: at the elbow, at the lateral end of the transverse cubital crease.Indications: rash/urticaria, elbow pain, abdominalpain, high blood pressure.

Spleen 10 (Sp-10)Location: on the medial thigh,with the knee in flexion, 3 finger-breadths above the upper/medial aspect of the patella, alongthe vastus medialis muscle.

Indications: eczema, urticaria,amenorrhea, dysmenorrhea,irregular menses, uterinebleeding, thigh pain, urinarydysfunction, digestive dysfunction

Clin Dermatol. 1998 Nov-Dec;16(6):659-88.

Acupuncture can beused to treat:

- Intractable pruritus- Atopic dermatitis- Psoriasis- Limited scleroderma- Herpes simplex/zoster

Am Fam Physician 2001; 64:1873-8

Mind-Body Connection:The Limbic system

George B. Murray, MDDirector of Psychosomatic ProgramHarvard Medical School

Limbic Music – (Massachusetts General Hospital: Handbook of General Hospital Psychiatry, 4th ed, p. 13-14)

“Persons interested in psychosomatic medicine have aninterest in how the body may influence the mind and howthe mind may influence the body … I submit here that apartial key to the understanding of the … mind-body meldis the limbic system, [which] subserves the emotions.”

NIH Consensus ConferenceJAMA, 1998; 280: 1518-24

Shown to be effective in post-operative pain, dentalpain, post-chemotherapy nausea/vomiting

Recommended as an adjunct treatment in addiction,stroke rehabilitation, asthma, headaches, fibromyalgia,myofascial pain, osteoarthritis, low back pain, carpaltunnel syndrome, tennis elbow, menstrual cramps

Immunomodulatory effects of acupuncture in the treatment of allergic asthma: arandomized controlled study.

Joos S, Schott C, Zou H, Daniel V, Martin E.

OBJECTIVE: According to Traditional Chinese Medicine (TCM) acupuncture is a suitabletreatment for complex chronic diseases such as bronchial asthma. In a randomized, controlled studywe investigated immunologic effects of Chinese acupuncture on patients with allergic asthma.PATIENTS AND METHODS: The effects of acupuncture treatment given according to theprinciples of TCM (TCM group, n = 20) were compared with those of acupuncture treatment usingpoints not specific for asthma (control group, n = 18). All patients were treated 12 times for 30minutes over a time period of 4 weeks. Patients' general well-being and several peripheral bloodparameters (eosinophils, lymphocyte subpopulations, cytokines, in vitro lymphocyte proliferation)were determined before and after acupuncture treatment. RESULTS: In the TCM group,significantly more patients indicated an improvement in general well-being (79% in the TCMgroup versus 47% in the control group; p = 0.049) after acupuncture treatment. The followingchanges were found in the TCM group: within the lymphocyte subpopulations the CD3+ cells (p =0.005) and CD4+ cells (p = 0.014) increased significantly. There were also significant changes incytokine concentrations: interleukin (IL)-6 (p = 0.026) and IL-10 (p = 0.001) decreased whereasIL-8 (p = 0.050) rose significantly. Additionally, the in vitro lymphocyte proliferation rateincreased significantly (p = 0.035) while the number of eosinophils decreased from 4.4% to 3.3%after acupuncture (p > 0.05). The control group, however, showed no significant changes apartfrom an increase in the CD4+ cells (p = 0.012). CONCLUSION: The results imply that asthmapatients benefit from acupuncture treatment given in addition to conventional therapy. Furthermore,acupuncture performed in accordance with the principles of TCM showed significant immune-modulating effects.

J Altern Complement Med. 2000 Dec;6(6):519-25.

Acupuncture: LI-4, Liv –3, LI-11, Sp-10, Sp-6, St-36, P-6

Trigger Point Injections: bilateral trapezius, splenius cervicis,rhomboid muscles

Dietary Changes: reduce intake of hot, spicy foods, greasy foods, redmeats, EtoH; increase intake of “cooling” foods like fruits (ie melonsetc) & vegetables; stop weight lifting supplements

Lifestyle changes: reducing exposure to hot/humid environments;stress management; limit sun exposure; continue regular aerobicexercise

Medications: titrated off Benadryl, Hydroxyzine, Zyrtec and AlbuterolMDI as symptoms improved

Treatment

Patient Follow-up & Feedback

After 1st treatment

“I have only 1-2 hives/day instead of the usual 20 per day”

After 2nd treatment

“This is the 1st time in over 5 months that I have had back toback days without hives and I have stopped taking anymedications”

“I have no more SOB or wheezing and I’m no longer usingmy inhaler.”

Patient Follow-up & Feedback

• Patient had treatment sessions once per week forapproximately two months.

• Subsequent sessions were spread out to every other week fora few weeks, then to once per month.

• Has had occasional mild recurrences of hives with stress,anger outbursts or a poor diet (ie. broke out with hives aftereating BBQ food).

• Now his symptoms from urticaria and asthma have fullyresolved. He has not needed further treatment for 1 ½ years.He continues to be off any medications.

Summary• Adverse drug reactions (ADRs) are 4th leading cause of death (IOMreport, 2000; Lazarou J et al JAMA 1998)

• Polypharmacy & drug-drug interactions are common issues, especiallyamong the elderly

• Finding effective ways to titrate off medications, especially for chronicmedical conditions, is becoming increasingly important

• Acupuncture and trigger point injections can help titrate off medicationsthrough re-regulation of different physiologic cascades including theinflammatory/immune pathways & HPA axis

• Integrative East-West Medicine is a potentially safe, efficacious andcost-effective approach to optimizing patient healthcare and reducingharmful side effects of medications