The 1st Form : Lung dryness form (hepatogenic upper respiratory tract infection form)

        Upper respiratory tract infection is the most frequently encountered disease in children; many viruses and bacteria can cause upper respiratory tract infection, virus infection being the most common.  Upper respiratory tract infection includes acute rhinopharyngitis (commonly called common cold), acute pharyngitis, acute tonsilitis and acute and chronic inflammation in various sites of the respiratory tract.  But the symptoms of upper respiratory tract infection are also prodromal symptoms of many virus diseases like measles, chickenpox, mumps and virus hepatitis.  Similarly, in the preicteric phase of acute hepatitis and active stage of chronic hepatitis, there may be repeated attacks of fatigue, listlessness, nasal obstruction and discharge, sneezing, sorethroat, chilliness, fever, cough, expectoration, generalized tiredness, marked regression of appetite, nausea and instability in sleeping.  Older children may feel tired and complain of symptoms like headache, vertigo, inability to concentrate, regression of memory, soreness of muscles and articulations and mental depression.  The severe cases (most are older children) may present serious clinical symptoms, uncontrollable cough (chiefly choking) and occasional shortness of breath; such patients generally have a long course.  X-ray examination usually shows no abnormality or the chest film only reveals increase of lung linings, network like shadows of lower lungs or small patchy infiltration characteristic of interstitial pneumonitis.  Clinically, it is often misdiagnosed as bronchopneumonia, asthma, or even pulmonary tuberculosis.  The effect of anti-inflammatory drugs is not satisfactory, but if there is association of increase of margin of liver dullness, the application of TCM drugs can yield very good results.  (A test of TCM treatment is therefore advisable).

       It is not difficult to differentiate pediatric upper respiratory tract infection with hepatitis.  If the patients’ symptoms occur repeatedly, it can not be explained by simple common cold.  If they have history of close contact with hepatitis or with family members suffering from hepatitis or hepatic carcinoma, or if they have positive antigen or antibodies, abnormal liver function or association of signs of hepatomegaly and percussion tenderness of hepatic region, then it can be ascertained that these symptoms are of the liver stagnation and lung dryness form induced by hepatitis.

      (It is worthwhile to say something about hepatomegaly in pediatric examination.  In the past, it was considered that a hepatomegaly of 3 cm in children was within normal range.  But clinical practice repeatedly demonstrated that in pediatric hepatomegaly, under TCM treatment, the lower margin of liver can recover to 1.5 cm above costal margin which proves that the hepatomegaly is actually produced by pathological changes. )

      Moreover, the result of blood examination in pediatric hepatitis can only serve as a reference; a positive result helps to confirm the diagnosis, but a negative result does not rule out hepatitis.  It is because:

First, the present examination methods can not entirely detect the seven types of hepatitis as well as other hepatophilic virus infections.  Laboratory examination reports of negative antigen and antibody of type A and type B hepatitis can not rule out the existence of other types of hepatitis.

Second, children with the so called “negative HBsAg” may be actually HBsAg positive in a very small number of cases.  The latter cannot be ruled out is due to the insensitivity of the method of examination.  The examination deviation or other factors can cause a negative result.  Some reports pointed out that patients with negative HBsAg when examined repeatedly for type B hepatitis virus DNA, had a 64% positive result.

       Therefore, clinicians must base on history, symptoms and signs and various related conditions to make a comprehensive estimation and should not give up diagnosis and treatment of pediatric hepatitis lightly.

Case 1-1

Lee – (computer no. 257) male, age 7 yrs.  His father, mother and Philippine housemaid all had hepatomegaly and were sufferers of chronic active hepatitis.

His first visit was on 28^th March 1998.  His mother said that the child had nasal hypersensitivity for a long time, especially during the change of weather and there was also occasional abdominal pain, yellowish urine, poor appetite, repeated oral ulceration affecting the intake of food.  Physical examination revealed a poorly nourished and underdeveloped thin child; a distended abdomen and varicosities over abdominal wall, protrusion of right hypochondrium and depression of left hypochondrium, percussion tenderness over hepatic region and hepatomegaly of 4.5 cm. Clinical symptoms improved after taking 3 parcels of TCM drugs, hepatomegaly reduced to 1.5 cm and the patient did not continue the TCM treatment.

One month later, that is on 1^st May 1998, a return visit was made with the complaint of fever and cough for 2 weeks and treatment by western medical drugs for 3 days was of no avail.  The patient turned to request for TCM treatment.  Physical examination: hepatomegaly of 3 cm.  He was treated according to the liver stagnation and lung dryness form of chronic hepatitis and 3 parcels of TCM drugs were prescribed.  After the medication, the patient went to stools five times a day, feces were paste-like, large in amount and black in color.  The anus was painful; cough was relieved and expectoration became less in amount.  In the morning, ocular discharge was found abundant.  Physical examination found the liver normal.  Cough stopped after taking 10 parcels of TCM drugs.  The child received 7 weeks of systemic TCM treatment and was then followed up.

In the return visit on 8^th September 1998, the child was well besides occasional wetness-heat abdominal pain and hepatomegaly was not found.

On 15^th December 1998, the patient took some modern medical drugs because of head injury and nausea and vomiting.  Examination did not reveal any abnormality of brain, but the liver was found to be enlarged 1.5 cm which returned to normal after taking 3 parcels of TCM drugs.  The child took another 10 parcels and went to Singapore travelling for 5 days.  When he came back to Hong Kong, he had repeated epistaxis and severe coughing.  Western medical drugs were taken with no avail and he had to seek for TCM drugs.  Physical examination revealed hepatomegaly of 3 cm and percussion tenderness over hepatic region.  Three parcels of TCM drugs stopped the epistaxis, coughing was relieved and the liver returned to normal.  A following course of 4 weeks TCM therapy was instituted and clinical cure was attained.

Physician’s comment :

In this case, the response of the patient after TCM therapy was apparent, showing the necessity of systemic therapy for chronic hepatitis.  The clinical symptoms and signs in the first visit were obvious and although the symptoms improved and the liver margin retracted after TCM therapy, yet the stoppage of treatment was too early.  It caused the reactivation of the virus infection and hence, the exacerbation of liver stagnation and lung dryness symptoms.  He turned to TCM therapy because of the ineffectiveness of western medicine.  Therefore, the liver returned to normal in 3 days and the symptoms disappeared in a week.  Treatment ceased after 7 weeks of systemic TCM therapy.  In the following three months the liver was still normal.  Two times of relapse of hepatomegaly occurred following head injury and traveling three months later.  However, all were satisfactorily cured with TCM therapy.

Case 1-2

Kwan–  (computer no. 731), male, age 2-1/2 yrs.

His father had type B hepatitis 10 more years ago.  (He was still a sufferer of chronic active hepatitis with hepatomegaly of 3 cm; he received TCM therapy and obtained clinical cure).  The patient experienced repeated coughing, abundant expectoration, poor appetite, wakeful sleeping, repeated episodes of German measles, all of which were of no avail with WM treatment.  He finally turned to TCM therapy on 6^th December 1996 at which time the child was found to be thin, and the tongue geographic appearance, breathing coarse, pulmonary rales not heard and a 3 cm hepatomegaly was discovered.  After taking 12 parcels of TCM drugs, the margin of liver dullness reduced 1.5 cm and his coughing decreased.  Another 9 parcels brought the liver to normal.  Five parcels of TCM drugs were taken afterwards but he could not finish the systemic course and stopped the medication.

A month more later, the patient was hospitalized because of vomiting caused by gastroenteritis.  He made a return visit after hospitalization.  Physical examination showed that the child had a yellowish thick tongue coating and a hepatomegaly of 1.5 cm.  After taking TCM drugs, the latter was normal and in the following 3 months interrupted TCM treatment was given for 7 weeks.  In this interval, hepatomegaly of 1.5 cm relapsed for two times, associated with transient cough, tongue coating, poor appetite, occasional German measles and wakeful sleeping.  After TCM treatment, the liver returned to normal. The patient carried through the 6 weeks systemic TCM therapy to the end.  He was followed up for half a year and no relapse was found.

Physician’s comment:

This patient’s father had suffered from type B hepatitis and the child had apparent symptoms of liver stagnation and lung dryness and wetness-heat vaporization form associated with hepatomegaly of 3 cm.  Due to interrupted administration of TCM drugs, clinical symptoms and hepatomegaly reappeared.  In the later period, the family members at last took the advice of physician and completed the systemic course of treatment.  The liver was normal in the following six months of observation.

Case 1-3:

Kong brother and sister.   Their father died of carcinoma of liver 3 years ago and at that time their mother was found to have positive type B hepatitis antibodies by blood examination but examination results of the siblings were negative.  Therefore, they received type A and type B hepatitis preventive injections.

Brother, Kong – (computer no. 74) male, age 9 yrs.  His first visit was on 8^th May 1993 with chief complaint of repeated nasal obstruction, copious expectoration, cough, fever, abdominal pain and distension, poor appetite and yellowish urine.  After 3 weeks of TCM therapy, the liver returned to normal.  In the following half a year, repeated administration of TCM drugs amounted to more than 30 parcels for the treatment of liver stagnation and lung dryness, oral ulcerations and for symptoms of exopathy.  The liver was not enlarged.  In 1994 and 1995, the patient was still under observation.  He made 9 return visits because of discomfort but abnormality of margin of liver dullness was not found.

Five years later (patient being 15 years old) a return visit was made on 9^th August 1998, when he complained of frequent abdominal pain, discomfort of stomache and intestines, loose stools being 1-2 times a day, associated with insomnia, fatigue, difficulty in falling asleep, nasal hypersensitivity, repeated nasal obstruction, abundance of nasal discharge, sneezing and multiple acne of face.  Physical examination: adequate nourishment and development, multiple acne of the face, tongue reddish and enlarged but without coating, apparent percussion tenderness over hepatic region, hepatomegaly of 3 cm.  After taking 9 parcels of TCM drugs, the liver returned to normal and clinical symptoms disappeared.  During treatment, the patient produced a large amount of nasal discharge in the morning associated with nasal obstruction and oral ulceration.  He was treated with TCM drugs for 4 weeks and was then followed up.  No complaints were made during observation.

In the following year, on 25^th November 1999, he came to the clinic complaining of a significant increase of 37.5 lbs of body weight in the recent six months.  His body weight was 67 kg, height 1.69 m, BMI = 23.45 which was within normal range.  He had repeated abdominal pain, wetness-heat stools, frequent nasal obstruction, abundant nasal discharge, sneezing, occasional cough, frantic ingestion of food when hungry, abdominal distension and shortness of breath.  Physical examination revealed an enlarged tongue with teeth prints, distended abdomen and hepatomegaly of 1.5 cm with percussion tenderness.  After taking 3 parcels of TCM drugs, the liver was normal.  He received a course of systemic therapy and achieved clinical cure.  He was then followed up.

Sister Kong (computer no. 73), female, age 8 yrs.

Her first visit was on 16^th May 1993.  Her mother substituted for the complaint which was repeated exopathy with fever, copious expectoration, fatigue, vertigo, thinness, poor appetite, ozostomia, hypochondriac pain, yellowish urine and constipation.  Physical examination revealed poor nourishment and development, light yellowish skin, pale mucosa, tongue coating thick and whitish, hepatomegaly of 3 cm with percussion tenderness.  She took TCM drugs in succession for 8 months.  The liver recovered to a completely normal state.  (In the early stage, the physician did not request the patient to take TCM drugs daily and decision had not yet been made as how long the course of systemic treatment should take).  Medication stopped in March 1994.

A return visit was made 4 and a half years later.  She had no symptoms, no hepatomegaly and had satisfactory nourishment and development and normal tongue appearance.

The father of the siblings died at the age of 30 from carcinoma of liver and although these two children had no positive blood examination results, it was still reasonable to make the diagnosis of liver disease and to give them preventive injections.  In their first visits, there were typical symptoms and signs of liver stagnation and lung dryness and wetness–heat vaporization forms of chronic hepatitis.  The sister was poorly nourished and underdeveloped with symptoms of deficiency of qi and weakness of blood.  Ideal results were obtained after systemic TCM therapy and the liver was normal during the several years of observation.  The brother had two episodes of relapse and yet clinical cure was obtained with repeated TCM therapy.  If the conventional standard of diagnosis of hepatitis was used to rule out chronic hepatitis, the chance of systemic TCM treatment would be lost and the prognosis would certainly be bad.  The best policy is that for children with a family history of liver disease, great attention must be paid to assure timely TCM treatment and a normal margin of liver dullness.

Case 1-4

Chan, (computer no. 181), male, age 4-1/2 yrs.

The mother visited the clinic for the first time in 1991 with the complaint of fatigue, repeated headache from exopathy, severe dysmenorrhea, loin pain (usually at ovulatory phase), abdominal distension, constipation, thick tongue coating and edema of lower extremities.  She was married over a year and still not pregnant.  The diagnosis was chronic hepatitis.  After four visits, her dysmenorrhea improved, the tongue coating disappeared and the enlarged liver of 1.5 cm became normal.  She was pregnant 7 months after treatment and delivered a child on 14^th April 1993.  Her parents also had chronic hepatitis and made frequent visits to the clinic.

In August 1997, when the boy was 4 years old, he made his first visit.  The mother said that the child had nasal hypersensitivity, poor appetite, thin body build, nasal obstruction and uninterrupted sneezing.  Nasal obstruction after affected sleeping at night and he had to seek for the help of nasal drug drops to relieve hypertrophy of nasal mucosa.  Physical examination revealed a lean child with hepatomegaly of 1 5 cm.  After taking 6 parcels of TCM drugs, the margin of liver dullness was normal.  Clinical cure was obtained after treatment with systemic TCM drugs.

In November 1998, he had a relapse which showed repeated nasal hypersensitivity complicated by many episodes of epistaxis, the blood rather large in amount.  His appetite was still poor, the body still thin and sleeping was not so good.  Physical examination: skin pale and yellowish, hepatomegaly of 3 cm.  After taking 7 parcels of TCM drugs, the liver was normal.  He stopped the medication after another 7 parcels of TCM drugs.

The child was seen 3 months later, complaining of tiredness, nasal obstruction, poor appetite, constipation and enuresis.  Physical examination found the liver enlarged again to 3 cm and vertical veins of the abdominal wall and hypochondria were apparent.  After taking 3 parcels of TCM drugs, the amount of stools became larger, being once a day.  Nasal obstruction alleviated and nasal spray was not necessary.  The liver was normal but enuresis was still present.  In the following 2 months systemic treatment was not administered.  The patient only took TCM drugs occasionally and hepatomegaly of 1.5 cm relapsed for two times when treatment was not persisted and there were also nasal hypersensitivity hoarseness of voice, cough, expectoration and epistaxis.  Finally, the patient took the advice of the physician and received a 4 weeks uninterrupted course of TCM treatment until clinical cure was attained.

Case 1-5

Lee (computer no. 2290), male, age 4-1/2 yrs.

His first visit was on 3^rd December 2000.  His grandmother had a history of cirrhosis of liver and cholecystitis.  His father was a carrier of type B hepatitis virus and his mother had a hepatomegaly of 3 cm.  The child frequently suffered from nasal obstruction, nasal hypersensitivity, epistaxis, sneezing, coughing, shortness of breath, insomnia, poor appetite, vomiting and over activity.  Physical examination revealed poor nourishment and underdevelopment, dark yellowish skin, edema of mucosa of lips and hepatomegaly of 3 cm.

After taking 3 parcels of TCM drugs, the liver was normal, but he still had much sneezing and occasional coughing.  His sleeping and appetite was satisfactory.  He had another 5 parcels of TCM drugs and his nasal obstruction was limited to night time, his lip mucosa was dry, desquamating and with fissures.  Another 6 parcels of TCM drugs brought the cessation of nasal hypersensitivity.  The feces were abundant, defecation being once a day.  During the course of treatment, sleeping was well but sometimes the appetite was not so good.  No other discomfort was experienced.  A total of 42 parcels of TCM drugs were taken, at the end of which clinical cure was obtained.  The patient was followed up.

Chui (computer no. 3261) female, age 6 yrs.

His first visit was on 18^th March 2003.  Her mother said that her daughter had long term coughing, shortness of breath and constipation.  She was treated with WM and TCM drugs and she used nasal spray to control nasal hypersensitivity and to improve shortness of breath but all were ineffective.  Physical examination revealed a hepatomegaly of 3 cm.  After taking 3 parcels of TCM drugs, the symptoms disappeared and she stopped the medication.

Three months later, the child began to cough again and in several days, expectoration was copious.  The mother brought the girl back for treatment and she was discovered to have a hepatomegaly of 1.5 cm (the first relapse of hepatomegaly).  After taking 4 parcels of TCM drugs, the liver was normal, but there was still occasional coughing.  Therefore, another 8 parcels of TCM drugs were given to her after which all symptoms disappeared and she stopped the medication herself.

But three weeks later, there was relapse of symptoms and she experienced fatigue and coughing.  The liver was found to be enlarged by 1.5 cm (the second relapse of hepatomegaly).  After taking 3 parcels of TCM drugs, the liver was again normal.  TCM therapy persisted for 3 weeks, during which time she had cough but with no sputum and had constipation after taking chicken wings.  Some time later, she had normal bowl movements and coughing occurred occasionally.  She had been treated with WM drugs for 4 days because of common cold.  She then made a return visit and hepatomegaly of 1.5 cm was found (the third relapse of hepatomegaly).  After taking 3 parcels of TCM drugs, the hepatomegaly disappeared.  Her mother accepted the physician’s advice and arranged the child a 3 weeks course of systemic TCM therapy.  The patient’s cough alleviated markedly and at the fourth week, it completely stopped.  Bowl movement was normal.  She was clinically cured and followed up.

This is a typical case of liver stagnation and lung dryness form of chronic hepatitis.  It is not difficult to find that in the TCM treatment of pediatric chronic hepatitis, it is important to do “without a break”.  In this case, the child had 3 relapses of hepatomegaly.  The first is due to stoppage of treatment just after 3 parcels of TCM drugs.  The second is because of discontinuation of the 8 parcels of TCM drugs by herself immediately after recovery of the liver and hence, causing relapse of clinical symptoms and hepatomegaly in a short time.  The third is due to the administration of WM drugs for 4 days to match the common cold while still in the course of TCM therapy.  Is it due to reinfection of “hepatophilic virus” or due to damage of liver by the WM drugs, it is hard to define.  The intake of dryness–heat food like chicken wings can arouse lung dryness cough and constipation.  This fact deserves attention.  Finally, her mother’s insistence on the administration of an uninterrupted course of systemic TCM therapy, enabled the child to obtain clinical cure.