Kolahdooz et al. Asian J Clin Case Rep Trad Alt Med. Jan-Mar 2018; 1(1-2): 12-21 Asian Journal of DOI: 10.22040/AJTCAM.2018.87088 Clinical Case Reports for Traditional and Alternative Medicine
ORIGINAL ARTICLE Open Access
A case report of chronic allergic rhinitis treatment in a 29-year-old woman based on Iranian traditional medicine Mehrdad Karimi1, Sima Kolahdooz2,*
1 Assistant Professor, Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran. 2 MD, PhD in Persian Medicine, Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran.
Received: 07 Oct 2018; Accepted: 24 Oct 2018; Published Online 22 Dec 2018
ABSTRACT Background: Allergic rhinitis is one of the most commonly diagnosed allergic diseases, the prevalence of which is increasing globally. The purpose of this case report is to outline the Iranian traditional medicine (ITM) approach to diagnosis and treatment of chronic allergic rhinitis. Case Presentation: A 29-year-old woman with a long history of symptoms of runny nose, sneezing and itchy throat was diagnosed with seasonal allergic rhinitis and treated with antihistamines. Since 9 years ago, the disease pattern changed from seasonal to a year-round state and the patient referred to the traditional medicine clinic due to inadequate response to conventional therapies and reluctance to consume oral corticosteroids. Initially, the six lifestyle essentials and prohibited foods were explained to the patient, followed by drug therapy to cleanse the head region and body and to eliminate the underlying causes of the disease. The post45-day treatment assessment showed a significant reduction in the severity and frequency of symptoms. Conclusion: Clinical decision-making in ITM is based on a holistic view of the patient rather than the disease, which is the case in conventional medicine. This case report is an example of a patient-based treatment protocol in the Iranian medical system. The systemic approach of ITM in dealing with a patient with allergic rhinitis and simultaneous attention to brain and whole-body cleansing along with the six essentials of lifestyle modification resulted in significant improvement.
Keywords: Allergic Rhinitis, Conventional Medicine,Iranian Traditional Medicine
Citation: Mehrdad Karimi, Sima Kolahdooz. A case report of chronic allergic rhinitis treatment in a 29-year-old woman based on Iranian traditional medicine. Asian J Clin Case Rep Trad Alt Med, Jan-Mar 2018; 1(1-2): 12-21
Corresponding Author: Mehrdad Karimi, MD, PhD in Persian Medicine, Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran. Email: [email protected]
© 2018 The Author(s). Open Access. This article is distributed under the SINAWEB Publication in http://sinaweb.net.
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Introduction to get familiar with the treatment methods used in traditional and complementary medicine schools. In ITM literature, AR symptoms are described Allergic rhinitis (AR) is an inflammation under the title catarrh. The term “catarrh” refers of the nasal mucous membranes due to the to the discharge or build-up of mucus in the nose reaction of the immune system to allergens or throat, or adjacent organs such as the chest, (1) that can be limited to the brain or be ears, eyes, etc., and the mechanism of disease associated with other systemic manifestations induction, diagnostic criteria and treatment have of inflammation and allergies in the body (2). been discussed extensively (19). The underlying The disease prevalence rate is about 10-30% in cause of the discharge accumulation in the nasal adults and 40% in children in different societies region is considered to be due to a weakness (3). Given the role of genetics for this disease, of brain digestion in providing its food from there is a familial history of atopy including mucosa or the reduced and excessive mucosa asthma and eczema in most cases of allergic received from the body. In such conditions, rhinitis (4). Symptoms may occur seasonally or the brain excretes this excessive mucosa to year-round (5), and clinical manifestations vary other organs in order to protect the health of from person to person, ranging from mild to the intended organ (20). Depending on the severely debilitating (6). Symptoms of mucous location of the discharge and the quality of the membrane inflammation manifest as itching, temperament involved, catarrh can manifest runny nose and nasal congestion (7). In some various symptoms including nasal congestion individuals, this inflammation may also involve and runny nose, itching and burning nose, red other members of the head and neck, including eyes, epiphora, itching ear, hoarseness, loss of the eyes, ears and pharynx, and induce symptoms taste, saliva accumulation, post-nasal drip, and a such as itching, redness and feeling of a foreign feeling of heaviness in the head and neck regions body in the eye, swelling, bruising and under-eye (21). Since many complications are ascribed to darkness, sore throat, and clogged or itchy ears this condition, Iranian physicians endeavored to (8-10). Chronic sinusitis is the most common cure (21). Familiarity with catarrh treatment in type of disease associated with allergic rhinitis, ITM can provide physicians and researchers with while complications such as otitis media, sleep new perspectives for a more systematic look at disorders or apnea, dental problems and palate AR and its permanent treatment, and reduce the disorders can also occur at a lower incidence high costs and complications of the disease and its rate (11, 12). Although AR is not a fatal disease, existing therapies. it can greatly affect quality of life in patients (13, 14). The disease imposes significant costs on the patients and the society both in terms of the Patient Introduction treatment and loss of individual performance 1- History and examinations based on the caused by sleepiness and drugs complications modern medicine school (15-18). Given the chronic nature and the The patient is a single 29-year-old woman born lack of definitive treatment for this disease in and resident in Tehran with a master’s degree in conventional medicine, it would be very helpful management who works as a sales staff member
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in an airline company. She had allergic symptoms smells. Eating warm-tempered foods like hot including severe sneezing, runny nose, redness spices also exacerbated the symptoms. The patient and itching of the eyes, itching of the throat and was moderately cold and relatively dry to touch hives in the spring since she was 13 and was later in the forearm region. Her pulse length was two diagnosed with seasonal AR and treated with and a half fingers, relatively short and slow. The antihistamines. Since the age of 20, the frequency wastes excreted from the body through urine and of allergic symptoms gradually increased in the stool and sweat was neither colored nor strong- patient who was at the present suffering from smelling. She did not have a hot or cold feeling excessive sneezing, nasal congestion and runny in the body and the extremities, but occasional nose, swollen throat, feeling of congestion in facial hot flashes were mentioned. She was an extrovert sinuses and upper respiratory tract and shortness person and she quickly became angry and calm. of breath in all seasons and at intervals of every She also complained of slowness in performing 2 to 3 days. Patient symptoms were more severe her daily affairs and being numb, tired and bored. during the night and in the morning. The patient’s Feeling of heaviness upon waking up in the symptoms began with a feeling of itching in the morning was also mentioned. The redness of the nose and throat, which urged her to use Flusinose cheeks, the dark facial color and the darkness of the eyes were evident while observing the head spray to prevent progression of symptoms to and neck region. There was mild moistness on blockage of the upper respiratory tract and the face and eyelids of the patient. All of the facial shortness of breath. Normal saline serum was signs had developed gradually during the last two also used to remove discharge through irrigation years and the allergic symptoms were exacerbated and gargling. Spices such as pepper, garlic, ginger, ever since. Other symptoms in the head and neck turmeric (to some extent), strawberries, eggplants, regions included ear pruritus and increased wax, fragrances, Peganum harmala L., cigarette smoke, a painful palate, runny nose and nasal congestion. polluted air and the smell of strong detergents In addition to the above symptoms, nasal dryness triggered or exacerbated symptoms. The patient with occasional epistaxis, a sense of oral viscosity had a history of surgery and hospital admission upon waking up, occasional hypersalivation with due to rhinoplasty at thirteen years of age. There fairly dilute consistency, and white thick postnasal is a family history of similar symptoms with mucus. She also had no problem in falling asleep, less severity in the patient’s mother, uncle and but stated that she was annoyed by sound and grandmother. light when falling asleep. She had to wake up at night for urination. The sleeping depth and theme 2- History and examinations based on of her dreams were mostly related to daily events. traditional medicine school Tongue examination revealed a scalloped tongue History and general examinations with a pale pink color, along with an evident The patient’s weight and height were 70 kg and 170 increase in the moisture content, and a dispersed cm, respectively. She was overweight and highly white coating on the entire surface, more prone to weight gain. She was intolerant to cold prominently in the posterior part. The results of weather, and her allergic symptoms exacerbated chest examination showed shortness of breath in warm temperatures or inhalation of warm and development of allergy symptoms caused
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by the lack of using drugs. Digestive symptoms visit, she went to the gym and performed aerobic included post-eating drowsiness, intense thirst activity three times a week. The air pollution rate with high appetite for drinking cold water and no of the patient’s place of residence (Tehran) was relief from thirst despite cold water consumption. relatively high. Average sleep range was 7 hours The patient preferred sour and somewhat bitter (11:00p.m. to 6:00 a.m.) She did not sleep during foods. The patient experienced excessive thirst the day. after consumption of kebab and dry foods and preferred dilute watery food to dry ones. While 3- Therapeutic measures examining the lower gastrointestinal tract, she The catarrh is caused by a kind of material complained of rumbles and the examining the dystemperament of the brain, so dilution and stool excretion pattern showed highly consistent cleansing is necessary to treat this kind of stool with a great deal of delay within one to dystemperament. To achieve the permanent four days and the feeling of lack of complete recovery for the disease, in addition to organ evacuation. The patient had black, conditioned cleansing, special attention must also be paid hair and dry skin. The results of examining uterus to removing the internal (inside the body) and and ovaries showed regular period with 24-day the external causes of substance formation. intervals and menstruation length of 7 days (the Modification of the external causes is carried first 2 days of moderate hemorrhage followed by out by altering the six lifestyle essentials and spotting) and severe dysmenorrhea on the first provision of health and nutrition measures. If two days. The hemorrhage volume was gradually there is excessive moisture in the body, sputum reduced from the 3 months before the visit. The dilution and cleansing should be carried out to patient was treated with spironolactone due to eliminate internal causes to prevent relapse. In acne, unwanted hair and polycystic ovary since the second place, it is necessary to correct the one and a half years before the visit. dystemperament and tonify the organs responsible for the first digestion (stomach) and the second History of patient’s sixth essentials digestion (liver) and the affected organ (brain) so The patient consumed fast food and mushrooms that re-accumulation of moisture doesn’t occur in frequently. She also consumed foods creating the body and brain. harmful vapors, such as walnuts in breakfast, garlic and cress with some foods. There were Measures of health and nutrition some problems with regard to eating and drinking External causes can exacerbate catarrh symptoms habits, such as not chewing food properly, with direct or indirect effect of the internal causes fast eating and salad and pickle consumption. on the brain. Drinking a lot of cold water (12 glasses a day) and consuming water upon waking up, after bathing, External causes with an intermediate effect and during exercise were among the patient’s bad on the brain drinking habits. In terms of physical activity level, The patient was recommended to avoid she regularly played basketball and volleyball consuming thick and viscous foods and mucus during the teenage years but quitted the sport producing foods such as mushrooms, cheeses, since the age of 20. About a few months before the
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yogurt, beef, camel meat, fish and shrimp, boiled exercise, and fruit and fluid consumption. Since egg whites, cucumbers, tomatoes, Olivier salad, quitting regular exercise was one of the reasons pasta, lasagna, pasta, pizza, fast food, halim, for the accumulation of excessive moisture in the kalleh pacheh, chicken, jelly and ice cream patient’s body, she was advised to have fast-paced and pastry sweets in order to reduce liver load walking at least once a day for half an hour. and satiety and provide an opportunity for the removing and cleansing of the waste material External causes with a direct and in the body. In addition to the foregoing, to intermediate effect on the brain prevent overproduction of vapors in the body Inhalation of warm smells through lead to dilution and their ascending to the brain, the patient was of moistures and their flow from the throat and recommended to avoid consuming foods that brain and thus catarrh symptoms in the patient. produce vapors in the body, such as walnuts, old The patient was advised to avoid these fragrances cheese, cress, turmeric, garlic and onions. The to the end of the therapeutic period. Exposure to use of warm spices such as pepper and ginger, by cold can prevent vapor reduction by obstructing heating the liver and the whole body, can warm the head pores, on one hand, and weaken its the phlegm and exacerbate catarrh symptoms in severity by creating a cold dystemperament in prone individuals and are included in the list of the brain. Hence, the patient was advised to avoid foods that should be avoided by the patient. The sudden changes in ambient temperature from hot patient was advised to avoid using cold water to cold and exposure to cold wind. and, when thirsty, drink a little bit of warm water and not drink water at fasting times, after bath Drug Precautions and exercises. The following recommendations Based on the measures taken for catarrh remedy were given to the patient in order to improve first and material dystemperaments, the following digestion (gastric) and second digestion (liver) goals were considered: and prevent production of thick phlegm and The first main goal: Affecting the material accumulation of excess moisture in the body: causes and reducing the feeling of heaviness in the the need to avoid doing things like overeating, body and brain. eat a meal without appetite as well as taking • Whole body cleansing by altering the material water, dough, soft drinks, salads, pickles and to a consistency that can be excreted through yogurt with food and eating two different kinds urine, sweating, diarrhea, menstruation (Nozj). of meals at one serving (fish and chicken, soup • Cleansing the wastes from the brain region with rice, etc.), avoid drinking cold water, as well through changing substance consistency and as at fasting times, during sleeping, between or opening the excretion pathway of nasal discharge after exercise and after bathing. In addition to through cleansing of the nose and throat the above measures, the patient was advised to • Preventing vapor ascend from the stomach dedicate enough time to each meal, chew well, and the whole body to the brain and stop eating food before full satiety, while Second main goal: Affecting the internal causes there is still some appetite for food, avoid heavy (correction of the status of the organs involved in physical activity after meals, observe at least 2 the digestion process) hours between meals and affairs like sleep, bath, • Ameliorating brain dystemperament and
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tonifying so that it does not create excessive Nozj process and remove excessive wastes, moisture and does not absorb moisture, phlegm, and Sekanjabin Onsoli was used to reduce and and excessive vapors from the body. decompose excessive body moistures. Sekanjabin • Ameliorating hepatic dystemperament and Onsoli also plays a role in resolving hepatic tonifying it as an organ responsible for the second obstructions. digestion and the main cause of the phlegm 3. Rahat capsule (containing Chinese rhubarb production in the body. paste, terminalia chebula, Senna, aloe Vera) 2 • Acting on the stomach as the starting point capsules in the morning and 2 capsules at nights of digestion in the body where chyle production Each of the four plants in the Rahat capsule act takes place as laxatives, with rhubarb also removes wastes in • Resolving constipation and defects in other addition to causing diarrhea. This compound also excretory pathways in the body with the aim of helps with the transmission of substance from disposing of wastes and prevention of retention. the head and upper parts of the body to the lower Considering the priority of cleansing the body extremities and the digestive tracts, specifically and brain from phlegm, the logical choice of improving the liver and stomach condition. herbs and drugs was made accordingly but the 4. Sweet almond oil, 2 drops per nostril once composition of the compounds was in such a way a day as to cover the goals of the second stage. Sweet almond oil was prescribed to relieve Prescribed drugs included the following: dryness of the nasal mucosa caused by frequent 1- Decoction of a combination of marjoram, nasal spray application. The mechanism of anthemis tinctoria, jujube, celery seed, anise, action of each plant used on the material and quince consumed upon waking up physical causes of the disease is derived from the The main use of the above compounds in the reference books and described in detail in Tables decoction focuses on the delicacy, fragmentation, 1 and 2. reduction and dilution of moisture and its excretion through urination and sweating, 4. Treatment outcomes and to some extent diarrhea. All the plants in One and a half months after the start of treatment, the decoction also played a role in improving the change in the patient’s symptoms were as its function by having different effects on the follows: liver, such as removing of wastes, resolving The morning swelling of the face and the lower obstructions, tonifying and correcting the liver eyelids were slightly reduced. temperament. Anise and marjoram were used in Regarding the gastrointestinal symptoms, it the decoction because they play an effective role should be noted that patient’s thirst was satisfied in expelling discharges from the head by opening only by drinking 5 glasses of cold water per day the blockage of the respective paths. instead of initial 12 glasses. She also had bowel 2- A tablespoon of jujube syrup (containing movement once a day, but stomach rumble did jujube and root of licorice) and Sekanjabin Onsoli not change significantly. In terms of general (containing the Sekanjabin and Drimia) in the symptoms, the feeling of tiredness, boredom and morning and at night a feeling of heaviness in the body did not change Jujube syrup was prescribed to help the significantly.
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Table 1: Effects of plants on material causes Organ Cleansing body Cleansing brain Preventing Plant moistures moistures vapor ascend Marjoram + + Chamomile + + Celery seeds + Anise + + Quince + + Jujube + + Licorice + + Sekanjabin + Onsoli + + Chinese Rhubarb + + Aloe vera + + Senna + + Terminalia chebula + + +
Table 2: Effects of plants on organs Organ Brain Liver Stomach Ameliorating Ameliorating Ameliorating Tonic Tonic Tonic Plant dystemperament dystemperament dystemperament Marjoram + + + + Chamomile + + + Celery seeds + + + + Anise + + + + + + Quince + + + + Jujube + Licorice + + Sekanjabin + Onsoli + + + + Chinese rhubarb + + + + Aloe vera + + + + + Senna + Terminalia chebula + + + + + +
Discussion reduced significantly. Following inflammation Allergic rhinitis is an inflammation in the nasal in the nasal mucosa, one or more symptoms of mucosa that develops following the reactions sneezing, itching, congestion and runny nose of the immune system to the allergens (7). The usually manifest. The presence of inflammatory prevalence of this disease is increasing in many symptoms in other parts of the head, including parts of the world (3, 22), and imposes a lot of conjunctiva, sinus, middle ear, nasopharynx, and healthcare costs on the patient and the society lower respiratory tract are often associated with (8). Inflammation of the throat and facial sinuses, the disease (22). Symptoms of this disease can be nasal congestion and nasal dryness were resolved, created in the head and neck area or in association and the post nasal drip and itching have been with general symptoms of allergy in the body (2).
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According to Iranian traditional medicine, the itching and swelling of the throat, and swelling cause of inflammatory symptoms in the brain obstruction in the facial sinuses and stomach and other parts of the head and neck includes rumble indicate the accumulation of moisture excessive discharge of accumulated mucosa in in the head and neck regions. Symptoms such as the head via the nose, throat and their adjacent slowness in daily activities, numbness and fatigue, members, and the presence of systemic allergic a feeling of heavy stomach during morning symptoms suggests that the accumulation of this after awakening, shortness of breath, excessive mucosa occurs throughout the body in addition thirst, stomach rumble, constipation, polycystic to the head. In terms of Iranian traditional ovaries, and the characteristics of the patient’s medicine, allergic diseases are a kind of material pulse indicate accumulation of moisture in the dystemperaments that can be created in one organ respiratory, digestive, urogenital and reproductive or in the whole body, and factors such as the basic organs and the whole body. The findings in the temperament and the internal and external causes patient’s history and examinations showed her of the dystemperament can affect the susceptibility basic temperament to be warmer and wetter, but of people and the course of the disease (23). The over time due to reasons such as non-observance evidence of classical medicine is also indicative of of proper eating habits and drinking and quitting the fact that a series of genetic factors, epigenetic regular exercise, led to an increased moisture and events, and exposure to environmental factors coldness and accumulation of thick mucus (mostly contribute to allergic diseases (3). phlegm) in the entire body and head and neck. Allergic rhinitis is commonly treated in Considering the material dystemperament in the classical medicine through the elimination of head and body, modification of the six lifestyle allergen agents and the use of antihistamines, essentials and drug therapy was recommended to corticosteroids, decongestants, mast cell the patient in order to cleanse excessive moisture stabilizers, anticholinergics to prevent and to eliminate the underlying causes of their inflammation or suppress the inflammatory accumulation in the body. For this purpose, herbs response to allergens (22). From traditional that could pave the way for the removal of the body medicine point of view, classical drugs can reduce mucosae from whole body through urination, the symptoms of allergic rhinitis by reducing the sweating and diarrhea in order to smooth, reduce, warmth and dilution of excessive moisture and, decompose and dilute them in addition to having in some cases, by drying them, but as long as specific effects on the brain. Following treatment, these excess moisture is not removed from the there were no sneezing, runny nose and excess body and the underlying internal and external production of saliva and the need for spraying causes are not resolved, they accumulate in the reached once or twice a day from 2-3 times a day. body and head region, and the disease will not Through their therapeutic effect on the organs be eradicated. We later consider the Iranian involved in the digestion process, mostly liver, the traditional medicine approach to the diagnosis prescribed herbs were also effective in removing and treatment of the above-mentioned patient, the underlying cause of the disease. Treatment based on the underlying cause of the disease in her. outcomes after a forty-five-day period indicated The patient’s complaint list including sneezing, a significant improvement in symptoms and a itching, runny nose and nasal congestion, reduction in the frequency of allergy symptoms.
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Conclusion 2014;4(S2):S18-S20. The Iranian traditional approach to manifestations 4. Torres-Borrego J, Molina-Teran A, Montes- of allergic rhinitis, through recognition of Mendoza C. Prevalence and associated factors external and internal causes of the disease and the of allergic rhinitis and atopic dermatitis in simultaneous attention to the removal of the body children. Allergologia et immunopathologia. and the head of the phlegm, significantly improved 2008;36(2):90-100. the patient’s symptoms within a relatively short time. According to the results of the treatment, 5. Bellanti JA, Wallerstedt DB, editors. Allergic it is necessary to perform combined traditional rhinitis update: epidemiology and natural Iranian medicine and classical medicine studies history. Allergy and Asthma Proceedings; 2000: aimed at discovering the underlying mechanisms OceanSide Publications, Inc. of the occurrence of allergic diseases in individuals so that therapeutic strategies can be developed 6. Bousquet J, Annesi‐Maesano I, Carat F, Leger and personalized treatment plans designed for D, Rugina M, Pribil C, et al. Characteristics patients. of intermittent and persistent allergic rhinitis: DREAMS study group. Clinical & Experimental Allergy. 2005;35(6):728-32. Contributing Contributors The patient was treated under the supervision of 7. Skoner DP. Allergic rhinitis: definition, Dr. Mehrdad Karimi, and Dr. Sima Kolahdooz epidemiology, pathophysiology, detection, cooperated with him in documenting and and diagnosis. Journal of allergy and clinical compiling the article. immunology. 2001;108(1):S2-S8. 8. Bielory L, Chun Y, Bielory B, Canonica G. Conflicts of Interest Impact of mometasone furoate nasal spray on There are no conflicts of interest. individual ocular symptoms of allergic rhinitis: a meta‐analysis. Allergy. 2011;66(5):686-93. References 1. Berrettini S, Carabelli A, Sellari‐Franceschini 9. Spector SL. Overview of comorbid associations S, Bruschini L, Quartieri F, Sconosciuto F, et al. of allergic rhinitis. Journal of allergy and clinical Perennial allergic rhinitis and chronic sinusitis: immunology. 1997;99(2):S773-S80. correlation with rhinologic risk factors. Allergy. 10. Mandhane SN, Shah JH, Thennati R. 1999;54(3):242-8. Allergic rhinitis: an update on disease, present 2. Rondón C, Campo P, Togias A, Fokkens WJ, treatments and future prospects. International Durham SR, Powe DG, et al. Local allergic rhinitis: immunopharmacology. 2011;11(11):1646-62. Concept, pathophysiology, and management. 11. Colás C, Galera H, Anibarro B, Soler R, Journal of allergy and clinical immunology. Navarro A, Jáuregui I, et al. Disease severity 2012;129(6):1460-7. impairs sleep quality in allergic rhinitis (The 3. Mims JW. Epidemiology of allergic rhinitis. SOMNIAAR study). Clinical & Experimental International Forum of Allergy & Rhinology. Allergy. 2012;42(7):1080-7.
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