Traditional Chinese Herbal The improvement has sustained to date. This case report demonstrates the positive Therapy for Chronic Rhinitis effects of Chinese Herbal Medicines in a in a Cat condition where there are few effective Western treatment options available. Bethany S Innis DVM CVA CCRT History A six-year-old neutered male Domestic Short Hair presented to an integrative private practice with a lifelong history of chronic rhinitis. He was adopted as a kitten from a shelter and had bilateral purulent nasal and ocular discharge when taken home. was normal otherwise. The primary care veterinarian had originally prescribed amoxicillin with clavulinic acid and antibiotic ocular ointment for 14 days. Minor improvements were noted in the amount of discharges. The cat’s energy level and quality of life otherwise continued to be normal. Blood work, skull and chest radiographs were normal. Castration was performed without event. Conjunctival herpes and Chlamydia cultures were negative. A nasal culture was not done at that time due to lack of equipment. Empiric courses of orbifloxacin, Abstract clindamycin and enrofloxacin yielded A six-year-old Domestic Short Hair castrated mild, none and marked improvements, male presented for herbal treatment of respectively. Month-long courses of chronic rhinitis. His condition had been enrofloxacin every few months were lifelong. Previous nasal biopsy determined implemented when the purulence chronic active plasmacytic and neutrophilic showed evidence of epistaxis. Nasal rhinitis and periodic cultures revealed many administration of triple antibiotic drops resistant infections. Periodic treatments with dexamethasone did not improve with enrofloxacin yielded the only clinical signs. positive results, but were associated with significant risk. Acupuncture was effective One year later, physical examination was but implausible. Traditional Chinese the same. The cat was of normal stature, Medicine was employed and Spleen Qi energetic and within normal limits other Deficiency with resultant Damp Heat was than the nasal discharge, ocular discharge diagnosed. San Ren Tang, or Three Seeds and respiratory noise. An endoscopic Decoction, was prescribed and yielded examination, flush and culture were dramatic improvement within one month. performed of his nasal passages. These

civtedu.org JIVT 1(2) October, 2011 19 showed inflammation, mucopurulant an investigation of nasal disease in the discharge and a culture resistant to all cat at the University of Bristol in 2004, a oral antibiotics available at the practice, retrospective study was undertaken of 77 except for enrofloxacin. Consultation with a cats presenting for nasal disease. Chronic human otolargyngologist led to an attempt rhinitis accounted for 27, or 35%, of cases. at a nasal steroid spray. This yielded only With these, clinical signs included nasal epistaxis and much agitation. Trial of oral discharge, sneezing, upper respiratory prednisone resulted in epistaxis and severe tract noise, ocular discharge, weight loss, drying of the nose. lymphadenopathy, , respiratory tract dyspnea, facial distortion and lethargy. Acupuncture required sedation due to Diagnostic procedures included nasal the cat’s fractious attitude but did yield radiography, endoscopy, nasal flush with several days’ reduction in upper respiratory culture and cytology. The only mode of noise and mucopurulant nasal and ocular treatment was antibiotic therapy, used discharge. Due to the sedation, however, in 22 (81%) of the cases. Amoxicillin and it was impractical to do acupuncture clavulinic acid was used for 16 of the cats. frequently. Acupuncture points used Of those available for follow up, 11 cats included GV20, GV14, BaiHui, LU1 and still had clinical signs (five of which were BL13. See Table 1 for special qualities and treated periodically) and only three had indications detailed for each point. (Note: resolution of clinical signs (Henderson et al having looked at this case again, I would 2004). This illustrates the few options and have used points directed more at tonifying remarkably poor treatment success for this the Spleen and draining Damp. These relatively common feline predicament. points would have included BL20, ST40, SP6 and are included in Table 1. Further Chinese Herbal Medicine has been studied discussion on Spleen tonification and Damp regarding chronic respiratory disease in draining follows.) humans. A 2003 randomized, placebo- controlled study was conducted to Two years later, another endoscopy with assess whether the common treatment nasal flush was performed, again yielding of Chinese herbal therapy for seasonal resistant culture results. A biopsy showed allergic rhinitis in humans was truly neutrophilic and plasmacytic rhinitis. The effective. A Traditional Chinese herb was condition was likely an plus chronic used and it, consisted of 18 single herbs. infection. Since his quality of life was never The herb was evaluated based on a Five affected, antibiotics were to be used as Point Scale as well as a Quality of Life necessary. Over the years, the cat had two Questionnaire. After eight weeks, the episodes of sterile cystitis that resolved severity of nasal and non-nasal symptoms without treatment and, very occasionally, was significantly less in the active soft stool. His diet was always Natural treatment group compared to the control Choice Weight Control that was measured group. Marked improvement rates were carefully as he had a tendency towards 60.7% and 29.6% for active and placebo weight gain. respectively (Xue et al 2003). This is one Chronic rhinitis in cats is prevalent yet study in many reflecting firstly, that herbal has few effective treatment options. In treatments are commonplace for human civtedu.org JIVT 1(2) October, 2011 20 rhinitis and secondly, that the treatments the quintessential cat formulas of veterinary are often very effective. herbal medicine, as well as a main formula to address the ubiquitous problem of Physical Exam Damp Heat in small animals. San Ren Tang Three years later, the cat was evaluated was developed to treat Damp Heat due again from a Chinese Medicine perspective. to poor Spleen function. The formula is His personality was vocal and social. He got designed for patients who show signs of on well with the other dogs and cats in the Damp but are not yet showing pronounced home. He was always hungry, his thirst was Heat signs. Heat signs include pruritus, normal. Bowel movements were regular, agitation, hematuria and mild fever or heat with an occasional soft stool. Urination, intolerance. Damp signs include greasy other than two incidents of stranguria and coat, cough (moist or productive), / hematuria, was normal. He had a tendency reverse sneezing, profuse eye discharge, to urinate inappropriately (in close chronic vomiting, dysuria, crystalluria, proximity to the litterbox) if the litterbox chronic conjunctivitis and heat intolerance. was not cleaned daily. He had no stiffness Diseases treated in veterinary medicine or trouble sleeping. He sought warm areas include the following: , nasal to sleep in and preferred cushioned beds, congestion, wheezing, snoring, canine except when it was very hot. He sneezed reverse sneezing, constipation, recurrent often and a brown- or red-tinged mucoid cystitis, inappropriate urination, urolithiasis, discharge would be evacuated. cystitis, weight gains, chronic vomiting, inflammatory bowel disease, gastritis, On physical exam, his body condition score seborrhea oleosa, allergic dermatitis and was 4/5. His coat was silky and smooth; fungal otitis externa (Marsden 2006). he was energetic and very vocal. He had yellow-brown crust over both nares and Biomedical aspects of the individual herbs very loud upper respiratory noise on comprising Three Seeds Decoction has inspiration. His eyes displayed yellow- been studied in detail. Apricot Seed, or Xing brown tinged epiphora bilaterally. His Ren (pictured below) , has been shown to inner pinnae had moist, brown discharge be an antihypertensive, antitussive and bilaterally. Everything else was within antiasthmatic, as well as antineoplastic normal limits. His tongue was thick, bright herb. Coix Seed, or Yi Yi Ren, has proven pink, scalloped and wet. His was quick and slippery. Active points were BL20 and BL23. My Chinese diagnosis at that point was Spleen Qi Deficiency with resultant Damp Heat accumulation. Table 2 illustrates clinical signs correlated with Traditional Chinese . Treatment The herbal formula chosen for treatment was San Ren Tang, Three Nut or Three Seeds Decoction. It has been described as one of civtedu.org JIVT 1(2) October, 2011 21 Appendix Table 1.

Acupuncture Point Special Qualities Indications GV20 Clears mind, tonifies Spleen, good for Liver Fire, Liver Yang Rising and Liver Stagnation, Yang Deficiency & Collapse, Blood Exhaustion, Dispels Wind

GV14 Dispels Wind and Heat, Tonifies Wei Qi, Opens all the Yang Channels, Tonifies or Drains Yang

Lumbosacral point/Yao Sciatica, Pelvic Limb Disorders BaiHui

LU1 Alarm Point Diagnostic, Respiratory, Cough, , Asthma

BL13 Lung Association Point Dispels Wind, Wind Cold, Helpful in Lung Disorders and Dry Skin

BL20 Spleen Association Drains Damp, Tonifies Qi and Blood Point

ST40 Luo Point, Influential Transforms and Disperses Phlegm Point for Phlegm

SP6 Master Point for the Disperses Damp, Damp Heat caudal abdomen and pelvic disorders Tonifies Qi, Blood and Yin, tonifies Spleen, Useful for Poor Shen

(Marsden and Wynn 2003)

effects on muscles (inhibitory on skeletal, suppresses nausea and vomiting, and stimulating on smooth muscle of uterus, reduces absorption of toxins through the varied on intestines) with a sedative, intestinal tract. analgesic, antipyretic and possibly antineoplastic action. Talcum, or Hua Shi, Pinellia, or Fa Ban Xia, has antitussive, when applied externally, absorbs large antiemetic and antineoplastic properties. amounts of chemicals and toxins to protect Cardamom, or Bai Dou Kou, has the against skin irritation. When ingested, it benefits of increased secretion of gastric protects the stomach lining from gastritis, acid, increased intestinal peristalsis and civtedu.org JIVT 1(2) October, 2011 22 decreased vomiting. Lopatherum, Dan Zhu and nasal discharge, though it was still Ye, is both antipyretic and diuretic in this present. Within one month, minimal or no combination. Magnolia Bark, or Huo Po, has respiratory noise was audible, the crust been shown to cause decreased secretion over his nares was gone as was his eye of gastric acid and to reduce contractions discharge. His energy level was dramatically of duodenum, it is a mild anticoagulant, increased. The cat still sneezed and mucoid CNS suppressant, and an antihypertensive. discharge would be present. He did not It has a stimulating effect on have any episodes of soft stool or cystitis at low dose, inhibiting at high dose and after starting the herbs. is an antibiotic (Streptococcus matuans, Every month or two, the cat would not be Staphylococcus aureus, Bacillus subtilis, medicated for 1-2 days due to owner non- Diplococcus pneumonia, Bacillus dysteneriae) compliance. At these times, several days’ (Chen 2004). later, a brown crust would reappear over

his nares and the loud respiratory noise and The biomedical aspects of the individual epiphora would return. As long as the herb herbs show why they would be useful in was resumed as soon as possible, the cat’s chronic respiratory and gastrointestinal signs again would disappear. After several diseases, in particular. months, the lag time it took for the signs The formula was obtained as a tincture to resolve lessened from one to two weeks, from Kan Herb Company. The dose was to two to three days. No repeat biopsy or 0.2ml / 5 lbs twice daily. The herb was other diagnostics were performed due mixed with his food and he took the full to clinical improvement and anaesthetic dose daily. requirement for attaining them, although having the diagnostics would have been Several months into the treatment, the cat’s ideal. diet changed from Natural Choice Weight Control to a blend of Wellness Grain Free Discussion and Natural Balance Limited Ingredient This case represents a common scenario Grain Free kibble. The protein bases were in veterinary medicine. Western medical Salmon and Duck. These are cooling and options are exhausted, leaving few other neutral in nature and are indicated for Heat options for treatment. Eastern medical conditions. The low carbohydrate food also treatment is considered and is a good promotes Spleen function and reduces the option due to its different overall approach. generation of Damp from a faulty Spleen. Focusing on an underlying cause for this The herbal treatment and the diet change cat’s lifelong respiratory issues is the crux of were staggered to better assess which the solution. treatment was affecting which clinical sign. Cats are prone to Spleen Qi Deficiency. Results Spleen Qi Deficiency can be caused by The patient was assessed on a daily basis overwork, complete fasting, inappropriate for epiphora, nasal discharge and upper diet and over-consumption of food . Within two weeks, (particularly carbohydrates). In small the patient had subjectively less ocular animals, diet seems to be the primary civtedu.org JIVT 1(2) October, 2011 23 Table 2

Clinical Sign Traditional Chinese Medical Pattern Tongue: thick, pink, scalloped, wet Damp Heat Pulse: quick, slippery Damp Heat Brown Discharge in Pinnae Damp Heat Increased Hunger, but not Thirst Damp Heat Yellow Nasal Discharge Damp Heat Epiphora Damp Stranguria Damp Hematuria Heat Excess Body Fat Phlegm (Marsden 2006) cause. Cats evolved as carnivores and the seeds. Apricot seed is used in the Upper current commercial mainstream diets Jiao as an antitussive. Cardamom seed has are very high in carbohydrates and may gastric anti-inflammatory effects and stops aggravate imbalances. Carbohydrates vomiting in the Middle Jiao. Coix seed theoretically drain the Qi of the Middle resolves colitis by inhibiting nitric oxide Jiao (where the Spleen and Stomach exist). synthesis and this effect extends to the Without proper Spleen function, the organ urinary tract. The other herbs support these is unable to transform fluids correctly, actions and promote normal peristalsis, hence Damp accumulates. This Damp tends mobilize small amounts of swelling and to accumulate were normal fluid would. reduce mucous production (Marsden Damp, in time, can become Damp Heat. In and Fougere 2009). See Table 3 for more this cat’s case, Damp Heat accumulated in detailed information on individual herb his Upper Jiao, within his nasal passages qualities. and his eyes. It occasionally took hold as The formula was developed originally to Damp Heat in his Lower Jiao within the treat human geriatric patients retaining bladder wall and his colon, resulting in phlegm and exhibiting Qi stagnation. These episodes of stranguria and hematuria. His geriatric patients exhibit Qi Deficiency, body fat was from phlegm, a result of Damp which when coupled with overeating or accumulation (Marsden 2009). over-consumption of cold or raw food, San Ren Tang, or Three Seends Decoction, leads to stagnation of food and Qi. The is designed to promote the descent of overall purpose of the formula is to: 1. Lung Qi, transform and dry Damp in the redirect Lung Qi and soothe the diaphragm Middle Jiao and drain Damp down to and and 2. to dissolve phlegm and promote out of the Lower Jiao (Marsden 2006). food digestion. In humans, a white greasy As the name indicates, it contains three tongue coating and slippery pulse suggest civtedu.org JIVT 1(2) October, 2011 24 Table 3

SAN REN TANG Pin Yin Name English Name TCM Action Biomedical Action Xing Ren Apricot Seed Ventilates and Antihypertensive, Antitussive and antiasthmatic, Antineoplastic regulates Lung Qi and relieves chest oppression

Yi YiRen Job’s Tears Dispels damp and Effects on muscles (inhibitory on skeletal, stimulating on smooth Seed/Coix Seed strengthens Spleen muscle of uterus, varied on intestines), Sedative, Analgesic, Antipyretic, Possibly Antineoplastic

Hua Shi Talcum Clears Heat, Dispels Applied Externally: absorbs large amounts of chemicals and Damp, Promotes toxins to protect from skin irritation. Applied Internally: protects Urination stomach lining from gastritis, suppresses nausea and vomiting, reduces absorption of toxins through the intestinal tract.

Fa Ban Xia Treated Pinellia Activate Qi Circulation, Antitussive, antiemetic, Antineoplastic Rhizome Dispel Dampness, Relieve Distension

Bai Dou Kou Chinese Cardamon Dries Damp, activates Increased secretion of gastric acid, increased intestinal Fruit Qi Flow peristalsis and decreased vomiting.

Dan Zhu Ye Lophatherum Leaf & Clears Heat, Dispels Antipyretic, Diuretic Stem Damp, Cools Heart, Promotes Urination

Hou Po Magnolia Bark Activate Qi Circulation, Decreased secretion gastric acid/reduced contractions of Dispel Dampness, duodenum, mild anticoagulant, CNS suppressant, Relieve Distension Antihypertensive, Simulating effect on respiration at low dose, inhibiting at high dose, Antibiotic (Streptococcus matuans, Staphylococcus aureus, Bacillus subtilis, Diplococcus pneumonia, Bacillus dysteneriae)

Tong Cao Tetrapanax Pith Clears Heat, Dispels Damp, Promote Urination

(Chen and Chen 2004)

Qi Deficiency and Phlegm Retention. It Although this cat’s exudates were yellow- is interesting to note that the human brown in color (which reflects heat) and indications focus most on respiratory his tongue and pulse reflected Damp Heat, symptoms and gastrointestinal upset. These he did not seem so affected by Heat that conditions of asthma and rhinitis are very he was restless and cool seeking, with common in our feline patients, in addition malodorous secretions or halitosis. It was to inflammatory bowel disease and for these reasons, coupled with the fact constipation (Chen and Chen 2009). that it is much more common to use San civtedu.org JIVT 1(2) October, 2011 25 Ren Tang for a cat as a first approach, that Marsden S (2006). Handbook for I chose San Ren Tang over Si Miao San. Si Veterinarians Classic Formulas for Animals. Miao San would have been indicated if Heat Scotts Valley: Kan Herb Company. essentials Signs were more pronounced. Wei Ling Marsden S and Fougere B (2009). CIVT 1002 of western Tang also addresses Damp, however the cat IVAS Course in Chinese Medicine. Sydney: would need to be cooler overall. veterinary College of Integrative Veterinary Therapies. herbal A limitation of this case is the less than Marsden S and Wynn S (2003). Manual of ideal use of antibiotics. It would have been medicine Natural Veterinary Medicine Science and more appropriate to initially flush and Tradition. St. Louis: Mosby. culture the cat’s nares and pharynx and use the sensitivity results to guide antibiotic use. Potentially, it could have reduced Plumb D (2005). Veterinary Drug Handbook, resistance in this cat. Enrofloxacin is a risky 4th Edition. Ames: Blackwell Publishing choice (of which the client was well aware). Ames. (VIN Online Version) It is contraindicated in young, growing Xue CC, Thien FC, Zhang JJ,next Da Costacourse C starts September 26 animals, due to the potential for cartilage and Li CG (2003). Treatment for seasonal abnormalities. Rarely, cats have have been allergic rhinitis by Chinese herbal medicine: reported to have ocular toxicity, mydriasis, a randomized placebo controlled trial. retinal degeneration and blindness (Plumb AlternTher Health Med. 2003, 9(5):80-7. n 2005). It was unfortunate that this cat was uncooperative for acupuncture treatment. Had a laser unit been available, this would ivas have been the perfect modality to use. certification vbma Conclusion in veterinary This case study demonstrates that Chinese chinesegraduate Herbal Medicine can positively affect chronic rhinitis in cats, even after Western herbalprogram in Medicine has not been effective. medicine References of western Chen J and Chen T (2004). Chinese Medical Herbology and Pharmacology. City of veterinary Industry: Art of Medicine Press. ivas civt certification herbal Chen J and Chen T (2009). Chinese Herbal in veterinaryon demand chinese – start when it suits you! Formulas and Applications. City of Industry: medicine Art of Medicine Press. herbal medicine

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