Western Medical Diagnosis Systemic Lupus Erythematosus.

Example 5: Fan, female, 45 years old. Joint pain, edema, anemia, liver function impairment, urine protein (2+), occult blood (2+), blood pressure 145/90 mmHg, ESR 72 mm/h. Previously hospitalized, diagnosed with Systemic Lupus Erythematosus. The patient has been taking hormones long-term, resulting in moon face and central obesity, extreme physical weakness, both pulses wiry-tight and rapid, weak pulse at the cun position, red and swollen tongue, thick greasy yellow coating.
[Western Medical Diagnosis] Systemic Lupus Erythematosus.
[Traditional Chinese Medicine Syndrome Differentiation] Wind-Dampness with Heat Invading the Interior, Chronic Disease Entering the Collaterals, Liver and Kidney Deficiency.
[Treatment Principle] Tonify Liver and Kidneys, while clearing Internal Heat.
[Formula] Modified Guizhi Shaoyao Zhimu Tang combined with San Chu Zeng Ye Tang: Epimedium 15g, Polygonum 10g, Tribulus 15g, Rehmannia 12g, Scrophularia 10g, Ophiopogon 10g, Dipsacus 10g, Eclipta 15g, Lycium 10g, Guizhi 10g, White Peony Root 20g, Anemarrhena 20g, Atractylodes 10g, Prepared Ephedra 10g, Ledebouriella 12g, Licorice 6g, Dried Ginger 6g, Aconite 15g (decocted first for 1 hour), Aconite 15g (decocted first for 1 hour), Liaoxixin 15g (decocted first for 1 hour), Semen Strychni 1 piece (fried in oil). After taking 15 doses, ESR dropped to 18 mm/h, urine protein (+), urine occult blood (-). Added Astragalus 30g and Salvia 30g to the above formula, ground into powder, sieved, mixed with honey to form pills, 6g each, taken three times daily, one pill each time, dissolved in warm water. Half a year later, upon follow-up, the patient reported that since starting the medication, her condition has remained stable, ESR is normal, and joints are no longer painful. Advised to continue consolidation treatment as before.

Example 6: Zhang, female, 39 years old. Has suffered from SLE since 2008, long-term use of prednisone, maximum dose 40 mg/day, currently 15 mg/day, plus two tablets of Tripterygium wilfordii, yet the condition remains recurrent and difficult to control, with normal urinalysis results. Present symptoms: patchy erythematous rash on the cheeks, red and itchy, painful, with a sensation of heat, bilateral conjunctival congestion, widespread joint pain that worsens several times a day, dry and bitter mouth, yellow urine, dry stools, thin greasy yellow coating, dark purple complexion, fine slippery pulse.
[Western Medical Diagnosis] Systemic Lupus Erythematosus.
[Traditional Chinese Medicine Syndrome Differentiation] Liver and Kidney Deficiency, Wind-Toxin Obstruction.
[Treatment Principle] Tonify Liver and Kidneys, dispel Wind and unblock the collaterals.
[Formula] Modified San Chu Zeng Ye Tang: Epimedium 15g, Polygonum 10g, Tribulus 15g, Rehmannia 12g, Scrophularia 10g, Ophiopogon 10g, Dipsacus 10g, Eclipta 15g, Lycium 10g, Codonopsis 10g, Astragalus 20g, Dang Gui 10g, White Peony Root 15g, Peach Kernel 10g, Safflower 6g, Honeysuckle 15g, Forsythia 15g, White Snake Tongue Herb 15g, Half Branch Lotus 15g. Decocted in water, one dose per day, total of 7 doses. Facial itching and joint pain have both eased, but still difficult to control; no improvement after adjusting the formula, so the original prescription is continued.

Seven: A Convergence of Ancient and Modern Theories
Systemic Lupus Erythematosus is not recorded under this name in ancient Chinese medical texts, but based on its clinical manifestations, it is generally considered equivalent to conditions such as “Yin-Yang Toxin,” “Blood Wind Sores,” “Cheek Ulcers and Boils,” “Facial Toxicity,” “Facial Wind,” and “Sunburn Sores” in traditional Chinese medicine.
The “Plain Questions · Great Discussion on the Correspondence of Yin and Yang” states: “When Yin prevails, Yang becomes diseased; when Yang prevails, Yin becomes diseased. When Yang prevails, there is heat; when Yin prevails, there is cold... Excessive joy or anger, excessive exposure to cold or heat, can lead to instability of vital energy. Therefore, excessive Yin inevitably leads to Yang dominance, and excessive Yang inevitably leads to Yin dominance.” This indicates that if Yin and Yang lose their balance, diseases will arise.
“The Synopsis of the Golden Chamber · Treatment of Diseases Caused by Lily, Fox, and Yin-Yang Toxin Based on Pulse and Symptoms” says: “Yang toxin manifests as red patches on the face resembling brocade patterns, sore throat, and pus-blood in the saliva... Yin toxin manifests as bluish discoloration of the face, body pain as if beaten, and sore throat.” This introduces the concept of Yin-Yang Toxin syndrome.
“The Gold Mirror of Medical Classics” notes: “Different types of qi... If this qi affects a person’s Yang, it becomes Yang toxin; if it affects a person’s Yin, it becomes Yin toxin.” This shows that “Yin-Yang Toxin” refers to a category of diseases caused by imbalances in Yin and Yang—either excess or deficiency.
“The Treatise on the Origins and Symptoms of Various Diseases · Cold-Induced Yin-Yang Toxin Symptoms” states: “To distinguish between Yin-Yang Toxin diseases, one must observe the hands and feet at the onset of the illness: cold fingers indicate Yin, non-cold fingers indicate Yang.” This describes the Raynaud phenomenon in the early stages of Systemic Lupus Erythematosus.
“The Treatise on the Origins and Symptoms of Various Diseases · Time-Related Yin-Yang Toxin Symptoms” says: “This refers to the two energies of Yin and Yang; if one is deficient, it becomes susceptible to toxins. If the body is heavy, with lower back pain, restlessness, red rashes on the face, sore throat, or diarrhea and frantic running, this is Yang toxin...” This section is similar to the acute attack phase of Systemic Lupus Erythematosus, or the clinical manifestations of hematological system damage, as well as the mental symptoms of central nervous system damage.
In summary, traditional Chinese medicine’s observation of this disease is meticulous, especially regarding its syndrome differentiation and treatment, which has increasingly attracted the interest and attention of medical experts both domestically and internationally.
Modern medical scholars’ different understandings of this disease:
Wu Lei et al. believe that SLE patients have inherent deficiencies in constitution, with depletion of liver and kidney essence and blood, and disharmony of zang-fu organs and qi-blood as the internal basis for disease onset. External adverse factors, namely pathogenic factors, are important causes of SLE. They propose treating SLE by supporting righteous qi and warding off external pathogenic factors.
Yang Zi and Fan Yongsheng explore the pathogenesis of SLE from the perspective of pathogenic factors lurking in Shaoyin, arguing that the nature of SLE’s pathogenic factors is mainly heat-toxin, with pathogenic factors hidden and qi-blood circulation obstructed, related to blood stasis, phlegm-blood, and phlegm-dampness. Their treatment should be staged: eliminate pathogenic factors in the acute phase, and tonify deficiency in the recovery phase.
Wang Yijun summarizes Professor Hu Yingqi’s experience and divides SLE into six syndromes for differentiated treatment: Qi-Ying syndrome, Yin-deficiency internal-heat syndrome, blood-stasis-heat-obstruction syndrome, Qi-Yin dual-deficiency syndrome, Spleen-deficiency-liver-depression syndrome, and Spleen-Kidney-Yang-deficiency syndrome, advocating combining syndrome differentiation with disease-specific treatment based on clinical pharmacology research.
Zhu Fubing et al. summarize Professor Liu Jian’s characteristics in syndrome differentiation and treatment of SLE, pointing out that he advocates treating the acute phase by addressing symptoms and the chronic phase by addressing root causes. In the acute phase, focus on clearing heat and detoxifying, while also strengthening the spleen and removing dampness; in the chronic phase, emphasize nourishing Yin and clearing heat, protecting the spleen and stomach, and emphasizing the use of blood-activating and stasis-resolving drugs throughout the entire process.

Physiology and Pathology
Rheumatoid Arthritis (RA) is a systemic disease characterized primarily by non-suppurative inflammation of the joints and surrounding tissues. Joint damage in this disease begins with synovitis, with synovitis being the basic pathology. As the disease progresses, the synovium undergoes stages of exudation, infiltration, hyperplasia, and granulation tissue formation. In the early stage, the synovium is congested and edematous, mainly infiltrated by lymphocytes, with plasma cells and multinucleated giant cells also present. Later, the synovium proliferates, granulation tissue forms, and synovial cells proliferate to form granulation vascular pannus. Vessels extend into the joint cavity, potentially causing adhesions. Under the action of hydrolytic enzymes contained in the vessels, articular cartilage is destroyed, collagen matrix of bones, ligaments, and tendons is eroded, ultimately leading to destruction of the joint cavity, fibrosis or ossification of granulation tissue, fusion of articular surfaces, resulting in stiff joints, dislocation, or ossification. Muscles and skin near the joints gradually atrophy, bones become decalcified and osteoporotic.

Two: Diagnosis and Treatment
(---) Clinical Diagnosis 1. Clinical Manifestations
Rheumatoid Arthritis often has a slow onset, with main clinical symptoms including:

(1) Systemic Symptoms: The disease develops slowly, and before joint symptoms appear, patients may experience fatigue, low-grade fever, decreased appetite, weight loss, muscle soreness, numbness in the limbs, cold hands and feet, anemia, and other systemic prodromal symptoms.
(2) Joint Manifestations: Rheumatoid Arthritis often symmetrically affects the joints of the limbs, with hand, wrist, knee, and foot joints being most commonly involved, followed by elbow, ankle, shoulder, and hip joints. Local manifestations include swelling, pain, and limited range of motion. Specifically, morning stiffness, pain, joint swelling, and movement disorders are prominent.
(3) Extra-Articular Symptoms: As a systemic disease, Rheumatoid Arthritis has the following extra-articular manifestations:
① Rheumatoid Nodules: Occur in 15%–25% of patients, mostly located at joint prominences and areas frequently subjected to pressure (such as the olecranon of the elbow), more common in patients with high rheumatoid factor titers, often reflecting active disease. ② Rheumatoid Vasculitis: In a small number of patients, vasculitis can affect internal organs, causing intestinal perforation, pericarditis, myocardial infarction, cerebrovascular accidents, etc. ③ Cardiac Manifestations: Pericarditis is a common cardiac manifestation of Rheumatoid Arthritis, usually detected during physical examination as painless pericardial friction rubs, generally transient and short-lived. ④ Pulmonary Manifestations: Lung involvement is a common extra-articular manifestation of Rheumatoid Arthritis. Pleurisy and pleural effusion are the most frequent. Large pleural effusions can cause respiratory distress requiring drainage, characterized by elevated protein and LDH, decreased glucose and complement C3, positive rheumatoid factor and immune complexes. Histological examination of pleural tissue may reveal rheumatoid nodules. If nodules are large or form cavities, or erode into bronchi or pleural cavity, they can cause coughing, hemoptysis, or pleural effusion. Rheumatoid pneumoconiosis (Caplan syndrome) and chronic fibrotic alveolitis often occur in advanced-stage patients, with poor prognosis.
2. Related Examinations
(1) Anemia: Generally mild to moderate anemia, normocytic and normochromic.
(2) Protein Examination: Serum albumin decreases, globulin increases; immunoelectrophoresis shows increased IgG, IgA, and IgM. Rheumatoid factor is positive in 80% of cases, but its titer does not necessarily correlate with disease severity, though it can indicate disease activity. Whether rheumatoid factor is negative or positive, it cannot arbitrarily rule out or confirm a diagnosis of Rheumatoid Arthritis; clinical manifestations must be considered. Recently, anti-Rheumatoid Arthritis collaborative antigen antibody (RANA antibody) has been found positive, providing strong evidence for diagnosing Rheumatoid Arthritis.
(3) Joint Cavity Puncture: May reveal opaque grass-yellow exudate, with rheumatoid cells found, but bacterial culture negative.
(4) X-ray Examination: Early stage shows swelling of periarticular tissues, with mild osteoporosis near the joints. As the disease progresses, due to destruction of articular cartilage, joint space narrows, articular surfaces become irregular, bone destruction or cystic radiolucent areas appear at joint margins, and osteoporosis becomes obvious. Late stage may involve partial joint dislocation or bony ankylosis.
3. Diagnostic Criteria
Typical cases, based on systemic symptoms, have symmetrical swelling and pain in small joints of the limbs lasting more than 6 weeks, morning stiffness, presence of rheumatoid nodules, tenderness in affected joints, functional limitation, rapid ESR, positive rheumatoid factor, and typical X-ray findings, making diagnosis relatively straightforward. In late stages, in addition to the above manifestations, there may be joint deformities, such as ulnar deviation of metacarpophalangeal joints, making diagnosis even easier.
(1) British Rheumatology Society Standards: ① Morning stiffness. ② At least one joint with pain or tenderness. ③ At least one joint with swelling and pain. ④ At least two joints with swelling (the interval between onset of these two joints should not exceed 3 months). Symmetrical joint swelling (proximal finger and toe joints do not necessarily need to be perfectly symmetrical). Subcutaneous nodules located on the extensor surface or bony prominences around the joints. Typical X-ray signs (not only degenerative changes, but also osteoporosis in areas adjacent to the affected joints). Positive rheumatoid factor. 9 Fluid in the synovial sac contains incomplete mucoprotein precipitation. ① Synovium exhibits three or more characteristic tissue changes: villous hyperplasia, superficial bone membrane cell proliferation often in a fence-like pattern; inflammatory cell infiltration, with a tendency to form “lymphoid nodules”; dense fibrous protein deposition on the surface or in the interstitium. ① Nodules exhibit characteristic tissue changes: granulomatous lesions, with necrosis in the center, surrounded by proliferating macrophages in a fence-like pattern, and chronic inflammatory cell infiltration and fibrotic changes around them. Among these 11 items, meeting 7 or more qualifies as typical Rheumatoid Arthritis; meeting 5 or more qualifies as Rheumatoid Arthritis; meeting 3 or more qualifies as suspected Rheumatoid Arthritis.
(2) American Rheumatism Association Revised Standards: ① Morning stiffness for at least one hour, lasting ≥6 weeks. ② Swelling in three or more joints, lasting ≥6 weeks. ③ Wrist, metacarpophalangeal, and proximal interphalangeal joints swelling, lasting ≥6 weeks. ④ Symmetrical joint swelling, lasting ≥6 weeks. Rheumatoid nodules. Hand X-ray signs change.

Positive rheumatoid factor. If four or more indicators are met, a diagnosis can be confirmed.
(3) National Integrated Traditional Chinese and Western Medicine Rheumatology Society Revised Standards: ① Diagnostic criteria: Symptoms mainly involve small joints, often multiple joints swelling or small joints symmetrically swelling (single cases must be differentiated from others, joint symptoms must last at least 6 weeks), morning stiffness. Physical signs: Affected joints swelling and tender, functional limitations or deformities, or ankylosis; some patients may have subcutaneous nodules. Laboratory tests: Positive rheumatoid factor, often accelerated ESR. X-ray examination: Emphasis on affected joints showing typical Rheumatoid Arthritis X-ray signs. Those with the above symptoms and signs, or those with positive rheumatoid factor, or those with typical X-ray findings, can all be diagnosed. ② Staging: Early stage: Most affected joints have swelling and pain, with limited mobility, but X-rays only show soft tissue swelling and osteoporosis. Mid-stage: Some affected joints have markedly limited functional mobility, X-rays show narrowed joint spaces or varying degrees of bone erosion. Late stage: Most affected joints develop various deformities or ankylosis, with difficulty in movement, X-rays show severe joint destruction, dislocation, or fusion.
4. Differential Diagnosis
(1) Osteoarthritis: Usually occurs in people over 50, with no systemic symptoms. Joints are not red or swollen, commonly affecting weight-bearing joints like knees and hips, with few joint deformities or muscle atrophies. X-rays show lip-like hyperplasia or bone spurs at joint margins, with calcium deposits around the joints. ESR is normal, rheumatoid factor is negative.
(2) Rheumatic Arthritis: Often occurs in adolescents, with sore throat before onset; commonly affects large limb joints, with migratory joint swelling, no permanent joint damage; may be accompanied by myocarditis; anti-streptolysin O titers are high, rheumatoid factor is negative. Salicylate preparations are effective.
(3) Ankylosing Spondylitis: Primarily affects the spine, but can also involve peripheral joints, thus sharing similarities with Rheumatoid Arthritis. Key differences: ① More common in males than females, peak incidence around age 20.

<!-- translated-chunk:6/19 -->