Keywords：专著资料, 全文在线浏览, 中西医结合, 临床资料, 第6部分
- Deficiency of both Qi and Blood Symptoms: Pale complexion, fatigue and weakness, dizziness and palpitations, shortness of breath and reluctance to speak, pale and plump tongue body with thin coating, and a moist, fine pulse. This type is commonly seen in cases of acute blood loss or severe megaloblastic anemia. Treatment principle: Tonify both Qi and Blood. Medicinal formula: Bazhen Tang with modifications. Dangshen 10g, Huangqi 10g, Baizhu 10g, Danggui 10g, Shudi 15g, Chenpi 6g, Zhigancao 5g, and Dazao 5 pieces. Decoct in water and take one dose daily. For those with excessive menstrual bleeding or persistent metrorrhagia, add Ejiao and Aiye Tan to tonify blood and stop bleeding. (4) Case studies on syndrome differentiation and treatment for this disease Case 1: Patient Li, female, 60 years old. She has a history of chronic gastritis and recurrent nasal bleeding for 2 years, which worsened over the past 3 days. After multiple treatments without success, she sought treatment from Professor Pei Zhengxue in August 1999. Initial consultation: The patient appeared listless and fatigued, with a sallow complexion, poor appetite, bitter and dry mouth, abdominal distension and constipation, intermittent nasal bleeding, a deep and fine pulse, and a red tongue with little coating. Laboratory tests showed: Red blood cells 2.01 x 10^12/L, mean corpuscular volume 120 fL, platelets 50 x 10^9/L, hemoglobin 50 g/L, and white blood cells 2.9 x 10^9/L. Bone marrow examination revealed a significant increase in nucleated cells, predominantly megaloblasts. Western medical diagnosis: Nutritional megaloblastic anemia. In addition to administering vitamin B12 500 μg intramuscularly once daily and folic acid 10 mg orally once daily, the focus was on using traditional Chinese medicine to regulate the spleen and stomach. Medicinal formula: Beishashen 15g, Maidong 10g, Yuzhu 6g, Shihu 6g, Danshen 10g, Muxiang 6g, Caodou 3g, Bohe Tan 15g, Danpi Tan 15g, Xueyu Tan 15g, Dahuang 6g, Huanglian 3g. Decoct in water, divide into two doses to be taken warm, one dose daily, for a total of 10 doses. Second consultation: After taking the above formula for 10 doses, the patient's nasal bleeding significantly decreased, and her constipation eased, but she still had poor appetite and a bitter taste in her mouth. The formula was adjusted by removing Bohe Tan and Danpi Tan, adding Huanglian 3g, Huangqin 10g, and Jiaosanxian each 6g. She continued to take the modified formula for another 10 doses and stopped taking vitamin B12 and folic acid, with instructions to improve nutrition and get adequate rest. Third consultation: After taking the original formula for another 10 doses, all symptoms improved, but she still experienced mild fatigue, poor appetite, and abdominal distension, with occasional nasal bleeding. Her tongue was red with a thin yellow coating, and her pulse was string-like. Laboratory tests indicated: Red blood cells 3.03 x 10^12/L, mean corpuscular volume 92 fL, platelets 60 x 10^9/L, hemoglobin 90 g/L, and white blood cells 3.2 x 10^9/L. Treatment continued to focus on strengthening the spleen and regulating the stomach, supplemented by soothing the liver. Medicinal ingredients: Muxiang 3g, Caodou 3g, Beishashen 10g, Maidong 10g, Yuzhu 6g, Baizhu 10g, Fuling 12g, Chaihu 10g, Baishao 10g, Danpi 10g, Zhizi 10g, Danggui 10g, Huanglian 3g, Huangqin 10g. Decoct in water, divide into two doses to be taken warm, one dose daily, for a total of 10 doses. Fourth consultation: After taking another 20 doses, all symptoms disappeared, and blood tests and bone marrow examinations showed normal results. There was no more nasal bleeding, and her mental state and diet had also improved significantly. Case 2: Mr. Wang, male, 50 years old. He has been experiencing discomfort in the stomach, postprandial fullness, dizziness, fatigue, and poor appetite for 3 years, sometimes accompanied by nausea and diarrhea. His tongue is pale with a thin white coating, and his pulse is string-like and fine. Laboratory tests show: Red blood cells 2.56 x 10^12/L, hemoglobin 82 g/L, mean corpuscular volume 98 fL. Gastroscopy indicates chronic inflammation of the gastric body. He had previously tried vitamin B12, folic acid, tinidazole, and other Western medicines for half a year without success, so he sought treatment from Professor Pei Zhengxue. The patient appears pale, listless, and thin, with a pale tongue and thin white coating, and a slippery pulse. He had previously been diagnosed with nutritional megaloblastic anemia through bone marrow examination at another hospital. Western medical diagnosis: ① Chronic gastritis; ② Nutritional megaloblastic anemia. Traditional Chinese medicine syndrome differentiation: Spleen and stomach qi deficiency. Treatment should focus on tonifying qi and strengthening the spleen, using Xiangsha Liu Junzi Tang with modifications. Medicinal formula: Muxiang 3g, Caodoukou 3g, Dangshen 10g, Baizhu 10g, Fuling 12g, Zhigancao 6g, Banxia 6g, Chenpi 6g, Quanshi 10g, Baishao 10g, Shenglongmu each 15g, Wuzegu 15g, Jiaosanxian each 6g. These herbs have the effects of tonifying qi, replenishing the middle jiao, strengthening the spleen and nourishing the stomach, promoting qi circulation and resolving stagnation, as well as drying dampness and eliminating phlegm. Decoct in water, divide into two doses to be taken warm, one dose daily, for a total of 10 doses. Second consultation: After taking more than 10 doses of the above formula, the patient reported that the discomfort in the stomach and postprandial fullness had significantly alleviated, but she still felt dizzy and fatigued, with occasional sleep disturbances. Examination of the tongue and pulse remained unchanged. Laboratory tests showed: White blood cells 2.9 x 10^9/L, hemoglobin 86 g/L, mean corpuscular volume 96 fL. Professor Pei Zhengxue believed that since the spleen generates blood and the heart governs blood, although the patient’s spleen and stomach function had improved, the anemia had not yet improved. Therefore, he switched to a treatment method that simultaneously treats the spleen and heart and tonifies both qi and blood, using Guipi Tang with modifications. Medicinal ingredients: Huangqi 30g, Danggui 10g, Dangshen 10g, Baizhu 10g, Fuling 12g, Zhigancao 6g, Yuanzhi 6g, Chao Suanzaoren 15g, Muxiang 3g, Longyanrou 10g, Shengdi 12g, Heshouwu 15g, Tudaohuang 12g, Nüzhenzi 12g. Decoct in water, divide into two doses to be taken warm, one dose daily, for a total of 10 doses. Third consultation: After taking more than 10 doses of the above formula, the syndrome of spleen and stomach qi deficiency and weak transformation function disappeared. The patient’s stomach discomfort further improved, and her diet, mental state, and sleep also improved. Follow-up blood tests showed: Red blood cells 3.4 x 10^12/L, hemoglobin 96 g/L, mean corpuscular volume 92 fL. Further adjustments were made based on the above formula, and after taking a total of 40 doses of traditional Chinese medicine, the follow-up blood tests returned to normal. Fourth consultation: The patient’s condition has remained stable, but 5 days ago, due to dietary indiscretion, she again experienced stomach discomfort, nausea, loose stools—up to 4 times a day—and poor appetite. Therefore, she revisited the clinic, considering it chronic gastritis combined with acute gastritis, and treatment was mainly based on traditional Chinese medicine. Medicinal ingredients: Chenpi 6g, Fuling 12g, Lianqiao 15g, Banxia 6g, Jiaosanxian each 6g, Cangshu 6g, Huanglian 6g, Muxiang 6g. Decoct in water, divide into two doses to be taken warm, one dose daily, for a total of 5 doses. Fifth consultation: The patient’s nausea and diarrhea have disappeared, but she still experiences stomach discomfort and poor appetite. Follow-up blood tests show: Red blood cells 3.6 x 10^12/L, hemoglobin 100 g/L, mean corpuscular volume 94 fL. Therefore, the formula was changed to Xiangsha Liu Junzi Tang combined with Banxia Xiexin Tang to enhance the functions of harmonizing the stomach and reversing upward flow, as well as opening blockages and relieving fullness. Decoct in water, divide into two doses to be taken warm, one dose daily, for a total of 10 doses. After taking these 10 doses, blood tests and bone marrow examinations were repeated, showing normal results, and there has been no recurrence in the 3-year follow-up. Aplastic anemia (AA), often referred to as "re-zhang," is a condition in which bone marrow hematopoietic function fails due to various causes and mechanisms. The main manifestations include reduced bone marrow hematopoietic function, resulting in anemia, bleeding, and infection syndromes caused by a decrease in all blood cell types. Based on the patient’s condition, blood test results, bone marrow findings, and prognosis, the disease is usually classified as severe or non-severe. From the perspective of etiology, AA can be divided into congenital (genetic) and acquired types. Acquired AA is further categorized into secondary and primary based on whether a clear cause exists; primary AA refers to cases with no identifiable cause. Causes and pathogenesis Most causes are unclear and may include: (1) viral infections, especially hepatitis viruses and parvovirus B19; (2) chemical factors, particularly chloramphenicol antibiotics, sulfonamide drugs, anti-tumor chemotherapy agents, and benzene; (3) long-term exposure to X-rays, radium, and radioactive isotopes. According to traditional theory, under certain genetic backgrounds, AA is considered a heterogeneous “syndrome” acquired after exposure to certain pathogenic factors, and it may develop through three mechanisms: primary or secondary defects in hematopoietic stem/progenitor cells (“seeds”), abnormalities in the hematopoietic microenvironment (“soil”), and immune-related abnormalities (“bugs”). II. Clinical manifestations (1) Severe aplastic anemia (SAA) Onset is sudden, progression is rapid, and the condition is severe; a small number of cases may progress from non-severe forms. (1) Anemia: Often progressively worsening, with obvious symptoms such as pallor, fatigue, dizziness, palpitations, and shortness of breath. (2) Infection: Most patients have fever, with body temperature above 39°C; some patients remain in uncontrollable high fever from onset to death. Respiratory tract infections are the most common, with Gram-negative bacilli, Staphylococcus aureus, and fungi being the main pathogens, often complicated by sepsis. (3) Bleeding: All cases exhibit varying degrees of skin, mucosal, and internal organ bleeding. Skin manifestations include petechiae or large ecchymoses, oral mucosa may have blood blisters, and there may be nosebleeds, gum bleeding, conjunctival bleeding, etc. When deep organs bleed, hematemesis, hemoptysis, hematochezia, hematuria, vaginal bleeding, retinal hemorrhage, and intracranial hemorrhage may occur, with the latter often endangering the patient’s life. (2) Non-severe aplastic anemia (NSAA) Onset and progression are relatively slow, and the condition is milder than severe cases. (1) Anemia: A chronic process, often characterized by pallor, fatigue, dizziness, palpitations, and shortness of breath after activity. Symptoms improve after blood transfusion, but the improvement is not lasting. (2) Infection: High fever is less common than in severe cases, and infections are relatively easy to control, rarely lasting more than a week. Upper respiratory tract infections are common, followed by gingivitis, bronchitis, and tonsillitis, while severe infections such as pneumonia and sepsis are rare. Common pathogens include Gram-negative bacilli and various cocci. (3) Bleeding: Bleeding tendency is milder, mainly affecting skin and mucous membranes, with internal organ bleeding being rare. Most cases present as skin petechiae or gum bleeding, and female patients may experience vaginal bleeding. Bleeding is relatively easy to control. However, prolonged ineffective treatment may lead to intracranial hemorrhage. III. Laboratory tests (1) Blood tests: SAA shows severe pancytopenia: severe normocytic normochromic anemia, with reticulocyte percentage often below 0.005 and absolute count <15 x 10^9/L; white blood cell count often <2 x 10^9/L, neutrophils <0.5 x 10^9/L, lymphocyte proportion significantly increased; platelet count <20 x 10^9/L. NSAA also shows pancytopenia, but not to the extent of SAA. (2) Bone marrow examination: In SAA, bone marrow proliferation is severely reduced in multiple areas, with significant decreases in granulocytes, erythroid series, and megakaryocytes, though their morphology remains roughly normal; lymphocyte and non-hematopoietic cell proportions increase markedly, and bone marrow trabeculae are largely empty. (3) Pathogenesis and other related tests: CD+4 cells: CD+8 cell ratio decreases, Th1:Th2 cell ratio increases; bone marrow cell chromosome karyotype is normal, bone marrow iron staining shows increased iron stores, neutrophil alkaline phosphatase staining is positive; hemolysis tests are all negative. IV. Diagnosis and differential diagnosis (1) Diagnostic criteria for AA: ① Pancytopenia, reticulocyte percentage <0.01, increased lymphocyte proportion; ② Generally no hepatosplenomegaly; ③ Bone marrow shows widespread or severe reduction in proliferation, with decreased hematopoietic cells and increased non-hematopoietic cell proportion, and bone marrow trabeculae are empty (those who can undergo bone marrow biopsy will find uniform reduction in hematopoietic tissue); ④ Other diseases causing pancytopenia must be ruled out, such as paroxysmal nocturnal hemoglobinuria (PNH), Evans syndrome, and immune-related pancytopenia. (2) Classification diagnostic criteria for AA: ① SAA-I: Also known as AAA, with sudden onset, progressive worsening of anemia, often accompanied by severe infection and/or bleeding. Blood tests meet any two of the following three criteria: reticulocyte absolute count <15 x 10^9/L, neutrophil count <0.5 x 10^9/L, and platelet count <20 x 10^9/L. Bone marrow proliferation is widely and severely reduced. If the neutrophil count in SAA-I is <0.2 x 10^9/L, it is considered extremely severe aplastic anemia (VSAA). ② NSAA: Also known as CAA, referring to AA that does not meet the diagnostic criteria for SAA-I. If NSAA worsens and its clinical, blood, and bone marrow findings reach the diagnostic criteria for SAA-I, it is then classified as SAA-I. (2) Differential diagnosis: (1) Paroxysmal nocturnal hemoglobinuria (PNH): Typical patients have episodes of hemoglobinuria, making it easy to distinguish. Atypical patients do not have hemoglobinuria episodes, but still have pancytopenia, and bone marrow may show reduced proliferation, easily misdiagnosed as AA. In PNH patients, CD55 and CD59 can be found in bone marrow or peripheral blood. (2) Myelodysplastic syndrome (MDS): Refractory anemia (RA) in MDS also presents with pancytopenia, and reticulocyte counts may sometimes be low or even decrease, with bone marrow potentially showing low proliferation, which can easily be confused with AA. (3) Autoantibody-mediated pancytopenia: Includes Evans syndrome and immune-related pancytopenia. (4) Acute leukemia (AL): Especially leukopenia and low-proliferation AL, Early stages do not involve hepatosplenomegaly, and peripheral blood cells of two or three lineages are reduced, easily confused with AA. (5) Acute hematopoietic dysfunction: Often caused by infection and medication, associated with malnutrition in children, with sudden onset often accompanied by high fever, severe anemia, rapid progression, and frequently misdiagnosed as acute aplastic anemia. The condition is self-limiting and does not require special treatment; recovery can occur within 2–6 weeks. (6) Other: Reactive hemophagocytic syndrome can also present with pancytopenia, but it is often triggered by infection, with high fever, hepatosplenomegaly, even jaundice and ascites, and mature tissue cells in the bone marrow significantly proliferate, sometimes exhibiting hemophagocytosis. V. Treatment (1) Supportive treatment 1. Protective measures Prevent infection; avoid bleeding; eliminate contact with various risk factors; administer prophylactic anti-infective treatment as appropriate; provide necessary psychological care.
- Symptomatic treatment (1) Correct anemia: It is generally believed that when hemoglobin is below 60 g/L and the patient has poor tolerance to anemia, blood transfusion can be performed, but excessive transfusion should be avoided. (2) Control bleeding: Use procoagulant or hemostatic drugs. Concentrated platelet transfusions are effective for severe bleeding caused by thrombocytopenia. If there is a deficiency in coagulation factors (such as in hepatitis), correction is necessary. (3) Control infection: For infectious fevers, secretions from suspected infected sites should be collected for bacterial culture and drug sensitivity testing. (4) Liver-protective treatment: AA is often accompanied by liver function impairment, so liver-protective medications should be used as appropriate. (5) Iron-removal treatment: For AA patients who have received long-term blood transfusions, serum ferritin levels rise, leading to “iron overload,” so iron-removal treatment can be administered as appropriate. (2) Treatment targeting the pathogenesis 1. Immunosuppressive therapy (1) Anti-lymphocyte thymocyte globulin: Mainly used for SAA. (2) Cyclosporine: Can be used for all cases of AA. Dosage and duration should be individualized, based on the patient’s hematopoietic function and T-cell immune recovery, potential adverse reactions (such as liver and kidney damage, gingival hyperplasia, and gastrointestinal reactions), as well as drug concentration, to adjust dosage and treatment course. (3) Others: Mycophenolate mofetil, cyclophosphamide, methylprednisolone, etc., can be used to treat SAA.
- Hematopoiesis-promoting therapy (1) Androgens are suitable for all cases of AA; (2) Hematopoietic growth factors are suitable for all cases of AA, especially SAA, where granulocyte-macrophage colony-stimulating factor (GM-CSF) or granulocyte colony-stimulating factor, as well as erythropoietin (EPO), are commonly used. These are generally used after immunosuppressive treatment for SAA, with dosage appropriately reduced, and it is recommended to continue for more than 3 months.
- Other For SAA patients under 40 years old, without infection or other complications, and with a suitable donor,
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