Wu Bin

(Wu Bin) Chapter Four: Infectious Atypical Pneumonia – Overview Infectious atypical pneumonia is a special form of pneumonia caused by the SARS coronavirus (SARS-CoV), characterized by its pronounced infectivity and potential to affect multiple organ systems. The World Health Organization (WHO) has designated it as Severe Acute Respiratory Syndrome (SARS). Clinically, the disease primarily manifests as systemic symptoms such as fever, fatigue, headache, and muscle/joint pain, along with respiratory symptoms like dry cough, chest tightness, and dyspnea; some cases may also present with gastrointestinal symptoms such as diarrhea. Chest X-ray findings often reveal inflammatory infiltrates in the lungs. Laboratory tests show normal or reduced peripheral blood white blood cell counts; ineffective antibiotic treatment is a key characteristic of the disease. Severe cases often exhibit marked respiratory distress and can rapidly progress to Acute Respiratory Distress Syndrome (ARDS). The disease first emerged in Guangdong, China, in November 2002, and subsequently spread to many countries worldwide. By August 7, 2003, the global total had reached 8,422 cases, with an average fatality rate of 9.3%, calculated based on reported cases. The SARS virus is a novel coronavirus belonging to the RNA family. Compared to currently known coronaviruses, its nucleotide similarity is extremely low. It belongs to the genus Coronaviridae, is an enveloped virus with a diameter ranging from 60 to 120 nm, featuring radiating, petal-like or ciliary protrusions approximately 20 nm or longer on its envelope—its base is narrow, resembling a crown, and it shares similarities with classic coronaviruses. The virus undergoes a lengthy and complex process of maturation; mature viruses appear spherical or oval, with significant differences in size and shape between mature and immature viral particles. Many unusual morphologies can emerge, such as kidney-shaped, drumstick-shaped, horseshoe-shaped, or bell-shaped, making them easily confused with cellular organelles. Early virions measure around 400 nm, while mature viruses can shrink to 60–120 nm. The virus replicates within the cytoplasm, utilizing cellular resources to carry out RNA replication and protein synthesis via RNA-dependent polymerases, assembling new viruses and budding out to be secreted outside the cell. At room temperature of 24°C, SARS virus can survive in urine for at least 10 days, in sputum and feces of infected patients for more than 5 days, and in blood for about 15 days. On surfaces, the virus can survive for 2–3 days. The virus is sensitive to both temperature and organic solvents; heating at 75°C for 30 minutes can inactivate the virus. Ultraviolet irradiation for 60 minutes can kill the virus, while 75% ethanol for 5 minutes can render the virus inactive, and chlorine-based disinfectants can inactivate the virus after 5 minutes of exposure. The pathogenesis of infectious atypical pneumonia remains unclear. SARS virus can directly target the immune system, and its pathogenesis may be closely linked to immune system damage. The virus plays an important role in the development and progression of the disease by influencing both cellular and humoral immune responses. After entering the body, the virus replicates within cells, triggering abnormal immune responses that lead to lymphocyte and leukocyte reductions, as well as pathological damage to peripheral lymphatic tissues. In most SARS patients, peripheral blood white blood cell counts are normal or reduced, while CD₃, CD₄, and CD₈ T lymphocytes are significantly lower than in healthy individuals; the more severe the illness, the more pronounced the decline in T lymphocyte counts. Due to immune system damage, patients develop immunodeficiency and various complications arise. Infectious atypical pneumonia primarily occurs during winter and spring, with an abrupt onset. Fever is often the initial symptom, with temperatures typically exceeding 38°C, occasionally accompanied by chills, headaches, joint pain, muscle soreness, fatigue, and diarrhea; upper respiratory tract catarrhal symptoms are uncommon, though cough may occur—often dry, with little phlegm, and occasionally bloody. Some patients may experience chest tightness, while severe cases may exhibit accelerated breathing, shortness of breath, or obvious respiratory distress. Pulmonary signs are often subtle, and some patients may hear a few moist rales or exhibit signs of pulmonary consolidation. Infectious atypical pneumonia is primarily transmitted through close-range droplets. SARS patients are the main source of infection, especially during the acute phase.

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Second Section: Infectious Diseases

The viral load in the respiratory secretions and blood of infected patients is extremely high, making coughing and sneezing highly effective means of spreading the disease. In recent times, respiratory droplets have become the most important route of SARS transmission. Aerosol transmission is another mode of airborne spread; by coming into contact with the excretions of infected individuals or other contaminated objects, the virus can also enter the body through the oral, nasal, and ocular mucous membranes, though this mode of transmission remains largely unexplored. Currently, there is no evidence to rule out the possibility of transmission via blood, sexual contact, or vertical transmission. The population is generally susceptible, with no significant difference in incidence between males and females; among those aged 20–40, approximately 70–80% are affected. The infection rate in children is relatively low, though the reason for this remains unclear.

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II. Diagnosis

(1) Epidemiological History

1. Close Contact History: Within the two weeks prior to onset, the patient had close contact with similar cases, or there is clear evidence of transmission to others.
2. Travel History to Epidemic Areas: The patient lived in an epidemic region or traveled to areas where SARS was currently prevalent within the two weeks prior to symptom onset.

(2) Symptoms and Signs
Fever (>38°C), cough, rapid breathing, shortness of breath, or respiratory distress syndrome; at least one of the following findings: lung rales or signs of pulmonary consolidation.

(3) Laboratory Tests

1. Peripheral Blood Cell Count: Early stages often show no increase in white blood cell count, or even a decrease.

2. SARS-Specific Antibodies: By comparing serum antibodies from the progressive phase with those from the recovery phase, antibody titers typically rise, indicating an antibody conversion or a fourfold or greater increase in antibody levels.

3. SARS RNA Detection: Use PCR techniques to detect positive SARS RNA results.

(4) Pulmonary Imaging Studies
Lung lesions may present as patchy or mottled infiltrates, or exhibit reticular changes of varying degrees.

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III. Traditional Chinese Medicine’s Understanding and Treatment of Infectious Atypical Pneumonia

(1) Historical Perspectives on Similar Infectious Atypical Pneumonia

Infectious Atypical Pneumonia (SARS) falls under the category of “plague” in Traditional Chinese Medicine’s warm-disease theory. Examining traditional Chinese medical literature, the Inner Canon already used the term “plague,” referring to it as “lai” or “warm plague.” As stated in the Suwen – Discussion on This Disease, “Clear air generates wind and dampness; in spring, dew and frost fall again, causing people to suffer early-onset plague, with dry throat and dry mouth, leading to lai, and warm diseases emerging.” Historical medical texts on SARS are discussed in detail in the relevant chapters of “Human Infection with Highly Pathogenic Avian Influenza.”

(2) TCM’s Understanding of the Pathogenesis of Infectious Atypical Pneumonia

Infectious Atypical Pneumonia is a newly discovered infectious disease in recent years. According to TCM theory, “SARS” falls under the category of warm diseases. Its etiological factors differ from the six external pathogenic factors—wind, cold, summer heat, dampness, dryness, and fire—instead being caused by “lai” (plague-like qi). The disease primarily affects the lungs, with pathological changes extending to the spleen and stomach. Based on the experience of Guangdong Provincial Hospital of Traditional Chinese Medicine and the clinical manifestations of SARS, the disease is classified into early stage, mid-stage, and late stage (peak period). The early stage is characterized by conditions such as damp-heat obstructing lung qi and exterior cold combined with interior heat and dampness. The mid-stage is marked by damp-heat accumulating toxins, latent pathogenic factors residing in the membrane origin, and obstruction of the Shaoyang meridian. The late stage is often associated with severe pathogenic factors, deficiency of vital energy, heat entering the blood, and internal closure coupled with external collapse. (Shenzhen Journal of Integrated Traditional Chinese and Western Medicine, 2003.8)

Currently, there is no unified name for “SARS” in TCM. It is sometimes referred to as “wind-heat,” “spring-heat,” “warm plague,” “damp-toxin plague,” “smell-toxin plague,” or “lung-toxin plague.” TCM views epidemics as arising from unique atmospheric energies—vile and foul qi entering through the mouth and nose, easily transmitted and sharing similar symptoms regardless of age or severity. Thus, “SARS” should be considered an epidemic disease. “Damp-toxin” refers to the causative factors, “smell-toxin” to the modes of transmission, while “lung-toxin” denotes the site of pathology—but none of these terms fully capture the clinical characteristics of SARS. The lungs are the primary site of pathology in SARS. TCM believes that “a person’s qi is bestowed upon the lungs, which governs dispersal and release, with a nature that is clear and refreshing.” “When warm evil enters the body, it first attacks the lungs,” and the symptoms produced when the epidemic evil invades the lungs are similar to those described in the Inner Canon – Discussion on Blockage: “When lung blockage occurs, one feels fullness, wheezing, and vomiting.” The underlying mechanism is that “the evil qi causes wheezing and blockage in the lungs.” The cause of the disease is that people are often susceptible to wind, cold, dampness, or other seasonal evils, and when these factors combine, illness arises. Specifically, SARS is often caused by the invasion of epidemic toxins. To emphasize the clinical characteristics of SARS, some suggest naming it “lung-blocked plague,” which aligns more closely with TCM theory. (Tianjin Journal of Traditional Chinese Medicine, SARS Special Issue, 2003.6)

Ma Chaoying believed that “SARS” belongs to the warm-disease category of TCM, with its cause being epidemic toxins. Warm diseases are a type of disease characterized by strong prevalence and contagiousness. The pathogenic factor behind these diseases is “epidemic toxins,” also known as “lai qi,” “厉 qi,” or “epidemic qi,” and because they are highly virulent, they are also referred to as “lì qi.” Among the six external pathogenic factors, they possess strong infectivity and can lead to widespread dissemination and epidemics. The formation of epidemic toxins is often linked to abnormal weather patterns—such as cold, hot, or stormy seasons, or prolonged periods of heavy rain—and these conditions can easily generate “lai qi.” Although epidemic toxins may vary in their nature between cold and heat, heat is more common as the dominant characteristic. Their pathogenic features include: they frequently affect both young and old alike, and anyone who comes into contact with them will become ill. As the Suwen – Discussion on Heat Injury states: “When the five plagues arrive, they all spread easily, affecting everyone regardless of age, with similar symptoms.” Chao Yuanfang of the Sui Dynasty also wrote in the Compendium of Various Disease Causes: “Warm plagues arise from imbalances in the seasons, from improper temperature and humidity, causing people to contract harmful qi, leading to illness—these illnesses spread easily, even wiping out entire families and infecting outsiders.” These passages all highlight the powerful pathogenic characteristics of epidemic toxins. The basic pathogenesis of “SARS” is due to excessive heat and toxin accumulation; in the early stages, the epidemic evil attacks the lungs, causing blockage in the defensive qi, resulting in fever, mild aversion to wind and cold, headache, cough with little phlegm, and chest tightness. As the evil moves deeper into the Qi, high fever, shortness of breath, and difficulty breathing emerge, along with restless wheezing. When heat and Qi are both burned, high fever leads to constipation, restlessness, and delirium; when heat damages the blood vessels, it not only causes upper and lower symptoms but also leads to bleeding, confusion, and convulsions. In the damp-heat type, the epidemic evil enters through the mouth and nose, directly reaching the membrane origin, causing blockage in the membrane origin. As the evil moves inward, it can invade the upper, middle, and lower jiao organs, affecting multiple viscera, resulting in various conditions such as dampness outweighing heat, damp-heat coexisting, or heat dominating over dampness. From the perspective of disease progression, this pattern aligns well with the changing patterns of warm disease in the defensive qi, the Qi, and the blood. Later stages often manifest as damage to the lung and stomach yin. (Jiangxi Journal of Traditional Chinese Medicine)

(3) TCM Differentiation and Classification, and Herbal Formulas

The efficacy of TCM and herbal medicine in treating “SARS” has drawn worldwide attention. Given that the pathogenesis of SARS involves the latent virus moving from the interior outward to the surface, treatment should focus on addressing the “pathway” through which the virus enters and eliminating the “pathways” through which it leaves. Removing the evil from the affected areas is the key to TCM treatment of SARS. Drawing on the concept of the membrane origin, employing methods to promote circulation and clear the pathways, and using the principles of lightness and clarity to open the Qi, formulas like Dazhuan Yin, Shengjia San, Sanren Tang, and Huopu Xia Ling Tang were employed to treat damp-heat types of SARS, yielding promising results—and this highlights a key strength of TCM and herbal medicine. (Journal of Zhejiang College of Traditional Chinese Medicine, 2003.7)

The basic pathogenesis of SARS is due to excessive heat and toxin accumulation; therefore, clearing heat, detoxifying, and avoiding evil are fundamental therapeutic approaches. Since the toxic evil may manifest differently at the defensive qi, Qi, blood, and blood vessel stages, in the early stages when defensive qi and Qi are both involved, treatment focuses on clearing heat, detoxifying, and releasing the defensive qi to dispel heat; the Yinqiao San is used with modifications. For cases where the Qi is primarily affected, treatment emphasizes clearing Qi, releasing heat, and generating fluids; the Baihu Tang combined with Sanhuang Detoxification Tang is used with adjustments, or the Chengqi Tang, which promotes bowel movement and clears heat. When Qi and blood are both burned and intestinal heat becomes congested, with symptoms like chest tightness and palpitations, the priority is to clear the intestines and release heat; the Taoren Chengqi Tang combined with Dajianxiong Tang, with modifications, or Qingwen Baidu Tang with adjustments are used. In cases where damp-heat initially blocks the membrane origin, with symptoms like chills and high fever, white, thick, and greasy coating on the tongue, and a purple-red tongue, treatment focuses on promoting circulation, clearing the pathway, and eliminating toxins; the Dazhuan Yin is used with modifications. When heat closes the heart envelope, with symptoms like burning body heat, confusion, limb weakness, and convulsions, treatment emphasizes clearing the heart, opening the orifices, and cooling the liver to detoxify; the Qinggong Tang combined with “Three Treasures” is used. When internal closure and external collapse occur, treatment aims to open and consolidate the defenses, and while removing the evil, large doses of Shenmai Injection can be used. In later stages, treatment emphasizes nourishing the lung and stomach yin and clearing residual toxins; formulas like Qingzao Jiufei Tang, Yangyin Qingfei Tang, Wuye Lugen Tang, and Shaoshan Mai Dong Tang can be used. In summary, treatment for this disease should focus on differentiation and classification, firmly grasping the main thread of clearing heat, detoxifying, and eliminating the evil. If the above herbal formulas are limited in clinical use, alternative Chinese patent medicines or new Chinese herbal preparations—such as injections—can be used instead.

Professor Deng Tie Tao believed that “SARS” falls under the category of spring-heat disease in TCM, with a pathogenesis characterized by damp-heat accumulating toxins, obstructing the middle and upper jiao organs, and easily consuming Qi while causing stagnation, even leading to internal closure and respiratory failure. He proposed TCM treatment plans for each stage of SARS: