A Case of Covid-19 Presenting with Alternating Fever and Chills

The patient, a 32 year old Caucasian male, presented to the clinic on April 24, 2020 with suspected Covid-19.

Initial Consultation • April 24, 2020

The patient had an exposure to a Covid-19 positive co-worker two weeks prior to presenting to the clinic. One week prior to presenting to the clinic, his toddler had a cough and fever, and his wife had severe fatigue and a sore throat for one day. In response to this, the patient had been self-isolating.

Five days ago, the patient developed a sore throat. Initially the sore throat was minor and the patient was not a concerned. The sore throat persisted and he began to experience a low-level headache, and upper back and neck tension.

One day ago, his headache started to intensify and he began to experience fever as high as 101.5°F, and chills that were described as “going to the bone”. In addition, he was experiencing severe body aches and joint pain. The patient took acetaminophen (Tylenol) and rested. When taking his temperature afterwards, he noted that it was reduced. He also had very low energy. That night he had significant sweating, which he described as “sweating out of every pore of his body”.

Due to his symptoms and his confirmed exposure, the patient received a Covid-19 test on April 24, 2020.

At the time of consultation, the patient was still experiencing fever and chills that were described as alternating. His temperature was above 99°F (self reported). The patient felt subjectively hot and also reported being sweaty. His body aches and joint pain had reduced, but were still present. The patient reported no coughing, but felt “tight through the ribs” when taking deep breaths. He was still experiencing a sore throat that was intermittent and not very severe. The soreness was localized to the middle of the throat and was more pronounced when swallowing. He reported that there was no phlegm. He was experiencing significant thirst and reported a “nasty” taste in his mouth. His headache was still present and was primarily in the frontal region and behind the eyes extending to the temporal region. His energy was slightly improved compared to the day before, but was still very low. His appetite was low with little desire for food, and he had not had a bowel movement in the last two days. His tongue was pale pink, with a thin white, moist coat, and teeth marks along the sides.

The patient was diagnosed with a shao yang (Lesser Yang) disorder complicated by invasion of a damp pathogen.

Diagnosis

shao ​yang pathogenic influence with dampness

Prescription

He was prescribed granules for the first 24 hours consisting of Xiao chai hu tang (Minor Bupleurum Decoction) 20g, and Huo xiang zheng qi san (Patchouli/Agastache Powder to Rectify the Qi) 10g. He was instructed to take 5g, three times per day. He was also prescribed 3 bags of loose herbs based on the same formulas, to be taken after the first 24 hours.

Loose Herb Formula - Xiao chai hu tang + Huo xiang zheng qi san

Formula Analysis

During this initial visit, the patient displayed clear signs of a shao yang disorder for which Xiao chai hu tang would be appropriate. Line 96 of the shang han lun 《傷寒論》states,

“When in cold damage that has lasted for five or six days or wind strike, there is alternating aversion to cold and heat effusion; the person suffers from fullness in the chest and rib-side, taciturnity with no desire for food or drink, … or thirst … then xiao chai hu tang governs.”[i]

This patient fits the time frame outlined in the shang han lun, as he is on day five of his disease. Although these time frames are arbitrary and often unreliable in modern clinic settings, they can still be observed for relevance.  He also exhibits alternating fever and chills, rib tightness, diminished appetite, and thirst.

Line 263 of the shang han lun states,

In disease of the shao yang, there is a bitter taste in the mouth, dry throat, and dizzy vision.”[ii]

This patient is exhibiting the ‘nasty’ taste in the mouth and dry throat.

The base of the formula is Xiao chai hu tang, with a few modifications. The shang han lun instructs us that “If there is thirst, remove ban xia and add ren shen”[iii]. In the Xiao chai hu tang presentation, there is heat as a result of constraint of qi. If the heat is great, it will begin to damage the fluids of the body, leading to thirst. In this event, Ban xia (pinelliae rhizome preparatum) which is warming and drying is removed so as not to injure the fluids further, and Ren shen (ginseng radix) is increased for its ability to engender fluids. In this formula, the Ren shen has been removed and Nan sha shen (adenophorea radix) has been added. Nan sha shen is sweet, cool, and slightly bitter. It has a greater ability to engender fluids, while also clearing heat from the Lungs and Stomach. Similarly, the Zhi gan cao (glycyrrhizae radix preparata) in the original Xiao chai hu tang has been replaced with Sheng gan cao (glycyrrhizae radix) for its greater ability to clear heat.

The base formula has also been modified by combining it with Huo xiang zheng qi san, which treats patterns in which an external wind-cold pathogen has invaded a patient with internal dampness.[iv]  Our experience has shown that Covid-19 patients have a tendency to have dampness creating stagnation in the middle burner, which contributes to the disease progression. As a result, in Covid-19 patients dampness is often addressed, even when the signs are not overtly apparent.

Footnotes

[i] Zhang, Zhongjing, et al. Shang Han Lun = On Cold Damage. Paradigm Publications, 1999

[ii] Ibid

[iii] Ibid

[iv] Scheid, Volker. Chinese Herbal Medicine: Formulas & Strategies. Eastland Press, 2009.

Follow Up Call • April 26, 2020

The patient was contacted on April 26 for a follow up call. The patient started the granular formula on April 24 for 2 doses. He started the loose formula on April 25 at midday and continued the loose herb formula from then onward.

The patient reported that once he began the herbs, his fever subsided and did not return. He had neither chills nor headache since starting the herbs.

The patient reported still being very fatigued, and tiring easily, and that his sore throat would “ramp up and down” and would not quit. He had not gotten the results from his Covid-19 test yet.

The patient was advised to continue taking the herbs and to return for a follow up consultation on April 27.

Second Consultation • April 27, 2020

The patient reported steady improvement since beginning the herbs. After taking the first dose of herbs, he felt like his fever was about to get worse, but it receded instead. He had some mild chills the first night after starting the herbs, but has not had any chills or fever since then. He still has a desire to wrap himself up in blankets.

His headache steadily declined and April 27, was the first day without any headache at the base of the skull or behind his eyes. His sore throat was immediately better after starting the loose herbs on April 25. It would still return, but was now “low key” in nature and more prevalent on the right side. He reported more energy since starting the herbs, but noted that if he were too active, he would become lightheaded or dazed, and would need to lie down.

On April 25, he had a bowel movement, and had regular bowel movements since then. He has also had a return of his appetite, but was craving ice cream, which he noted was unusual for him. Typically, he had no desire for sweet foods when not ill.

When asked about breathing and chest tightness, the patient reported that he could take a breath, but that it felt like there was a tight band around the rib cage from front to back. He also reported a few coughing episodes that were not severe.

The patient reported significant thirst, with a desire for cold beverages, although he had been limiting himself to room temperature water. He had an aversion to hot tea or coffee. He also reported that in the prior week, he had prominent thirst and reduced urinary output, but after the first round of herbs, his urine was clear and the volume was normal.

His tongue was slightly pale with darker edges on the left and a slightly red tip. The coat was thin, white, and slightly greasy. The sublingual veins were dark and distended, with the left being more prominent than the right.

Diagnosis

shao yang pathogenic influence with dampness

Prescription - Xiao chai hu tang + Huo xiang zheng qi san

Formula Analysis

The formula focused on harmonization of the shao yang, with a reduced emphasis on transforming dampness in the middle burner. There were still many signs from line 263 of the shang han lun, indicating that the disease was still affecting the shao yang. Tian hua fen (trichosanthis radix) was substituted for Ban xia, because  the patient exhibited more pronounced heat at his second consultation, as evidenced by his significant thirst with desire for cold beverages, the aversion to hot beverages, the craving for ice cream, and the red tongue tip. Tian hua fen retains an ability to transform phlegm, but clears and drains heat from the Lungs while also generating fluids.[i]

Only Jie geng (platycodi radix) was retained from Huo xiang zheng qi san, although the idea of using aromatic herbs to transform dampness and turbidity in the middle burner is retained through the addition of Pei lan (eupatorii herba). Jie geng guides the action of the formula to the upper part of the body, where most of the remaining symptoms can be seen. It also acts to open the Lungs, dispel phlegm, and benefit the throat.[ii] Pei lan is often used when there is distending headache, stifling sensations in the chest, and chills and fever due to summerheat-dampness.[iii]

Footnotes

[i] Bensky, Dan, et al. Chinese Herbal Medicine: Materia Medica. Eastland Press Inc., 2004.

[ii] Ibid

[iii] Ibid

Third Consultation • May 4, 2020

The patient reported that the headache and sore throat had resolved as of April 29, 2020. His restricted breathing was better. He still felt some tightness in the upper back that felt like it was “wrapping around”.

His thirst remained and he reported drinking 2 jars of water per day. He also still had the bad taste in his mouth. His energy had improved and he noted more stamina as of May 3, 2020. His appetite had returned and he was now craving fried restaurant food.

His tongue had a pale red body that was puffy and slightly dusky along the edges. There were visible teeth marks. The tongue coat was thick, with a slight yellow color towards the root. The sublingual veins were dark and distended, with the left being more prominent than the right.

Diagnosis

shao yang pathogenic influence with dampness

Prescription - Hao Qin Qing Dan Tang

Formula Analysis

At this point, most of the patient’s symptoms had resolved. The remaining symptoms were mild chest restriction, thirst, and bad taste in the mouth. The patient’s tongue coat was also displaying a change in color towards the root of the tongue. There is no reason to think that the pathogen has transferred to another stage, but the remaining signs and symptoms indicate that the pathogen may have transformed to more heat. As a result, the formula was changed to Hao qin qing dan tang (Sweet Wormwood and Scutellaria Decoction to Clear the Gallbladder). The zhong ding tong su shang han lun 《重訂通俗傷寒論》Chapter 7, Line 38 states:

To cast out exterior cold and outthrust exterior summerheat, if the heat is severe and the chills are light, then use xin jia mu zei jian to clear and drain it, or use hao qin qing dan tang to cool and harmonize it.[i]

Hao qin qing dan tang “is a combination of three formulas: Minor Bupleurum Decoction (Xiao chai hu tang), which clears heat constraint from the lesser yang; Warm Gallbladder Decoction (Wen dan tang), which clears heat, expels phlegm, and regulates the Glalbladder and Stomach; and Jasper Powder (Bi yu san), which clears heat, resolves toxicity, and expels dampness. Artemisiae annuae Herba (qing hao) is added to vent the exterior aspect.”[ii] In this case, the formula continues to employ the idea of Xiao chai hu tang with the substitution of Tian hua fen for Ban xia to harmonize the shao yang, and adds the idea of Wen dan tang to transform phlegm, but omits the use of Bi yu san, as the heat which is present has not risen to the level of heat toxicity yet.

Footnotes
[i] 表寒去而伏暑外潰。熱重寒輕者。則以新加木賊煎清洩之。或用蒿芩清膽湯涼解之。

[ii] Scheid, Volker. Chinese Herbal Medicine: Formulas & Strategies. Eastland Press, 2009.

Outcome

One week after starting the last herb formula, the patient reported a full recovery and was discharged from treatment.