Corona Virus Pneumonia (COVID 19)- Chinese Medicine Pathopysiolgy

By: Keren Zelicha

Traditional Chinese medicine has played an important role in the treatment of novel corona virus pneumonia (COVID-19 disease). In these article I will explore the TCM pathology and treatment strategy for coronavirus pneumonia. As I wore before in the article “Exploring novel corona virus pneumonia”, we saw that this disease is related to the Wen Bing theory diseases. How does corona virus (SARS-CoV-2) infect the body? What can we say about the disease progression from a Traditional Chinese Medicine point of view?

Here is what I have read and investigated:

How does corona virus (COVID-19) affect the body?

The Coronavirus can be latent between 4-14 days, but there were even reports of 24 days of incubation. The coronavirus starts by infecting our upper respiratory tracts – the throat. At this stage some people will develop fever, sore throat and dry cough others will not have any symptoms.

Later on, it enters the lungs attacking type 2 pneumocytes cells in the alveoli. This invasion will cause a cascade event of an inflammatory mediators inside the alveoli. The body immune system reacts to the virus by releasing many cytokines. This immune response, can lead to an uncontrolled cytokine storm and will also damage alveoli healthy cells. Lung capillary permeability increases due to this inflammation. All the plasma from the blood will start leaking out to the interstitial spaces and into the alveoli causing edema. That can damage the alveoli and the patient will need to work harder in breathing, to supply oxygen to the whole body.

The swelling, inflammation and impaired flow of oxygen cause pus and pneumonia. In some cases, the patient will need to be put on a ventilator. Sever cases will develop an Acute Respiratory Distress Syndrome: The lungs will be “drown” by fluids, no amount of breathing support can be helpful, and the patient dies. When the disease cannot be controlled, the patient condition will aggravate, sepsis and organ failure can occur due to hypoxia (Lack of oxygenation).

What kind of damage happen inside the lungs due to corona virus COVID-19?

The corona virus inside the body has a physiological damage and a physical damage specifically to the lung membranes. Body autopsies showed a very thick, sticky discharges that are clogging out the small alveoli’s space in the lungs. That’s why the cough is dry and the phlegm is very hard to cough out. In addition, autopsies showed that the lungs lose their spongy- elasticity. They become stiff and rigid instead. That’s why it is very difficult to inhale. Most of the patients report that inhalation is much more difficult than exhalation!

What are Corona virus (SARS-CoV-2) clinical symptoms?

The clinical symptoms are mainly fever, dry cough and fatigue. Shortness of breath and difficulty breathing gradually appear. Some people will have joint pain, lack of taste and smell.

The uncommon symptoms are: sputum, headache, diarrhea.

Common clinical laboratory findings are leucopenia and lymphopenia- both are cardinal features of the new coronavirus (COVID-19) that symbolize a viral infection. Mild thrombocytopenia is also common. In advanced cases, DHL (Lactate dehydrogenase) and CK (creatinine kinase) are also high indicating muscle damage or multiple organ dysfunction or failure.

One of the frequent signs that are found in CT scans are Ground Glass opacity. They are white patches in the lungs that can clearly be seen on CT scans. These patches appear in different pulmonary abnormalities: infections/ edema/ interstitial lung disease etc. They represent air, fluids and inflammation in the lungs. In coronavirus those Ground Glass Opacity are extended to the edge of both lungs.

Traditional Chinese Medicine explanation for corona virus (COVID-19):

From a Chinese medicine point of view, corona virus can be regarded as a Wen Bing disease.

The pathophysiology of coronavirus (COVID-19) is an epidemic evil lodging in the triple burner Mo Yuan “Source membrane” (lung membranes). This epidemic evil can block the qi axis, suppress yang, damage qi transformation & transportation and producing toxic damp pathology.

Let us look on the characteristics of corona virus disease:

Combining the clinical manifestations of greasy tongue coating, fatigue, lack of sense of smell and taste and uncomfortable stools, we can see that dampness plays a major part in the pathology. Since we also see leucopenia, lymphopenia and sometimes mild thrombocytopenia, we can realize that qi and blood are depleted.

Except from the toxic damp pathogenic factor, the disease is manifested as a compromised water metabolism state.

This may lead to an overall damage through the triple warmer mechanism transmitting the disease to other organs and systems. The toxic damp pathogenic evil can hide in the Mo Yuan “source membrane” which is related to the fascia in modern point of view.

The Mo yuan is related in Wen Bing theory to the triple warmer since it is in charge of water metabolism and qi flow. At COVID-19 disease, the virus attacks lung’s parenchyma which contain the alveoli.  The internal surface of the alveoli is lined by the epithelium, which is covered by a thin liquid film. The alveolar septal walls are composed of interstitial cells and the Extra Cellular Matrix- all consist different types of collagen molecule. We can See them as triple warmer Mo Yuan “source membrane”. It is exactly where the coronavirus hides and attacks the lungs.

The progression of Corona virus disease:

Wei qi travels to fight the evils and to block them from spreading on. This battle on the one hand can rise the temperature in order to resist the virus but on the other hand may also damage the cells of the Mo yuan- source membrane (lung parenchyma). The presence of the pathogen, and the body reaction in the “Mo yuan” will decrease blood circulation and increase muscle tension. Qi and blood cannot flow freely. Water cannot be transferred easily. This produces accumulation of fluid and toxicity inside the lung interstitium space and inside the alveoli.

It is important to notice that in most cases the cough is dry. We might think that it’s a matter of dryness and use moistening herbs. This is a deception, and it is very tricky. The lungs alveoli are drowning by thick- sticky phlegm that is very hard to expectorate. The lung organ itself lose its elasticity. It becomes stiff. That’s why the cough is dry.

Chinese medicine key symptom for diagnosing corona virus:

The tongue in coronavirus pneumonia is a key symptom! Usually it is thick and greasy, reflecting a damp phlegm hidden pathology. It will be a fatal mistake to use here moistening herbs! We should pay attention to the person and its pulse and tongue! We should also take in mind that each country has a different climate that can affect the pathogenesis of the disease.

Clinical manifestation note for corona virus:

Some of the patients mention that during the morning they feel better but after the sunset their cough, fatigue, chills and other symptoms aggravates. The Yellow emperor -Su wen chapter 3:   [1]

《素问·生气通天论》： “故阳气者，一日而主外。平旦人气生，日中而阳气隆，日西而阳气已虚，气门乃闭”

Yang energy is in charge of the superficial region at day time, it begins to circulate at sunrise, flourishes at noon and declines between noon and sunset with the doors of energy (pores) beginning to close

It may be that some patients have Yang qi deficiency that causes their symptoms such as cough to aggravate during the evening. In these patients the cough may be with sputum or little sputum, the tongue would be swollen, with white slippery coating. But if the cough is dry and the tongue is red without coating, then it may be that we are in the late stages of the disease that injured lung qi and yin.

Corona virus pneumonia is a wen bing disease:

1. Wei qi level damage: The mild early stage manifested as fever, dry cough, nasal congestion, shortness of breath, fatigue, muscle pain, headache.
2. Qi level damage: The next stage is manifested with a high fever, lung inflammation, pneumonia, shortness of breath, dry cough. The edema and inflammation are symptoms of damp- phlegm and the patient will need ventilation aid. The amount of heat versus damp- phlegm may vary among patients. But we need to remember that damp toxicity is still the main pathology. As the disease progresses oxygen is depleted to the organs, Zheng qi may be damaged. Lethargy, difficult breathing, dark complexion all happen since oxygen cannot be transported throughout the body. This is a point of change, from a heat stage to a colder– deficient nature of the disease.
3. Ying & Blood level damage: The body is undergoing a major cytokine storm that lead to Acute Respiratory Distress Syndrome and organ failure. The lungs are blocked by the phlegm fluids, the inflammation is excessive, and the whole body organs are not nourished by oxygen. This is an excess and deficiency stage of the disease. Blood stagnation might appear due to lack of blood nourishment.

Recovery stage is manifested with lung – spleen qi deficiency. Some of the patients will have lung yin deficiency due to the heat scorching the fluids. Many of the patients will be discharged from hospital but still will need ventilation aid for a while.

Chinese medicine treatment strategy for Coronavirus (COVID-19):

In this case it is not enough to use cooling pungent herbs to clear heat and reduce the temperature. This will not address the moisture and toxic dampness inside the lungs. The technique has to include resolving water retention, breaking accumulation to expel the pathogen out.

In order to transform damp toxicity and accumulation, it is necessary to work on triple warmer’s water passages including:

1. Diffusing the lung.
2. Transforming damp in Spleen stomach- Large intestine systems.
3. Passing damp-water through kidney.

This will help regulating the triple warmer and its functions in all “three Jiaos”. This a unique treatment strategy taken form Wen Bing Theory.

Transforming damp, resolve toxin and out-thrust evil are also important strategies and depend on the disease manifestation. In some cases, damp phlegm can be changed into heat. Using small doses of clearing heat toxic herbs such Ban lan gen or Lian qiao may be relevant.

Corona virus Clinical note:

We should pay attention to the amount of cold clearing heat-toxic herbs since they can damage the Zheng qi and Yang. This way the body will be deficient and won’t be able to heal itself. In addition, we must not forget that coronavirus patients are already taking antibiotics to treat their pulmonary inflammation/ pneumonia. These medications are considered cold nature so there is no need to add strong cooling herbs. [2]

We all need to consider the patient’s constitution and make an accurate differentiation to treat the condition.

Summery:

In this article I tried to present traditional Chinese medicine pathophysiology for Coronavirus (COVID-19). It is important to notice that this virus is manifested as a Wen Bing epidemic disease. Coronavirus main pathogen is damp toxicity lodging in the Mo yuan (source membrane) – lung parenchyma which contain connective tissue. The virus enters the body through the mouth and nose attacking lung organ. A sever pneumonia can be developed resembling a qi level disease of a Wen Bing theory.

The treatment strategy should focus on transforming damp, clearing heat- toxicity, supporting Zheng qi, but also on harmonizing triple warmer functions by working on:

1. The upper jiao: diffusing lung qi
2. Middle Jiao: transforming & transporting spleen- stomach- large intestine qi and fluids
3. Lower jiao: passing water damp through the kidney

In the next article I will try to focus on the treatment for coronavirus using Chinese herbs and formulas.

Stay tuned!

Press here for a related video on COVID-19: Corona Virus: Epidemiology, Pathophysiology, Diagnostics

Bibliography:

[1] A complete translation of nei jing- Henry C. Lu page 80

[2] Corona Virus (Covid-19) Successful case Study by Jin Zhao and Colleagues botanicalbiohacking.com