Janelle Bartow

Case Study

Malaria

2/21/05

Case Study

                    Bob is a 61 year old man who had a 105 degree fever for three days in early December 2004.  He had profuse night sweats, delirium, chills, and an inner ear infection. He believes these fevers, which occur every 10 years or so are a recurrence of malaria he contracted 30 years ago. He has not had a recent blood smear to verify that he has malaria.  However, he has had a recent blood test that shows he is anemic. I first saw him nearly two months after his fever.

                    Bob’s main complaints were incontinence and fatigue, both of which began soon after the malarial fevers.  The incontinence was mostly at night.  Bob said he would wake up to urinate twice a night, but in the act of urinating he would start to lucid dream of other things, then wake up to find himself still urinating. He would lose all sense of time and feel like he had been urinating for hours, so he would stop his stream of urine and go back to bed. Later in the night he would have incontinence.  Occasionally during the day he would have incontinence if he sneezed or strained his abdominal muscles.

                    His pulse was very thin and weak, almost imperceptible, which is in stark contrast to his physical appearance: he is a 6’ man who weighs 200lbs and looks very healthy and strong.

                    Bob’s tongue body was thin, pointed, with red sides and tip.  He had a yellow coat, mostly at the root and very distended sublingual veins.

                    Diagnosis: Taxation Malaria with yin, blood and Yuan Qi deficiency.

                    Acupuncture: SJ 5, GB41, GB 26, Du 20, ST 36, Indirect Moxa on Ren 6.

                    Herbs: Xiao Chai Hu Tang Pills 12 pills 3x a day.

                    Follow-up Visit the next week: the patient reported that the lucid dreams have stopped, he slept soundly for 3 nights in a row (which has never happened in his entire adult life), and his fatigue is slightly improving.  His incontinence improved, but is still occurring. He said 4 nights previously he woke up with a fever, chills, sweats, and incontinence. He took an anti-malarial homeopathic remedy that a friend made for him and the fever has not returned.  He also had a headache over his left eye and a neck ache near GB 20 on the left side.  He also revealed that he was born jaundiced and had a history of parasites including liver flukes as an adult.

                    Acupuncture: GB 20 (L), GB 21 (L), GB 14 (L), GB 34 (L), GB 41 (L), SJ 5 (R), ST 36, 3  cones of direct moxa on Ren 6.

                    Herbs: Xiao Chai Hu Tang pills 12 pills 3x day.

                    Another follow-up visit two weeks later showed that he is sleeping 7 hours a night, no headaches this week, and only had 2 bouts of daytime incontinence when sneezing and straining his abdominal muscles.  He had no recurrence of fever and the night sweats have stopped. His is seeing an Ayurvedic herbalist and taking turmeric and Ashwagandha; he continued taking Xiao Chai Hu Tang pills but lowered the dose to 8 pills 3x a day.

Biomedical Overview

                    Malaria is a parasitic infection caused by the bite of the female Anopheles mosquito one to three weeks after initial contact. The mosquito injects an immature form of the parasite into the blood stream, which eventually lodges in the liver. Inside the liver they develop and reproduce asexually to be released into the bloodstream. Once in the blood, the parasites invade red blood cells and reproduce asexually.  Eventually, the red blood cell ruptures, releasing ever growing numbers of parasites into the bloodstream. When large numbers of red blood cells rupture at the same time, the patient will have alternating fever and chills.[1]  Usually, the patient feels very cold at first, begins shivering and then develops a fever.  Patients often feel very thirsty and have a severe headache.  After a few hours, the patient has whole-body perspiration and the fever breaks[2].  Depending on a person’s constitution, there can be a range of other symptoms including diarrhea, incontinence, vomiting, mania, depression, psychotic episodes, bizarre dreams, lumps under the rib cage, extreme fatigue, acute renal failure, pulmonary edema, seizures or coma.  In severe cases, the spleen can become so overwhelmed with the job of breaking down the fragments of red blood cells that it becomes enlarged and, in severe cases, may rupture.

Biomedical Treatment

                    Western medicine focuses more on prevention than treatment. DDT and other insecticides have been used worldwide to kill mosquitoes, which creates other health and environmental toxicity problems.  Due to the short life-cycle of mosquitoes, they can be

killed in large numbers with insecticides, but often evolve to develop a resistance to the chemicals. Western antimalarial drugs like chloroquine have limited usage because of parasitic resistance. Western travelers to malarial areas are often advised to take prophylactic antimalarial treatment, which often have unpleasant psychological side effects like depression, anxiety and mania. Travelers are also advised to wear 35% DEET bug spray over long sleeve shirts and pants, to stay indoors at dusk or dark, and to sleep under a mosquito net.  According to the UN, about 300-500 million people contract malaria every year, and more than one million people annually die from malaria.  Sub-Saharan Africa has the highest incidence of malaria, accounting for 85% of the world’s malaria[3].  

                    Western diagnosis of malaria is made from a peripheral blood smear.  There are four different species of parasites: Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale and Plasmodium malariae . There are many different antimalarial drugs, but a chloroquine injections over a course of 5 to 10 days is standard; it is often combined with tetracycline. If chloroquine resistance is suspected in a particular geographic location, quinine can be used.  Other antimalarial drugs may include: mefloquine, halofantrine, clindamycin, and dichlorquinazine[4].  Chloroquine’s side effects include: nausea and vomiting, headache, dizziness, blurred vision, and itching. Chloroquine may worsen the symptoms of psoriasis. Mefloquine’s side effects include nausea, dizziness, difficulty sleeping, and vivid dreams. Mefloquine has very rarely been  reported to cause serious side effects such as seizures, hallucinations, and severe anxiety[5].

TCM Diagnosis and Treatment

                    TCM treats malaria (Nue Zheng) as an epidemic evil that invades the shao yang channel, causing a ying and wei disharmony. The evil may be warm or cold.  Malaria is classified many different ways in TCM. The disease can be classified by the duration between the attacks of fever and chills: 24 hour malaria, 48 hour malaria (usually the Plasmodium vivax parasite), and 72 hour malaria (usually Plasmodium malariae).  Or, the initial attack could be classified by heat, cold or accompanying symptoms. Additionally there are two less-commonly seen forms of the disease: taxation malaria (chronic malaria) and gastrointestinal malaria.  The differential diagnosis table that follows classifies malaria by heat, cold and accompanying symptoms.

               In the acute stage, it is recommended to needle the points 1-2 hours before the anticipated onset of fever and chills (depending which cycle the patient gets the malarial attacks: 24, 48 or 72 hour cycles).  Moxibustion after acupuncture improves the effectiveness of the treatment.  Du 14, SI 3 and PC 5 are traditional malaria points[7]. 

                    Research has shown that TCM is very effective at curing malaria through herbs and acupuncture.  In a study done between 2000 and 2002 acupuncture and e-stim were used on 46 cases of acute gastrointestinal malaria.  Patients were diagnosed as having malaria by a blood smear. Treatment consisted of the following points: Erjian (M-HN-10) was pricked and 8-10 drops of blood were squeezed out (this detoxifies and clears heat). Then Du 14 was pricked and cupped for 10 minutes to allow 10-20 drops of blood to come out (this clears the yang channels). Then the patients were asked to lie down and e-stim was applied to points needled at Ren 12, ST 25, Ren 6, ST 36, and PC6. Electrical pulses were applied at a frequency of 100 pulses per minute for 20 minutes. Treatment happened daily for 5 days. A blood smear was then performed  and determined whether or not the patient had a reduced number of Plasmodium parasites. Of the 46 cases, 33 showed an elimination of parasites and relief of physical signs and symptoms; and 13 showed an obvious reduction of Plasmodium parasites and improvement of physical signs and symptoms[8].  This is in an area of Zambia were chloroquine works 50% of the time, and it’s side effects are mostly gastrointestinal, thereby worsening the patients’ symptoms.

                    Another study on the herb Qing Hao and its derivative, artemether, showed a 90% cure rate of Plasmodium falciparum.  The herb was given in an oil preparation of 900mg in a three day course of treatment, or a four day course of treatment of an oil preparation of artemether.  These herbal preparations were used as the first drug of choice in areas of China from 1973 to 1980 that showed resistance to chloroquine[9]. 

Alternative Medicine

                    Research on malarial mice injected with turmeric show an 80% reduction in the parasite[10]. Ashwagandha is a qi tonic herb that is used in Ayurvedic medicine to help with the fatigue and anemia of taxation malaria. The suggested dosage is 1 teaspoon of powder twice a day, boiled in milk or water[11]  A fascinating study done by “Homeopaths Without Borders” was done in Ghana. The study compared a variety of homeopathic remedies to Chloroquine and found that Arsenicum album ,China, Natrum muriaticum ,Nux vomica, Pulsatilla and Sulphur  were as effective as Chloroquine[12] 

Summary

                    Malaria is an ancient disease that persists in the modern world despite pesticides,  urban sprawl,  and western drugs.  TCM provides a safe and effective way to treat malaria; and it is underutilized in the developing world. 

Bibliography

Alao, Adekola and Mantosh Dewan, “Psychiatric Complications of Malaria: A Case Report.” International Journal of Psychiatry inMedicine. Vol 31 (2) (2001): 217-223.

China Cooperative Research Group. “Clinical Studies on the Treatment of Malaria with Qinghaosu and Its Derivatives.” Journal of Traditional Chinese Medicine 2, 1 (1982): 45-50.

Dugbartey, Anthony et al. “Delayed Neuropsychiatric Effects of 

Malaria in Ghana.” Journal of Nervous and Mental Disorders.Vol. 186,

3 (1998): 183-186.

Frawley, David and Vasant Lad. The Yoga of Herbs: An Ayurvedic Guide  to Herbal Medicine. Wisconsin: Lotus Press, 1986.

Hong, Zhang and Ren Lin. “Treatment of Gastrointestinal Malaria by Acupuncture: A Report of 46 Cases.” Journal of ChineseMedicine. 72 (6) (2003): 26-27.

Seifert, Garry and Jian Min Wen. Warm Disease Theory.  Massachussetts: Paradigm Publisher, 2000.

Sionneau, Philippe and Lu Geng, The Treatment of Disease in TCM: General Symptoms. Boulder: 

Blue Poppy Press, 2000.

Wu, Yan and Warren Fischer. Practical Therapeutics of TCM. Massachussetts: Paradigm Publisher, 1997.

Yau, James Tin. Treatment of Disease with Acupuncture, Volume II. Massachussetts: Paradigm Publisher, 1987.

Yunnan Provincial Anti-Malaria Institute and Menhai Commune Health 

Center. “Malaria Eradication in Menghai People’s Commune.” Chinese Medical Journal, 2, 4 (1976): 257-262.

Web Citations

For an overview of the lifecycle of Plasmodium sp. parasites and 

pictures of blood smears: http://www.biosci.ohio-state.edu/~parasite/plasmodium.html..

For a list of side-effects from Western antimalarial drugs: 

http://www.cdc.gov/ncidod/dpd/parasites/malaria/hcp_malaria_pregnant.htm.

For a review of the study about Turmeric as an anitmalarial in mice: http://www.newscientist.com/article.ns?id=mg18524812.100.

For information about dosages and products made from Ashwagandha: 

http://herbalremedies.com/ashwagandha1.html.

For the complete article about the study of homeopathic remedies in 

Ghana: http://www.giriweb.com/vanerp.htm.

[5] http:/www.cdc.gov/ncidod/dpd/parasites/malaria/hcp_malaria_pregnant.htm

[12] http://www.giriweb.com/vanerp.htm.