Space-time acupuncture for intractable cough after lupus nephropathy: A case report and literature review.

RATIONALE: Some intractable chronic cough remains a common complaint for seeking medical care. Unexplained cough in lupus nephropathy patient is rare and therapeutic options are limited. PATIENT CONCERNS: A 57 year-old woman with a 7-year history of lupus nephropathy. She has suffered from chronic cough for 3 years accompanied with chronic low back pain and fatigue, as the conventional therapy cannot relieve the symptoms. DIAGNOSES: The woman is diagnosed as intractable cough after lupus nephropathy.
INTERVENTIONS: 9 times space-time acupuncture (STA) treatment was performed. OUTCOMES: The cough, as well as other uncomfortable symptoms like chronic low-back pain and fatigue have resolved, and no relapse for one year follow-up. LESSONS: STA may be an effective therapy to treat intractable chronic cough.

Introduction

Acupuncture for common cough has been reported[ for years, while its effect of intractable cough after lupus nephropathy has not been recorded yet. So, this paper will cover our successful case of intractable cough after lupus nephropathy treated by acupuncture.

Case description

A 57 year-old woman, diagnosed with lupus nephropathy in 2009 and placed on long-term immunosuppressant therapy, has suffered from intractable cough for nearly 3 years. However, primary causes like postnasal drip syndrome or organic diseases of respiratory, lung and chest have not been found. Lupus nephropathy has been controlled with 3 months hospitalization therapy in 2009, and the use of immunosuppressant drug has never halted since then. To treat cough, she underwent hospitalization therapy with western medicine and herbs for many times, but the effect is not obvious. At 19:00 on November 14, 2016, she visited our clinic and wanted an acupuncture treatment. Her main symptoms include dry cough without phlegm, attacking irregularly, accompanied by dry throat itching, feeling chilly and weary all over, slight low-back pain, and loss of appetite. Medical test showed the total protein (TP) is 59 g/L (conventional units 60–80 g/L), and other indicators are of negative values.

Based on her clinical symptoms and traditional Chinese medicine (TCM) theory, we used space-time acupuncture (STA) for treatment and stopped all cough medicine and herbs. STA includes 3 groups of acupoints, namely time acupoints, space acupoints, and experience acupoints. Time acupoints are selected from 1 of the 4 groups of SP4-PC6, LU7-Kl6, GB41-TE5, and BL62-SI3 according to time of meridian flow periods of the day. Space acupoints include 3 groups (Fig. 1, Fig. 2, Fig. 3) based on Chinese ancient sudokus theory of square of nine. Experience acupoints are ST41, ST36, SP6, KI 3, and ST40. Patient was seated at treatment table. Time acupoints are vertically inserted with the sterility and disposable acupuncture needle (0.30×40 mm, Maanshan bond medical instruments co., LTD, Maanshan, China) after disinfection using 75% alcohol, and clockwise twisted slightly. The space acupoints in back and waist are obliquely inserted with the tip downward with the same manipulation. Then hold the patient to lie down with the needles compressed in back. The space acupoints of head-hand and abdomen-leg, and experience acupoints are vertically inserted by the same manipulation. Each group of time acupoints and space acupoints are inserted following the order of meridian flow time period. Needle-retaining duration is about 40 min, and infrared electromagnetic therapeutic apparatus (Warren Chongqing Medical Instrument Co., Ltd, Chongqin, China) is used to irradiate around the navel area. The patient is treated every other day. And after 5 times treatment, cough and other secondary symptoms like dry throat itching, feeling chilly, and weary all over, slight low-back pain and loss of appetite are markedly improved. TP has reached to 65 g/L. After another 4 times treatment, all the symptoms have disappeared. For 12 months follow-up, there is no relapse of cough.

Figure 1

Acupoints of group 1, which consists of GV14, BL13,GV8, BL18, BL23 and GV1.

Figure 2

Acupoints of group 2, which consists of GV24, EX-HN5,GV29, LI20, LI4 and GV24.

Figure 3

Acupoints of group 1, which consists of CV22, ST21,ST25, CV6, CV4 and LR3.

Discussion

Accurate epidemiology of cough in lupus nephropathy has not been reported by now. A study[ indicates cough in systemic lupus erythematous is prevalent, and the common causes are bronchial asthma, postnasal drip syndrome, pneumonia, diffuse parenchymal disease lung, tuberculosis, and gastro esophageal reflux disease. Most of them are easy to control. However, the cause of this female patient is undefined and may be classified as unexplained chronic cough. There is also no direct evidence that the cough is resulted from the drug side effect in long-term treating of lupus nephritis. Based on the CHEST guideline and expert panel report,[ the diagnosis and management of unexplained chronic cough are limited and need further study evidence. That might be the potential reason that the alleviation of cough cannot be reached by previous systematic practice.

As far as we know, the effective outcome of acupuncture for intractable cough after lupus nephropathy has not been reported, although acupuncture for general cough and other respiratory system disease has been used widely in China, Japan, and Australia.[ STA[ is characterized as special acupoints combination according to meridian flow time period theory and classic book Hetu Luoshu. In the theory, qi in meridian regulates and governs the energy in body according to specific time period. By STA, 1 of the 4 given acupoints combination groups of SP4-PC6, LU7-Kl6, GB41-TE5, and BL62-SI3 will be selected according to the patient visit time. Hetu Luoshu is manifested as Sudoku, and acupoints are selected correspondingly as shown in Figures 1–3 according the condition of patient. In this case, we used 3 acupoints groups, namely meridian time flow theory, Hetu Luoshu and experienced points. This approach is discovered and initially applied by Professor Miansheng Zhu. The experience acupoints of ST41, ST36, SP6, KI 3, and ST40 have the function of tonifying spleen and kidney, and reducing phlegm in TCM theory. This is the first report of a successful treatment case for intractable cough after lupus nephropathy and with no relapse in 12 months follow-up visit by STA.

The limitation of this report is that the cause of cough cannot be found and the effect by self-healing cannot be eliminated. Besides, the STA appears more complicated in operation comparing to common acupuncture, but a clinician can master STA skills from standard training. However, the value of STA in this patient is hinted both in main other complains, and has enhanced her life quality. This report shows a comprehensive therapeutic effect of acupuncture, and it could be a reference for treatment of some unexplained chronic cough. Further estimation of the STA efficacy and safety in cough after lupus nephropathy should be implemented.

Conclusions

The patient suffering from long time intractable cough after lupus nephropathy has be successfully treated and other complaints like dry throat itching, feeling chilly and weary all over, slight low back pain and loss of appetite also resolved by STA. It indicates that some intractable and unexplained chronic cough could be cured by STA. Randomized controlled trial could be used to evaluate the efficacy and safety of STA for cough after lupus nephropathy.

Statement of ethical

As a case report study, the ethical approval is not necessary. The patient has approved to publish her information and patient consent form has been signed in person.