key: cord-0944612-exq7rre8 authors: Hung, Shou-Wen; Liao, Yuan-Ching; Chi, I-Chang; Lin, Ting-Yen; Lin, Yu-Chuan; Lin, Hung-Jen; Huang, Sheng-Teng title: Integrated Chinese herbal medicine and Western medicine successfully resolves spontaneous subcutaneous emphysema and pneumomediastinum in a patient with severe COVID-19 in Taiwan: A case report date: 2021-12-13 journal: Explore (NY) DOI: 10.1016/j.explore.2021.12.005 sha: 884740657ee56f756f1c5044e58bfb229b414d04 doc_id: 944612 cord_uid: exq7rre8 CASE: : Serious complications of severe coronavirus disease 2019 (COVID-19) include subcutaneous emphysema (SE) and pneumomediastinum, which are complicated to treat with conventional Western medicine. We report how combining Chinese herbal medicine (CHM) with Western medicine quickly resolved a patient's COVID-19-associated pulmonary complications, shortened hospital stay and improved quality of life. CLINICAL FEATURES AND OUTCOME: : A 59-year-old male with a history of smoking and tumors was diagnosed with COVID-19 in May 2021. At hospitalization, his oxygen saturation (SpO(2)) was 80%, he had a continuous severe cough, rapid shallow breathing, spontaneous SE and pneumomediastinum. By Day 4 of hospitalization, his condition was worsening despite standard care, so CHM was added. After 3–5 days, his coughing had lessened and supplementary oxygen therapy was de-escalated. Nine days after starting CHM, the SE had completely resolved and the patient avoided intubation. His WHO OS 10-point Scale score had fallen from 6 to 3 points and the modified Medical Research Council Dyspnea Scale score from 4 to 2 points. He was hospitalized for 19 days. At 1 week post-discharge, the patient could handle most of his daily activities and experienced minor shortness of breath only when performing labor-intensive tasks. At 1 month, his work output was restored to pre-COVID-19 levels. CONCLUSION: : CHM combined with standard Western medicine improved pulmonary function, respiratory rate, blood oxygen saturation and shortened the hospital stay of a patient with severe COVID-19 complicated by SE and pneumomediastinum. . Chest X-ray results are presented in Figure 2 . Other symptoms included a dry mouth with a thick yellow coating on the tongue, a change in taste sensation, a bitter taste in the mouth, diarrhea, and loss of appetite. Within When CHM was combined with conventional medicine for the patient's treatment, his clinical symptoms began to improve. Respiratory rate was less than 24 breaths per minute and saturation of peripheral oxygen was stable for 3 consecutive days, as shown in Figure 3 . 13 The crackling sensation on palpation of the affected area of subcutaneous emphysema improved gradually. The respiratory supportive system was de-escalated after 3-5 days of CHM treatment. After 9 days of combination treatment with CHM, the subcutaneous emphysema subsided completely; the WHO OS 10-point scale score was reduced from 6 to 3 points and the mMRC Dyspnea Scale score was reduced from 4 to 2 points. After a total hospitalization of 19 days, the patient was discharged on Day 25, with a score on the WHO OS 10-point scale of 1 and an mMRC Dyspnea Scale score of 1. Post-discharge, the patient could independently manage most of his daily activities and experienced only mild shortness of breath when performing labor-intensive tasks. At 1 month of follow-up by telephone, he reported that he was able to work normally, at the same level of output as he had prior to COVID-19 infection. Laboratory data during hospitalization are shown in Figure 3 . Figure 4 presents the patient's blood oxygen variations, oxygen therapy requirements, and clinical pulmonary function evaluations during hospitalization. This middle-aged patient was a smoker with a cancer history who suffered from 23 Evidence also shows that the general population has turned to TCM during the COVID-19 pandemic, with one survey from Hong Kong conducted from November to December 2020 revealing that traditional, complementary and integrative medicine was commonly used there for COVID-19 prevention and treatment. 24 An animal study has indicated that severe acute age-related tissue damage, improve antibody production and reduce the inflammatory reaction that occurs after infection. 26, 27 Quercetin has the potential to inhibit the extent of SARS-CoV-2 infection by binding with the active sites of 3CL and ACE2, the main proteases of SARS-CoV-2, and thus inhibit viral propagation. 28 Natural products may therefore have potential as food supplements to protect older adults with multiple chronic diseases against bodily harm caused by COVID-19 infection. The Ganlu Xiaodu Decoction is amongst the top three most commonly prescribed prescriptions for patients with severe COVID-19. 29 The formula is well-known for its ability to clear heat and resolve toxins, based on TCM theory. A cytokine storm in a critically ill patient may be life-threatening and contribute to multiple organ failure. We therefore adopted a modified Ganlu Xiaodu Decoction to reduce extensive lung inflammation and 16 inhibit viral replication. The mixture of herbal materials in the modified Ganlu Xiaodu Decoction is shown in Supplementary Table 1 . We report the details of a patient with SE and pneumomediastinum associated with severe COVID-19 infection that occurred 12 days following symptom onset in the absence of mechanical ventilation. The patient suffered from painful swelling and palpable crepitus that developed in the cheeks, neck and the chest wall, similar to symptoms described in a previous report. 48 SE is very rare in the general population, with fewer than 10 cases per 100,000 annually. 49 The prevalence of SE in COVID-19 is still unclear. One study noted that 13.6% of patients on mechanical ventilation with ARDS and COVID-19 suffered from SE. 5 It is interesting that up to 36% of patients with COVID-19 infection who were not on mechanical ventilation or who were not intubated were observed to have SE in another study. 48 Generally, spontaneous SE without other complications improves within 3-5 days and completely subsides within 7-10 days. However, mortality is reported to be as high as 30% in patients with severe COVID-19 complicated by SE. 48, 50 In our case, after receiving combination treatment with CHM and Western medicine, the patient's breathing and blood oxygen saturation improved and remained stable. Respiratory support was de-escalated from a non-rebreathing mask to a nasal cannula every 3-5 days. Serum LDH concentrations continued to fall. SE resolved completely after 9 days, which is much shorter than the time taken for it to completely subside among patients with comparably severe COVID-19 infection. 20, 48 The total duration of hospitalization for the current case was 19 days, shorter than that in a previous retrospective cohort report. 51 18 We have described the case of a patient with severe COVID-19 complicated with SE and pneumomediastinum treated with the modified Ganlu Xiaodu Decoction. During hospitalization, liver and kidney functions were normal. According to scores on the WHO OS 10-point scale and mMRC Dyspnea Scale and clinical symptoms under combination therapy continuously improved during hospitalization, with noted improvements in the patient's respiratory rate and blood oxygen saturation, the short hospital stay and improved quality of life after discharge. Shou-Wen Hung and Yuan-Ching Liao wrote the manuscript and collected research data. I-Chang Chi, Ting-Yen Lin and Yu -Chuan Lin collected research data. Hung-Jen Lin provided administrative support and instructed on the TCM prescription. Sheng-Teng Huang organized the manuscript, provided technical assistance and edited the manuscript. All of the authors approved the final manuscript. The authors declare there are no conflicts of interest. A new coronavirus associated with human respiratory disease in China Coronavirus disease (COVID-19) pandemic. 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MacDonald (China Medical University, Taichung, Taiwan) for her critical reading and revision of our manuscript. We obtained written informed consent from the patient for scientific purposes. This study was approved by the Institutional Review Board of China Medical University Hospital (CMUH110-REC2-127). The datasets used during this study are available from the corresponding author on reasonable request.