A Case Report: Treating Fever in Post-Thyroid-Cancer and Post-Breast-Cancer Myelodysplastic Syndrome with the Method of "Great Fever Removed with Sweet-Warm Herbs"

Patient Ye, female, 64, retired worker, from Kecheng District, Quzhou City, Zhejiang Province. Online video consultation on September 6, 2021. The patient had previously been hospitalized at the People's Hospital of Kecheng District, Quzhou (admission no. 0000012, ID 04099462). Discharge diagnoses: 1. Myelodysplastic syndrome (MDS-EB-2; IPSS intermediate-2; WPSS very-high-risk; IPSS-R high-risk group); 2. Postoperative breast cancer; 3. Postoperative thyroid cancer; 4. Hypothyroidism; 5. Hypertension; 6. Anxiety state; 7. Schistosomal liver disease; 8. Splenomegaly; 9. Gallstones; 10. Right lung nodule; 11. Uterine fibroids; 12. Sacral canal cyst.

The patient had been feverish for over a year. In 2020 hormone therapy had once been effective, but now it was no longer working. The fever caused severe discomfort and she was emotionally pessimistic. Every night around 8 p.m. she spiked a fever, max 38.5°C, min 37.7°C; every day she sweated heavily, her clothes soaked, her hair as if washed. A year ago when fever came she felt generalized cold and shivering; this year she was heat-intolerant — even with the air conditioner in the twenties she still felt hot. She had recited the Buddha's name for thirty years and been a long-term vegetarian. Her blood counts were low; gums did not bleed. Before onset she had red plaques on the body surface, which did not resolve after treatment, mainly concentrated on the arms. Dry mouth, poor appetite, dark urine, frequent urination; since childhood she had had incomplete voiding. Poor sleep. The tongue surface was patchy with cracks. Fever did not resolve after sweating, and broke by morning. Constipated. She had previously been hospitalized for severe anxiety and still took anti-anxiety medication.

The case was very complex and I found it tricky. For the first prescription I considered a modified combination of Sanren Tang, Zhizi Dadouchi Tang, and Qinghao Biejia Tang: Dadouchi (Sojae Semen preparatum) 10 g, Chao Zhizi (fried Gardenia) 10 g, Xingren (Armeniacae Semen) 10 g, Huashi (Talcum) 15 g (wrapped decoction), Tongcao (Tetrapanacis Medulla) 6 g, Baidoukou (Amomi Fructus rotundus) 6 g, Zhuye (Phyllostachys Folium) 6 g, Houpo (Magnoliae Cortex) 6 g, Yiyiren (Coicis Semen) 15 g, Fabanxia (prepared Pinellia) 10 g, Chaihu (Bupleurum) 10 g, Huangqin (Scutellaria) 10 g, Dangshen (Codonopsis) 30 g, Huangjing (Polygonati Rhizoma) 30 g, Shayuanzi (Astragali complanati Semen) 10 g, Tusizi (Cuscutae Semen) 10 g, Nüzhenzi (Ligustri lucidi Fructus) 10 g, Mohanlian (Ecliptae Herba) 10 g, Xuanshen (Scrophulariae Radix) 30 g, Shengdihuang (Rehmanniae recens) 24 g, Maidong (Ophiopogonis Radix) 24 g, Baishao (Paeonia alba) 12 g, Danggui (Angelica) 12 g, Baiwei (Cynanchi Atrati Radix) 10 g, Fuping (Spirodelae Herba) 6 g, Qinghao (Artemisiae annuae Herba) 10 g, Zhi Biejia (prepared Carapax Trionycis) 15 g, Zhimu (Anemarrhenae Rhizoma) 6 g, Mudanpi (Moutan Cortex) 6 g. Two packages a day, each divided into two doses, taken after lunch every two hours. Report back to me after one day.

On September 8, the family reported: after four doses on the 7th, the highest temperature was 37.8°C; at night she felt a little cold, but later was hot again; only the irritability had lessened. I had them add Banlangen (Isatidis Radix) 20 g and Daqingye (Isatidis Folium) 20 g to the prior formula and continue one more day. That night the patient's temperature exceeded 39°C and she began to show aversion to cold.

The previous formulas had not worked, so I changed the approach to: Guizhi (Cinnamomi Ramulus) 10 g, Baishao 10 g, Zhi Gancao (prepared licorice) 6 g, Dangshen 30 g, Zhizi 10 g, Dadouchi 10 g, Shengjiang (fresh ginger) 7 slices, Dazao (jujube) 7 pieces, Xianhecao (Agrimoniae Herba) 50 g, Sheng Huangqi (raw astragalus) 30 g, Danggui 10 g. Still two packages a day, same dosing method.

On September 10, the family reported that fever still arrived on schedule at night and broke by early morning on its own. They asked how to continue. The patient's blood counts had recently stayed very low, and the family was anxious, fearing the MDS would progress to leukemia.

The earlier formulas had not produced an immediate fever-breaking effect, showing the approach was wrong. I decided to switch to the "great fever removed with sweet-warm herbs" approach, treating with modified Guipi Tang (Spleen-Restoring Decoction): Sheng Huangqi 30 g, Dangshen 30 g, Fuling (Poria) 10 g, Baizhu (Atractylodis macrocephalae Rhizoma) 10 g, Zhi Gancao 10 g, Danggui 10 g, Yuanzhi (Polygalae Radix) 10 g, Muxiang (Aucklandiae Radix) 6 g, Suanzaoren (Ziziphi Spinosae Semen) 10 g, Mudanpi 10 g, Digupi (Lycii Cortex) 10 g, Chaihu 10 g, Huangqin 10 g, Huangjing 30 g, Xianhecao 50 g, Yumixu (Maydis Stigma) 15 g, Lufengfang (Vespae Nidus) 15 g, Jiao Maiya (charred Hordei Fructus germinatus) 30 g, Jiao Shanzha (charred Crataegi Fructus) 6 g, Yujin (Curcumae Radix) 10 g. One package a day, decocted twice, divided into three doses.

On September 11, the family reported this formula worked better; the temperature had come down somewhat, but she still had fever. I had them continue one more day and observe. On September 12, the family reported the temperature was under control and no longer feverish, but at midnight she felt aversion to cold and in the early morning felt hot and restless. I had them add Qinghao 10 g (added late) to the prior formula (modified Guipi Tang). I told the family that fever from such a major illness naturally fluctuates, and to continue the prior formula and observe one more day. On September 14, the family reported that the patient had not spiked a fever at 8 p.m. the previous evening; she had only a brief fever around 1:30 a.m. of 37.7°C that quickly broke, with no recurrence of the chills-then-heating pattern.

The prior formula was effective, so I considered strengthening the righteous-supporting and heat-clearing forces, and adjusted further: Dangshen 30 g, Fuling 10 g, Baizhu 10 g, Zhi Gancao 10 g, Danggui 10 g, Yuanzhi 10 g, Muxiang 6 g, Suanzaoren 10 g, Mudanpi 10 g, Digupi 10 g, Chaihu 10 g, Huangqin 10 g, Huangjing 30 g, Xianhecao 50 g, Yumixu 15 g, Lufengfang 15 g, Jiao Maiya 30 g, Jiao Shanzha 6 g, Yujin 10 g, Daqingye 15 g, Banlangen 15 g, Shudihuang (prepared Rehmannia) 10 g, Baishao 10 g, Huaishanyao (Dioscoreae Rhizoma) 10 g, Xiyangshen (Panacis Quinquefolii Radix) 6 g, Shayuanzi 10 g, Tusizi 10 g, Mohanlian 10 g, Nüzhenzi 10 g.

Along with this formula I also had the patient take Huangqi Shengmai Yin oral liquid. Over the following week the patient reported fever only once. The family asked whether to stop; I felt this problem could not be resolved so quickly and that she needed to continue for a while. The family also reported the patient had long had a poor appetite and easy nausea and regurgitation, so I had them add Fabanxia 10 g and Houpo 10 g to the last prescription and continue for five more days.

This patient's fever had lasted a very long time, and the cascade of problems it brought made her quality of life poor. With the pandemic ongoing, face-to-face consultation was impossible, and I could only help relieve her suffering remotely by video. To avoid prescription errors and the harm that prolonged use might cause, I asked the family to report once daily until the patient's temperature was controlled.

The "method of removing great fever with sweet-warm herbs" was founded by Li Dongyuan, one of the four great masters of the Jin-Yuan period. It uses qi-and-blood-tonifying herbs with a moderate addition of fever-relieving herbs such as Chaihu to treat febrile diseases in weak, deficient patients; its representative formulas are Guipi Tang and Buzhong Yiqi Tang. The patient I treated had, on Western examination, low blood counts and long illness with deficiency — precisely the conditions for this method. Once the sweet-warm method was adopted, it indeed produced an immediate fever-breaking effect.