SARCOIDOSIS
Sarcoidosis is an immune-system-based disease in which an excess production of cytokines (immune system messengers) leads to a type of inflammatory process. The cause of the disease is unknown, but is assumed to involve one or more of a viral infection, bacterial infection, or environmental antigen; it can also occur with immune-based drug therapies, such as interferon administration. There is a genetic component that contributes to a higher incidence of sarcoidosis among northern Europeans (especially Swedes) and among American blacks. Sarcoidosis rarely occurs in the Orient, making it difficult to obtain direct information about traditional Chinese medical treatment of the disease.
The defining characteristic of the disease is formation of granulomas, accumulations of immune cells that are normally intended to surround and neutralize bacteria or other foreign bodies (1). In sarcoidosis, the granulomas don't form an encasement. The most common site for granuloma formation is in the lymphatic system, but they also appear in the lungs, liver, eyes, skin, and joints. The site of the main disease manifestation is related to the extent of cytokine deposition by activated immune cells in different parts of the body.
Each of the granulomas may completely resolve (as usually occurs with infection-induced granulomas) or they may proceed to a fibrotic stage. Over time, increasing numbers of granulomas and accumulation of fibrotic tissue can disrupt normal body functions; the specific symptoms will depend on the sites of accumulation. On the other hand, many patients remain largely asymptomatic with limited levels of granuloma formation.
Sarcoidosis often remits spontaneously and may have a course of several months or years before clearing up. Remission rates are as high as 85% after 9 years, and the remission rate for groups of patients appears to depend on both the disease site and genetic background. About 10% of patients develop serious disability, such as ocular damage, respiratory impairment, or liver damage, but the mortality is low (rated as less than 3%), and is primarily associated with the pulmonary development of the disease.
The main treatment, when anything is offered, is to administer corticosteroids, as these drugs will inhibit the granuloma formation and, thereby, relieve symptoms. However, such treatment is not expected to alter the overall disease process. Due to the adverse effects of long-term administration of steroids, the treatment is usually administered only temporarily (up to a year) unless the disease remains highly active (2).
Currently, drug development efforts are being aimed at identifying the primary cytokines involved in the disease (possibly interleukins 12 and 15, designated IL-12, IL-15, and interferons) and finding agents that can specifically inhibit them. Such carefully targeted drugs may minimize side effects that occur when there is a general disruption of the immune system induced by broad-acting agents like the corticosteroids (3, 4, 5). It has been found that in patients who experience disease remission, there is a higher level of TGF (transforming growth factor), which is a known inhibitor of IL-12 and interferon gamma. Therefore, treatments that provide or increase TGF levels might help reduce the granuloma formation.
In the absence of direct reports of sarcoidosis treatment from the Orient, the approach of using Chinese herbs must be pursued by utilizing a traditional Chinese medicine interpretation of all available data.
Characteristics of the disease during its early stages involve accumulation of material (granulomas), representing a type of excess pattern. The granulomas initially are soft and resolvable small masses, having a tendency to swell the lymph nodes (they can also swell the liver, spleen, or other organs), implying formation of a "phlegm-mass." Fever is present in many patients, but is not universal. The tendency to have fever may imply the role of damp-heat rather than cold-damp in terms of the excess syndrome. Herb formulas that are traditionally aimed at resolving phlegm masses and, especially those that treat lymph node swellings, are appropriate to consider. The persistence of a progressive disease also suggests the presence of a "toxin" in accordance with the use of the term in Chinese medical texts; therefore, herbs for removing toxin would be a reasonable component of the therapy. Antitoxin herbs may inhibit viruses and bacteria that can contribute to the disease; the immune system can be over-stimulated by the presence of these pathogens.
As sarcoidosis advances, the process of fibrosis becomes a serious concern, and this hardening process (similar to scar formation) usually corresponds to the traditional category of blood stasis. In modern efforts to prevent fibrosis, blood-vitalizing herbs are used, and salvia has become the main focus of research (for example, it is proposed as a treatment for liver fibrosis in hepatitis). Salvia, red peony, tien-chi ginseng (sanqi), and rhubarb have been suggested as herbs for alleviating autoimmune and other immune-stimulation disorders and alleviating fibrosis. As sarcoidosis progresses still further, symptoms begin to manifest according to the organs affected. This aspect of the disease is difficult to generalize; treatment would be adjusted to correspond to the symptoms.
An example of a formula suitable for a damp-heat accumulation syndrome of the type described is presented in A Bag of Pearls (6) as Scrophularia 12. Herbs in the formula that resolve phlegm-mass include scrophularia, pinellia, fritillaria, prunella, citrus, and atractylodes; herbs that clear heat and clean toxin include scrophularia, prunella, bupleurum, forsythia, and lonicera. Another example is Blue Citrus Tablets; the herbs that resolve phlegm-mass include blue citrus, prunella, oyster shell, curcuma, and trichosanthes fruit; the herbs that clear heat and toxin include bupleurum, prunella, oyster shell, paris, and dandelion.
The two formulas have the following herbs in common: prunella, a type of citrus (i.e., chenpi or qingpi), and peony. The presence of these herbs reflects certain basic principles of herb formulation for treating masses. According to Oriental Materia Medica (7), prunella is bitter, cold, and affects the liver and gallbladder. Its actions are to disperse liver heat and dissolve accumulations. It is used in cases of goiter, scrofula, conjunctivitis, carbuncle, incised wound toxin [probably an abscessing infection], ocular swelling and pain, etc. Among its main active constituents are triterpene saponins, oleanolic and ursolic acid (see: Platycodon and other herbs with triterpene saponins). Blue citrus (qingpi) and citrus (chenpi) are described as having bitter and pungent taste and warm nature; blue citrus (the immature fruit) has the action of soothing the liver [regulating qi circulation] and breaks [stagnant] qi formation, disperses accumulations, and dissolves phlegm. The mature citrus (chenpi) regulates qi, strengthens the spleen, dries moisture, and transforms phlegm. Peony is said to be used to "control pain and release qi;" it has been described as having the property of "softening" the liver to promote the normal circulation of liver qi (this refers to its blood-nourishing quality to moisten a dry liver condition and its sour quality, which is associated with softening masses. The cold nature also alleviates liver heat syndromes that can cause the liver qi to course irregularly and contribute to formation of accumulations.
Scrophularia 12 was modeled after formulas reported in the Chinese literature for treating lymphatic swellings, including lymphatic cancers, and other soft swellings that were detectable visibly or by palpation ("beneath the skin" is the typical designation in the Chinese texts). Blue Citrus Tablets was modeled after formulas used for the treatment of breast lumps, such as occurs with fibrocystic breast disease. Although the disorders treated in China by similar formulations are different than sarcoidosis, they have overlapping characteristics that would lead one to adopt them for use in treating a new disease.
In addition to utilizing one of these (or similar) formulas, salvia can be obtained, in amounts comparable to those used in China in order to prevent fibrosis, by using the single-herb salvia tablet (Dan Shen Pian; Pine Mountain). Any of these preparations should be selected by the practitioner only after evaluating the constitutional and disease-specific indicators to determine the formula's suitability. Continued monitoring will help detect any signs that indicate whether or not the herbs remain appropriate or need to be adjusted.
From the traditional perspective, because this disease develops gradually-with the internal organs being affected and no obvious external causative factor-it would likely be deemed to arise primarily as the result of emotional disturbance. Accumulative disorders are often ascribed to liver/spleen type syndromes, in which anger, anxiety, and worry contribute to the organ system problems. The splenic disorder leads to the phlegm-accumulation (the spleen fails to transform and transport the food-based fluids) and the liver disorder leads to stagnation and formation of localized accumulations. Of course, other emotions can contribute the syndrome, such as grief affecting the lungs, causing the phlegm to accumulate and impeding proper circulation of fluids downward (with the lungs being a primary site of attack in sarcoidosis). Therefore, addressing emotional conditions is potentially important to the therapy (see: Emotions and Health). The "toxin" component of the disease would be an outside influence, such as a virus or a drug, affecting a person with the predisposing factors that include emotional effects on the internal organs and genetic background.
Dietarily, one would expect that an excess type diet, which allows phlegm to accumulate, should be avoided in an effort to resolve sarcoidosis. Fruits and non-fatty vegetables (e.g., broccoli but not avocado) would be an important therapeutic dietary component, while fatty meats, especially pork, and all kinds of heavy deserts would be contraindicated. Fish, which is used in Chinese dietetics to drain excess dampness, would be appropriate. Alcohol, which contributes to dampness and heat, on the other hand, would be contraindicated; green tea might be the ideal beverage, as it is considered cooling and phlegm-resolving (see: Beverage teas for health). A small study (8) carried out in the Balkans suggested some therapeutic benefit could be attained for patients with sarcoidosis by therapeutic fasting for those with the early stage of the disease (duration less than one year). In organizing an appropriate diet, it is important to make sure that there is adequate nutrition; from the traditional viewpoint, liver blood deficiency can contribute to liver qi stagnation and lump formation.
Acupuncture therapy for sarcoidosis would be aimed at draining excess, and especially resolving phlegm accumulation. ST-40 (fenglong) is a well-known example of a point used to transform phlegm-damp. Acupuncture may be especially suited to addressing individual constitutional patterns and symptomatic manifestation of the disease (e.g., one might add GB-23, zhejin, in cases of sarcoidosis yielding difficult breathing), while herbal therapies can be used to address the more general characteristics of the disease.
May 2000