背景:本报告介绍了一名诊断为原发性干燥综合征的患者的独特病例和相对罕见的中医模式,被称为寒热结合模式和寒湿综合症。使用中草药成功治疗了患者的病情,特别是加味的大柴胡汤和灵桂术甘汤。
方法:一名56岁的女性患有慢性干眼和口腔超过10年。她最初是用中草药(TCHM)处方管理的,包括增液汤,但治疗效果并不令人满意。随着疾病的发展,由于烦恼和失眠的症状,她被诊断出患有焦虑症。阿普唑仑和文拉法辛治疗未能缓解这些症状。最近,她的一般情况逐渐恶化,症状包括嘴里有苦味,头晕,潮热,发冷,食欲不振,胸部不适,还有便秘.
方法:经过一系列检查,包括Schirmer试验和唇腺活检,她被诊断出患有干燥综合征。
方法:尽管常规使用毛果芸香碱治疗,透明质酸钠滴眼液,文拉法辛,和阿普唑仑,口干症状加剧。因此,她通过TCHM寻求进一步干预。
结果:加味大柴胡汤加减灵桂术甘汤治疗8周后,她报告干燥相关症状和睡眠质量显著改善.
结论:本病例报告显示TCHM可有效治疗原发性干燥综合征,并应考虑更广泛的应用。此外,这强调了通过在临床环境中确定患者的特定辨证来为患者量身定制治疗方案的重要性。
BACKGROUND: This report presents a unique case of a patient diagnosed with Primary Sjögren\'s syndrome and a relatively rare traditional Chinese medicine pattern, known as the combined cold and heat pattern and cold-dampness syndrome. The patient\'s condition was successfully managed using Chinese herbal medicine, specifically the modified Da-Chai-Hu decoction and Linggui Zhugan decoction.
METHODS: A 56-year-old woman had chronic dry eye and mouth for over 10 years. She was initially managed with traditional Chinese herbal medicine (TCHM) prescriptions, including the Zengye decoction, but the therapeutic effects were unsatisfactory. As the disease progressed, she was diagnosed with an anxiety disorder due to symptoms of vexation and insomnia. Treatment with
alprazolam and venlafaxine failed to alleviate these symptoms. Recently, her general condition gradually worsened, with symptoms including a bitter taste in her mouth, dizziness, hot flashes, chills, poor appetite, chest discomfort, and constipation.
METHODS: After a series of examinations, including a Schirmer test and labial gland biopsy, she was diagnosed with Sjögren\'s syndrome.
METHODS: Despite regular treatment with pilocarpine, sodium hyaluronate eye drops, venlafaxine, and
alprazolam, the dry mouth symptoms intensified. Consequently, she sought further intervention through the TCHM.
RESULTS: After 8 weeks of treatment with the modified Da-Chai-Hu decoction and Linggui Zhugan decoction, she reported a significant improvement in her dryness-related symptoms and sleep quality.
CONCLUSIONS: This case report demonstrates that TCHM can effectively treat Primary Sjögren\'s syndrome, and should be considered for broader applications. Furthermore, this underscores the importance of tailoring treatment formulas to patients by identifying their specific syndrome differentiation in a clinical setting.