Treatment of Systemic Lupus Erythematosus in a 44-year-old Female Patient according to Iranian Traditional Medicine in Bojnurd

Introduction

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease which affects several systems and organs of the body at different times and causes extensive damage to connective tissues, blood vessels and serous membrane [1]. This disease has unknown aetiology and different clinical and laboratory symptoms, and has a wide geographical spread around the world, so that there have been numerous differences in its symptoms between various ethnic and geographical groups [2]. The prevalence of lupus is estimated to be 40 per 100,000 in Iran, and it is based on a comprehensive community-oriented study on the control of rheumatic diseases by the Rheumatology Research Centre of Tehran University of Medical Sciences [3]. This disease usually has an adverse effect on a patient’s physical, psychological and social health by involving the body’s vital organs. Living with the disease’s symptoms, including skin and appearance symptoms, can lead to a threat to identity, changes in roles, and changes in mental image or lifestyle in the long term, and thus any major change or reduced ability to function needs more physical, social, and psychological adaption by the patient and his or her family. The patient and the family need time to accept the change in individual ability for doing tasks and proper planning in this field [4]. As a systemic disease, SLE has different clinical symptoms that may not occur at the same time and could be displayed at different periods. Therefore, the disease’s diagnosis is based on different diagnostic criteria; and the American College of Rheumatology criteria are the first and foremost [5]. Therefore, patients are evaluated in terms of different clinical symptoms (constitutional, musculoskeletal-mucosal, skin-mucous, neural-mental, respiratory, cardiovascular, and blood symptoms) as well as paraclinical tests, including complete blood count, platelet count, inflammatory factors, serum creatinine, and urine analysis, in addition to immunological tests such as antinuclear antibodies, complement factors, and rheumatoid factors [6]. The treatment of SLE is very complicated and requires great accuracy. Furthermore, the treatment strategy requires familiarity with the clinical symptoms of the disease and the associated side effects of treatment in addition to disease severity and its prognosis based on valid clinical classification [7]. Based on the teachings of modern medicine, lupus is not treated, but controlled and managed. Patients should consult their physicians regularly and be monitored as well. The physician regularly changes the types of treatment depending on the status of the disease. The most important measures for lupus treatment are as follows: 1) Anti-inflammatory drugs such as indomethacin, ibuprofen, celecoxib, piroxicam, meloxicam, mefenamic acid, and naproxen, which reduce the patient’s joint and muscle pain. 2) Hydroxychloroquine is applied for treating skin lesions, fatigue and joint pain. 3) Corticosteroid or Cortisone is applied in severe cases of the disease. 4) Drugs that weaken the immune system such as azathioprine, cyclosporine, cyclophosphamide, methotrexate and mycophenolate are used in some patients with SLE. These medications weaken the immune defence system and increase the risk of infection in patients [8]. In other words, all the treatments for SLE have relative effects on the patient and can even lead to severe complications. Therefore, we should evaluate new combined methods and drugs that have the highest therapeutic effect in the short term and report them scientifically based on a combined school of modern and traditional medicine, or in other words, the Iranian Effective Medicine (IEM).

Case Presentation

Medical History andExaminationaccording to ModernMedicine

The patient was a 44-year-old woman with a history of SLE for approximately five years along with underlying diseases, including ulcers, asthma, hypertension and diabetes, in the past 10 years. The patient was an official in the defence ministry, but was retired due to the history of diseases, particularly the SLE diagnosis, and disease status according to the Medical Council. The patient had a bachelor’s degree in nursing and was living in Tehran. She weighed about 87 kg and her height was about 152 cm. Guided by an acquaintance, the patient came to Hajtaleb medical centre of traditional and modern medicine for treatment, with a bad complaint of constitutional symptoms, skeleton-muscular symptoms, skin symptoms, and neural-mental symptoms related to SLE in addition to relevant medical treatment complications. According to the patient’s examination upon her arrival at the clinic, she was anxious, tired and depressed and had a severe headache, bone pain, generalized obvious oedema, cold and wet skin. The patient’s vital signs were as follows—temperature: 37.8°C, respiratory rate: 19 per minute, pulse rate: 90 per minute, blood pressure: systolic 170 mm Hg to diastolic 90 mm Hg. Based on the full history and medical documents, the patient had the following illness records.

A–She had a history of diabetes since January 1998. The patient went through her tests under the supervision of an endocrine disease specialist at Tehran Pathobiology Laboratory Centre. The patient was under the treatment of oral Glibenclamide 5 mg and Metformin 500 mg twice a day, and after a few months it was changed to injections of regular insulin and NPH in different doses due to lack of appropriate response. According to available documents, the patient had fasting blood sugar of about 309, 280, 245, 187 and 161 at different times. Two-hour glucose after meals was 590, 330, 280, 275, and 198. She had a brief history of repeated blood fat and glucose 2+ in urine.

B–Patient had a history of asthma with recurrent weekly attacks and then monthly since 2001. She underwent treatment under lung disease and infectious disease specialists. She was treated with Salbutamol and Becotide inhalers, and Bromhexine and Theophylline syrups, and hydrocortisone tablet. She had a history of frequent hospital admissions in the emergency department for severe asthma attacks. The patient had a history of broad-spectrum antibiotics. C–The patient had a history of dyspepsia and epigastric pain since 2006, and mentioned a history of ulcers and positive H. pylori infection in endoscopic procedure in 2009. She was under the supervision of a gastroenterology specialist. The patient underwent quadruple therapy against Helicobacter and long-term treatment by Omeprazole while fasting once a day. D–The patient had a history of headache, palpitations, blurred vision, and high blood pressure since 2008. She was under the supervision of cardiovascular disease specialist, and had undergone all cardiovascular and 24-hour blood pressure controls, heart echo stress test, and heart scan and colour Doppler ultrasound of the renal artery. She was prescribed Losartan 25 mg tablet twice a day and hydrochlorothiazide 50 mg tablet daily.

E–The patient had a history of fever, fatigue, loss of appetite, frequent dizziness, abundant hives and rash especially on the face and back of the spine along with symptoms of arthritis including pain and swelling, oedema, and warmth in the joints of the left hand wrist and elbow muscles, and big toe since 2008. The patient was under the supervision of a rheumatology disease specialist. The patient underwent full blood tests and a biopsy of skin areas with hives as well as a full bone scan. The patient received service exemption in 2009 on the basis of the American College of Rheumatology criteria and her physician’s view, as well as the Medical Council Commission of Khanevadeh Hospital affiliated to NEZAJA Department of Health with a diagnosis of SLE and osteoporosis. The patient underwent regular chemotherapy with specified treatment regimens and varied doses of corticosteroid therapy and methotrexate and Hydroxychloroquine pills, folic acid tablet, and intramuscular vitamin D3, and vitamin D3 tablet, and Osteofos tablet after the diagnosis and till her admission to the clinic.

Medical History andExaminationsaccording to IranianTraditional Medicine

The patient had no knowledge of traditional medicine therapies, and did not follow the eating practices and health protection principles of traditional medicine in everyday life. The patient had a dominating but simple bad temperament and was phlegmatic (cold and moist), but melancholic bad temperament was created in different parts of body (cold and dry). The patient's innate temperament (congenital) seemed to be a combination of mucus and melancholy. She was severely depressed, sad and disappointed. Her pulse was weak and had low intensity. The cold and moist was felt by touch, but there was abnormal swelling because of too much consumption of Corticosteroid.

According to the patient’s physical condition, her sufferings from various diseases, extensive use of chemical drugs, side effects of medication, and bad psychological and mental conditions, it was necessary pay attention to several important points: We were faced with four diseases and their complications as well as the rates of medicines and their complications in the patient. The patient was very weak with unsteady mental conditions. She lacked confidence in medicine due to the lack of efficacy and recovery during the past four years. How should we initiate the methods of traditional medicine treatment? What kind of drugs and methods and in what order and time intervals should we use them? And to what extent should we use the knowledge of traditional medicine? During therapy by IEM methods, we should decide how to cut off the chemical drugs that were consumed by the patient for several diseases in order to receive treatment for recovery and prevent the new problem caused by the discontinuation of corticosteroid, and also how to replace the drugs and methods of effective medicine. Could we think of full recovery of this patient? If we had a start and an end, how long would it take?

Treatment

Measures to Protect Health and Nutrition:

The patient’s treatment started on 21/06/2012. In the first session, the patient underwent the full counselling about the disease and the IEM methods, and it was emphasized that the treatment should be long-term and continuous, so that it might take several years. On the other hand, according to the patient’s mental condition and her lack of trust in medical schools, the necessary explanation was given to patient about disease refractory and maybe incurability, and also the possibility of her treatment based on IEM. During this session, the patient’s questions were scientifically answered as she was an experienced nurse. This session was held in the presence of her husband as he reassured the patient on his trust in the initiation and continuation of the treatment. According to the patient’s conditions, duties were assigned for family members in order to help the treatment.

The nutritional instructions and especially the six essential principles of health in traditional medicine (including air, movement and rest, sleep and waking, retention and vomiting, food and beverage, and mental events) were fully explained to the patient. A CD that included the nutritional practices was given to the patient for learning the principles of nutrition in traditional medicine in order to help the treatment. In particular, some foods such as spices and cold- temperament foods like vinegar of pickled vegetables, buttermilk, yogurt, icy water, salad, ice cream, cold- temperament fruits, etc. were removed from the patient’s diet. For preventing the patient’s problems with this diet, milk was recommended instead of buttermilk and yogurt, and various vegetables were recommended instead of salad, and she was recommended to eat any food with its reformer. There were a few meat dishes, and so they were recommended to be excluded for some time, and thus nutritious foods were recommended to strengthen the patient’s physical force. It was emphasized that a compliance with the nutrition principles would be very effective in the treatment process.

Pharmaceutical measures:

Herbal and combination drugs were given to this patient according to the temperament and disease status. Due to the situation’s complexity, medical measures with traditional methods were very difficult for this patient, and thus innovation and personal clinical experience were used for the patient’s medical measures with the IEM system. Therefore, the drugs were used was along with the identification of active ingredients and medicine, and the patient’s temperament; and most importantly, traditional and herbal drugs were prescribed for this patient in a such a way that it should achieve several goals: 1) They should play temperament reforming roles and solve the patient’s material and simple bad temperament in the entire body and the organs. 2) They should be the alternatives to the patient’s modern medicine. 3) They should strengthen the patient’s body forces. 4) They should not have side effects in the patient. 5) The plants, which were known and had available plant therapies, were applied to the patient. 6) The regimes of herbal drugs were constantly changed during treatment in order to avoid the dependency of the patient’s body on them.

Furthermore, we used medicinal plants that were mucus mature and also had active ingredients for treatment of lupus and control of co-morbidities as well as played the roles of laxatives and mucus disposal.

Nigella Sativa: This plant was prescribed orally with honey. Nigella is a potent anti-phlegm drug as it matures the phlegm and the plant’s active ingredient also plays an effective role in strengthening the immune system and reduces body swelling and pain in the patient. On the basis of the patient’s temperament, Nigella was one of the best medicines applied during the treatment. A daily dose of two teaspoons of Nigella Sativa mixed with honey was prescribed for three months.

Camomile: This is a potent anti-inflammatory plant, and thus played an effective role in reducing the treatments for arthritis and asthma in the patient. In this case, this plant was used along with thyme and mallow because these two are among the best plants that strengthen the anti-inflammatory property of this plant in the presence of chamomile, especially Thyme, which was very useful for the patient’s asthma based on experience and scientific reports. According to the experience of the patient’s physicians, this combination had scientific and specific effects due to the active ingredients and also a strong melancholy cleaning combination. This plant was prescribed to be boiled and then drink one to three cups per day according to the patient’s situation.

Combination of Lavender, Valerian and Orange Blossom: These three are the best plants that affect the nerves in traditional and modern medicine, and they are prescribed to treat depression and strengthen the brain and nerves. In addition to a strong effect on the nervous and psychiatric systems, they can restore the patient’s morale and this increases blood flow and faster disposal of mucus. Among the three, Lavender has a special feature in pain-killing and anti-anxiety treatment. These three plants were prescribed to be boiled and then drink one or two glasses per day during treatment with regard to the patient’s overall health.

Sesame Oil: This oil is one of the drugs that should be prescribed for massage of patients with lupus for a long time because it has strong effect on the patient’s power, anti-inflammatory processes and increased blood flow, cleaning (corrupted humours mature) and laxatives (excretion of humours), and anti-pain. However, the use of oil massage during the treatment of these patients depends on their individual temperaments and conditions.

Sekanjabin Syrup: In addition to being a useful beverage for almost all temperaments and most diseases, Sekanjabin syrup has an extraordinary effect on the treatment of autoimmune diseases. Therefore, it was prescribed long-term for this patient. However, the application and the time of Sekanjabin syrup in IEM differ from that in traditional medicine.

Rose and Securigera Varia: These two plants were used as laxatives on this patient at a specified time and certain circumstances that were different from other patients.

Manual Measures:

Cupping Therapy: Cupping the full back especially around the chest and waist backbone was advised every other day because it strengthens the body and increases blood flow as well as helps dispose corrupted humours, and most importantly, it strengthens the immune system. It can even help to mature mucus.

Massage: Long-term sesame oil massage was advised on the patient’s back for about 15 minutes per night during treatment.

Hijama (Bloodletting or Wet Cupping): Hijamawas advised for several times for this patient. However, it was carried out with little blood-letting. According to IEM, Hijamais effective in reducing symptoms in patients with rheumatologic problems and it should be done periodically by taking into account the patient’s general condition and body forces. It has both stimulation effect and disposes the corrupted mucus. Hijamawas often performed between two shoulders with low blood and for a total of four times during treatment. If Hijama is unprincipled in these patients, it could have adverse effects.

Leech Therapy: Leech therapy is not a kind of manual action in IEM because the leech is used due to the effective ingredient of saliva, and its blood taking is second priority. According to the anti-inflammatory compounds of leech saliva and Hirudin, which increases body flow in the patient’s body, leech therapy plays an effective role in treatment. However, the use of leeches in these patients by IEM is the like other methods a new model combined with personal experiences, so that the leech therapy period was very different in this patient, and thus we cannot define a constant framework that is used for all patients. Leech therapy was mainly done on the ankles, over liver from the back, and behind the ears; and the sizes and numbers of leeches were changed according to the patient’s conditions and recovery during treatment. Due to the long duration of treatment and number of treatments, we could not be sure of the exact number of leech therapies for this patient. However, the patient underwent approximately 10 sessions of leech therapy. The following points were taken into account during the patient’s leech therapy:

A) With respect to the patient’s anaemia and to overcome her phlegmatic temperament, and also to prevent more phlegm in the patient due to bleeding by leeches and not to increase dried body, the patient’s drinking was enhanced and smaller leeches used.

B) To maintain the patient’s physical force during leech therapy, the gap between leech therapies was increased in order to give the patient’s body the opportunity to have natural reconstruction.

Treatment Results

The signs of recovery appeared after disappearance of headache and reduced muscle pain after a week of treatment by IEM, and the patient had good general status and more confidence in IEM after the second week. In the third and fourth weeks of recovery, Corticosteroid was discontinued according to scientific principles and a certain gap, and the other drugs consumed by the patient for co-morbidities were discontinued as well. The patient’s clinical symptoms were regularly controlled during the discontinuation of drugs. The discontinuation of chemical drugs, especially Corticosteroid and Methotrexate, was one of the most important stages of the treatment in that recovery became faster by the discontinuation of chemical drugs and influence of drugs and therapies of effective medicine, and the pain and symptoms of the disease were completely controlled after about three months, and then the clinical tests began for checking the patient’s status. The first tests indicated that the SLE and diabetes items had become normal and this was satisfactory along with the recovery signs for the physician, the patient and her family, so that there were no clinical and laboratory symptoms of the diseases after six months, and the patient did not use any chemical drug. Finally after four years of follow-up, the patient did not have any symptoms of lupus, diabetes, hypertension, asthma, headache, and digestive problems in 2016, and thus all the tests were repeated and all of them came out normal.

Discussion

SLE is an autoimmune systemic disease with vast clinical and immunological symptoms. The susceptibility to this disease is gender based, so that it is more frequent in young women at childbearing age than men with a gender ratio of 9:1. This ratio is lower before puberty and after menopause [9-10]. The disease has a variety of unpredictable symptoms, which can vary from mild to serious in the patients [11]. It is very unexpected, often debilitating and disfiguring; and its treatment requires prescription of potential toxic drugs [12]. The high morbidity and cost of treating this disease impose a significant burden on the patient and the community health system [1]. On the other hand, due to the growth of this disease in Iran and its chronic nature, we need more effective and less costly methods of treatment. Therefore, considering the high cost of treatment and repeated hospitalizations and also serious complications of medications, different methods have been used to treat this disease around the world and new therapies are being investigated [12] as this article can be assessed in this regard. The patients studied in this report had SLE and did not respond to common treatments. Nowadays, all treatments applied for SLE have relative effects on treatment. Therefore, this report attempts to use the most effective and safest methods in modern and traditional medicine schools for patient healthcare and treatment by integrating the modern and Iranian traditional medicine called IEM, and then report them scientifically.

According to the report, the patient had an incurable disease called SLE. The patient was treated by modern medicine methods. There has not been any reported treatment and pathophysiology for this disease and similar ones in traditional medicine of Iran and other countries. In summary, there is no specific definition of SLE in traditional and modern medicine, so that there is no specific diagnosis and treatment for SLE in traditional medicine based on the evidence in available sources. The important thing in this patient was that along with the presence of lupus, there were three refractory diseases, including blood pressure, asthma and diabetes, and she also took chemical medicines according to modern medicine. In addition to these diseases, she suffered from their complications and consumed drugs, so that severe headache, body swelling, severe overweight, severe depression, etc. often made the pain more than the diseases for the patient; so that she was referred to the traditional medicine clinic with sever joint pain, skin problems, severe headache, depression and anxiety, and explained her physical-mental conditions as follows: ‘Every day when I wake up, I think “Oh God, what’s today going to like?” My joints ache; I am overweight by being over 80 kilos. When I wake up in the morning and want to get out of bed, I have to struggle with myself for two or three hours to move my body. Sometimes, I walk on all fours in order to make my joints a little softer. I have high blood pressure, and I feel this severe ache on the back of the head is due to blood pressure, and thus I increased drugs”. These words were a part of the patient’s symptoms and conditions.

Given the status of disease and other diseases, the consumption of chemical drugs, the side effects of medications, and the patient’s psychological conditions, treatment was impossible with any of the sources in traditional and modern medicines because the illness and other co-morbidities created complex temperament in the whole body and organs, and it was very difficult to make a decision for treatment. There was no accurate definition of these diseases and their treatment in traditional medicine texts; and traditional medicine just considered them as combined diseases, but when the patient was suffering from SLE and three other dangerous diseases, the question was how we should manage the situation towards recovery with the help of methods and drugs of traditional medicine. Therefore, we sought to treat the patient based on the teachings of IEM with a new approach to traditional medicine of Iran and use of modern medicine; hence, the drugs and methods of traditional medicine were used with new creativity and approach, and without any side effects on the patient, and thus the treatment methods and consumed drugs were changed and considerable recovery was observed [13].

In this case, the principles of nutrition, and especially the six essential principles, according to IEM were considered for this patient. Despite the fact that IEM represents dietary instructions in accordance with temperament, it also paid attention to active ingredients that are recommended in modern medicine, and thus food having the active ingredients for strengthening the body force was used, and this type of diet that pays attention to both temperament (in traditional medicine) and active ingredient of foods (in modern medicine) is called the principle of Iranian effective nutrition. In other words, if we only consider the food temperament, and not its ingredients, we will not achieve any result, and vice versa, if we pay attention to the active ingredients of food and ignore the temperament, the treatment won’t be successful. Several studies have found that changes towards a healthy lifestyle, including the consumption of healthy food, proper nutrition, exercise, not smoking, and living with good mental health, can raise the health indices even in a patient and significantly reduce the risk factors and complications of a disease [14]. In this study, a CD containing the nutritional practices was given to the patient to learn the principles of nutrition in traditional medicine in order to help the treatment. The pharmaceutical measures were used in this case according to the temperament and disease condition, and the combination of drugs such as Nigella Sativa, along with thyme and mallow, combined with lavender, valerian and orange blossom, sesame oil, Sekanjabin syrup, rose and Securigera Varia. The application of laxatives and cleaner and the type of applied plants in IEM was based on objective evidence of personal clinical experience. In particular, the time of applying the laxatives and cleaners is longer for these patients, and famous medicinal plants are used because if we want to use synthetic drugs, which are referred in traditional medicine books, we will not be able to properly justify the possible side effects or treatment progress due to the lack of sufficient scientific evidence to confirm them. However, when we use the plants with scientifically described properties in traditional medicine and in herbal medicine, the prescription and control of symptoms and the justification of recovery process will be scientific. Therefore, when we use a plant like lavender as a cleaning drug for the nerves, we utilize the plant’s temperament and pay attention to its active ingredient as a cleaning medicine, and it is prescribed on the basis of clinical experience. On the other hand, the effects or possible side effects of this herb are explained in numerous herbal medicine books. The drug therapy for this patient was complex, and along with clinical experience in Iranian effective medicine, and therefore it cannot be used for another patient with lupus unless the physician has sufficient experience in medical application and is particularly experienced in treating autoimmune diseases [15-16]. In this case, there was accumulation of melancholy in all parts of the patient’s body, and it was increasing daily due to various reasons. All informants know the principles of traditional medicine and the harmful accumulation of melancholy in the body, as it is worse than the other temperaments such as choler, phlegm and sanguine, and is harder to excrete. However, the accumulation of melancholy is different in each patient and disease, especially in patients who have several diseases and have used various medications with different side effects in the long term. This patient had such a situation. Therefore, a complex melancholy should have a tough melancholy disposal as it cannot be put in any form. The method of effective medicine uses the principles of traditional and modern medicine, but it does not use anyone’s predetermined format, but provides a better format. It was the same in this case and the melancholy disposal on this patient was performed in such a way that it caused recovery from the disease. The effective medicine physician used the most effective and safest melancholy disposal method based on the experience of several years [13]. Unfortunately, no study has been conducted on leech therapy. We could not perform more blood sampling on this patient due to severe complications of the disease and the medications consumed as well as poor physical and psychological forces. Furthermore, according to the patient’s phlegmatic temperament, it was better to avoid getting high blood sample and the relative contraindication of blood and leech therapy was in traditional medicine. Saliva therapy was the leech therapy approach used on this patient, and there was no need for blood sampling. However, since leeches do give saliva unless they take blood, we had to take blood by using leeches; and therefore we increased intake of beverages for the patient and used smaller leeches. Furthermore, we increased the gap between the leech therapies in order to give the patient’s body the opportunity for natural reconstruction. According to the anti-inflammatory compounds of leech’s saliva and Hirudin, which increase the patient’s body flow, leech therapy played the effective role in the treatment [17]. In conclusion, given the history of medicine over the last century, we can conclude that none of the medical schools are complete in the world; hence, medical schools such as modern medicine, traditional medicine of Iran, Ayurveda in India, Chinese medicine, etc. aim at protecting human health and imparting treatment, which are the real purposes of medicine. However, they have numerous strengths and weaknesses due to the lack of comprehension despite providing striking medical services.

Conclusion

As a combination of the two effective approaches of modern and traditional medicine schools, Iranian medicine can have effective results in treating certain diseases such as SLE. Therefore, the use of effective medicine method will reduce high costs of treatment and the use of chemotherapy drugs in treating SLE. Given the patient’s recovery process with an approach to her physical force, mental status, blood sugar control, and significant recovery from SLE and underlying diseases, it seems that the combination of modern and traditional Iranian medicine can pave the way for most of the common diseases, and thus it is necessary to conduct wide assessments and studies on different diseases based on the teachings of IEM.

List of Abbreviations

SLE: Systemic Lupus Erythematosus

IEM: Iranian Effective Medicine

CM: Centimetre

KG: Kilogram

MG: Milligram

FSB: Fasting Sugar Blood

C: Centigrade

MMHG: Millimetres of Mercury

CD: Compact Disk

%: Percentage

Competing Interests

The authors have no conflict of interest in publication of this article.

Contributing Authors

This article is the outcome of treatment measures by Dr. Hassan Hajtalebi. Dr. Hassan Khani and Hamid Hajtalebi cooperated in documenting and writing the article.

Acknowledgments

The paper’s authors appreciate the cooperation by the patient and her family for participation and completing all the treatment and healthcare processes, and all nurses at the Hajtaleb Medical Complex of Alternative and Complementary Medicine for performing the treatment processes for the patient.