THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 18, Number 5, 2012, pp. 509512

Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2011.0292

Case Report

A Case of Unilateral Pleural Effusion Secondary

to Congestive Heart Failure Successfully Treated
with Traditional Chinese Herbal Formulas
Han-Dao Lee, MD,1 and Hsien-Hsueh Elley Chiu, MD1,2

Abstract

Objectives: A case is presented that illustrates the potential effect of traditional Chinese medicine (TCM) herbal
formulas on treatment for unilateral pleural effusion secondary to congestive heart failure (CHF).
Subject: A 79-year-old woman experienced episodic dyspnea with unilateral pleural effusion for 2 years.
Thoracocentesis with pleural fluid analysis revealed no infection, tuberculosis, or malignancy. She had received conventional treatment for CHF but the symptoms persisted. Therefore, she visited the authors TCM
clinic for help.
Interventions and outcome: This patient was treated with TCM herbal granules including Shengmaisan, Xiebaisan,
and Tinglizi, 3 times a day for 4 weeks. The daily dosage was adjusted on the basis of the patients clinical
response and her follow-up chest x-ray studies. After 8 months of treatment, her symptoms improved and the
pleural effusion showed significant regression.
Conclusions: It is suggested that TCM herbal formulas could play an important role in preventing the progression of unilateral pleural effusion secondary to CHF, in case of poor response to conservative treatment.
Additional studies about the mechanism of action of the medication involved are warranted.

Introduction

pleural effusion is the result of fluid accumulation in

the pleural space, which indicates the presence of pulmonary, pleural, or extrapulmonary disease.1 Although many
different diseases may cause a pleural effusion, the most
common causes in the United States are congestive heart
failure (CHF), pneumonia, and cancer.2 The overall prevalence of heart failure in a population-based Rotterdam study
was estimated at 3.9%, which increases rapidly with age.3
According to the guidelines of the European Society of Cardiology, heart failure is a pathophysiologic state with the
following features: symptoms (e.g., shortness of breath or
fatigue, at rest or during exercise, ankle swelling) and objective evidence of cardiac dysfunction.4 Increased interstitial
fluid in the lung due to elevated pulmonary capillary pressure
leads to both pleural effusion and pulmonary edema, causing
exertional breathlessness.5,6 Since CHF-related effusions are
typically bilateral, thoracocentesis is indicated if effusion is
seen unilaterally or has not responded to diuretic therapy.7
Approximately 75% of effusions due to CHF resolve within 48
hours after diuresis is begun.8 However, there are still some

cases that do not respond to conventional therapy or thoracocentesis. In the Chinese medicine concept, there are several
strategies of treating refractory pleural effusion, including
herbal formula, acupuncture, and food therapy. This case
report deals with a patient who had unilateral pleural effusion
secondary to CHF and who was successfully treated with
Traditional Chinese medicine (TCM) herbal formulas over an
8-month follow-up period.
Case Report
A 79-year-old woman had been in good health until 2
years ago, when she started to have coughs and severe
dyspnea on exertion. Her initial chest plain film study
showed unilateral pleural effusion on the right side. The
pleural fluid analysis after thoracocentesis revealed neither
bacterial infection nor malignancy. Unilateral pleural effusion secondary to CHF was suspected. She was treated
conservatively with diuretic pills and the symptoms subsided. However, the same situation recurred in March 2010.
This time her chest plain film study showed left-side pleural
effusion. She repeated thoracocentesis 3 times for relief of

Division of Acupuncture and Chinese Traumatology, Departments of 1Traditional Chinese Medicine and 2Neurology, Kaohsiung Chang
Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.

509

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LEE AND CHIU

FIG. 1. Chest plain films series. A. First visit to clinic. B. Three (3) months later. C. Six (6) months later. Unilateral pleural
effusion on the left side gradually subsided after treatment with Traditional Chinese Medicine herbal formulas.

symptoms. Due to the symptoms persisting, she visited the

TCM clinic for help on July 29, 2010.
The patient had past history of asthma since childhood
and cerebrovascular disease with a small infarct in 2003. Her
current medication included aspirin (500 mg per day), rosuvastatin (10 mg per day), and asthma controller with Seretide
evohaler (salmeterol/fluticasone combination) and tiotropium inhaler. These modern medications had been used on a
long-term basis by this patient.
The patients chief complaint during her first visit was of her
recurrent dyspnea on exertion, cough, and dizziness. On
physical examination, the patient had a pale-white appearance,
and a wheezing breathing sound and deep-weak-fine pulse
were noticed. Tongue diagnosis revealed fine texture, redness,
dryness, and yellow coating. Initial chest radiography, on July
29, 2010, showed left-side pleural effusion, infiltrations in bilateral lower part of the lungs, and mild-to-moderate cardiomegaly (Fig. 1A). The TCM diagnosis of the deficiency of
Heart Qi, accompanied by Lung Heat that consumes Yin, were
concluded. The prescription of TCM herbal formulas included
ingredients (Tables 1 and 2) administered daily in three separate doses. The herbal granules used were all prepared and

Table 1. Ingredients of Traditional Chinese

Medicine Herbal Formula
Chinese names
Shengmaisan
Renshen
Maimendong
Wuweizi
Xiabaisan
Sangbaipi
Digupi
Gancao
Gengmi
Tinglizi

Scientific names

Daily dosage (g)/

concentration ratio
3 (10:10:5)

Panax ginseng
Radix ophiopogonis
Schisandra chinensis
3 (4.5:4.5:2.25:6)
Cortex mori
Cortex lycii
Radix glycyrrhizae
Semen oryzae
Lepidium apetalum willd

1.5

extracted by standard procedure in Taiwan Good Manufacturing Practice (GMP) Pharmaceutics.

After 1 month of TCM treatment, the patients dyspnea
was relieved and coughs became less frequent. To maintain
the therapeutic effect, the original TCM formulas were continued but with a daily dosage decrease by one third, separated into twice per day. After 3 months of treatment, a
follow-up chest plain film study showed moderate regression of left-side pleural fluids (Fig. 1B). The TCM formulas
were adjusted to one third of the original daily dosage, being
taken once per day. Her repeated chest plain film study, on
January 6, 2011, disclosed a sharper costophrenic angle on
the left side (Fig. 1C).
The patient returned to TCM clinics for monthly follow-up
and received continuous TCM treatment until March 2011.
She did not take any conventional diuretic medication during this 8-month treatment period. Her chest plain film
studies have been conducted monthly, which indicated no
sign of recurrence of left-side pleural effusion. There was a
continuous follow-up of the patient over the last year, and
she was in stable health when this report was prepared. In
addition, there were no obvious side-effects reported
throughout the treatment period.
Discussion
The patient in this report was diagnosed with recurrent
unilateral pleural effusion secondary to CHF. During March
to June in 2010, she had been treated conservatively with
diuretics and received thoracocentesis 3 times. Because there
was no spontaneous regression of pleural fluids, she chose
alternative TCM treatment.
In Taiwan, TCM doctors usually preferred to prescribe
concentrated herbal granules with formulas plus a specific
single herb according to the patients symptoms. The herbal
granules were prepared with an all-raw herbal mixture
cooked and concentrated following GMP standard process.
Unlike ground herbal powders, the extract granules not only
retain the same ingredients and the spirit of traditional herbal decoction, but also have been screened from pesticides

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511

Table 2. Function and Indication of Traditional Chinese Medicine Herbal Formula

Chinese names

Function

Shengmaisan

!
!
!
!

Tonify Qi
Nourish Yin
Stimulate pulse
Prevent excessive sweating

Xiabaisan

!
!
!
!
!
!
!

Clear Lung Heat

Relieve asthma and cough
Nourish the stomach
Purge the lung
Relieve asthma
Promote water metabolism
Disperse swelling

Tinglizi

Indication
Qi-Yin deficiency in Heart failure, coronary artery disease, and chronic
Pulmonary-Heart disease, with symptoms of profuse sweating, thirst,
shortness of breath, dry cough, fatigue, palpitations, irregular
heartbeats, dry mouth, red Tongue without much saliva, and a weak
and thready pulse
Lung heat has damaged Yin, causing cough, asthma, fever rising in the
afternoon, thirst, spontaneous sweating, red lips and cheeks, facial
edema, red Tongue, and rapid pulse.
Asthma due to water retention in the lungs, water distention in the chest
and ribs, cough due to the retention of phlegm and fluid, pulmonary
abscess

and heavy metals. In this way, it is much more convenient

and efficient for the patient to take their medication than
with previous methods.
Shengmaisan is an old TCM herbal formula consisting of
three raw herbal components: Panax ginseng, Radix ophiopogonis,
and Schisandra chinensis. P. ginseng tonifies Qi, R. ophiopogonis
nourishes Yin, and S. chinensis astringes and invigorates Qi.
This formula has long been used for treatment of Qi-Yin deficiency due to consumption of Qi and Yin by heat. It is especially
prescribed for patients with heart failure and ischemic heart
disease.9 In the Cochrane library systemic review, the author
suggested that Shengmaisan might be beneficial for CHF compared to placebo or plus usual treatment compared to usual
treatment alone.10
Xiebaisan is a TCM herbal formula made of four raw herbs:
Cortex mori, Cortex lycii, Radix glycyrrhizae, and Semen oryzae.
C. mori and C. lycii clear Lung Heat; R. glycyrrhizae and
S. oryzae nourish the stomach. It has been used clinically to
treat the common cold, asthma-like diseases, or any other
condition associated with pulmonary inflammation. In a
previous study, Lee proved the hypothesis that Xiebaisan
inhibited the inflammatory process in lung tissue through
suppression of the IjB signaling pathway.11
In the TCM theory, dyspnea on exertion, cough, and deepweak pulse relate to deficiency of Heart and Lung Qi;
dry-red Tongue and fine pulse reveal deficiency of Yin.
Shengmaisan is indicated for Qi-Yin deficiency in heart failure. When it comes to the excessive and long-term fluid accumulation in the Lungs, the authors believe Heat evil exists
as a result of sputum production. Xiebaisan and Tinglizi both
act to clear Lung Heat and purge retention of phlegm and
fluid from the Lungs.
Due to the patient not receiving any diuretic pills during
TCM treatment period, the therapeutic benefits were confirmed by observing improvements of clinical symptoms
and following up chest plain film studies monthly. After
1-month treatment with Shengmaisan, Xiebaisan, and Tinglizi combination formulas, the patients exertional dyspnea and cough subsided, which was consistent with the
regression of pleural fluids. The dosage of the treatment
formulas was then reduced without changing or adding a
single herb. If the patient could maintain the therapeutic
effect under low-dose treatment, the authors would consider completing the treatment course. This experience

suggested that TCM could act to prevent the progression

of pleural effusions secondary to noninfectious causes: in
this case, heart failure.
Conclusions
A patient diagnosed with unilateral pleural effusion secondary to CHF has been successfully treated with TCM
herbal formulas alone for 8 months. Although the efficacy of
TCM has not yet been proven in this case, the authors believe
that Shengmaisan exerted its function on Heart Qi and Yin
tonification over heart failure; Xiebaisan and Tinglizi act to
clear Lung Heat and disperse phlegm resulting from pleural
fluids. TCM herbal formulas could play an alternative role in
preventing the progression of pleural effusions, in case of
poor response to conservative treatment. Further studies on a
possible mechanism of action of the herbal medicine involved here are warranted.
Disclosure Statement
No financial conflicts exist.
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LEE AND CHIU

Address correspondence to:
Hsien-Hsueh Elley Chiu, MD
Division of Acupuncture and Chinese Traumatology
Department of Traditional Chinese Medicine
Kaohsiung Chang Gung Memorial Hospital
Chang Gung University College of Medicine
No.123, Dapi Road, Niaosong District
Kaohsiung City 83301
Taiwan
E-mail: elley@adm.cgmh.org.tw

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