Long COVID with marked fatigue, anosmia and headache
This is the case of a 20-year-old woman who contracted COVID-19 on 28 October 2020. She initially presented with nasal congestion and clear rhinorrhoea (both anterior and posterior), marked fatigue, followed 2–3 days later by anosmia and ageusia, severe headache, and alternating fever and shivering.
First consultation, 17 November 2020 :
Marked fatigue persists, together with bilateral temporo-parietal headache, posterior nasal drip, and hyposmia of approximately 80% (only 20% of odour perception remains).
In addition, there is marked chilliness with very cold feet, and an occasional sensation of feverishness. Fatigue is pronounced; sleep is good but she constantly wants to sleep (about 11 hours per night). There is marked thirst, with a preference for hot drinks. No appetite. Perspiration is normal. Stools and urine are normal. The pulse is deep (chen) and weak (ruo). The tongue tip is slightly red, and the tongue coating is thin and white.
Prescription based on Ma Huang Fu Zi Gan Cao Tang:
Ma Huang 10g, Fu Zi 15g, Zhi Gan Cao 10g, Bai Zhi 12g, Da Zao 10g.
4 sachets — one sachet per day, taken in three doses.
Second consultation, 4 December 2020 :
Following the herbal treatment, the headache has resolved, the sense of smell has almost fully returned (80–90%), the posterior nasal drip has stopped, but some anterior nasal discharge remains. Fatigue is slightly reduced, and the need for sleep has somewhat decreased. Appetite has returned but remains small. There is still a mild sensation of feverishness followed by chilliness (without sweating). Thirst is still marked, with a preference for hot drinks. Stools and urine are normal. The pulse is deep (chen) and weak (ruo), except at the right guan (middle) position, where it is tight (jin). The tongue is pale, the tip is slightly red, and the coating is white.
Prescription based on Tong Mai Si Ni Tang:
Gan Jiang 15g, Fu Zi 30g, Zhi Gan Cao 10g, Bai Zhi 10g, Sha Ren 6g.
5 sachets — one sachet per day, taken in three doses.
By the end of this herbal treatment, fatigue had resolved, sleep had normalized, the sense of smell had fully returned, and appetite was normal.
Commentary :
This case involves an attack by a pathogenic factor on a patient with a yang-deficient constitution. The pathogenic factor is blocked at the surface (taiyang), while the interior is vacuous and weak (yang deficiency of shaoyin) — hence the presence of fever alongside a deep and weak pulse, marked chilliness, and excessive need for sleep.
Since the illness had been established for several days, Ma Huang Fu Zi Gan Cao Tang was prescribed rather than Ma Huang Xi Xin Fu Zi Tang, in accordance with articles 301 and 302 of the Shang Han Lun:
Article 301:
"When shaoyin disease has just begun, if however there is fever and the pulse is deep (chen), Ma Huang Xi Xin Fu Zi Tang governs."
(少阴病，始得之，反发热，脉沉者，麻黄细辛附子汤主之。)
Article 302:
"When shaoyin disease has been contracted for two or three days, [one gives] Ma Huang Fu Zi Gan Cao Tang in order to produce mild sudorification. As on the second or third day there is no [interior] pattern¹, therefore mild sudorification may be performed."
(少阴病，得之二三日，麻黄附子甘草汤微发汗，以二三日无证，故微发汗也。)
Following the herbal treatment, the pathogenic factor was expelled from the surface (taiyang), but yang deficiency remained in the interior at shaoyin, with a slight escape of yang, producing an occasional lingering sensation of feverishness. As the internal yang deficiency was not very severe, there was (as yet) no diarrhea; and as the escape was fairly slight, there was no sweating. Article 370 of the Shang Han Lun was used as the basis for prescribing Tong Mai Si Ni Tang:
Article 370:
"When there is lienteric diarrhoea, cold in the interior and heat on the exterior, sweating and reversal (jue), Tong Mai Si Ni Tang governs."
(下利清谷，里寒外热，汗出而厥者，通脉四逆汤主之。)
By the end of the herbal treatment, the yang had returned to its root, and consequently the symptoms resolved.
¹ In the Song edition, the text reads: "there is no pattern" (wu zheng 无证). In the Cheng Wu-ji edition, in the Jin Kui Yu Han Jing, and in the Jiao Zheng Song Ban Shang Han Lun, it reads: "there is no interior pattern" (wu li zheng 无里证). This indicates the absence of diarrhoea, vomiting or other signs pointing to a marked internal deficiency.