A 49-year-old man with a three-year history of severe gouty arthritis and hyperuricemia was successfully managed using a Damp-Heat clearing and turbidity-transforming herbal strategy combined with localized bloodletting.

Case ID: CHC-0075

Case Summary

This case describes a 49-year-old man who presented with a three-year history of hyperuricemia and recurrent gouty arthritis. Despite seeking previous treatments, he continued to suffer from severe red, swollen, hot, and painful ankle and toe joints. The original report documented a conventional diagnosis of hyperuricemia and gouty arthritis, and a TCM assessment of Damp-Heat Fixed Impediment (Zhuo Bi) driven by Damp-Turbidity and Blood Stasis. He was managed through an integrative approach combining localized filiform needle bloodletting with an internal modified Simiao Wan (Four-Marvel Pill) decoction to quickly clear the damp-heat, transform the metabolic turbidity, and resolve the joint swelling.

Patient Presentation

• Patient: 49-year-old male (Surname: Zhao).
• Main Complaint: Shooting pain in the lower back, accompanied by red, swollen, hot, and painful bilateral ankle and toe joints.
• History: The patient sought consultation on August 7, 2021. He had a somewhat weak constitution and was moderately obese. He had suffered from gouty arthritis for over three years, with chronically elevated uric acid levels. Despite long-term treatment elsewhere, the results were poor.
• Associated Symptoms: In addition to the acute ankle and toe inflammation, his knees and heels felt sore, weak, heavy, and ached with a dull pain. He had no obvious aversion to cold or fever. His appetite, spirit, bowel movements, and urination were all normal.

Examination and Diagnosis

• Imaging & Labs: Erythrocyte Sedimentation Rate (ESR) was 20 mm/h. Blood Uric Acid was heavily elevated at 600 μmol/L.
• Conventional Diagnosis: 1. Hyperuricemia; 2. Gouty arthritis.
• TCM Tongue and Pulse: The tongue body was dark red with teeth marks (齿印) on the edges. The coating was thick and greasy, with a pale yellow root. The pulse was stringy and slippery (脉弦滑).

TCM Assessment

The original practitioner interpreted the presentation as Damp-Heat Fixed Impediment driven by Damp-Turbidity and Blood Stasis (湿热着痹 – 湿浊瘀阻证).

According to the holistic principles of yin and yang Chinese Medicine the modern consumption of rich, greasy, and sweet foods (“膏粱厚味”) frequently impairs the Spleen’s digestive fire. The Yellow Emperor’s Inner Classic states, “The transformation of rich foods produces large boils.” When the Spleen fails to properly transport and transform nutrients, it generates internal dampness which eventually turns into pathological Damp-Heat.

In this moderately obese patient, his underlying Spleen and Kidney Yang deficiency allowed this heavy, turbid Damp-Heat to sink into the lower body and block the meridians. Over time, this thick “turbidity” (high uric acid) congealed with localized blood stasis, settling into the joints to cause the severe redness, heat, and swelling. The dark red tongue with a thick greasy coating, teeth marks (indicating Spleen deficiency), and the slippery pulse provided objective confirmation of this heavy damp-turbidity trapping the blood.

Treatment Approach

The primary treatment principle was to clear dampness and transform turbidity, invigorate blood and resolve stasis, dissipate swelling and stop pain (清湿化浊，活血化瘀，消肿止痛). The strategy utilized localized mechanical release (bloodletting) to immediately vent the acute heat and pressure from the joints, combined with an internal decoction to correct the underlying metabolic dysfunction (Spleen/Kidney dampness).

Interventions and Herbal Formulas

• Acupuncture / Bloodletting:
  • Filiform needle bloodletting (毫针刺络) was applied directly to the red, swollen bilateral ankle and toe joints to instantly release the trapped heat and static blood.
• Internal Herbal Formula (August 7, 2021): A 14-herb decoction acting as a heavily modified Simiao Wan (Four-Marvel Pill).
  • Clearing Damp-Heat (The Core): Huang Bo (12g), Cang Zhu (12g), Yi Yi Ren (Coix Seed, 12g), and Huai Niu Xi (Achyranthes, 12g) form the classic Simiao Wan. Cang Zhu strongly dries Spleen dampness, Huang Bo clears lower-body heat, Yi Yi Ren gently leaches out dampness without damaging Yin, and Niu Xi strengthens the bones and guides the medicine downward.
  • Transforming Turbidity and Draining Dampness: Mian Bi Xie (Dioscorea, 20g), Fang Ji (10g), and Fu Ling (30g) are critical additions used to separate the clear from the turbid and heavily flush the metabolic waste (uric acid) out through the urine.
  • Moving Blood and Resolving Stasis: Dan Shen (10g), Chi Shao (10g), Tao Ren (10g), and Tu Bie Chong (Ground Beetle, 5g) forcefully unblock the micro-circulation and dissolve the stubborn stasis inside the joint capsules.
  • Stopping Pain and Relaxing Sinews: Mu Gua (Papaya, 10g) and Yan Hu Suo (Corydalis, 10g) relax the tight sinews and provide strong pain relief. Gan Cao (5g) harmonizes the formula.
  • Administration: 5 doses prescribed. Soaked for 20 minutes, decocted twice, and taken warm after meals. The patient was also strictly instructed to limit smoking/alcohol and maintain a low-purine diet.

Follow-Up

• Second Visit (August 12, 2021): After taking just two doses, the patient reported that his lower back, knees, and heels felt relaxed and the aching had stopped (though the ankle redness and swelling remained). After the third dose, the ankle and toe inflammation visibly decreased. After finishing the fourth and fifth doses, the redness, swelling, heat, and pain in the ankles and toes completely disappeared.
• Formula Adjustment: The practitioner noted the patient’s pulse had returned to a moderate state (no longer stringy). To consolidate the cure and strengthen the joints, the turbidity/stasis-breaking herbs (Mian Bi Xie, Tu Bie Chong, Tao Ren) were removed, and Sang Ji Sheng (Taxillus, 10g), Lao Sang Zhi (Mulberry Twig, 10g), and Lu Xian Cao (Pyrola, 10g) were added to deeply nourish the Liver and Kidneys and strengthen the bones. (5 doses prescribed).
• Outcome: A one-year follow-up confirmed that the patient experienced absolutely no relapse of the gouty arthritis.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the targeted TCM strategy for hyperuricemia (high uric acid) using the concept of “Transforming Turbidity.”

While conventional medicine relies on drugs to block uric acid production or increase excretion, TCM views high uric acid as a physical manifestation of “Damp-Turbidity” (湿浊) caused by dietary excess and Spleen failure. Professor Zhao brilliantly utilized Simiao Wan as the base to clear the inflammatory heat, but the true metabolic correction came from adding heavy doses of Mian Bi Xie, Fu Ling, and Fang Ji. These herbs specifically target the body’s water pathways to “ascend the clear and descend the turbid” (升清化浊). Combined with insect medicinals like Tu Bie Chong to break up the crystallized stasis in the joints, this formula effectively lowered the uric acid burden and rapidly resolved a stubborn three-year affliction in under a week.

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Source Original source: Zhanjiang Second Hospital of Traditional Chinese Medicine / Traditional Chinese Medicine Bureau of Guangdong Province Original title: 【以案说医】招仕富：清湿化浊，活血化瘀，消肿止痛法治疗高尿酸血症案 Practitioner: Professor Zhao Shifu (招仕富) Publication date: August 18, 2024 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation