刘松山教授治疗重度再生障碍性贫血一则

Professor Liu Songshan’s Experience in Treating Severe Aplastic Anemia: A Case Report

摘要: 患儿何某，男，6岁，依据血常规、骨髓穿刺及活检等检查结果，西医明确诊断为重度再生障碍性贫血。因病情反复、控制欠佳，反复进行输血及血小板对症支持治疗，逐步进展为输血依赖性铁过载。本次因“确诊再生障碍性贫血1年余，反复输血依赖”就诊。四诊信息：神疲乏力，面色苍白，形寒肢冷，纳可，眠欠佳，小便调，大便稍溏，舌淡，苔薄白，边有齿痕，脉沉细。中医诊断：虚劳病–脾肾两虚证。西医诊断：再生障碍性贫血。干预措施：中医治法：健脾补肾。黄芪15 g、白术10 g、茯苓10 g、生地黄10 g、酒女贞子5 g、鹿角胶10 g、盐补骨脂10 g、巴戟天10 g、茵陈10 g、金钱草10 g、盐菟丝子10 g、黄芩10 g、太子参15 g、续断10 g。西医治疗：长期口服司坦唑醇片(2 mg/片)，1片/天。疗效转归：经治疗后神疲乏力，面色苍白，形寒肢冷，眠欠佳，大便稍溏等临床症状得到明显改善，脱离输血及输血小板，血象明显改善。生活质量明显提高。

Abstract: Mr. He, male, 6 years old, with complete diagnostic criteria including blood routine examination, bone marrow aspiration and biopsy, was clearly diagnosed as severe aplastic anemia (SAA). Due to poor disease control and recurrent episodes, the patient received repeated blood transfusions and platelet transfusions as symptomatic supportive treatment, and gradually progressed to transfusion-dependent iron overload. The patient presented with confirmed “aplastic anemia for more than one year and repeated transfusion dependence”. Four diagnostic information: Mental fatigue, pale complexion, cold limbs, fair appetite, poor sleep, normal urination, loose stools, pale tongue with thin white coating and teeth marks, sinking and thready pulse. TCM diagnosis: Consumptive disease, identified as spleen-kidney deficiency pattern. Western medicine diagnosis: Severe aplastic anemia. Intervention: TCM treatment focused on strengthening the spleen and tonifying the kidney, using Huangqi (Astragali Radix) 15 g, Baizhu (Atractylodis Macrocephalae Rhizoma) 10 g, Fuling (Poria) 10 g, Shengdihuang (Rehmanniae Radix) 10 g, Jiunvzhenzi (Ligustri Lucidi Fructus) 5 g, Lujiaojiao (Cervi Cornus Colla) 10 g, Yanbuguzhi (Psoraleae Fructus) 10 g, Bajitian (Morindae Officinalis Radix) 10 g, Yinchen (Artemisiae Scopariae Herba) 10 g, Jinqiancao (Lysimachiae Herba) 10 g, Yantusizi (Cuscutae Semen) 10 g, Huangqin (Scutellariae Radix) 10 g, Taizishen (Pseudostellariae Radix) 15 g, Xuduan (Dipsaci Radix) 10 g. Western medicine treatment was given Stanozolol Tablets (2 mg/tablet), 1 tablet/day, for long-term oral administration. Outcomes: After treatment, the patient’s clinical symptoms, such as mental fatigue, pale complexion, cold limbs, poor sleep, and loose stools, were significantly improved. The patient was weaned off blood transfusion and platelet transfusion, and blood counts were significantly improved. The quality of life was markedly enhanced.