以溫病思維治療不明發熱患者臨床病案報告

Fever of Unknown Origin : A Clinical Case Report of Treatment Based on Warm Disease

發燒可見於多種疾病之併發症狀，傳統在治療發燒找出原因後可以從治療疾病如給予抗生素或者給予退燒藥物治療，但在許多狀況下仍有找不到原因的發燒，被稱作為不明發熱（feverof unknow origin），診斷標準包括：(1) 有些情況下體溫會超過38.3℃； (2) 至少持續三周以上； (3)住院一星期以上但未找到明確病因，而老年人的不明發熱經常是常見疾病的不典型症狀，但因為疾病表現出的症狀不典型，難以進行解釋，同時治療後改善緩慢。這位患者因肝門部膽管癌合併膽管炎開刀後開始反覆發燒，在西醫照護一段時間後，會診中醫一起介入治療，患者在會診當時，除了有反覆發燒的問題，還兼見不定處的出疹漸至全身發紅，中醫以溫病思想為出發點，初起邪同時在氣分與營分，以化斑湯為主改善發熱不退、無汗而遍身發紅的症狀，隨著熱邪傳到中焦陽明，此時患者表現已轉成腑氣不通，故使用到大承氣湯治療，並且根據其發熱惡寒症狀加上白虎加人參湯治療，後並用生津滋陰的藥物扶正固本。患者在治療過程中又突發高燒，西醫不建議給予任何口服藥物，所以更換不同劑型和途徑，使用大黃甘草湯敷貼神闕穴治療，在發燒減退、病況穩定時再回歸原本的治療思維與模式去介入，經過一個多月的照護，患者順利從安寧病房出院回家休養。

Fever is a common medical sign caused by many different diseases. The clinicians usually make the diagnoses before treatments. In some particular conditions, however, the febrile illness without definite etiology could be defined as fever of unknown origin (FUO). The standardized definition of FUO are: (1) Fever higher than 38.3ºC on several occasions；(2) Duration of fever for at least three weeks；(3) Uncertain diagnosis after one week of admission in the hospital.
In the elderly, FUO is sometimes the result of atypical presentation of common disease. It is hard to make prompt diagnosis and corresponding treatment. Then the course of diseases became protracted. This patient in this case was first admitted to the Gastro-intestinal ward. After the procedure for management of Klatskin tumor, fever started to show on and off through a period of time. Considering the pattern of disease, we use the Warm Theory to treat the patient. The decoction of Hua Ban Tang ( 化斑湯) was given as the treatment. With the change of patient’s condition, we altered the use of decoction from time to time under close observation. The Da Cheng Qi Tang ( 大承氣湯) was used to clean up the interior heat and excess. And we also added Bai Hu Jia Ren Shen Tang ( 白虎加人參湯) after the presentation of aversion to cold with fever. The fever has gradually subsided and the condition became more stable. After more than one month treatment course, the patient discharged from Hospice ward successfully.