| Objective:To study the dynamic changes and the corresponding clinical significance of serum concentrations of pro-and anti-inflammatory cytokines, monocyte human leukocyte antigen-DR (HLA-DR) , TLR2 and TLR4 mRNA expression in patients with severe sepsis;To investigate pathogenic features of severe sepsis by analyzing TCM syndrome;and explore the efficacy of "fusu yin" in treating severe sepsis (SS) as well as its mechanisms from the view of immunomodification and regulating TLR2 and TLR4 mRNA expression, which may provide a new way and thought for the treatment of SS with the combination of Chinese medicine and western medicine, reducing the fatality of SS as well.Methods:Our study was performed at the First Affiliated Hospital of Guangzhou University of TCM. From April 2004 to November 2005 patients admitted to the intensive care unit (ICU) , who fulfilled with ACCP/SCCM Consensus Conference criteria of severe sepsis were enrolled in this prospective study. Subjects in this study were randomly divided into group F and group A. 20 cases in group F were treated with Fusu yin capsule and routine western therapy, however 20 cases in group A were treated with placebo and routine western therapy . Another group of 15 healthy individuals were also included in the study as controls. Group A was divided into two subgroups according to the progrosis: survival group (n=9) and the death group (n=11). The traditional Chinese medical (TCM) features of the different symptom types in SS patients were investigated on admission . And on admission (before treatment), on Days 3 and day7 after starts of treatment, Acute Physiology and Chronic Health Evaluation (APACHE Ⅱ) scoreswere also recorded, then 10 ml peripheral blood samples were obtained from patients .The serum concentrations of TNF-a^ IL—6? IL—10 were measured by means of ELISA, HLA-DR expression was assessed by means of flow cytometry , and the expression of TLR2 and TLR4 mRNA in monocyte were observed by method of RT- PCR.Results:K The type of TCM syndrome: In SS patients, the percentage of the excess syndrome is 10%, which of the excess & deficiency syndrome is 85% and deficiency syndrome is 5%. Heat toxin constipation blood stasis are the main pathogenic factors, and the deficiency of qi and yin was mostly seen in SS.2^ 28-day all-cause mortality: The mortality rate was 30% (6/20) in group F, while that of in group A was 55% (11/20) . There was a significant difference between two groups.3n Changes of cytokines: On admission, patients with severe sepsis had significantly higher concentrations of all measured cytokines compared to normal controls (P <0. 01) , and there is no significant difference between the two treatment group;On day 3, TNF-a^ IL—6 levels in group F decreased significantly (P<0. 05) , while IL—10 level had no remarkable change. The difference of TNF-a^ IL —6 levels between F and A group were significant (P<0. 05);On day 7, the levels of TNF-a^ IL-6 and IL—10 in two groups declined , but the dereasing degree of concentrations in group A was slighter than that in group F, so there was also significantly different between two group. In accordance with progrosis, surviors had lower concentrations of all measured cytokines than nonsurviors on day 3 and day 7 (P<0. 05) .4, Monocyte HLA-DR expression: On admission HLA-DR expression were obviously lower in SS than those in normals (P<0.01) , while there is no significant difference between the two treatment group. On day 7, HLA-DR expression in two treatment were obviously higher (P<0. 01) . After treatment monocyte HLA-DR expression in surviors increased remarkably, but there was no significant change in nonsurviors. Surviors had higher monocyte HLA-DR expression than nonsurviors at the same time points (P<0. 01) .5^ monocyte TLR2 and TLR4 mRNA expression: On admission TLR2 and TLR4 mRNA expression were less in SS patients than those in normals (P<0.01) , and there is also no significant difference between the two treatment group. Aftertreatment TLR2 and TLR4 mRNA expression in group F increased remarkably on day3, while these changes occurred in group A until on day7. TLR2 and TLR4 mRNA expression in group A were lower than those in group F on day3 and day7. TLR2 and TLR4 mRNA expression in surviors reached normal levels on day7(P>0. 05) , but there was no significant increase in nonsurviors. It was . found that mRNA expression was higher in surviors than in nonsurviors at every observation points (P<0. 01) .6> APACHEIIscore: Before treatment there is no significant difference between group F with group A. Scores had a decrease trend declined in two groups during the treatment. On day3 and day 7, compared with group A, scores declined significantly in group F(P<0. 01). APACHEII scores gradually decreased with the patients' condition improved, vice versa. Nonsurviors had higher scores from day 3 after treatment than surviors (P<0.05) .7, Correlation analysis: At the same time points, there was a significant positive correlation between APACHEII score and serum cytokine concentrations (P<0. 05) , in addition, TLR2 mRNA expression was also positively correlated with monocyte HLA-DR expression (P<0. 01), so as TLR4 mRNA expression (P<0. 01).Conclusions:K Based on the analysis of TCM syndrome and tutor' s clinical experiences, we believe that the pathogenic feature is deficiency in origin and excess in superficiality. It is to say the fundamental is the deficiency of qi and yin , while the superficiality is heat, toxin, blood stasis, which manifests body resistance weakened and pathogenic factors prevailing, so strengthening healthy qi to eliminate pathogenic factors is identified as the basic therapeutic principle. We bring forward therapeutic principles, such as " tonifying qi and yin, clearing away heat-toxin, promoting blood circulation to dissipate blood stasis, removing stasis by purgation" .2, Combined the syndrome differentiation of TCM with APACHE II score may help to describe the condition of patients with SS more objectively.3, Significantly lower HLA-DR expression was found in the patients with SS, while the serum concentrations of pro-and anti-inflammatory cytokines were higher than those in healthy controls, which was associated with increased mortality . Our study demonstrated patients with SS were in a status of immunological disturbance which is characteristics by specific depression ofimmune function and nonspecific increase activation of inflammatory reaction . Higher APACHEII score indicated worse patients' condition, poorer outcome and higher mortality rate. Dynamic monitoring serum concentrations of cytokines and HLA-DR expression, which especially combined with APACHEII score, would be helpful to evaluating the condition and prognosis of patients with SS.4> Decreaesd TLR2 and TLR4 mRNA expression were closely associated with patients' poor outcome. And there were significant positive correlations between TLR2/4 mRNA expression and monocyte HLA-DR expression (P<0. 01), which suggests TLR2/4 mRNA expression may reflect host' immune status to a certain extent.5> It could effectively regulate immune function, alleviate symptoms, decrease the mortality and improve the prognosis of SS patients by using Fusu yin capsule and the conventional western therapy. The mechanism may be related to decreasing levels of pro-and anti-inflammatory cytokines, up-regulating the monocyte HLA-DR expression, TLR2 and TLR4 mRNA expression as well as strengthening the host' s response to stress.
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