Cellulitis caused by bear‐related trauma successfully treated with an additional dose of eppikajutsuto

In 2023, there were 70 cases of trauma caused by black bears in Akita Prefecture, accounting for the highest number of cases in Japan. Twenty patients with severe trauma were treated at the Akita University Hospital, and wound infections occur in 21% of the cases [1, 2]. Therefore, from 2024, a treatment policy for the concomitant use of hainosankyuto (HNST) and antimicrobial agents has been adopted. Herein, we describe a case in which a combination of antimicrobial agents and HNST did not control the infection, and eppikajutsuto (EPTJ) was useful in this patient, who also developed cellulitis. A 61-year-old man with a history of hypertension encountered a black bear while farming and was bitten on the right leg. No active bleeding was observed; however, a bite wound was observed on the right leg and a claw abrasion wound was observed on the left lower leg. The wounds were then cleaned and left open. The patient's white blood cell count was 11,000/μL, and the C-reactive protein level was 0.04 mg/dL. His height, weight, and body mass index (BMI) were 164 cm, 60 kg, and 21.6 kg/m2, respectively. Sulbactam/ampicillin (3 g) was injected intravenously, and oral administrations of clavulanate (CAV)/amoxicillin (AMPC) (AMPC, 1,500 mg/day; CAV, 375 mg/day) and HNST extract (7.5 g/day, TJ-122; Tsumura & Co., Tokyo, Japan) were initiated [3]. Acetaminophen was administered as an add-on treatment for the pain. On day 2 after the injury, the bite wound was sutured, left partially open, and drained using a gauze. On day 4 after the injury, the bite wound was reddish, hot, and swollen (Figure 1a); therefore, it was opened and washed. For symptomatic relief of the inflammatory swelling, an additional 7.5 g/day of EPTJ extract (TJ-28; Tsumura & Co.) was administered [3]. The wound culture results were negative. Thereafter, the redness, swelling, and heat of the bite wound were reduced, and the wound was closed using a Steri-Strip (3 M Japan Limited, Tokyo, Japan) on day 19 after the injury. On day 25 after the injury, the patient was painfree, the administration of all internal medications was completed, and the follow-up visits were terminated (Figure 1b). The patient was administered HNST for 25 days and EPTJ for 21 days. In short, he received Glycyrrhiza root at a dosage of 5.0 g/day for 21 days, with no observed adverse events, including pseudoaldosteronism. HNST consists of Platycodon root, immature orange, peony root, Glycyrrhiza root, jujube, and ginger, and it has heat-clearing, detoxifying, expectorant, and draining actions. Therefore, it has been used to treat pyogenic diseases of the skin and mucous membranes. HNST is effective in the treatment of recurrent lower extremity cellulitis [4], and we have been using it as a treatment strategy with antimicrobial agents to prevent wound infection due to bear-related trauma, which, in this case, developed into cellulitis. EPTJ consists of gypsum, ephedra herb, Atractylodes lancea rhizome, jujube, Glycyrrhiza root, and ginger, and it is used to treat acute joint swelling, pain, and fever. Gypsum exhibits a heat-clearing effect. The combination of ephedra herb with gypsum results in the absorption of fluid, which drains into the urine, resulting in an enhanced anti-inflammatory effect. We have previously reported that it could also be used to treat cellulitis [5]. In the present case, the symptoms of redness, heat, pain, and swelling reduced after the additional use of EPTJ, and wound healing was achieved. In bear trauma, jidabokuippo is often used to treat subcutaneous hemorrhage [2]; however, in this case, HNST was selected for infection control. Whether it is better to use a combination of HNST and EPTJ from the beginning, or whether HNST should be discontinued and EPTJ should be administered alone, is a subject for future study. This case demonstrates that EPTJ is useful for the treatment of severe cellulitis. We acknowledge Editage (https://www.editage.jp) for proofreading the manuscript. Hajime Nakae received honoraria from the Tsumura Co. The other authors declare no conflicts of interest. N/A. We obtained informed consent from the patient. N/A. N/A.