736 CORRESPONDENCE

Pakistan. This past year, new training initiatives began. The cleansed with an alcohol pledget and allowed to dry. The IMC started an eight-month program to upgrade the clinical center of the site is marked and "bracketed" with four me- skills of Afghan physicians, began a four-month program to tered doses at close range ofthe aerosolized beclomethasone. train Afghans as field microscopists, and conducted a for- The patch is then applied in the usual fashion to this pre- malized retraining program for previously trained medics. pared area. Gradually, Afghanistan's shattered health care system is be- In three years, I have encountered 15 patients with a ing rebuilt. "patch rash" and have treated all of them in this manner. In In addition, the IMC has expanded its services to other 12 patients, the rash has been prevented as long as they regions ofthe world. In Honduras, health care services were continued this pretreatment before applying a clonidine provided to more than 130,000 Nicaraguans displaced by patch. When they failed to do so, the rash promptly reap- civil war. In southeast Angola, the IMC is conducting an peared, only to disappear when the beclomethasone spray immunization program to inoculate 60,000 children and was again used. In the 3 patients who did not respond to this women ofchildbearing age and to train local personnel. This pretreatment, the patches were discontinued, and oral agents program also includes emergency food, agricultural assis- were employed. tance, and nutritional and water assessments. Future health The 12 patients who did respond favorably have now been care and training projects are planned for other African coun- observed every 4 to 12 weeks for an average of 15 months tries, Central America, and for Cambodia and Kurdistan. without any reappearance of the contact dermatitis. The IMC is the compilation of its medical personnel, The good control of the hypertension in these 12 patients many of whom volunteer to work under difficult conditions. has not deteriorated with this treatment. No significant Many challenging opportunities exist in the international changes in their therapeutic regimens have been made during health care field. I invite you to join our corps and train this follow-up period. This would indicate that the beclo- people to help themselves. methasone spray does not diminish the absorption or action For further information on IMC programs, your readers of the clonidine applied to the skin surface. can call the Recruitment Department at (213) 670-0800. Tra- Clinicians and patients alike have applauded the use ofthe vel expenses, room, board, medical insurance, and a transdermal clonidine patch. It is regrettable that contact monthly stipend are provided. dermatitis sometimes mars its performance. The pretreat- ROBERT R. SIMON, MD ment procedure described may allow us to continue this ef- Chairman ofthe Board fective in of our International Medical Corps treatment many hypertensive patients. 5933 W Century Blvd, Suite 310 Los Angeles, CA 90045 JOHN A. McCHESNEY, MD Hypertension Clinic University of California, San Francisco, Medical Center Room 478-A, Box 0320 Preventing the Contact Dermatitis Caused by a 400 Parnassus Ave Transdermal Clonidine Patch San Francisco, CA 94143 TO THE EDITOR: The centrally acting antihypertensive agent, REFERENCES 1. Weber MA, Drayer JI, McMahon FG, Hamburger R, Shah AR, Kirk LN: clonidine, is now available in a transdermal treatment form Transdermal administration of clonidine for treatment of high blood pressure. Arch and has been shown to be highly effective in the control of Intern Med 1984; 144:1211-1213 hypertension. 1-3 2. McChesney JA, Ryan C, Shaw RE, Fishman-Rosen J, Murphy MC: Transder- mal clonidine for the treatment ofessential hypertension. Compr Ther 1987; 13:49-53 This "Catapres-Transdermal Therapeutic System" 3. Hollifield J: Clinical acceptability oftransdermal clonidine: A large-scale evalu- (Boehringer Ingelheim, Ltd) is a multilayered skin patch in ation by practitioners. Am Heart J 1986; 112:900-906 three sizes that continuously delivers either 0.1, 0.2, or 0.3 mg of clonidine systemically and daily for seven days before being replaced. With its use, patient compliance is greatly Possible Complications of Acupuncture enhanced and the "steady state" of drug delivery decreases TO THE EDITOR: I read with great interest the report by the incidence of adverse side effects, except for one trouble- Wright and colleagues in the January 1991 issue on bilateral some problem-an erythematous, pruritic rash beneath the tension pneumothoraces resulting from acupuncture.' Eight patch in about 12% to 20% ofpatients.2"3 The rash may occur years ago I saw a similar case of bilateral tension pneu- with treatment with all three patch sizes and is more common mothorax in a nonasthmatic patient that was initially mis- in white patients. It frequently causes patients to discontinue taken for an anaphylactic reaction. the use of transdermal therapy. My several attempts to prevent this rash-more frequent Report ofa Case changes of the patch or the use of steroid creams around the The patient, an elderly Chinese man, was brought to the patch-all resulted in failure. Three years ago I began pre- emergency department by ambulance in severe respiratory treating the skin application site with an aerosolized spray distress. He was brought from an acupuncture office where medication containing beclomethasone dipropionate. The he had just received treatment by acupuncture for unilateral results have been gratifying. shoulder pain. His skin was covered with oil of wintergreen. This anti-inflammatory agent is marketed as Vancenase On arrival, he had tachypnea, was unable to speak, and he Nasal Inhaler (Schering) and is contained within an aerosol had hypotension with a systolic blood pressure of 80 mm of canister with a propellant that dries instantly on contact with mercury and sinus tachycardia. He was diaphoretic with the skin, thereby creating ideal conditions for clonidine patch marked use of the accessory muscles of respiration. Auscul- application. The original Vancenase is used, not the aqueous tation of the chest revealed faint inspiratory and expiratory preparation. wheezing symmetrically. The trachea was midline. The pa- In this pretreatment, the skin application site is first tient was promptly intubated and was administered intrave- THE WESTERN JOURNAL OF MEDICINE * JUNE 1991 * 154 * 6 737 nous epinephrine, diphenhydramine, aminophylline, and REFERENCE methylprednisolone sodium succinate for presumed anaphy- 1. Gasman JD, Varon J, Gardner JP: Revenge of the barbecue grill-Carbon mon- oxide poisoning. West J Med 1990; 153:656-657 laxis to the liniment used in the acupuncture. A chest x-ray * * * study was done that showed bilateral, nearly complete pneu- mothoraces. Bilateral chest tubes were placed, which re- TO THE EDITOR: We read with great interest the report by sulted in a prompt resolution of the hypotension and respira- Gasman and co-workers regarding carbon monoxide (CO) tory distress. He was discharged well several days later and poisoning in a family using charcoal for indoor cooking pur- was thought to have no underlying pulmonary disease. poses.' The article did an excellent job of highlighting a This case, and that reported by Dr Wright and associates, recurrent and insidious environmental health hazard. The indicate a potentially lethal complication of thoracic acu- authors made a few technical points, however, that merit puncture. I am also aware of a number of patients who have further comment. had unilateral pneumothorax related to attempted cortico- The authors quote a normal range for carboxyhemoglobin steroid injection of the shoulder or thoracic trigger points. (COHb) saturation ofless than 0.150 (< 15%). Most observ- Practitioners in any field of medicine who use thoracic injec- ers agree that COHb levels as low as 10% to 15% can be tion techniques must exercise caution in the depth of inser- responsible for headaches and dizziness. A 1989 study impli- tion and be aware of the potential for pneumothorax. cated carboxyhemoglobin levels as low as 2% in reducing DAVID WILLMS, MD exercise tolerance among patients with coronary artery dis- Pulmonary/Critical Care Center ease and angina.2 Further, in a large population-based sur- Sharp Memorial Hospital 7901 Frost St vey, 95% of nonsmokers were found to have COHb satura- San Diego, CA 92123 tions below 0.02 ( < 2.0%) and 95% of smokers below 0.085 REFERENCE (<8.5%).? Hence, more reasonable "normal" ranges are 1. Wright RS, Kupperman JL, Liebhaber MI: Bilateral tension pneumothoraces 0.02 or less (s2.0%) for nonsmokers and below 0.09 after acupuncture. West J Med 1991; 154:102-103 (<9.0%) for smokers, with an irreducible minimum of 0.003 to 0.005 (0.3% to 0.5%) due to porphyrin catabolism. The authors also state that dissolved CO combining with Carbon Monoxide Poisoning cytochromes, not impaired oxygen delivery due to COHb TO THE EDITOR: We read with interest the report by Gasman formation, is responsible for the toxic effects of CO. They and colleagues regarding an indoor barbecue and carbon base this assertion on a 1976 report in which anemic dogs monoxide poisoning in the December 1990 issue.1 We have transfused with CO-saturated blood failed to show signs of encountered a similar group of patients that underscores CO toxicity. In studies ofexperimental animals perfused with some of the authors' points: a hemoglobin substitute (a fluorinated compound without Two 31-year-old non-English-speaking women were special affinity for CO), however, the animals tolerated at- brought to the emergency department by paramedics, who mospheres of 3% to 5% CO-environments that would have suspected the patients had food poisoning. They had abdomi- been rapidly fatal had the primary mechanism of CO toxicity nal pain, nausea, vomiting, dizziness, and headache. One been the interaction of dissolved CO with cytochromes.4 had had a single episode ofdiarrhea. They had shared a meal The authors make the point that "patients with severe of barbecued beef. Three other members of the household neurologic or cardiovascular symptoms or very high COHb had experienced similar but milder symptoms that did not concentrations would benefit from hyperbaric oxygen." Al- require treatment. though hyperbaric oxygen does substantially hasten the elim- The results of a physical examination of both patients ination of CO and the reduction of COHb levels in CO poi- were normal. On further questioning, the women admitted soning, there have yet to be any controlled studies showing that the beef had been prepared on a barbecue stove in their that the ultimate outcome in patients treated with hyperbaric closed apartment. They had been reluctant to provide this oxygen is better than in patients treated with normobaric information to the paramedics because, having been in the oxygen. United States for only a brief period of time, they assumed Concern over the type of event outlined in Dr Gasman's the paramedics-because of their uniforms-had police report prompted the California Department of Health Ser- functions. vices to issue a public warning in January 1990 cautioning Once this item of history had been obtained, the patients against the use of gas ranges and unvented gas or kerosene were placed on 100% oxygen therapy. Carboxyhemoglobin heaters for indoor heating, as well as the practice of using levels were measured and found to be 38.3% and 31.9%. The charcoal for indoor cooking. The advisory especially tar- other members of the household were called and evaluated. geted Asian immigrants because the traditional use of char- All had normal findings on physical examinations. Carboxy- coal for indoor cooking purposes has been previously re- hemoglobin levels were 25.5%, 21.2%, and 18.5%. ported within this community. We are appreciative of Dr These cases underscore the similarity that carbon monox- Gasman and colleagues for again bringing this issue to the ide poisoning may display to food poisoning, especially when forefront. DENNIS SHUSTERMAN, MD, MPH more than one patient is involved. The difficulty of obtaining Air Toxicology and Epidemiology Section an accurate history because of language barriers and social KAI-SHEN LIU, PhD, MPH background may enhance the challenge of arriving at the Air and Industrial Hygiene Laboratory California Department ofHealth Services correct diagnosis. 2151 Berkeley Way GEORGE STERNBACH, MD Berkeley, CA 94704 Emergency Medicine Service KENNETH W. KIZER, MD, MPH JOSEPH VARON, MD Director Department ofMedicine California Department ofHealth Services Stanford University Medical Center 714/744 P St Stanford, CA 94305 Sacramento, CA 94234-7320