Correspondence

The Dangers of Carbon Monoxide

N Engl J Med 1995; 332:894March 30, 1995

Article

To the Editor:

In their Clinical Problem-Solving article “Pain in the Marriage,” Mevorach and Heyman (Jan. 5 issue)1 opportunely highlighted the possibility that exposure to carbon monoxide can precipitate unstable angina. This point has received very little attention in the recent literature on unstable angina. We screened 104 hospitalized patients with unstable angina for exposure to carbon monoxide.2 Three patients had definite intoxication, and another five had evidence of minor exposure. All three cases of serious intoxication were due to faulty kerosene heaters.

Routine history taking should include questions about the kind of indoor heating used. Carboxyhemoglobin levels should be measured in all suspected cases. Given that the carboxyhemoglobin levels observed in such cases were in the range of 10 to 20 percent, administering 100 percent oxygen would probably be more practical than using hyperbaric oxygen therapy.

Martin V. Balzan, M.D.
Joseph M. Cacciottolo, M.D.
St. Luke's Hospital, Guardamangia, Malta

2 References

1
Mevorach D, Heyman SN. Pain in the marriage. N Engl J Med 1995;332:48-50
Full Text | Web of Science | Medline

2
Balzan MV, Cacciottolo JM, Mifsud S. Unstable angina and exposure to carbon monoxide. Postgrad Med J 1994;70:699-702
CrossRef | Web of Science | Medline

To the Editor:

Mevorach and Heyman provided an interesting and timely reminder that cardiac ischemia is an important manifestation of carbon monoxide poisoning. They mention cherry-red discoloration of the skin and mucous membranes as a sign that should suggest this diagnosis. However, in a recent review of 100 confirmed cases,1 cherry-red discoloration was present in only 1. Therefore, this often-quoted sign is in fact relatively rare, and its absence certainly does not exclude serious carbon monoxide poisoning.

Mark Turner, M.B., Ch.B.
Royal Naval Hospital Haslar, Gosport Hampshire PO12 2AA, United Kingdom

1 References

1
Gorman DF, Clayton D, Gilligan JE, Webb RK. A longitudinal study of 100 consecutive admissions for carbon monoxide poisoning to the Royal Adelaide Hospital. Anaesth Intensive Care 1992;20:311-316
Web of Science | Medline

To the Editor:

Carbon monoxide buildup in the home may be the result of a defective furnace, cracked heat exchanger, blocked chimney, malfunctioning space heater, or improperly ventilated fireplace or wood stove. Readers should be aware that tragedy can be prevented by the use of relatively inexpensive carbon monoxide detectors. The U.S. Consumer Product Safety Commission recommends that every home be protected with at least one such device outside each sleeping area.

Richard D. Perera, M.D.
Berkshire Physicians & Surgeons, Pittsfield, MA 01201

To the Editor:

History does indeed repeat itself. The Clinical Problem-Solving feature “Pain in the Marriage” brought to mind a very similar earlier case study1 in the Journal, which was subsequently expanded and published in the New Yorker.2

The diagnostic acumen and caveats of the authors in each instance are praiseworthy and not to be forgotten.

Robert J. Hubsmith, M.D.
1395 State Hwy. 23, Butler, NJ 07405-1725

2 References