TOIL
tient, precipitate ventricular fibrillation due to the movement required and seriously hamper cardiopulmonary resuscitation if it becomes necessary, as is frequently the case. Physicians should be aware of these considerations when determining a therapeutic approach to the patient with hypothermia.
XIm.)
New topical corticosteroid
JAMES B. RUELER, MD Staff physician Ambulatory care medical services Veterans Administration Hospital Portland, Ore.
COMPOSITION
Each g of TOPICORT Emollient Cream contains 2.5 mg (0.25%) of desoximetasone. INDICATIONS For the relief of acute or chronic corticosteroidresponsive dermatoses.
CONTRAINDICATIONS
In untreated bacterial, fungal and moat viral lesions of the skin (including herpes simplex, vaccinia and varicella) and hypersensitivity to any of the components of the preparation.
WARNINGS
Systemic side-effects including adrenal suppression may occur with topical corticosteroid preparations, particularly when these preparations are used over large areas or for an extended period of time or with occlusive dressings. The safety of topical corticosteroid preparations durin g pregnancy and lactation has not been established. When md icated, they should not be used extensively, in large amounts or for prolonged periods of time on pregnant patients or nursing mothers. TOPICORT Emollient Cream 0.25% is not for ophthalmic use.
PRECAUTIONS
If local infection exists, suitable concomitant antimicrobial or antifungal therapy should be administered as primary therapy. If a favorable response does not occur promptly, application of the corticosteroid should be discontinued until the infection is adequately controlled. If local irritation or sensitization develops, TOPICORT Emollient Cream should be discontinued and appropriate therapy instituted. The use of occlusive dressings increases the percutaneous absorption of corticosteroids. For patients with extensive lesions it may be preferable to use a sequential approach, treating one portion of the body at a time. The patient should be kept under close observation if treated with large amounts of topical corticosteroid or with the occlusive technique over a prolonged period of time. Occlusive dressings should not be applied if there is an elevation of body temperature. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. Topical corticosteroids should be used with caution on lesions close to the eyes.
ADVERSE REACTIONS
TOPICORT Emollient Cream 0.25% is well tolerated; side-effects have been extremely rare. Similar to other topical corticosteroid preparations, it may cause burnin. sensation, dryness, itching, erythema, change in skin pigmentation, folliculitis, pyoderma, striae, telangiectasia and skin atrophy. The following reactions are reported when corticosteroid preparations are used extensively in intertriginous areas or under occlusive dressings: maceration of the skin, secondary infection, striae, miliaria, hypertrichosis, localized skin atrophy, adrenal suppression and posterior subcapsular cataracts.
OVERDOSAGE Symptoms
Toxic effects due to prolonged percutaneous absorption of large amounts of corticosteroids may include: reversible suppression of adrenal function, skin striae, ecchymoses, discoloration or atrophy, acneiform eruptions, hirsutism, infection. Prolonged systemic corticosteroid action may cause hypertension, peptic ulceration, hypokalemia, muscle weakness and wastage and subcapsular cataracts.
Treatment
Treatment should include symptomatic therapy and discontinuation of corticosteroid administration. In chronically affected patients, a gradual discontinuation may prevent the development of steroid withdrawal symptoms.
DOSAGE AND ADMINISTRATION
Apply a thin film of TOPICORT (desoximetasone) Emollient Cream 0.25% to the affected skin areas twice daily. Rub in gently.
SUPPLY
TOPICORT Emollient Cream 0.25% is supplied as a formulation containing 0.25% desoximetasone, in tubes of 20 g and 60 g.
Hoechst Pha,maceui.cai O,o,s,on. Canad,an Hoechst Lid. Moni.eaI EO,dHOECOS,R.O Tode..kccfHce.h.AG
1477/7107/E
References 1. WIcKSTROM P, RuIx E, LILJA GP, et al: Accidental hypothermia. Core rewarming with partial bypass. Am J Surg 131: 622, 1976 2. LAUFMAN H: Profound accidental hypothermia. JAMA 147: 1201, 1951 3. WEYMAN AE, GREENBAUM DM, GRACE WJ: Accidental hypothermia in an alcoholic populalion. Am J Med 57: 13, 1974 4. HUDSON LD, CONN RD: Accidental hypothermia. Associated diagnoses and prognosis in a common problem. JAMA 227: 37, 1974 5. GREGORY RT, DOOLITTLE WM: Accidental hypothermia. Part II: Clinical implications of experimental studies. Alaska Med 15: 48, 1973 6. SEREDA WM: Treatment of hypothermia (C). Can Med Assoc 1 112: 931, 1975 7. Bo.sir. E: Re-warming of three poisoned patients with profound accidental hypothermia. Ugeskr Laeger 139: 706, 1977 8. HUNT PK: Treatment of hypothermia (C). Can Med Assoc 1 112: 931, 1975
Primary Hemophilus influenzae pneumonitis in an adult To the editor: In children it is well recognized that Hemophilus influenzae commonly causes meningitis and, less frequently, epiglottitis and otitis media. In adults epiglottitis and, more commonly, acute exacerbations of chronic bronchitis are due to this organism. Acute primary bronchopneumonia in an adult without any predisposing disease, as described below, is a rare manifestation of infection with H. influenzae. A 44-year-old man, with a record of good health and no underlying pulmonary or cardiovascular disease, became acutely ill with cough, chills and vague right-sided chest pain. The cough, initially dry, rapidly became productive of sputum; the chest pain increased in severity, became sharp and midsternal and was made worse by coughing and movement. On admission the patient looked ill and was flushed and sweating. The pulse rate was 96 beats/mm, respiratory rate 32/mm and temperature 39.5 0C. Rales were heard at both lung bases. Findings on examination of all other systems were normal. A chest roentgenogram at the time of admission showed patchy infiltrates in the lower lobes and the right middle lobe, more extensive on the right than the left. There was no effusion in either pleural space. The leukocyte count was 12.0 X 109/L (37% polymorphs, 54% band cells and 7% lymphocytes). A diagnosis was made of bronchopneumonia. Sputum and blood
were sent for culture and sensitivity tests and the patient was given ampicillin, 1 g q6h intravenously. The sputum was copious and purulent; Gram's stain and culture demonstrated no recognizable pathogens. After 2 days' incubation the blood cultures revealed organisms subsequently shown to be H. influenzae sensitive to ampicillin. The organism was tested for production of penicillinase by means of a modified starch iodide reaction and gave a negative reaction. The patient's condition did not change during the ensuing 48-hour period but after the dosage of ampicillin was changed to 2 g q6h intravenously there was progressive clinical improvement. The fever settled after 5 days of therapy and there was roentgenologic resolution at the time of discharge when the leukocyte count had decreased to 7.9 X 109/L (51% polymorphs and 10% band cells). The patient was discharged with instructions to take ampicillin orally for 7 days. Standard medical texts have drawn attention to H. influenzae as a cause of pneumonitis secondary to an underlying respiratory problem such as pre-existing bacterial pneumonitis or viral influenza. The rarity of this organism as the etiologic agent in primary bacterial pneumonitis was confirmed by Marraro, McCleskey and Mitchell1 in a recent publication in which they reported pneumonitis in a mother and her child caused by penicillinase-producing H. influenzae biotype 3 isolated from a number of sites. This case and our own, the organism from which was not available for subsequent serotyping or biotyping, indicate the importance of H. influenzae as a causative agent of primary bacterial pneumonitis in adults. It would therefore appear pertinent to emphasize the need for the laboratory staff to report encapsulated strains of this organism isolated from sputum of patients with pneumonitis and perhaps from adults with pharyngitis; the frequent occurrence of H. influenzae, mainly nonencapsulated strains, in the upper respiratory tract of adults often leads laboratory staff to ignore a few such colonies in the belief that they are merely commensals. Further, although not constituting a problem in our particular case, the increasing prevalence of p-lactamase-producing H. influenzae underlines the need for the laboratory staff to test significant clinical isolates for the production of the enzyme. I.W. GEERE, MB, CH B, FRCP[C] M.K.B. SEGU, MD Regina General Hospital
Regina, Sask.
Reference I. MARRARO RV. MCCLESKEY FK, MrFCHELL IL:
Pneumonia due to Haemophilus in!luenzae (H. aegyptius) biotype 3. J Clin Microbiol 6: 172, 1977
CMA JOURNAL/DECEMBER 17, 1977/VOL. 117 1375