should alert the clinician to use fludrocortisone with caution and the plasma albumin level should be carefully monitored-since any fall in the latter will potentiate the effect of the mineralocorticoid. The development of the nephrotic syndrome or of congestive cardiac failure, by producing fluid retention and secondary aldosteronism, has a "protective effect" in relieving the postural hypotension in autonomic neuropathy, although vascular reflexes such as the Valsalva manoeuvre and blood pressure response to sustained handgrip will still be abnormal."' Fludrocortisone may therefore have to be balanced with a diuretic to avoid serious postural hypotension or excessive fluid retention. Provided fludrocortisone is used with caution in these conditions, it is most useful for treating diabetics with troublesome postural hypotension.

Plasma immunoreactive beta-melanocyte stimulating hormone (beta-MSH) has been measured in patients taking a progestogen-only oral contraceptive and in patients taking combined estrogen-progestogen therapy, of whom some had chloasma. Plasma levels did not differ significantly from those in a group of age- and sex-matched controls. It is concluded that the pigmentation of chloasma is not due to increased plasma concentrations of immunoreactive beta-MSH.

A case of the carcinoid syndrome with unusual skin lesions is described. A rise in blood prostaglandin activity associated with noradrenaline-induced flushing is reported. The significance of prostaglandins in the carcinoid syndrome is discussed. CASE REPORTA 73-year-old widow was referred with a 2-year history of an itchy rash on the abdomen. Itching preceded the formation of blisters, each of which healed over a period of about 6 weeks to leave a white scar-like lesion. After i year the blistering ceased, but the itching persisted. Over the same period, she admitted to attacks of flushing of the face. These occurred between one and six times a day, and each lasted about a minute. She also complained of diarrhoea with up to three semi-formed motions per day. She had noted that flushing coincided with her bowel action and also exacerbated her itching. During the first year of her illness she had lost over 12 kg in weight, but recently there had been an increase in weight due to the development of congestive cardiac failure, with swelling of the legs and abdomen, and increasing breathlessness.On examination there was gross telangiectasia of the face and neck, both in the form of dilated venules and dot-like petechial angiomata (Fig. i). A difluse erythema involved both the dorsa and palms of the hands. On the abdomen there were many white macules each with a halo of erythema and telangiectasia (Figs. 2 and 3).In addition, she was in congestive cardiac failure with signs of tricuspid valve incompetence and stenosis. The liver was enlarged four fingers' breadth below the right costal margin, and its edge was nodular. InvestigationsThe diagnosis of the carcinoid syndrome was confirmed by finding the 24 h urinary excretion of 5hydroxyindoleacetic acid to be increased to between 200 and 400 mg (normal 4-14 mg). The serum alkaline phosphatase was raised to 116 units (normal 20-90 units), suggesting the presence of hepatic secondary deposits. This was confirmed by a liver scan which showed several filling defects. No F 547

No abstract