The glucagonoma syndrome is characterized by necrolytic migratory erythema, glossitis, ungual dystrophy, diabetes mellitus, anemia, weight loss, elevated plasma glucagon levels and an alpha-cell glucagon-secreting neoplasm of the pancreas. We are reporting a case of this syndrome in a middle-aged woman, in whom the first complaints and signs were cutaneous. The recognition of the distinctive skin manifestations of the syndrome led to early diagnosis and treatment of the underlying malignant pancreatic tumor.

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The review article by Ellison and Felker (Nov. 16 issue) 1 has a two-edged potential. Physicians are encouraged to use diuretics as first-line therapy for heart failure, but discontent with the drugs runs like a thread through the review. We had hoped that the section on other approaches and future directions would address how to minimize the use of diuretics. Long-term use of diuretic therapy for chronic heart failure may contribute to neurohumoral stimulation. 2 Therefore, not only does skillful use of diuretic therapy remain fundamental to the successful management of heart failure, but so do strategies for their avoidance. First-line use of diuretics might influence adequate dosing of cardioprotective drugs, and the promotion of cardiac regeneration may become impractical. The latter is of particular importance the younger the patient with heart failure.

✓ Two cases of metastatic glioma with hypercalcemia are presented. Elevated serum calcium secondary to metastatic central nervous system tumors may be more common than is generally supposed, and the symptoms of hypercalcemia may be mistaken for those of increased intracranial pressure.