Case A 49-year-old milkman presented after the acute onset of blurred vision, anorexia, malaise, weight loss and ankle swelling. There was also a 4-month history of progressive dyspnoea, weakness, parasthesiae, tinnitus and hearing loss and earlier nerve conduction studies had revealed a demyelinating peripheral neuropathy. After a normal CT scan, undertaken because the patient had papilloedema, the patient's blood pressure (200u120) was treated with atenolol and he was referred to the Centre

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... r Nephrology at the Royal Free and University College Medical School. On examination he had a 6 mm purple nodule on the anterior chest wall and gynaecomastia. Blood pressure was 130u95, the patient was b-blocked and loud P2 and S3 heart sounds were heard. Ankle and sacral oedema, bilateral pleural effusions and ascites were present but there was no palpable organomegaly or lymphadenopathy. Fundoscopy showed bilateral papilloedema and a single right flame-shaped haemorrhage. The blind spot was enlarged bilaterally and Rinne's test was positive bilaterally. Examination of the peripheral nervous system revealed upper limb hyporeflexia and proximal loss of power, absent reflexes, and reduced distal sensation in the legs. Routine investigations demonstrated significant renal impairment, urea 21 mmolul (0.5-4.7), creatinine 174 mmolul (60 -120) without significant proteinuria