Gynaecomastia induced by angiotensin converting enzyme inhibitor.

somewhat but he remained disabled. Although clinical and laboratory evidence argued against neurosyphilis, a two week course of doxycycline was then given, but the patient did not improve over the next four weeks. His sNmptoms subsequentlI improved considerablN on increasing doses of levodopa with carbidopa. This man developed a severe symmetrical parkinsonian syndrome responsive to levodopa whose striking feature was its sudden onset. The only precipitant apparent in the history and from investigations was the flurbiprofen. There are reports of extrapyramidal syndromes in patients taking non-steroidal anti-inflammatory drugs'' but few specifically of parkinsonism. Parkinsonian symptoms have appeared in a few patients taking indomethacin (Merck Sharp and Dohme, personal communication) and been worsened by sulindac in a patient with idiopathic Parkinson's disease already receiving a levodopa and carbidopa preparation.' Conversely, diflunisal improved symptoms in six patients with Parkinson's disease.' Flurbiprofen has been associated with various motor disorders including ataxia (five reports), tremor (four reports), and myoclonus, akathisia, hypertonia, and extrapyramidal disorder (one report each). (Boots; Committee for the Safety of Medicines, personal communications). To these should now be added the akinetic rigid syndrome. It is unknown how flurbiprofen mediated its effects, but they were only partially reversible. The findings in the positron emission tomography scan indicated nigrostriatal cell loss, as is seen in idiopathic Parkinson's disease,6 in contrast with the normal appearance seen in some patients with parkinsonism induced by neuroleptic drugs (D J Brooks, personal communication). We suspect that this patient had subclinical nigral cell loss, which rendered him susceptible to a superimposed drug effect.