We report an 18-year-old 46, XY phenotypic girl who has been on alternate-day dexamethasone therapy for 10 years. The patient was seen at our hospital for right-sided inguinal hernia at the age of 4 years. Biopsy of the herniated gonad showed testicular tissue, and the karyotype of the peripheral lymphocytes was 46, XY. The diagnosis of 17α-hydroxylase deficiency was established by the evaluation of adrenal steroidogenesis at the age of 6.1 years when hypertension was clearly recognized, and was confirmed later by the gene analysis of CYP17 which disclosed a compound heterozygote. The growth rate was suppressed during the initial treatment with daily administration of 0.25-0.5mg dexamethasone. Switching to alternate-day regimen of dexamethasone 0.5mg/dose improved height velocity. Subsequent addition of low-dose estrogen therapy induced pubertal growth spurt. The blood pressure and adrenal hormone levels remained almost within the normal range throughout the course. Adrenal function was evaluated at the age of 15 years. Plasma ACTH and corticosterone levels were high only just before the next administration, when the plasma dexamethasone concentration should be at the nadir. Since corticosterone possesses glucocorticoid activity and can work as a glucocorticoid reserve, it is assumed that this mode of dexamethasone administration can be a safe treatment for this disorder. We conclude that the patient with childhood 17α-hydroxylase deficiency can be safely and effectively treated with alternate-day dexamethasone without interfering with linear growth.
A splicing junction mutation at nucleotide 656 (A->G substitution, I2G) in the steroid 21-hydroxylase gene (CYP21) is the most frequently detected mutation in patients with the salt-wasting and simple-virilizing forms of steroid 21-hydroxylase deficiency (approximately 60%). In this disease, prenatal diagnosis and treatment to minimize the effects of excess androgen in affected females has been advocated. Therefore, to detect the I2G mutation rapidly, accurately, and without the use of radioisotope, we developed a modified polymerase chain reaction (PCR) with a mismatched 3' nucleotide primer to introduce a new restriction site upon PCR amplification of the mutant allele. This allowed the mutant allele to be identified readily by restriction enzyme digestion of the PCR product, and subsequently this PCR product was subjected to restriction enzyme digestion for diagnosis. Chorionic villus biopsy samples (CVS) were obtained at 10 to 11 weeks gestation from two females carrying fetuses at risk for steroid 21-hydroxylase deficiency. Prenatal diagnosis was successful in both cases. One affected female was treated with dexamethasone to term. In the other case, treatment was withdrawn at an early stage when testing revealed a normal fetus. The results demonstrate the rapid and accurate detection of the I2G mutation by this method, thereby indicating the feasibility of for prenatal diagnosis of the I2G mutation.
Pregnancy in the rat and mouse is characterized by a developmental switch in expression at midgestation between the related placental lactogens I and II (PL, PUT) suggesting that these proteins have important but different roles. The factors that control this differential gene expression are poorly understood. In this paper we describe experiments which investigate the effects of EGF and TGFα on rPLI and rPLII mRNA levels in the rat choriocarcinoma cell line, Rcho. This cell line has been widely used as a model system for studying genes expressed in the rodent placental giant cell. We find that in these cultures both growth factors produce a two fold increase in endogenous rPLI mRNA levels, and a two fold decrease in rPLII mRNA levels. Using DNA transfection assays we have tested the effects of TGFα on the expression of hybrid rPLI and rPLII 5'flanking/luciferase reporter constructs in Rcho cells. The transfected rPLI/luciferase reporter constructs produce a similar twofold increase in reporter expression to that seen for the endogenous mRNA, suggesting that EGF/TGFa positively regulate rPLI mRNA levels by effects on gene transcription. Unlike the endogenous gene, however, the rPLII/luciferase constructs show a five fold increase in rPLII-directed luciferase expression in the presence of TGFα. The effect of EGF/TGFα on placental rPLII mRNA levels appears to involve negative response element(s) located elsewhere in the gene to those regions tested.
Rat pituitary LH shows an electrical charge heterogeneity owing to their carbohydrate moiety. The biological potencies of these isoelectric components increase with increasing pi when examined by in vitro testosterone production in isolated rat Leydig cells. The present study was carried out to clarify if this tendency was also true with of in vivo action and to estimate their kinetic parameters. Seven isoelectric components of LH, i.e. X (pI 7.9), A (8.4), B (8.8), C (9.1), D (9.3), E (9.6) and F (9.8), were administered to cannulated adult male rats. Blood samples were serially collected over a 5h period from the conscious animal, and rat LH and testosterone were assayed by RIA. The doses of a single component showed a linear relationship with the areas under the curve (AUC) of the blood LH. The testosterone AUC also correlated well with LH AUC. It was found that the components with lower pIs had longer half-lives and larger LH AUC, and smaller total body clearance rates with highly significant correlation coefficients. The in vivo bioactivities of the components expressed as testosterone AUC increased with decreasing pIs, indicating that the in vivo bioactivity was much influenced by the total body clearance rate. The intrinsic activities of the components were calculated as ratios of testosterone AUC to LH AUC where the effect of the clearance rate (or biological half-life) was eliminated. The intrinsic activities of components were not significantly different among the components except component X which showed a smaller activity. These data indicated that, with the exception of component X, an LH component with a lower pI has a longer biological half-life, resulting in a higher in vivo potency, quite contrary to the tendency of in vitro potency.
Metabolic abnormalities in thyroid hormonogenesis cause congenital goiter. Here we studied a case of mild hypothyroidism caused by a novel missense mutation in the thyroglobulin (TG) gene. A female patient underwent thyroidectomy twice at the age of 27 and 43 years because of gradual enlargement of the thyroid. By RNase cleavage assay and PCR direct sequencing we identified a thymine to cytosine transition at nucleotide 3828 (from the transcription start site) which causes amino acid change from cysteine to arginine at codon 1263. A pedigree study suggested autosomal recessive inheritance due to consanguineous marriage of her parents. Immunohistochemical study suggested impaired intracellular transport of the mutant TG. Sensitivity to endoglycosidase H confirmed that the mutant TG failed to reach the Golgi compartment. Native polyacrylamide gel electrophoresis and Western blot analyses showed that formation of monomers and homodimers was defective with abundant high molecular-weight aggregates which are normally formed transiently after translation. To examine if the mutant TG is functionally defective, we separated thyroid tissue extract on a Biogel A5m column and measured T4 and T3 released from proteins in each fraction by treatment with proteinase K. Although thyroid hormones released per mole of the mutant TG protein did not decrease, those released per mg of total protein decreased. In conclusion, the missense mutation in the TG gene caused congenital goiter with mild hypothyroidism due to an altered protein structure which resulted in defective intracellular processing and premature degradation by “quality control” mechanisms. Although the tissue TG content was greatly reduced, the hypothyroidism was mild with slow progression of the goiter, because the mutant TG was a relatively good substrate for the synthesis of the thyroid hormones.
A case of pheochromocytoma arising from an accessory adrenal gland in a patient with multiple endocrine neoplasia type 2A (MEN 2A) is reported. This tumor resulted in autonecrosis which caused transient expression of clinical symptoms. Scintigraphy of the abdomen identified the existence of an additional accessory adrenal gland because of which the patient did not require a supplement of hydrocortisone after bilateral total adrenalectomy. Pheochromocytoma arising from an accessory adrenal gland is rarely reported, and spontaneous remission of clinical symptoms due to necrosis of the pheochromocytoma without a clinical emergency is also unusual. Accessory adrenal glands can be the cellular basis for pheochromocytoma, and the importance of continual follow up for pheochromocytoma in subjects with MEN 2A should be emphasized.
The purpose of the present study was to investigate postsurgical change in body composition in patients who have undergone surgery for acromegaly. Eight patients with acromegaly had determination of serum GH, insulin-like growth factor-I (IGF-I), height, body weight, and bioelectric impedance before surgery and at 2 weeks, 1 month, 3 months, and 6 months after surgery. Body composition was analyzed by bioelectric impedance analysis (BIA). We analyzed body fat (BF), body lean mass (BLM), body cell mass (BCM), total body water (TBW), intracellular water (ICW) and extracellular water (ECW). The serum GH concentration and IGF-I had decreased significantly 2 weeks after surgery. Body weight had decreased significantly 1 month after surgery and recovered 3 months after surgery. BIA showed that TBW and BCM had decreased significantly 2 weeks after surgery. BF gradually increased up to 1 month after surgery and was increased significantly at 3 months after surgery. The percent ratio of TBW/body weight decreased and the percent ratio of BF/body weight increased during the 6 months after surgery. The percent ratio of ECW/TBW did not change during the 6 months following surgery. In conclusion, the rapid body weight loss which occurred within 2 weeks after surgery was caused by decreases in TBW and BCM. The recovery of body weight, which was seen later than 1 month after surgery, was caused by an increase in BF. The postoperative change in body composition in acromegaly ceased 3 months after surgery.
The clinical significance of anti-pituitary antibodies (APA) was examined by enzyme-linked immunosorbent assay (ELISA) in individuals with non-insulin dependent diabetes mellitus (NIDDM). Serum samples were obtained from 150 NIDDM patients and 45 normal subjects. Urinary C-peptide (U- CPR) was also measured for the NIDDM patients. APA-positive serum was incubated with porcine pancreas, liver, kidney, or spleen powder and analyzed by immunoblot. The prevalence of APA was found to be significantly (P<0.05) higher in NIDDM patients (24.7%) than in the controls (6.7%) by ELISA. The index values for APA were inversely related to the levels of U-CPR (P<0.005). The levels of U-CPR were significantly (P<0.0001) lower and the prevalence of insulin deficiency was significantly (P<0.05) higher in NIDDM patients who were APA positive than in those who were APA negative. The presence of APA may therefore be related to reduced secretion of insulin in NIDDM patients. In Western blot analysis, preincubation of APA-positive sera with porcine pancreas powder prevented recognition of the 22-kD protein (APA). The possibility of a common autoantigenicity in the pancreas and the pituitary was indicated.
The optimal timing for discontinuing treatment with a long-acting gonadotropin-releasing hormone (GnRH) analog (TAP-144SR) was investigated in patients with central precocious puberty (CPP). Thirty-five girls with CPP (21 with idiopathic disease and 14 with organic disease) were treated with the analog for 3 to 5 years. No significant differences were seen between the idiopathic and the organic CPP in the suppressive effect of bone maturation. Advancement of bone maturation was noticeably suppressed during the period between bone ages (BA) of 11.0 and 11.9. The height standard deviation score (Ht-SDS) for BA was consistently improved from 10 to 11.5 years of BA, and patients reached peak Ht-SDS at a BA of 11.5 years. The ΔHt-SDS (annual change in Ht-SDS) was noticeably decreased at BA over 12 years in spite of prolongation of the treatment. In the eight patients who have reached final height, the average Ht-SDS was -0.49 at end of the treatment (BA 11.7 years) and the final Ht-SDS was -1.1SD, respectively. Predicted adult height at the end of the treatment was significantly higher than the actual final height (P<0.01). The results suggest that a fall in Ht-SDS for BA which usually occurs at approximately 12 years of BA, is an indication for cessation of the treatment with TAP- 144SR, and residual growth potential judged solely from BA may be decreased in girls with CPP after discontinuation of the treatment.
To evaluate the prevalence of lymphocytic infiltrate in a large series of pituitary adenomas, we retrospectively studied tumor tissues from 1400 patients. Based on immunocytochemical data, tumors were classified as PRL (n=411), multihormonal (n=310), immunonegative (n=275), ACTH (n=166), GH (n=137), alpha subunit (n=44), FSH and/or LH, (n=42), and TSH (n=15) adenomas. The lymphocytic infiltrate was diagnosed on histological examination and investigated by immunostaining with anti LCA (human leucocyte common antigen), anti CD45RO (human T cell) and anti CD20 (human B cell) antibodies. Lymphocytic infiltrate was present in 40 adenomas (2.9%), 26 females and 14 males, aged 18 to 77 years (mean±SD, 37±14 years). The tumors were 19 PRL, 8 multihormonal, 4 GH, 4 alpha subunit, 3 ACTH, and 2 immunonegative adenomas. In PRL adenomas, the sex ratio (female/male) and the age were similar in patients with and without lymphocytic infiltrate (2.8 vs. 4.6 and 29±6 years vs. 32 ±11 years, respectively). The frequency of lymphocytic infiltrate was similar in PRL, GH, ACTH and multihormonal adenomas, but lymphocytic infiltrate was significantly more frequent in PRL adenoma than in immunonegative adenoma, and in alpha subunit adenoma than in immunonegative, ACTH and multihormonal adenomas. The lymphocytic cells were almost exclusively T cells. We conclude that lymphocytic infiltrates are rare in pituitary adenomas. Their frequency is not statistically different in major categories of secreting adenomas (PRL, GH, ACTH, multihormonal). Their pathophysiological significance remains to be established.
Post-exercise hyperketonemia in poorly-controlled diabetic patients is a well recognized phenomenon, but because studies concerning changes in ketone body metabolism in muscle during and/or after exercise are scarce, we measured the intramuscular 3-hydroxybutyrate (3-OHBA) and lactate concentrations in 12 diabetic (streptozotocin-induced; 60mg/kg, ip) and 13 non-diabetic control rats before and after a 1-h muscle contraction. One thigh tetanic contraction was elicited at a tetanic frequency of 60tetani/min and the other thigh was kept resting. We used a microdialysis technique in both quadriceps muscles, vastus lateralis, and the right jugular vein. Blood flow in both femoral muscles was also monitored before and after contraction. Dialysate 3-OHBA and lactate levels in contracting and non-contracting muscles and in blood showed a significant increase after contraction (P<0.05) in diabetic rats. In control rats there was no significant change in dialysate 3-OHBA or the lactate concentration in contracting and non-contracting muscles or in blood before and after contraction. A significant increase in contracting muscle blood flow was observed only for the first 5 min after contraction in diabetic and control rats. These results suggest that 3-OHBA uptake in contracting muscle is reduced, and that this phenomenon may play a role in post-exercise ketosis in diabetes.
As we had an opportunity to take blood samples from a totally thyroidectomized patient who had attempted suicide by taking 2, 000μg of Levothyroxine (L-T4), the serum levels of thyroid hormones were sequentially measured to investigate the metabolism of circulating thyroid hormones in an athyreotic human. The serum concentrations of most thyroid hormones reached a peak on the second day, but the serum T3 level showed a peak one day later. The maximum concentrations of T4 (315μg/l), FT4 (48.8ng/l) and Rt3 (0.80μg/l) were very high, while the peak T3 level (1.92μg/l) did not exceed the upper limit of the normal range. The serum T4 and rT3 levels returned to their normal range 13-17 days after the suicide attempt. The TSH level was suppressed rapidly and reached its nadir (0.044mU/l) on the 6th day. During this period, the T1/2 and MCR of serum T4 were 10.4 days and 0.64 l/day, respectively, which values were almost equivalent to those observed during 15 days after discontinuation of the maintenance L-T4 therapy. In summary, the oral intake of a large amount of L-T4 at one time does not induce a proportional increase in the T3 level in an athyreotic person. The MCR of serum T4 is decreased and the T1/2 of serum T4 is prolonged, probably due to the lack of intrathyroidal deiodination. These findings support the conclusion that the D1 activity in the thyroid is one of the major determinants in the metabolic clearance of serum T4.
The effects of melatonin on twice daily surges in PRL and luteal function were studied in pseudopregnant (PSP) rats. Cyclic rats received pinealectomy or sham operation under pentobarbital anesthesia on diestrus 1. Pinealectomized rats immediately received a melatonin capsule (the PINX+Mel group) or a blank capsule (the PINX group), and sham group of rats received a blank capsule (the control group). After operation, all rats were maintained under the same photoperiod conditions (14L: 10D), and estrous cyclicity was examined. At the 8th estrous cycle after operation, PSP was induced by mechanical stimulation of the uterine cervix. The last day on which the rat exhibited the estrous smear was designated as day 1 of PSP. Blood samples were obtained by jugular venipuncture under light ether anesthesia between 1200 and 1300h on days 1, 3, 5, 7, 9 and 11, and between 0000 and 0100h on day 13 of PSP. All rats were decapitated between 1200 and 1300h on day 13 of PSP, and trunk blood was collected. A silicon catheter was inserted into the right jugular vein under ether anesthesia on day 4 of PSP. Blood samplings were performed every 2h between 1000h on day 5 and 1000h on day 6 of PSP. Serum concentrations of melatonin, PRL and progesterone were measured by radioimmunoassay. Pinealectomy or melatonin installation did not disturb the estrous cyclicity or the induction of PSP. There were no differences among the three groups of rats during PSP in the pattern or serum PRL concentrations, and there were no significant differences among these three groups in the serum progesterone concentration or weight of the corpus luteum. The present results indicated that the continuously high or low melatonin in the physiological range did not affect the rhythm or strength of PRL surges or luteal function in PSP rats.
A 33 year-old Japanese woman complained of generalized fatigue, recurrent infections and gradual weight loss 1 year after her first delivery. During delivery, no excessive bleeding or change in blood pressure was noted. On endocrinologic examination 2 years after delivery, she was found to have severe adrenal insufficiency and hypothyroidism. Pituitary function tests revealed impaired responses of ACTH, PRL and gonadotropins, and normal response of GH. TSH response to TRH was delayed but not exaggerated. Cranial magnetic resonance imaging showed an empty sella. The adrenal glands were responsive to extrinsic ACTH, and adequately accumulated 123I-adosterol. Antipituitary and antithyroid autoantibodies were detected in her serum. She was diagnosed with partial hypopituitarism associated with empty sella syndrome. Approximately 2 months after administration of cortisone acetate 25mg/ day her general condition was noticeably improved, with normalization of thyroid function and improvement of gonadotropin responses to GnRH. This case suggests that a physiologic dose of glucocorticoid is necessary to maintain not only thyroid function but also some of the remaining pituitary functions in patients with empty sella syndrome manifesting hypopituitarism.
We report the case of a 31-year-old woman with a pituitary adenoma who suffered symptomatic pituitary apoplexy. The patient developed a severe headache 2min after undergoing a combined anterior pituitary function (CAP) test. Emergent computed tomography revealed a hemorrhagic pituitary tumor with evidence of a small subarachnoid hemorrhage. The headache improved spontaneously within half a day. Transsphenoidal surgery was performed 4 days later. Histologic examination demonstrated that the tumor was an eosinophilic adenoma with areas of diffuse hemorrhage. Although pituitary apoplexy caused by endocrinological testing has been reported in only 28 patients, apoplexy caused by a CAP test has been reported in only 1 patient. All of the previous cases had pituitary macroadenomas, 69% of which were involved in suprasellar extension. Non-functioning adenomas (24%) and prolactinomas (24%) were the most often affected by endocrine stimulation tests. With respect to the stimulants of pituitary adenomas, gonadotropin-releasing hormone (76%), TSH- releasing hormone (69%), and insulin (34%) were primarily responsible for the apoplexy. This case report with the literature review suggests that routine testing on pituitary function should be ordered cautiously given the risk of possible apoplexy.
Although previous studies have suggested that human peripheral blood mononuclear cells (PBMCs) may express pro-opiomelanocortin (POMC) mRNA and synthesize its related peptides, the patho-physiological role of POMC expressed in peripheral cells is not known. In this study, we investigated the POMC gene expression in various types of human leukemia cell lines by Northern blot analysis and the reverse transcribed-polymease chain reaction (RT-PCR) method. The POMC mRNA was not detected by Northern blot analysis in all cell lines tested except the Jurkat cell line which is derived from T-lymphoblastic leukemia. The POMC mRNA expressed in the Jurkat cells was smaller than that in the human anterior pituitary gland. The RT-PCR method revealed that a truncated-POMC transcript could be detected not only in lymphoblastic leukemia cells but also in erythroid and myeloid cells. Interestingly, two cell lines of monocytic leukemia, J-111 and U937, did not express the truncated- POMC mRNA. Treatment with concanavalin-A stimulated truncated POMC mRNA expression and ACTH-like immunoreactivity in lymphoblastic leukemia cells with T-(Jurkat) and B-(BALL-1) lymphocyte phenotypes. These results confirm that human leukemia cells except for monocytic cells express a truncated-POMC mRNA as well as in the human normal PBMC.
Previously we reported a high ratio of free insulin-like growth factor-I (IGF-I) to total IGF-I (fit IGF-I ratio) during early infancy when rapid growth is observed, indicating that high levels of free IGF-I (fIGF-I) may be related to the growth of infants. Rapid growth is also observed during puberty. The purpose of this study is to investigate a possible relationship between pubertal growth and fIGF-I. Here, fIGF-I and total IGF-I (tIGF-I), the f/t IGF-I ratio and proteolysis of IGFBP-3 were studied in the circulation of patients with precocious puberty and normal pubertal subjects, and they were compared with those of prepubertal and adult populations. Higher absolute plasma fIGF-I values were observed in the pubertal children (3.89±1.09ng/ml, N=45) than in the normal prepubertal children (2.06±1.01 ng/ml, N=31; P<0.05) and adults (2.18±0.68ng/ml, N=49; P<0.05). Furthermore, there was a correlation between the levels of fIGF-I and height velocity in the prepubertal and pubertal groups (r=0.722, N=76, P<0.0001). Compared to the f/t IGF-I in the prepubertal and adult populations, no increase in fit IGF-I ratios was observed, and the proteolysis of IGFBP-3 was not detected in sera from the pubertal children. These data suggest that the increase in the absolute levels of fIGF-I is related to pubertal growth.
We report a case of POEMS syndrome with various endocrine dysfunctions. A 49-year-old man was admitted to our hospital for pretibial edema and general fatigue. He had weakness of the lower extremities, hepatomegaly, monoclonal protein (IgG-λ type), impotence, pigmentation and hypertrichosis. Endocrinological examination revealed impaired glucose tolerance, primary hypothyroidism and hypogonadotropic hypogonadism. After three months of treatment with corticosteroids, he showed an improvement in gonadotropin secretion, but no considerable change in the secretion of the other hormones. To our knowledge, this is the first case that showed an improvement in gonadotropin secretion as a result of corticosteroid therapy in POEMS syndrome.
We present a 25-year-old woman with amyloid goiter due to hypersensitivity vasculitis, who developed transient thyrotoxicosis resembling subacute thyroiditis. She received prednisolone (20mg/ day) for three years for hypersensitivity vasculitis, and was diagnosed as having secondary amyloidosis by biopsies of the stomach, rectum and kidneys. She noticed neck swelling with severe right neck tenderness, palpitation, hyperhidrosis and weight loss. An elastic firm diffuse goiter was palpable, and the upper pole of the right lobe was extremely tender. Her serum free T4 and T3 levels were high, and the serum TSH was suppressed to subnormal. She was positive for serum C-reactive protein. Anti- thyroidal autoantibodies were all negative. Her thyrotoxicosis subsided spontaneously within one week. Serum titers of antibodies to various viruses were unchanged during the clinical course for two weeks, but she was positive for HLA B35. Examination of a needle-biopsy specimen of the thyroid gland showed extensive amyloid deposition and no evidence of subacute thyroiditis. We considered her transient thyrotoxicosis to be associated with amyloid goiter. The clinical course of this case was similar to the subacute thyroiditis-like syndrome, first described by Ikenoue et al. When patients with primary or secondary amyloidosis have symptoms and signs of subacute thyroiditis, but develop an unusual course, amyloid goiter should be considered.
We report on two siblings with classic simple virilizing 21-hydroxylase deficiency whose neonatal screening for serum 17α-hydroxyprogesterone (17-OHP) gave normal results. The proband, a girl with clitoromegaly whose screening 17-OHP value had been 9.2ng/ml, was diagnosed at the age of 6 months, and her elder brother with the initial screening level of 15.7ng/ml was diagnosed at the age of 6 years due. to precocious puberty. Although the occurrence of false-negative cases is extremely rare, it can happen in a simple virilizing form of 21-hydroxylase deficiency. This experience informs that normal results for neonatal screening cannot be an excuse for not evaluating siblings of the proband with congenital adrenal hyperplasia.