Epigenetic profiling of the H19 differentially methylated region and comprehensive whole genome array-based analysis in Silver-Russell syndrome

Silver-Russell syndrome (SRS) is a clinically and genetically heterogeneous congenital disorder characterized by severe growth retardation. Hypomethylation of the differentially methylated region (DMR) of the H19 gene and uniparental disomy of maternal chromosome 7 is present in ∼45% of the patients with SRS so more than half of these patients have no known genetic etiology. We combined several molecular technologies including multiplex methylation polymerase chain reaction, methylation-sensitive multiple ligation probe-dependent amplification, and methylation-sensitive high-resolution melting to assess the epigenetic status of 34 patients with SRS. Additionally, we applied a whole genome strategy to detect copy number changes and loss of heterozygosity. Thirteen patients (38.2%) had hypomethylation of the DMR of the H19 gene and none had uniparental disomy of maternal chromosome 7. The whole genome arrays identified five patients (14.7%) with microdeletions on chromosomes 1q23q24.3, 7p15.3, 13q31.3, 14q32.31, and 15q26.2qter, respectively. The overall mutation detection rate was 52.9% by the epigenetic study and the whole genome strategy. Although epimutation may be the major cause of SRS and can be identified by multiplex methylation polymerase chain reaction, the whole genome approach also provides information on the etiology of SRS. If no epimutation is identified in the patients with typical SRS, microdeletions should be suspected.

Premature thelarche in Taiwanese girls

This study was conducted to understand the clinical features and natural course of Taiwanese girls with premature thelarche (PT). The medical records of 91 Taiwanese girls with PT who were diagnosed younger than six and have been regularly followed up for more than two years were reviewed. For comparison, GnRH test was also done in 25 girls with central precocious puberty (CPP) and 10 normal prepubertal girls. The age of onset of these patients was 1.5 +/- 1.6 years and 79% of them developed PT before the age of two. Girls with PT had intermediate degree of hypothalamic-pituitary-ovarian activity between prepuberty and CPP with FSH-predominant response to GnRH stimulation. 87% of patients have complete regression of breast development during 3.8 +/- 2.5 years' follow-up but 19% of them have progressed to CPP during follow-up. We conclude that Taiwanese girls with PT more often developed within the first two years of life. Activation of hypothalamic-pituitary-gonadal axis with predominant FSH activity during infancy may contribute to its development. In addition, PT is not always a benign self-limited condition, and clinicians should be cautious about pubertal development of these patients.

Effect of puberty onset on spontaneous hepatitis B virus e antigen seroconversion in men

BACKGROUND

Male predominance is a remarkable phenomenon in hepatitis B virus (HBV)-related liver disease. This study elucidated the effects of puberty on spontaneous hepatitis B virus e antigen (HBeAg) seroconversion in boys.

METHODS

One-hundred HBeAg-positive chronic HBV-infected males recruited at younger than 10 years of age who had been followed for >10 years were selected randomly from our long-term followed cohort into this study. Serum testosterone levels, androgen receptor exon-1 CAG repeat number and steroid 5alpha reductase type II (SRD5A2, valine vs leucine alleles) polymorphism were determined. Serial clinical data, HBV genotype, and spontaneous HBeAg seroconversion age were also analyzed.

RESULTS

Seventy-two subjects had spontaneous HBeAg seroconversion during the follow-up period. Subjects with serum testosterone levels > or =2.5 ng/mL at 15 years old (earlier-onset puberty, n = 87) had earlier HBeAg seroconversion (median age, 13.2 vs 22.5 years; hazard ratio = 2.95; P = .005), higher peak alanine aminotransferase levels when HBeAg positive (305.7 +/- 372.7 vs 154.8 +/- 126.0 IU/L; P = .006), and a greater HBV viral load reduction from 10 to 20 years of age (1.6 +/- 2.4 vs 0.2 +/- 1.4 log10 copies/mL; P = .009) than those with serum testosterone levels <2.5 ng/mL (later-onset puberty, n = 13). Valine allele carrier at the SRD5A2 V89L polymorphism was also associated with earlier spontaneous HBeAg seroconversion (median age, 11.7 vs 18.7 years; hazard ratio = 1.88; P = .028).

CONCLUSION

Earlier-onset puberty and increased SRD5A2 enzyme activity are associated with earlier HBeAg seroconversion, higher serum alanine aminotransferase levels, and a greater HBV viral load decrement in chronic HBV infected males.

Etiology and clinical features of isosexual precocious puberty in Taiwanese girls: twenty-three years' experience in National Taiwan University Hospital

The aim of this study was to elucidate the etiology and clinical features of Taiwanese girls with isosexual precocious puberty. 460 girls with precocious puberty were enrolled in this study. 284 of them had a GnRH test and 179 girls with gonadotropin-dependent precocious puberty (GDPP) underwent brain MRI. Our results showed 7% of these 460 girls had gonadotropin-independent precocious puberty (GIPP). The other 93% patients had GDPP and 96% of them were idiopathic. Functional ovarian cyst and hypothalamic hamartoma were leading causes of GIPP and organic GDPP, respectively. The presence of undetectable basal serum FSH and LH levels had a specificity of 95% in girls with GIPP. Among girls with GDPP, those aged < 5 years had a higher percentage of detected CNS lesions than older girls (8% vs 3%). Girls with organic CNS lesions also had more advanced bone age SDS (6.9 +/- 3.3 vs 3.3 +/- 1.9), larger uterine volume (13.8 +/- 12.1 vs 6.6 +/- 8.1 cm3), higher basal serum estradiol (33.5 +/- 17.1 vs 26.8 +/- 18.2 pg/ml), and higher peak LH level after GnRH stimulation (45.2 +/- 36.2 vs 25.8 +/- 27.3 U/l) than those with idiopathic GDPP. In conclusion, GIPP is uncommon in Taiwanese girls with precocious puberty. Functional ovarian cyst and hypothalamic hamartoma are leading causes of GIPP and organic GDPP, respectively. The presence of neurological deficit, younger age at onset of puberty, presence of menstruation, rapid advance of bone age, markedly enlarged uterus, high serum estradiol, and high peak LH level after GnRH stimulation are suggestive of organic GDPP.

Caloric restriction in Alström syndrome prevents hyperinsulinemia

Alström syndrome (AS; OMIM 203800) is an autosomal recessive disorder characterized by cone-rod dystrophy, dilated cardiomyopathy, sensorineural hearing impairment, developmental delay, and most case had both childhood-onset obesity and hyperinsulinemia. Currently, the pathogenesis of this disease is not clear. Here we report on an 18-month-old boy with Alström syndrome. He had obesity but with normal insulin and glucose levels. Molecular analysis of the ALMS1 gene revealed a 19 base pair homozygous deletion 11116_11134del in exon 16. His body mass index decreased from 25.0 to 20.7 after calorie restriction for 9 months, and his insulin and glucose levels remained normal. Finding in this case suggests that hyperinsulinemia is a secondary event in Alström syndrome, and early-commenced treatment prevents hyperinsulinemia.

Evaluation of beta-cell function in diabetic Taiwanese children using a 6-min glucagon test

This study evaluates the effects of glucagon 30 mug/kg (maximal 1 mg) on beta-cell function in children by C-peptide determined before and 6 min after intravenous administration. From 1990 to 2005, 118 Taiwanese children with newly diagnosed diabetes mellitus (98 children with type 1 and 20 children with type 2) and 29 normal Taiwanese children were enrolled in this study. Fasting and 6-min post-glucagon C-peptide levels were analyzed. In the pre-pubertal group, the median fasting serum C-peptide levels were 0.2 and 0.8 nmol/l in type 1 diabetes and normal children, respectively. These levels rose to 0.3 and 1.9 nmol/l after glucagon stimulation. In the pubertal group, the median fasting serum C-peptide levels were 0.3, 1.0 and 0.9 nmol/l in type 1 diabetes, type 2 diabetes and normal children, respectively. They rose to 0.4, 2.5 and 2.7 nmol/l after glucagon stimulation. Both fasting and post-glucagon C-peptide levels in type 1 diabetes patients were significantly lower than those of normal children and children with type 2 diabetes. The optimal cut-off values to distinguish type 1 diabetes patients from those with type 2 as determined by the receiving operating characteristic curve were 0.7 and 1.1 nmol/l, respectively. The sensitivities of both C-peptide values were 93%. The post-glucagon C-peptide level was more powerful in distinguishing type 1 diabetes from type 2 diabetes with higher specificity (95% vs. 85%). The 6-min glucagon test is valuable in assessing beta-cell function in children and can help pediatricians in the differential diagnoses of diabetes mellitus in children.

Slipped Capital Femoral Epiphysis as a Complication of Growth Hormone Therapy

Slipped capital femoral epiphysis (SCFE) is a rare complication of growth hormone (GH) therapy. Here, we report three patients who developed SCFE during GH therapy. The first two patients had hypopituitarism and had started GH therapy at the age of 15 years 6 months and 13 years 9 months, respectively. SCFE developed 4 years and 1 year after GH therapy, respectively. The third patient had Prader-Willi syndrome with obesity and hypogonadism and began GH therapy at the age of 12 years and 11 months. SCFE developed 2 months after starting GH therapy. Pain over the hip joints or over the knees is an early sign of SCFE. Despite recommendation, none of the three patients continued GH therapy. A high index of suspicion during GH therapy in patients at high risk of SCFE is important for early diagnosis and appropriate management.

Long-term outcome of hormonal status in Taiwanese children with Hashimoto's thyroiditis

The objective of this prospective study was to evaluate both thyroid function in children with Hashimoto's thyroiditis and the necessity of lifetime thyroxine replacement therapy. A total of 47 patients with goiter and positive thyroid auto-antibodies participated in the study. Serum thyroxine and thyrotropin levels and titers of thyroid auto-antibodies were checked regularly throughout the follow-up period. At the beginning of the study, 25 patients were diagnosed as euthyroid, but at the end of the study, 22 patients initially diagnosed with euthyroidism remained euthyroid, while eight patients with subclinical hypothyroidism and three patients with overt hypothyroidism had become euthyroid. Thus, of the 22 patients with thyroid dysfunction at diagnosis, subclinical or overt, 11 became euthyroid during the follow-up period. The effect of thyroxine treatment on thyroid auto-antibody titers was not significant.

CONCLUSION

Our data shows that Hashimoto's thyroiditis in children has a benign course and that thyroid function in one half of the patients with thyroid dysfunction at diagnosis reverts to normal. Careful follow-up of thyroid function is important in order to determine the necessity and timing of thyroxine replacement therapy.

Carbonyl compounds in the roadside environment of Hong Kong

The levels of carbonyl compounds were determined at the roadside urban station at the Hong Kong Polytechnic University (HKPU) campus during January 2002 to February 2002. Nine carbonyl compounds were quantified in this study. Temperature and solar radiation were found to affect the photochemical reactions of the carbonyls. Formaldehyde/acetaldehyde ratio ranged from 1.27 to 1.35. Strong correlations between formaldehyde and acetaldehyde were found, in the time period 1800-2100, which indicated that they were originated from the same sources during this time period. Roadside carbonyl samples were also collected at four other roadside environments during 2001. Kwai Chung (KC) station showed the highest average formaldehyde and acetaldehyde concentrations due to its highest traffic flow, especially for diesel vehicles. High concentration of toluene emitted from gasoline-fueled vehicles was believed to be the cause of high benzaldehyde level at the Central (CT) station through the photochemical oxidation of toluene. The average concentrations of formaldehyde and acetaldehyde in Hong Kong are well within the ranges reported in roadside environments of other urban cities. However, Mexico City in Mexico and Cairo in Egypt had much higher concentration levels of formaldehyde and acetaldehyde than in Hong Kong roadside environment due to the incomplete combustion of different fuel compositions.

A summary of recent findings on birth outcomes and developmental effects of prenatal ETS, PAH, and pesticide exposures

Inner-city minority populations are high-risk groups for adverse birth outcomes and also more likely to be exposed to environmental contaminants, including environmental tobacco smoke (ETS), benzo[a]pyrene B[a]P, other ambient polycyclic aromatic hydrocarbons (global PAHs), and residential pesticides. The Columbia Center for Children's Environmental Health (CCCEH) is conducting a prospective cohort study of 700 northern Manhattan pregnant women and newborns to examine the effects of prenatal exposure to these common toxicants on fetal growth, early neurodevelopment, and respiratory health. This paper summarizes results of three published studies demonstrating the effects of prenatal ETS, PAH, and pesticides on birth outcomes and/or neurocognitive development [Perera FP, Rauh V, Whyatt RM, Tsai WY, Bernert JT, Tu YH, et al. Molecular evidence of an interaction between prenatal environment exposures on birth outcomes in a multiethnic population. Environ Health Perspect 2004;12:630-62; Rauh VA, Whyatt RM, Garfinkel R, Andrews H, Hoepner L, Reyes A, et al. Developmental effects of exposure to environmental tobacco smoke and material hardship among inner-city children. Neurotoxicol Teratol 2004;26:373-85; Whyatt RM, Rauh V, Barr DB, Camann DE, Andrews HF, Garfinkel R, et al. Prenatal insecticide exposures, birth weight and length among an urban minority cohort. Environ Health Perspect, in press]. To evaluate the effects of prenatal exposure to ETS, PAHs, and pesticides, researchers analyzed questionnaire data, cord blood plasma (including biomarkers of ETS and pesticide exposure), and B[a]P-DNA adducts (a molecular dosimeter of PAHs). Self-reported ETS was associated with decreased head circumference (P = 0.04), and there was a significant interaction between ETS and adducts such that combined exposure had a significant multiplicative effect on birth weight (P = 0.04) and head circumference (P = 0.01) after adjusting for confounders. A second analysis examined the neurotoxic effects of prenatal ETS exposure and postpartum material hardship (unmet basic needs in the areas of food, housing, and clothing) on 2-year cognitive development. Both exposures depressed cognitive development (P < 0.05), and there was a significant interaction such that children with exposure to both ETS and material hardship exhibited the greatest cognitive deficit (7.1 points). A third analysis found that cord chlorpyrifos, and a combined measure of cord chlorpyrifos, diazinon, and propoxur-metabolite, were inversely associated with birth weight and/or length (P < 0.05). These results underscore the importance of policies that reduce exposure to ETS, air pollution, and pesticides with potentially adverse effects on fetal growth and child neurodevelopment.

Novel deletion mutations of the DAX1 (NR0B1) gene in two Taiwanese families with X-linked adrenal hypoplasia congenita

OBJECTIVE

To analyze the DAX1 (NROB1) gene in Taiwanese families with adrenal hypoplasia congenita.

PATIENTS AND METHODS

Two unrelated Taiwanese patients were followed up at our pediatric endocrine clinic. Both patients presented with adrenal crisis. One patient entered puberty spontaneously. However, arrest of puberty was noted in the following years and hypogonadotropic hypogonadism was confirmed by GnRH test. The other patient was still prepubertal. Sequencing of the DAX1 (NROB1) gene was carried out in both patients and their respective family members.

RESULTS

Two different novel mutations were identified. The first patient had one base (G) deletion at nucleotide 159, resulting in a frame-shift and a premature stop codon at position 84. The other patient had one base (G) deletion at nucleotide 831, leading to a frameshift and a premature stop codon at position 371. Family studies revealed that their mothers and sisters were heterozygotes for the mutations while their maternal grandmothers did not carry the mutations.

CONCLUSIONS

Two Taiwanese patients with adrenal hypoplasia congenita were detected to have novel mutations of the DAX1 (NR0B1) gene. Family studies suggested that such mutations resulted from de novo mutation of the DAX1 (NROB1) gene in their mothers. These data indicate that molecular analysis of the DAX1 (NR0B1) gene is important for the diagnosis and genetic counseling of children with primary adrenal insufficiency.

New simple tests for age-at-onset anticipation: application to panic disorder

Recently, testing for anticipation has received renewed interest. It is well known that standard statistical methods are inappropriate for this purpose due to problems of sampling bias. Few statistical tests have been proposed for comparing mean age of onset in affected parents with mean age of onset in affected children. All of them are difficult to compute and lack software to perform the tests. In this report, we formulate the problem in terms of symmetry tests. We propose a simple generalized paired t-test and a Wilcoxon signed rank test to adjust for the bias caused by the right truncation of both the parent's and child's ages at onset. We also extend the generalized paired t-test to a random effects model that enables analysis of correlated data from nuclear families, and could be further extended to larger family structures. We illustrate the approaches with an example of panic disorder.

Adult height of patients with classical congenital adrenal hyperplasia

BACKGROUND AND PURPOSE

Data on factors that affect the final height of patients with classical congenital adrenal hyperplasia (CAH) are limited. This study investigated the factors that can affect height outcome of patients with classical CAH.

METHODS

A retrospective study of 44 patients (16 males, 28 females) with classical CAH who had attained the adult height without gonadotropin-releasing hormone analog therapy was conducted. Adult height standard deviation scores (AHSDS) and target height standard deviation scores (THSDS) were determined. The impact of type, gender, control of disease activity or occurrence of precocious puberty on height was analyzed.

RESULTS

The difference between AHSDS and THSDS of the 44 patients was -0.7 +/- 1.0 and was greatest in simple-virilizing males (-1.1 standard deviation score [SDS]). However, no significant differences in height outcomes were identified between genders and types. The differences between AHSDS and THSDS of patients with good control of disease activity or normal puberty were -0.3 SDS and -0.4 SDS, respectively, which were better height outcomes than those of the other groups (p < 0.05).

CONCLUSIONS

Classical CAH can lead to reduced adult height. Good control of disease activity and the prevention of the occurrence of precocious puberty is important to achieving normal adult height outcome.

Effect of cordycepin on Hantaan virus 76-118 infection of primary human embryonic pulmonary fibroblasts--characterization of apoptotic effects

The cDNA microarray technique was used to study gene epression in human embryonic pulmonary fibroblasts (HEPF) infected with Hantaan virus (HTNV) under the influence of cordycepin (Cor), an inhibitor of post-transcriptional pre-mRNA polyadenylation. Four apoptotic genes, the insulin-like growth factor binding protein 1, NFkB inhibitor alpha, caspase-3 and NFkB1 were up-regulated in both infected and uninfected Cor-treated cells and two cell cycle-associated genes, CDC-like kinase and beta-induced transforming growth factor were up-regulated in Cor-untreated cells but down-regulated in Cor-treated cells. Cell morphology examination, quantitative RT-PCR, and immunofluorescence (IF) test suggested that following the Cor treatment the HTNV infection took place, but late viral gene expression was slightly reduced. Three parameters, namely caspase-3 activity, annexin V binding, and cell cycle were used to detect apoptosis. The results suggested that the induction of apoptosis in HEPF by HTNV started at 6 hrs post infection (p.i.). Following the Cor treatment, however, the caspase-3 activity began to increase at 24 hrs p.i. Thus it is suggested that inhibition of de novo late viral protein synthesis by Cor changes the apoptosis pathway and cell cycle by delaying caspase-3 gene expression and by up/down-regulating of expression of other apoptotic and cell cycle-associated genes. This implicates that HTNV can induce apoptosis in HEPF even without de novo viral protein synthesis and with a reduced and slowed viral maturation.

Physiological changes of adrenal androgens in childhood

BACKGROUND AND PURPOSE

To investigate the change in serum dehydroepiandrosterone sulfate (DHEAS) and androstenedione concentrations during childhood and to clarify the relationship between adrenarche and gonadarche.

METHODS

A cross-sectional study of 577 healthy children (297 boys and 280 girls), with ages ranging from 5 days to 12 years was conducted. After complete physical examination and recording of any sign of puberty, blood samples were drawn for the determination of serum DHEAS and androstenedione concentrations. For comparison, blood samples were also drawn from 39 normal adults, 23 men and 16 women.

RESULTS

In both genders, the DHEAS and androstenedione levels at birth were 3.0 +/- 1.3 mumol/L and 4.1 +/- 2.3 nmol/L, respectively. They fell rapidly within 6 months, and were maintained at a low level until 6 years of age. After the age of 6, the levels of both adrenal androgens were significantly increased (p < 0.05). Adrenarche occurred at the age of 7.7 +/- 1.1 years in boys and at the age of 7.7 +/- 1.0 years in girls. Gonadarche occurred at the age of 11.2 +/- 0.8 years in boys (n = 33) and at the age of 10.3 +/- 0.8 years in girls (n = 46). The onset of adrenarche occurred about 2 to 3 years earlier than the onset of puberty (p < 0.001).

CONCLUSIONS

Serum levels of adrenal androgens change dramatically during childhood. Serum concentration of DHEAS is a good marker for adrenal androgens production because gonadal androgens may interfere with serum concentration of androstenedione. For Taiwanese children, the onset of adrenarche occurred between the ages of 6 and 8 years, which was 2 to 3 years earlier than the onset of puberty.

Reversible mitral valve prolapse and mitral regurgitation in children with Graves' disease

An association between mitral valve prolapse (MVP) and hyperthyroidism has been described in adults. However, the long-term prognosis when associated with significant mitral regurgitation remains unclear. Three consecutive children with Graves' disease were found to have a loud mitral regurgitation murmur (grade III/VI) and echocardiographic evidence of MVP with moderate mitral regurgitation. The cardiac manifestations included palpitations, exertional dyspnea, and exercise intolerance. The electrocardiograms at presentation were sinus tachycardia in all cases. All had hyperthyroidism and positive thyroid antibodies. Exophthalmos occurred in two and appeared later than the cardiac symptoms in one. The cardiac murmur disappeared in all patients when antithyroid agents controlled the hyperthyroidism. Follow-up echocardiography showed normal in one and MVP with mild mitral regurgitation in two. We conclude that MVP and significant mitral regurgitation can occur in children with hyperthyroidism, especially those with Graves' disease. The prognosis is good after adequate medical control of the hyperthyroidism.

Seasonal and diurnal variations of volatile organic compounds (VOCs) in the atmosphere of Hong Kong

Ambient VOCs samples were collected at three locations (PolyU campus (PU), Kwun Tong (KT), Hok Tsui (HT)) in Hong Kong during the periods of November 2000-February 2001 and June 2001-August 2001. Also the concentrations of VOCs in Cross Harbor tunnel in Hong Kong were obtained in order to determine the vehicular sources of VOCs. Toluene was the most abundant VOC detected in Hong Kong. At the PU station, which is close to a main road, the concentrations of most VOCs were higher in summer than in winter. However, at the background location HT, the concentrations of all VOCs except tetrachloroethene were higher in winter than in summer. Regional physical dispersion/transportation and mixing depth may be the reasons for higher VOC concentrations in winter at HT. The BTEX (benzene:toluene:ethylbenzene:xylene) ratios of PU and KT during winter period were (1.9:10.1:1.0:1.8) and (1.9:10.4:1.0:1.5), and (0.9:8.3:1.0:2.2) and (0.8:29.6:1.0:1.8) for summer season, respectively. The xylene/ethylbenzene (X/E) ratio was used to assess the relative age of the air parcels in this study. The concentrations of VOCs in the atmosphere in Hong Kong were mainly affected by direct emissions from vehicles, evaporation of fuels, photochemical reactions and few industrial emissions. The BTEX ratio in the tunnel was 2:10.4:1:3.2. The BTEX ratios at PU and KT during the winter period were similar to that in tunnel (except for xylenes). The X/E ratio in the tunnel was higher than that in the ambient air. This indicated that the freshly emitted xylenes in the tunnel decayed at different rates from OH-oxidation in the atmosphere. Good BTEX correlations (r>0.8) were found at PU and KT in winter (**P<0.01). Vehicular exhaust was the dominant source at PU and KT stations, and less evaporation of fuel or additive occurred at low temperature in winter. Diurnal variations of mean BTEX concentrations at the roadside monitoring station (PU) showed two peaks associated with traffic density and vehicle type.

Arachnoid cyst with GnRH-dependent sexual precocity and growth hormone deficiency

The coexistence of gonadotropin-releasing hormone (GnRH)-dependent sexual precocity and growth hormone deficiency in patients with arachnoid cysts is rarely reported, and its pathogenesis is not well recognized. This report describes an 11-year-old female who had a huge intracranial arachnoid cyst with initial symptoms and signs of sexual precocity. Her brain magnetic resonance imaging revealed distorted hypothalamus with a thin and stretched pituitary stalk. After treatment with cysto-peritoneal shunting and gonadotropin-releasing hormone analogue, her puberty was arrested and subnormal growth rate was observed. Catch-up growth was detected after growth hormone therapy. Hence, coexistence of gonadotropin-releasing hormone-dependent sexual precocity and growth hormone deficiency in this patient was confirmed.

Hypopituitarism associated with neurofibromatosis type 1: report of one case

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder with a wide range of clinical manifestations. Hydrocephalus unrelated to brain tumors is rare in neurofibromatosis type 1. A 16-year-and-6-month-old girl with primary amenorrhea was found to have hydrocephalus associated with neurofibromatosis type 1. After endocrine and brain imaging study, the cause of primary amenorrhea was proven to be hypopituitarism due to hydrocephalus. She entered puberty soon after relieving the hydrocephalus with a ventriculoperitoneal shunt. However, arrest of puberty was noted three months later. Therefore estrogen replacement therapy was given. Early detection of hydrocephalus was difficult in this patient. From the experience of our case, MRI study of brain is indicated in patient with neurofibromatosis type 1 and endocrine dysfunction.

Permanent neonatal diabetes mellitus manifesting as diabetic ketoacidosis

Neonatal diabetes mellitus (NDM) is a very rare disease defined as hyperglycemia that occurs during the first month of life, requires insulin treatment, and lasts more than 2 weeks. There are 2 types of NDM: permanent neonatal diabetes mellitus (PNDM) and transient neonatal diabetes mellitus (TNDM). We report a case of PNDM in a 3-day-old female infant. This full-term neonate was born small for gestational age. Respiratory distress, poor activity, hypothermia, poor feeding, dehydration, and ketoacidosis were noted at the age of 3 days. After insulin therapy and fluid replacement, her condition became stable. Glucagon test done at the age of 26 days showed serum C-peptide level to be low for her age. During the first year of life she had catch-up growth, but insulin therapy was still required. Serum C-peptide level was undetectable at the age of 15 months. The course of this case indicates the importance of a high index of suspicion for patients with PNDM in order to correct metabolic derangement as early as possible and facilitate normal growth and development under insulin therapy.

Methimazole-induced lupus erythematosus: a case report

A 15-year-old girl had a history of diffuse goiter and received methimazole treatment 2 months before admission to the hospital. She developed bilateral lower leg edema 5 days before admission and the laboratory examinations revealed leukopenia, anemia, proteinuria, and granular cast. Positive antinuclear antibodies and anti-double strand (anti-ds) DNA antibodies were noted, although complement levels were not reduced. Myeloperoxidase antineutrophil cytoplasmic antibody was positive. A renal biopsy disclosed that there was focal segmental glomerulosclerosis. Methimazole was discontinued, and she was treated with prednisolone and Plaquenil, after which the symptoms and laboratory tests became normal within 40 days. The prednisolone was discontinued after treatment for seven months. Currently, the anti-dsDNA, C3, C4, CBC, urinalysis, and thyroid function tests are within normal limits. With hydroxychloroquine and levothyroxine, she was free of symptoms after discontinuation of methimazole until now (about 21 months).

Oral clodronate therapy for hypercalcemia related to extensive subcutaneous fat necrosis in a newborn

Hypercalcemia is occasionally found in newborns with subcutaneous fat necrosis and carries potential life-threatening risk. Bisphosphonates have been recently introduced in the treatment of subcutaneous fat necrosis in newborns. We report a case of extensive subcutaneous fat necrosis in a female infant complicated with intractable hypercalcemia. Standard treatment for hypercalcemia was given, including saline hydration, a low calcium diet, furosemide, and glucocorticoid, but without response. Serum 1,25-dihydroxyvitamin D level was elevated at 126 pg/mL, 25-hydroxyvitamin D level was normal, and intact parathyroid hormone was suppressed at < 1 pg/mL. Oral clodronate disodium, a second-generation bisphosphonate, was administered, and resulted in the normalization of serum calcium, urine N-telopeptide, urine calcium/creatinine ratio, and serum intact parathyroid hormone level. This case suggests that oral clodronate may be an effective treatment for subcutaneous fat necrosis with hypercalcemia in newborns.