[Sheehan's syndrome: experience in Africa]

Ischemic necrosis of the antehypophysis is still observed in developing countries. Its prevalence is unknown, but a significant number of the patients are young women. Traditions of home delivery and lack of obstetrical facilities are the main risk factors. The clinical manifestations are often quite typical but atypical signs including neuropsychiatric ore water metabolism disorders are observed. The delay to onset of overt disease can be very long. Ischemic necrosis of the antehypophysis should be entertained as a possible diagnois in women with hypopituitarism.

Hypopituitary females have a high incidence of cardiovascular morbidity and an increased prevalence of cardiovascular risk factors

We recently reported that female patients with hypopituitarism receiving controlled thyroid and steroid hormone substitution, but without GH replacement, had a more than 2-fold increase in cardiovascular mortality compared to the general population. In the present study we investigated the incidence of cardiovascular disease as well as the prevalence of cardiovascular risk factors in 33 females with hypopituitarism for 6-46 yr (median, 18) compared to those in 33 control subjects recruited from the general population in the same geographical area and matched for sex, age, smoking habits, educational level, and residence location. The patients were with a very high probability GH deficient, as 29 had subnormal serum insulin-like growth factor I levels, and the other 4 were GH deficient, as assessed by an insulin tolerance test. The incidence of cardiovascular disease was significantly higher among the hypopituitary patients (incidence ratio, 3.7; 95% confidence interval, 1.2-11.3), and the consumption of cardioactive drugs was also significantly higher (P = 0.002). Hypopituitary patients had a lower degree of physical exercise during their spare time (P = 0.02), a higher waist/hip ratio (P = 0.01), lower high density lipoprotein cholesterol (P = 0.002), and higher low density/high density lipoprotein ratio (P = 0.009). Furthermore, the patients had a significantly increased left atrium size (P = 0.05), but no difference was observed for other cardiac measures. In the patients, serum insulin-like growth factor I levels significantly correlated with left ventricular mass index (r = 0.48; P = 0.006), suggesting that GH has a strong impact on cardiac size. More episodes of bradycardia (P = 0.05), but no increased occurrence of extrasystolies, were encountered in the patients during 24-h continuous electrocardiogram monitoring. Carotid artery intima-media thickness and plaque numbers did not differ between patients and controls. In conclusion, hypopituitary females exhibit an increased incidence of cardiovascular disease, higher cardioactive drug consumption, and an increased prevalence of cardiovascular risk factors. The increased cardiovascular morbidity could not be ascribed to inadequate estrogen or thyroid hormone treatment, and unsubstituted GH deficiency is probably an important contributing factor.

Pituitary dysfunction, morbidity and mortality with congenital midline malformation of the cerebrum

The purpose of this study was to review systematically a series of patients with congenital midline brain defects and pituitary dysfunction in early childhood and to quantitate the degree of dysfunction and clinical outcome. This study was a retrospective analysis of case notes of patients with pituitary dysfunction associated with either a midline cerebral anomaly and/or optic nerve hypoplasia. Forty patients were studied: 2 with semilobar holoprosencephaly, 2 with lobar holoprosencephaly, 18 with septo-optic dysplasia with an intact septum pellucidum, 7 with septo-optic dysplasia with an absent septum pellucidum, 7 with agenesis of the corpus callosum and 4 patients with isolated pituitary hypoplasia. An early age of diagnosis, feeding difficulties, neurodevelopmental disability, visual impairment and seizures were common occurrences. Despite disordered neuro-anatomy, most seizure disorders were caused by hypoglycaemia or hypernatraemia. Hypotensive/hypoglycaemic crises accounted for two out of three deaths within the study population. Most of patients had multiple pituitary hormone deficiency with growth hormone and adrenocorticotrophic hormone deficiency occurring most commonly. Unequivocal isolated hypothalamic dysfunction was an uncommon finding. In congenital midline brain malformation there is a spectrum of disordered neuro-anatomy associated with variable pituitary dysfunction. Clinical manifestations such as convulsions and developmental delay may be due to disordered metabolism and/or neuro-anatomy.

CONCLUSION

Children with congenital midline brain defects frequently manifest convulsions, neurodevelopmental disability and poor growth due to disordered metabolism and/or neuro-anatomy. Treating clinicians must be aware of the complex, dynamic neurological and metabolic nature of these patients and their potential for early demise.

Optic nerve hypoplasia with posterior pituitary ectopia: male predominance and nonassociation with breech delivery

PURPOSE

To determine whether posterior pituitary ectopia in children with optic nerve hypoplasia has a male predominance or an increased incidence of breech delivery.

METHOD

Retrospective analysis of 12 children with optic nerve hypoplasia and posterior pituitary ectopia.

RESULTS

Eleven of 12 patients with posterior pituitary ectopia were boys. No child had a history of breech delivery. Two children had a history of breech positioning but were delivered by cesarean section.

CONCLUSION

Posterior pituitary ectopia with optic nerve hypoplasia shows a strong male predominance but no association with breech delivery.

Role of radiation therapy in clinical hormonally-active pituitary adenomas

BACKGROUND AND PURPOSE

The outcome following radiation therapy (RT) of hormonally-active pituitary adenomas was assessed. The purpose of this analysis was to determine the control rate after radiation, identify any prognostic factors and evaluate the late toxicity.

MATERIALS AND METHODS

From 1972 to 1986, 145 patients received RT for hormonally-active pituitary adenomas. The median age was 39 years (range 15-76), with 81 males and 64 females. There were 52 patients with acromegaly, 64 with prolactinoma, and 29 with Cushing's disease. The median follow-up was 7.3 years. RT was given as primary treatment in 17 patients, after initial surgery in 65 patients, and as part of salvage therapy in 63 patients. The median total dose was 50 Gy (daily fraction: 2 Gy). Tumor control was defined as normalization of basal hormonal level and lack of progression of adenoma assessed by imaging studies. The following factors were analyzed for prognostic significance in tumor control: age, sex, tumor type, direction of tumor extension, radiation dose, and radiation field size.

RESULTS

The 10-year actuarial proportion of patients with persistent elevated hormone level were 61% following RT alone, and 44% with the addition of medical management. The progression-free rate was 96% at 10 years. Of the 20 deaths, three patients died with uncontrolled pituitary adenoma and three died of treatment complications. The actuarial 10-year overall and cause-specific survival rates were 86% and 97%. The actuarial rates of radiation-induced hypopituitarism were 35%, 22% and 22% at 10 years for thyroid, glucocorticoid and gonadal functions, respectively. None of the factors examined were found to be significant predictors of tumor control.

CONCLUSIONS

Post-operative external beam RT is highly effective in preventing recurrence of space-occupying effects of hormonally-active pituitary adenomas. However, long-term biochemical remission is observed only in approximately 40% of patients (at 10 years), with an additional 20% requiring medical therapy. Malignancies of the CNS can develop as an infrequent late event.

Psychiatric Morbidity in Adults with Hypopituitarism

Forty-one adults with established hypopituitarism and deficiency of growth hormone (GHD) were compared to an age and sex-matched group with another chronic metabolic disorder (diabetes mellitus) using standardized psychiatric rating and diagnostic measures. Nineteen (46%) of the GHD group were identified as definite psychiatric cases compared with 10 (24%) of the diabetics (odds ratio 1:9:1). The most frequent DSM III-R axis I psychiatric diagnoses were major depression (32% GHD patients and 10% of diabetic patients) and dysthymia. The risk of being a psychiatric case showed an association with duration of illness in the diabetic group, but not in the GHD group. Biochemical indices were not related to the risk of being a case in either group. Hypopituitarism is associated with a higher prevalence of psychiatric disturbance than can be attributed solely to the presence of a chronic disorder.

Sheehan's syndrome in a developing country, Nigeria: a rare disease or problem of diagnosis?

Over a five year period, 11 cases of Sheehan's syndrome were seen in the Endocrinology Unit of a teaching hospital in Ibadan, Nigeria. The mean age at diagnosis was 35.1 years; the mean parity was four and the average interval between the obstetric injury and diagnosis was 6.9 years. Four patients were in middle socio-economic class and seven were in low socio-economic class. The most frequent presenting symptoms were failure of lactation (11 out of 11 patients) and amenorrhoea (9 out of 11 patients). Seven patients had multiple endocrine insufficiency involving essentially all pituitary cell types. Six out of 8 patients were lost to follow-up. In a review of autopsy records over a 5-year period at the same institution, out of 1,951 post-mortem examinations, no additional cases of Sheehan's were found. With an average of about two clinical cases per year, it would seem that Sheehan's syndrome is still a relatively rare entity in this part of the world in spite of the poor level of obstetric care generally available. There is a need for increased awareness about this disease on the part of practitioners in developing countries in order to establish whether this rarity is real or it is due to missed diagnosis.

Epidemiologic survey of patients treated with growth hormone in France in the period 1959-1990: preliminary results

Because the delivery of growth hormone (GH) was centralized from 1977 in France, it has been possible to conduct, during the second half of 1990, a nationwide survey of the health status of patients treated with GH from the year 1959. A questionnaire regarding the 5,546 patients recorded for the period 1959-1990 was sent to the prescribers or the patients. 5,418 more or less completely documented reports were obtained. The mean age of the patients at the onset of GH treatment was 11.0 +/- 4.1 years. 1,937 of them had at this time some important disease associated with GH deficiency. The mean duration of treatment was 3.99 +/- 3.05 years. 3,446 patients were still under follow-up. Very recent information (1990-1991) was given for 82.7% of patients, less recent data (1985-1989) for 13.4%. For 3.9%, no data beyond 1985 were obtained. 77 patients had died, 38 from neoplastic disease (mainly recurrence of a primary malignancy), 10 from accident, 3 by suicide, 7 with neurological disease [only 1 case of Creutzfeldt-Jakob disease (CJD) was reported at the time of the survey], the others from various causes. No abnormal frequency of posttreatment leukemia, lymphoma, malignancies, hip diseases, glucose intolerance or other disease focusing attention, was found in the survey. From the time when this survey was completed (December 1990) to that of this report (May 1992), other cases of CJD have been reported in France: 3 ascertained, 7 clinically resembling but not yet certain. These 10 patients were treated for complete GH deficiency, 6 of congenital or neonatal cause and 4 after neurosurgery.(ABSTRACT TRUNCATED AT 250 WORDS)

An apparent cluster of congenital hypopituitarism in central Massachusetts: magnetic resonance imaging and hormonal studies

Between 1980 and 1989, five infants (four males and one female) with congenital hypopituitarism were born within a relatively sparsely populated area of central Massachusetts, an incidence 25-fold greater than expected. In all infants the pituitary stalk was undetectable on magnetic resonance imaging, and a bright spot on T-1 weighted imaging, probably representing posterior pituitary tissue, was found ectopically located inferior to the median eminence. The height of the anterior pituitary remnant on magnetic resonance imaging varied from undetectable to 4 mm, and similarly, on hormonal testing a spectrum of deficiencies of GH, TSH, ACTH, and gonadotropin was observed. The magnitude of the hypopituitarism was less in the three patients whose anterior pituitary remnant was greater than 2 mm, and in them, TRH testing resulted in exaggerated TSH and PRL responses, suggestive of hypothalamic disease. In contrast, in the other two patients in whom the anterior pituitary remnant was less than 2 mm in height, hypopituitarism was more severe, and TRH administration resulted in little if any TSH or PRL response, characteristic of pituitary disease. The size of the anterior pituitary remnant correlated significantly with that of the ectopic posterior pituitary bright spot (P less than 0.005). We conclude that patients with congenital hypopituitarism may exhibit a spectrum of hormonal responses, varying from findings typical of hypothalamic to those characteristic of primary pituitary disease. The pattern of hormonal responsiveness is dependent on the quantity of residual anterior pituitary tissue and probably results from abnormal transport of the hypothalamic hypophyseal releasing hormones rather than to any putative hypothalamic abnormality. The significant correlation between the size and function of the anterior pituitary gland and the size of the ectopic posterior pituitary remnant suggests that the fetal pituitary gland may secrete a factor necessary for the growth and descent of the neuroepithelium to form the infundibulum and posterior pituitary gland.

[Endocrine diseases at the National Hospital of Niamey (Niger). Apropos of 195 cases]

The authors report 195 cases of endocrine diseases diagnosed in a department of internal medicine at the National Hospital of Niamey (Niger) from January 1982 to December 1986. Diseases of the thyroid gland were largely predominant (70.8%), with simple (34.9%) and nodular (19%) goiters. Hypothyroidism and thyroiditis were not frequent (2 and 2.6%, respectively). The rarity of thyroid cancers (1%) was in relation to the direct hospitalization of these patients in the surgical department. They were not included in this study. In spite of the magnitude of tuberculosis endemicity in Niger, primary adrenocortical deficiency (Addison's disease) was absent. The frequency (15.4%) of postpartum hypopituitarism (Sheehan's syndrome) is explained by sahelian customs: a great majority of African women delivered at home without medical assistance.

Neonatal hypopituitarism: a neurological perspective

Twelve patients presented with evidence of hypopituitarism in the neonatal period, but only four were correctly diagnosed at that time. Craniofacial, optic and neurological features were common. Optic hypoplasia occurred in six cases, large anterior and posterior fontanelles in four, wide sutures in four, depressed nasal bridge in three, facial palsy in three, and one infant had an asymmetrical, crying facies. Seizures occurred in three during the neonatal period and in eight at a later age. All 12 had hyperbilirubinaemia, 11 had hypoglycaemia, and micropenis occurred in five of the seven boys. This survey suggests that the incidence of neonatal hypopituitarism may have increased.

Growth hormone deficiency: a hidden obstetrical trauma?

Fetal presentation, mode of delivery and onset of labour were reviewed in 177 patients with documented growth hormone deficiency. Non-cephalic presentations were about ten times more frequent in this group of patients than in a control population. All children with breech position were delivered vaginally and spontaneously, suggesting a pituitary insult during vaginal delivery. 'True idiopathic' isolated growth hormone deficiency was frequently found in association with induction of labour. The data indicate that even a mild birth trauma may result in growth hormone deficiency.

[Sheehan syndrome in the Republic of Niger. 19 cases]

From February 1983 to December 1985, the authors investigated 19 african women with Sheehan's syndrome in Niamey (Republic of Niger). A 15 points diagnostic score was systematically used. Two signs were indispensable for the diagnosis: post-partum agalactia (or severe hypogalactia) and amenorrhea. At least 9 points score was found for every case. Eighteen patients lived along a major road in Niamey and in Dosso departments. The prevalence of this disease is probably important but many cases were not diagnosed since there was no medical examination. Sheehan's syndrome was predominantly diagnosed among Fulani women. Young women (mean age: 26 years) in intensive sexual life, primiparous (8/9) or multiparous (11/19) were concerned. Emergence circumstances of signs were: childbirth at home (18/19), severe vaginal bleeding at placental birth (14/19), rare transfusions (2/19). The infant of a mother with Sheehan's syndrome had a poor prognosis: 9 deaths among 11 deliveries for multiparous, 7/8 for monoparous. The infants were stillborn or more often dead during the first months. Deaths were in relation to absence of maternal lactation. For the primiparous, then infertile women because of hypopituitarism, the repudiation becomes often the only social way of life. Lasting hormonotherapy was not available because 18/19 patients were very poor. Prevention is not possible before long, especially in primiparous, because of: the mentality: the first delivery at home with the mother is the traditional habit; the importance of the required measures.

Detection of congenital hypopituitary hypothyroidism: ten-year experience in the Northwest Regional Screening Program

We examined the results of the Northwest Regional Screening Program (NWRSP) over its first 10 years to determine whether the detection of hypopituitary hypothyroidism is a justified advantage of the primary thyroxine (T4)-supplemental thyroid-stimulating hormone (TSH) screening strategy, and to determine whether all such infants will be detected by this screening approach. Between May 1975 and May 1985, the NWRSP screened 850,431 infants, detecting 192 infants with primary hypothyroidism (1:4429) and eight with hypopituitary hypothyroidism (1:106,304). In 11 additional infants, TSH deficiency, not detected by the screening program, was diagnosed on recognition of clinical features over the same period. Thyroid hormone treatment was begun in seven of the 11 infants prior to obtaining the screening sample results because of clinical symptoms of hypopituitarism, including hypoglycemia, persistent jaundice, microgenitalia, diabetes insipidus, midface hypoplasia, cleft lip or palate, or abnormalities of vision. The other four infants were not detected despite clinical features of hypopituitarism (in retrospect) and low serum T4 with TSH concentration below assay sensitivity on at least one screening sample. The most accurate assessment of total cases comes from Oregon, where all cases of congenital hypopituitarism are referred to our center; we estimate a frequency of 1:29,000. In our experience, a combination of newborn T4-supplemental TSH screening measurements and recognition of clinical features of hypopituitarism is the optimal strategy for detecting infants with congenital hypopituitary hypothyroidism.

Treatment of prolactinoma based on the results of transsphenoidal operations

Ninety-eight patients (16 male, 82 female) with prolactinomas were treated by transsphenoidal operation. The postoperative course was closely related to the tumor size and the preoperative levels of serum prolactin. In 37 (74%) of 50 patients with microadenomas, the levels of serum prolactin returned to normal postoperatively. There were 48 patients with macroadenomas; 27 of these were expansive and 21 were invasive. In 9 (33%) of the 27 patients with expansive macroadenomas, the postoperative levels of prolactin returned to normal; this was not the case in any of the 21 patients with invasive macroadenomas. Of 81 premenopausal women, 35 (43%) resumed normal menstruation postoperatively. All patients with preoperative deficits in the visual field experienced postoperative improvement. There were no postoperative deaths or serious complications in this series. Our data indicate that microprolactinomas are highly curable by transsphenoidal operation alone. In women who plan to have children, prolactinomas should be removed immediately. On the other hand, in patients with macroprolactinomas who manifest high levels of serum prolactin, initial treatment with bromocriptine should be considered because there is little hope for surgical cure and postoperative bromocriptine treatment might be necessary.

[Contribution to the study of endocrinopathies in black Africans (author's transl)]

For a long time endocrine pathology was unrecognized or even denied to exist in Black Africans, but this is not true. It seems to be recognized more frequently since medicalization has increased. This pathology does not present any particularities. Hyperthyroidism appears frequently, at least in urban areas. A series of 87 personal cases has permitted a review of the principal clinical and biological aspects; myasthenia seems to be particularly important; radical treatment is preferred over prolonged medical treatment which is not within the financial possibilities of our patients. There have been 30 observations of cortico-adrenal anomalies of which 7 known personally. It must be noted that the Black living in his traditional rural environment presents a certain degree of physiological hypocorticism with respect to whites and especially Blacks of higher social standing. Pathological hypocorticism is essentially due to tuberculosis; the melanodermia is evident to an alert observer. Metabolic hypercorticism produces the usual manifestations. Only 9 cases of Sheehan syndrome have been reported (5 personal). In the Black African woman, it appears earlier than in Europe often due to premature nuptiulity and the higher incidence of tachyparity. One is surprised that this syndrome is detected so rarely; it is, without a doubt, often well tolerated during a long period of time therefore goes undetected.

[A study on the incidence of post-partum hypopituitarism, (Sheehan's syndrome)]

The frequency of post-partum hypopituitarism (Sheehan's syndrome) is difficult to assess. It is the purpose of this paper to ascertain the incidence of post-partum hypopituitarism in Okayama Red Cross Hospital. Out of 19,302 women who delivered at the hospital during 10 years from 1961 to 1970, we selected 1.010 women who had a blood loss of 500 ml. or more at delivery. Firstly, after having sent the selected women a questionnaire by post, we investigated whether they had Sheehan's syndrome or not from the response of the 392 women who replied to the questionnaire. Secondly, 126 of the 392 women who came to our clinic when requested were examined concerning blood picture, fasting blood glucose, and the serum levels of cholesterol, thyroxine, cortisol, GH, TSH, LH and FSH. As a control, 24 women who had had a normal delivery were examined as described above. No advanced hypopituitarism or mild hypopituitarism was found in this follow-up study. Compared with Sheehan's series in England, it was found the incidence of post-partum hypopituitarism in Okayama was presumably less than in England. Suggestions for this discrepancy are as follows: (1) competent obstetric care and a rapid blood transfusion after gross post-partum hemorrhage in Okayama Red Cross Hospital. (2) an incomplete report of the incidence of post-partum hypopituitarism due to those who did not reply to the questionnaire. (3) the rarity of the frequency of Sheehan's syndrome in Japan.