Hyporeninemic hypoaldosteronism in infancy: a familial disease

Hyporeninemic hypoaldosteronism was found in two male siblings with urinary salt wasting and low plasma sodium levels. The eldest, aged 1 yr, had growth retardation, with hyponatremia and normal plasma potassium levels. The second, aged 2 months, had low plasma sodium and high plasma potassium levels. Both were severely and repeatedly hypoaldosteronemic. Primary adrenal deficiency was excluded by ACTH testing, which showed a good aldosterone rise and normal responses of other steroids. Both children had low PRA compared to that in age-matched normal subjects. The eldest sibling also had decreased total renin, low inactive to total renin ratio, and a subnormal level of angiotensinogen. The father had low plasma angiotensinogen levels. Congenital deficiency of renin activity and/or angiotensinogen production is suggested as the primary abnormality.

Plasma growth-promoting activity measured as thymidine activity in constitutionally short children

Growth-stimulating activity of plasma was measured, both as thymidine activity using a lymphocyte bioassay and as sulfation activity using a cartilage bioassay, in 72 constitutionally short children aged 1-6 years and 38 age-matched controls. Plasma transferrin was also measured. No significant differences were found between the two groups. However, short children aged 1-3 years did not have higher thymidine activity than children aged 4-10 years, whereas in normals the thymidine activity was significantly higher in the first years of life. Thymidine activity was lower in female than in male constitutionally short children.

[Neonatal Basedow's disease with premature craniosynostosis and stenosis of the aqueduct of Sylvius]

Newborn from mother with untreated Graves' disease, born with thyrotoxicosis and exophthalmia, treated with carbimazole from age 6 weeks. At age 8 months, persisting hyperthyroidism requiring the continuation of treatment, and premature craniosynostosis with dilatation of cerebral ventricles suggesting a stenosis of the aqueduct of Sylvius.

Glucose metabolism in hyperinsulinemic infants: the effects of fasting and sodium DL-beta-hydroxybutyrate on glucose production and utilization rates

Glucose metabolism was investigated in four infants aged 3-32 months with persistent hypoglycemia and hyperinsulinism of neonatal onset. Fasting hypoglycemia was found to be due both to an insulin-induced decrease in hepatic glucose output to 3.95 +/- 0.30 (SEM) mg/kg X min, a value about two thirds of normal, and to a glucose utilization rate of 4.25 +/- 0.32 mg/kg X min, which exceeded glucose production by about 8%. Simultaneously, and despite hypoglycemia, fasting plasma D-beta-hydroxybutyric acid concentrations were inappropriately low: 406 +/- 146 microM, presumably the result of elevated circulating insulin levels. The infusion of sodium DL-beta-hydroxybutyrate resulted in an increase of plasma glucose (48 +/- 7 vs. 32 +/- 7 mg/dl, P less than 0.01) and lactate (1704 +/- 217 vs. 964 +/- 149 microM, P less than 0.005), without detectable changes in insulin secretion estimated from circulating C-peptide values. Unexpectedly, the increase of plasma glucose was due to the restoration of glucose production up to 6.7 +/- 0.2 mg/kg X min. The individual increments of plasma lactate and glucose production rate were linearly correlated (P less than 0.01). These results together with the known inhibitory effect of ketone bodies on pyruvate dehydrogenation, suggest both increased production of lactate from peripheral recycling of glucose carbon and an increased conversion of this gluconeogenic precursor into glucose.

[Precocious puberty in boys. Study of a series of 34 cases]

Thirty-four boys with true precocious puberty were observed: In 28, precocious puberty was related to intracranial causes (17 tumors, 11 other lesions), in 3, it was due to extrapituitary gonadotropin-secreting tumors and in 3 it appeared idiopathic. The clinical development of sex characteristics was slower than the advance of bone age and the increase in hormone levels (plasma testosterone and pituitary gonadotropin reserve as measured by the LH-RH test). Cyproterone treatment seemed more effective than medroxyprogesterone, with respect to both sexual development and evolution of the bone age/height age ratio or the predictable adult height.

Prolactin and thyrotrophin responses to thyroliberin (TRH) in patients with growth hormone deficiency: study in 167 patients

Both thyrotrophin (TSH) and prolactin (Prl) were studied under thyroliberin (TRH) stimulation tests in 167 hypopituitary dwarfs out of GH or T4 treatment. TSH and/or Prl responses were either low, normal or exaggerated and/or protracted. Various abnormal patterns were observed in most of the patients with low T4 but also in many patients with normal T4. The TSH response should be considered together with the value of T4. A normal response of TSH with a low T4 reflects a relative TSH deficiency from pituitary or hypothalamic origin. There was no clear relationship between the cause or type of hypopituitarism and the pattern of the responses of either TSH or Prl. The abnormalities of TSH and Prl were not related to each other except in patients with a past history of breech delivery. Then both TSH and Prl have to be measured after TRH in order to obtain full information from the test about hypothalamo-pituitary function. The frequency of the exaggerated and/or delayed or protracted responses of TSH and Prl with normal or low T4 is probably mostly related to hypothalamo-pituitary dysfunction. Abnormal responses of TSH or Prl, seldom of both hormones, were observed in otherwise isolated growth hormone (GH) deficiency, leading to a modification of such a diagnosis after the TRH test. Actually, the TRH test may be useful to ascertain the diagnosis of GH deficiency when the GH responses to provocative tests are borderline.

[Isolated breast prematurity in young girls]

The clinical and follow-up data of the isolated premature thelarche are reviewed in a series of 61 girls aged 6 months to 6 years. Transitory increase of plasma estrogens was observed in some cases. The results of LHRH test were similar to those from normal girls of the same age. Premature thelarche could be a normal variant in girls, related with the physiologic unsteadiness of the prepubertal female pituitary-gonadal axis.

[Isolated hypothyroid dwarfism. Study of 18 cases]

Isolated hypothyroid dwarfism is defined by growth retardation without other clinical symptoms or signs of thyroid insufficiency. This study reports 18 cases: 6% of a series of cases of hypothyroidism in childhood. The main features are: mean bone age lower than height age; low plasma thyroxine in 16 patients, definitely low triiodothyronine in one only, high plasma TSH in all cases, with exaggerated response to TRH stimulation test; enlarged sella turcica in 11 patients. The thyroid gland was ectopic in 14 patients, the 4 others had a thyroid in normal place. Treatment with thyroid hormones sharply increased the growth velocity and the bone maturation. However its delay did not allow to obtain a complete catch-up of height.

[Treatment of congenital hypothyroidism by L-thyroxine in solution. Posology]

A solution of levothyroxine (5 micrograms/drop) has been used in congenital hypothyroidism detected after neonatal screening. Optimal doses were variable among individual patients. With 5-7 micrograms/kg during the first month of treatment, then 4 to 5 micrograms/kg, it was usually possible to obtaining normal plasma T4, which seems more important that to normalize TSH. Overdosage is to be avoided as well as insufficiency of treatment.

Growth hormone response to thyrotropin-releasing hormone and oral glucose-loading tests in tall children and adolescents

The effects of TRH and oral glucose loading on the release of GH were investigated in 10 children or adolescents with constitutional tall stature. Eight of these children had a family history of above average height. The mean (and SEM) baseline GH levels (3.12 +/- 2.0 ng/ml) were similar to those in control subjects. Somatomedin activity, measured by sulfate incorporation into chick embryo cartilage, was elevated. Oral glucose loading caused an early significant increase in plasma GH at 30 min in 2 of these subjects and a late rise at 180 min in 4 others. Intravenous injection of synthetic TRH (0.2 mg/m2) caused a marked increase in plasma GH (17 +/- 3.0 ng/ml) in 7 of the 10 patients; the peak of GH was observed within the first hour after the injection of TRH in 3 cases, while a later peak was observed in the second hour after injection in 4 others. Peak plasma PRL (47 +/- 3.8 ng/ml) and TSH (20 +/- 1.2 microU/ml) levels in response to TRH were normal. These results suggest a disorder of hypothalamo-pituitary regulation of GH secretion in certain children with apparently constitutional tall stature. Similar findings in a probably preacromegalic girl are reported.

Results of early treatment of cryptorchidism with human chorionic gonadotropin

One hundred and fifty-three children with common cryptorchidism, 109 unilateral and 44 bilateral, excluding those with associated malformations or abnormalities, were treated at age 6 to 59 months with human chorionic gonadotropin given as nine intramuscular injections on alternate days. Treatment before age 3 years resulted in complete failure in 81%. At 3 to 4 years of age treatment resulted in failure in 55%, but 19% of the patients showed complete testicular descent and 26% showed partial descent. The percent of failures was increased when the dose of human chorionic gonadotropin was lower than 1,000 IU/m2 injection and when the cryptorchid testis was very high. No correlation was found between endocrine data and the clinical results. The plasma testosterone concentration after the third injection of human chorionic gonadotropin was not significantly different in successfully and unsuccessfully treated patients. However, testosterone levels were significantly lower in patients treated at 36 to 59 months of age than in those treated at an earlier age, in contrast to the significantly better clinical results obtained in the older group. Thus human chorionic gonadotropin is not a valuable means of obtaining descent of undescended testes before age 3 years and is of limited usefulness at age 3 to 4 years.

[Goiter due to accidental poisoning with lithium. A propos of a case]

A case of goiter in a 8 year-old child is reported. It resulted from a protracted treatment with lithium at high daily dose. The blood level of lithium was very high. Blood iodine and thyroid hormones were normal. This fact points out the importance of careful anamnestic investigation.

[Investigation of delayed puberty]

Delayed puberty is defined as the total or almost total absence of development of sex characteristics at an age exceeding the mean by two standard deviations: approximately 15 years in boys and 13 years in girls. A double sense has been given to this term, which is usually applied to permanent hypogonadism as well as to normal but delayed maturation. In practice, certain signs can assist formulation of a prognosis, and if necessary the type of therapy required. Data on which can be based the diagnosis, surveillance, and medical conduct in sexually immature adolescents are discussed. Their interpretation is simple when elevated gonadotrophins levels indicate a primary gonadal lesion, or when the delayed puberty results from a general disease disturbing body maturation. In other cases, interpretation of data is often very difficult and is sometimes a very slow process. Because of these difficulties, the diagnosis between simple delay and gonadotrophic insufficiency is discussed in this report on the basis of a retrospective study conducted for a long enough period to have arrived at a definite conclusion.

[Precocious puberty in girls. Study of 98 cases]

A study of 98 cases of true sexual precocity in girls shows a frequency three times higher between 5 and 7 years than before age 5. Detectable causes (intracranial lesion and Mac Cune-Albright syndrome) were found in 56% of cases before 5 years and only 18% after age 5. The plasma levels of estradiol and gonadotropins and the gonadotropins response to LHRH did not differ significantly from those found at the corresponding stages of normal puberty. Plasma dehydroepiandrosterone was lower. Pelvic ultrasonography sometimes discovered follicular cysts. 44 patients treated with medroxyprogesterone acetate were followed for one or several years. Results on sexual development and plasma estradiol were good in most of them, with individual variations, Improvement in the ratio of bone age as height age and in the expected adult height was obtained but without statistical significance.

Simultaneous study of somatotrophic and corticotrophic pituitary secretions during ornithine infusion test

An ornithine infusion test was performed in fifty-four children with constitutional short stature. The ornithine infusion induced an elevated level of GH at 45 min (mean value = 873 pmol/l) and a similar rise of cortisol levels (mean value = 544 nmol/l). An important peak of ACTH appeared 15 min before the increase of cortisol. In three panhypopituitary dwarfs studied, no elevation of GH or cortisol was observed. The well tolerated ornithine infusion test allows the simultaneous study of the somatotropic and corticotropic pituitary secretions in children with delayed growth.

Age-related variation in growth-promoting activity human plasma measured in human lymphocytes

The age-related variations in the growth-promoting activity of human plasma have been studied from birth (cord blood) to adulthood using a bioassay which measures the incorporation of tritiated thymidine into lectin-activated human lymphocytes. Cord blood values were low (0.69 +/- 0.004 U/ml). A definite increase was found at 5 days of age, correlating with the level at birth. Higher levels were attained after 1 month of age, with a 2-fold increase during the first months of life. Lower values were found in children 1-10 yr old, and high levels were found during puberty. This pattern, different from those of sulfation activity and plasma somatomedins suggests that factors other than somatomedins may be involved in growth stimulation during the first year of life in humans.

[Gonadotropic insufficiency associated with the cytomegalic type of congenital adrenal hypoplasia (author's transl)]

Two adolescents with chronic adrenal insufficiency, presumably secondary to the cytomegalic type of congenital adrenal hypoplasia, developed a gonadotropin deficiency at puberty, which was both delayed and incomplete. Endocrine studies demonstrated in plasma low LH levels which failed to increase after LH-RH, higher levels of FSH, low basal testosterone concentration but increasing normally after HCG stimulation. Azoospermia was demonstrated in one case. In parallel with those previously reported, these two new cases show that the association between gonadotropin deficiency and congenital adrenal hypoplasia is not accidental, even if the relationship between the two components of the syndrome is still unclear.

[Serum somatomedin activity in children after surgery for craniopharyngioma (authors transl)]

Serum somatomedin activity was measured in 43 sera from 22 children aged 5 to 15 years operated on for a craniopharyngioma. All had a complete growth hormone deficiency and none received growth hormone therapy. At the time of the study, hydrocortisone therapy was given 29 times and thyroid powder 33 times. In these conditions, a highly significant correlation was found (r = 0.652, p less than 0.001) between somatomedin activity and growth velocity during the past three months. A negative correlation was also found with serum cortisol in patients who did not receive hydrocortisone (r = 0.654, P less than 0,05) and a positive correlation with serum concentrations of T4 (r = 0.640, p less than 0.05) and %3 (r = 0.956, p less than 0.001) in patients who did not receive thyroid powder. In contrast, no correlation was found with serum prolactin and insulin concentrations. These data establish than in children operated for craniopharyngioma, growth is related to a generation of somatomedin independent of growth hormone secretion, and closely controlled by endogenous secretions of cortisol and thyroid hormones.

[Epidemiology of hypothyroidism due to congenital malformation of the gland: athyreosis or ectopic thyroid (author's transl)]

The neonatal characteristics of 322 cases of hypothyroidism due to congenital malformation of the gland --athyreosis or ectopic thyroid--were compared with a national sample of births (N = 11,373), and a sample of births in public hospitals in Paris (N = 12, 895), in order to see if genetic factors were involved in the etiology of the disease. The hypothesis of multifactorial inheritance has been especially studied. Factors which appeared compatible with a multifactorial etiology were: marked excess of females (74%); higher frequency of twins (3.4%), of maternal familial thyropathy (9.2% among the mothers), of familial cases of thyroid malformations (11 cases); higher frequency of associated malformations of multifactorial origin (5.4%). But this type of malformation was not more frequent among siblings and relatives of the studied cases; it is thus not possible to accept the hypothesis of multifactorial inheritance without reservation.

[Puberty and adult height in congenital virilizing adrenal hyperplasia (author's transl)]

A study of 52 pubertal patients having been treated for virilizing adrenal hyperplasia (38 females and 14 males) leads to emphasize the importance of the precocity and accuracy of treatment. In patients with delayed treatment, mainly when they are girls, an advanced or true precocious puberty will increase the advance of bone age and reduce adult height. But, whatever be the time of onset of treatment and of pubertal achievement, no important or sustained sexual improvement was found in patients receiving a well-controlled treatment.