A retrospective review of pituitary MRI findings in children on growth hormone therapy

Management of Neonatal Isolated and Combined Growth Hormone Deficiency: Current Status

Congenital growth hormone deficiency (GHD) is a rare disease caused by disorders affecting the morphogenesis and function of the pituitary gland. It is sometimes found in isolation but is more frequently associated with multiple pituitary hormone deficiency. In some cases, GHD may have a genetic basis. The many clinical signs and symptoms include hypoglycaemia, neonatal cholestasis and micropenis. Diagnosis should be made by laboratory analyses of the growth hormone and other pituitary hormones, rather than by cranial imaging with magnetic resonance imaging. When diagnosis is confirmed, hormone replacement should be initiated. Early GH replacement therapy leads to more positive outcomes, including reduced hypoglycaemia, growth recovery, metabolic asset, and neurodevelopmental improvements.

Hypoglycemia and jaundice in newborns with pituitary stalk interruption syndrome

Pituitary stalk interruption syndrome (PSIS) is a rare disease associated with either isolated growth hormone deficiency (GHD) or combined pituitary hormone deficiency (CPHD). In older children and adults, most patients experience short stature or hypogonadism. Neonatal PSIS is extremely rare and is difficult to recognize due to absence of dwarfism. However, when this condition occurs in newborns, it is often life-threatening. Here, we collected patients with neonatal PSIS to clarify its characteristics to improve its early diagnosis.The patients included in this study were treated at the pediatric endocrine department of Shandong Provincial Hospital from January 2017 to July 2020. We obtained the clinical characteristics, endocrine hormone levels, pituitary magnetic resonance imaging (MRI) and further genetic data for all the patients. Hormone therapy was first given at the time of diagnosis, and the patients received regular follow-up.Three neonatal patients were identified in our clinic. The characteristics of these patients included hypoglycemia and jaundice, as well as CPHD, which included features such as micropenis and hypothyroidism. Genetic etiology was still hard to discover. All the patients responded well to alternative therapy, and the longest follow-up period was 3 years. Regular replacement ensures good prognosis.Sustained hypoglycemia and jaundice in newborns, indicate the presentation of PSIS. Early recognition is of great importance to avoid a life-threatening crisis.

Prevalence of brain MRI findings in children with nonacquired growth hormone deficiency: a systematic review and meta-analysis

PURPOSE

To verify and integrate the prevalence and phenotype of abnormalities in the sellar region in patients with growth hormone deficiency (GHD) using MRI data.

METHODS

We searched PubMed and EMBASE up to December 14, 2020. The inclusion criteria were as follows: (1) pediatric patients diagnosed with nonacquired GHD and (2) detailed data sufficient to assess the proportion of sellar and parasellar abnormalities on brain MRI scans. Finally, thirty-two studies with 39,060 children (mean or median age, 3.4-14.1 years) were included. The number and type of MRI findings from all included studies were pooled by two authors. The heterogeneity across studies was evaluated with the Q test or the inconsistency index (I²) statistic. Subgroup analyses were performed according to the type of GHD (isolated GHD [IGHD] vs. multiple pituitary hormone deficiency [MPHD]), MRI magnet, geographical region, and cutoff serum growth hormone (GH) level.

RESULTS

The pooled proportion of sellar and parasellar abnormalities was 58.0% (95% CI, 47.1-68.6%; I², 98.2%). The MPHD group showed a higher proportion of sellar and parasellar abnormalities and pituitary stalk interruption syndrome than the IGHD group (91.4% vs. 40.1%, P<0.001; 65.3% vs. 20.1%, P<0.001). The patients in studies with low peak GH levels on stimulation tests were more associated with severe MR abnormalities (cutoff GH ≤ 5 μg/l vs. cutoff GH = 10 μg/l; 72.8 % vs. 38.0%; P<0.001).

CONCLUSION

The types and incidence of MRI abnormalities of the sellar region differ significantly between the IGHD and MPHD groups.

A novel diagnostic tool for the evaluation of hypothalamic-pituitary region and diagnosis of growth hormone deficiency: pons ratio

Backgrounds Limitations in the evaluation of the pituitary size and changes according to pubertal status make its validity questionable. Recently, in a small-scale study, pons ratio (PR) has been suggested as a more sensitive tool for diagnosis and etiological evaluation of growth hormone deficiency (GHD). The aim of the study is to evaluate the diagnostic value of PR in the diagnosis of GHD. Methods We retrospectively evaluated the pituitary magnetic resonance imaging (MRI) of 133 patients with a diagnosis of GHD. Primary axis (PA) was assigned as a line crossing the mid-sagittal dorsum sella and fourth ventricle. PR was defined as the pons height above the PA divided by total pons height. The PR of patients with GHD was compared to subjects without GHD. Results Study included 133 patients with GHD and 47 controls. In total, 121 (91%) patients had isolated GHD and 12 (9%) patients had multiple pituitary hormone deficiency. The PR of the patient group (mean: 0.32 ± 0.89; range: 0.14-0.63) was significantly higher than controls (mean: 0.26 ± 0.067; range 0.19-0.44) (p: 0.000). The optimal cut-off value of PR for GHD diagnosis was 0.27 (sensitivity 71% specificity 56%). There was a negative correlation between anterior pituitary height (APH)-SDS and PR (p: 0.002; r: -0.27). APH was increased, but PR remained unchanged in pubertal patients (p: 0.089). Conclusions PR measurement is a noninvasive, practical method with a cost-benefit clinical value. As it is not affected by pubertal status, PR is potentially a more sensitive tool for evaluation of pituitary gland in GHD patients compared to APH.

The Severity of Growth Hormone Deficiency Does Not Predict the Presence or Absence of Brain Magnetic Resonance Imaging Abnormalities - A Retrospective Review

BACKGROUND

The Growth Hormone Research Society recommends that all patients diagnosed with growth hormone deficiency (GHD) should undergo brain magnetic resonance imaging (MRI). This is still a point of controversy in patients with mild GHD, as the level of peak growth-hormone (GH) as a predictor of brain MRI abnormality has not yet been established. The objective of this study was to determine if peak GH level, determined by stimulation tests, can predict the presence or absence of brain MRI abnormality.

METHODS

This study was a retrospective chart review from 2008-2015. Patients were aged 2-18 years, and had growth failure and GHD as determined by stimulation test. Patients with history of brain tumour, chemotherapy and brain surgery, prior to the diagnosis of GHD, were excluded.

RESULTS

A total of 386 patients were included. GH values (mild versus severe GHD) did not predict brain MRI abnormality with any agent (clonidine: p=0.07; arginine: p=0.17; glucagon: p=0.42). Abnormal MRI was apparent in 19.2% of the patients with mild GHD and 24.8% of the patients with severe GHD (p=0.17). Severe MRI abnormality was seen in 6.1% of the patients with mild GHD and 15.0% of the patients with severe GHD (p=0.009).

CONCLUSIONS

The severity of GHD based on peak GH levels on stimulation tests did not predict the presence or absence of brain MRI abnormalities in our study population; however, severe GHD was more strongly associated with severe brain MRI abnormalities. Based on these results we recommend obtaining brain MRI in all patients with GHD.

Isolated Growth Hormone Deficiency Type 2 due to a novel GH1 Mutation: A Case Report

Isolated growth hormone (GH) deficiency (IGHD) type 2 is a rare autosomal dominant disorder characterized by severe short stature with low GH level. Timely diagnosis is important for optimal results of recombinant human GH (rhGH) treatment and detection of additional pituitary deficiencies in affected relatives. A male child presented at the age of one year with severe, proportionate short stature [-4.9 standard deviation score (SDS)] and with a normal body mass index (-1.1 SDS). Physical examination revealed frontal bossing, midfacial hypoplasia, normal external genitalia and no dysmorphic features. Paternal and maternal heights were -6.1 and -1.9 SDS. Serum insulin-like growth factor-1 (IGF-1) and IGF-binding protein-3 were undetectable and the peak GH concentration by clonidine stimulation test was extremely low (0.18 ng/mL). Brain magnetic resonance imaging showed anterior pituitary hypoplasia. Genetic analysis identified a novel heterozygous mutation (c.291+2T>G) expected to lead to splicing out exon 3 of GH1. rhGH from age 2.4 years led to appropriate catch-up. In conclusion, we identified a novel GH1 gene mutation in an infant with classical IGHD type 2 presentation.

Severe, persistent neonatal hypoglycemia as a presenting feature in patients with congenital hypopituitarism: a review of our case series

Background Persistent hypoglycemia (PH) beyond 3 days of life warrants investigation which includes a critical sample. We report our case series of five neonates who presented with PH as the first sign of congenital hypopituitarism. Design This is a case series. Methods/Results This is a case series of five neonates evaluated at our academic institution in a 3-year period (2013-2016), who presented with persistent severe hypoglycemia and were subsequently diagnosed with congenital hypopituitarism. All neonates were full term (mean gestational age 39.8 ± 1.4 weeks) born by caesarian section with a mean weight of 3.5 ± 0.16 kg and a mean length of 51.2 ± 1.2 cm at birth. All five neonates had PH beyond 3 days with an average blood glucose (BG) <35 mg/dL at presentation, requiring a mean glucose infusion rate (GIR) of 7.22 ± 1.98 mg/kg/min. The average BG during the critical sample was 42 ± 0.16 mg/dL (three patients). The mean duration of requirement of the glucose infusion was 6.2 ± 3 days during the immediate neonatal period. Diagnosis of the hypopituitarism took 2-52 days from the initial presentation of hypoglycemia. Besides growth hormone (GH) deficiency, cortisol deficiency was diagnosed in all the five neonates. Neuroimaging findings in all the neonates were consistent with pituitary stalk interruption syndrome (hypoplastic anterior pituitary, ectopic posterior pituitary [EPP] and interrupted pituitary stalk). Conclusions Hypoglycemia is a common metabolic complication affecting an infant in the immediate neonatal period. Delay in the diagnosis of hypopituitarism presenting as hypoglycemia is the result of the lack of awareness among neonatologists and/or pediatricians. We propose that providers be cognizant that PH can be the only presentation of hypopituitarism in the neonatal period. Therefore, having a high index of suspicion about this condition can avoid a delay in the evaluation, diagnosis and treatment of hypopituitarism.

Limited Utility of Biochemical Screening for Pituitary Deficiencies and Adverse Effects in Idiopathic GH Deficiency

Context

In children with isolated growth hormone (GH) deficiency (GHD), routine biochemical screening for multiple pituitary hormone deficiencies (MPHD) and adverse effects related to growth hormone (GH) treatment are frequently performed. More evidence is needed to support this practice.

Objectives

To evaluate the rate of development of MPHD among children initially diagnosed with isolated GHD and to assess the utility of screening tests to identify complications of GH therapy.

Design

Retrospective analysis of subjects treated with GH since 2005. For the first objective, only subjects diagnosed with GHD were included. Subjects were excluded if GHD was associated with an acquired disorder or condition known to be associated with pituitary abnormalities. For the second objective, other GH-treated diagnoses were included.

Patients

A total of 328 subjects (171 with GHD, 154 with idiopathic short stature, and three with SHOX deficiency).

Results

In subjects with isolated GHD, MPHD was diagnosed in seven (4.2%) after a mean of 35.4 months (range, 9.4 to 68.0). Sex, age at diagnosis, duration of GH, and peak stimulated GH levels were not associated with developing MPHD. Among subjects with an MRI abnormality, 13.9% developed MPHD (OR, 6.3; 95% CI, 1.2 to 33.7). In the entire cohort, three subjects (0.9%) developed dysglycemia, and no subject had persistently abnormal liver or renal function tests.

Conclusions

There is a limited role for routine biochemical screening for MPHD in children with idiopathic isolated GHD or for adverse effects in otherwise healthy children. Routine biochemical screening for MPHD should be limited to those with an abnormal MRI.

Pulsatile GnRH Therapy May Restore Hypothalamus-Pituitary-Testis Axis Function in Patients With Congenital Combined Pituitary Hormone Deficiency: A Prospective, Self-Controlled Trial

CONTEXT

The effectiveness of pulsatile gonadotropin-releasing hormone (GnRH) therapy in patients with congenital combined pituitary hormone deficiency (CCPHD) has not been investigated because of the limited number of patients, as well as these patients' presumed pituitary hypoplasia, poor gonadotrophic cell reserve, and impaired gonadotrophic response to GnRH.

OBJECTIVE

To assess the pituitary response to pulsatile GnRH therapy in men with CCPHD.

DESIGN

Prospective, self-controlled, 3-month clinical trial.

SETTINGS

University endocrine clinic.

PATIENTS

Men with hypogonadotropic hypogonadism caused by CCPHD.

INTERVENTION

Pulsatile GnRH was administered subcutaneously for 3 months.

MAIN OUTCOME MEASURES

Primary endpoints were total serum testosterone, testicular volume, and luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels. Secondary endpoints included occurrence of spermatogenesis.

RESULTS

A total of 40 men with CCPHD completed the study. Of these, 60% (24 of 40) showed a good response to pulsatile GnRH treatment (response group). At 3 months, their LH and FSH levels increased to within the normal range and their testosterone levels increased to 8.67 ± 4.83 nmol/L. Of the patients in the response group, 33.3% (8 of 24) of them achieved spermatogenesis. The remaining 40% (16 of 40) of patients had a poor response to pulsatile GnRH treatment. Magnetic resonance imaging (MRI) did not reveal any correlation between pituitary response and pituitary height and/or integrity of the pituitary stalk.

CONCLUSIONS

This study suggests that gonadotrophs in patients with CCPHD can exist and be functional-even with MRI evidence of pituitary hypoplasia or dysplasia. Pulsatile GnRH therapy restored pituitary-testis axis function in 60% of patients with CCPHD. These results may directly guide the clinical therapeutic choice.

MRI features of growth hormone deficiency in children with short stature caused by pituitary lesions

We verified the advantages of using magnetic resonance imaging (MRI) for improving the diagnostic quality of growth hormone deficiency (GHD) in children with short stature caused by pituitary lesions. Clinical data obtained from 577 GHD patients with short stature caused by pituitary lesions were retrospectively analyzed. There were 354 cases (61.3%) with anterior pituitary dysplasia; 45 cases (7.8%) of pituitary stalk interruption syndrome (PSIS); 15 cases (2.6%) of pituitary hyperplasia due to primary hypothyroidism; 38 cases (6.6%) of Rathke cleft cyst; 68 cases (11.8%) of empty sella syndrome; 16 cases (2.8%) of pituitary invasion from Langerhans cell histiocytosis; 2 cases (0.3%) of sellar regional arachnoid cyst and 39 cases (6.8%) of craniopharyngioma. MRI results showed that the height of anterior pituitary in patients was less than normal. Location, size and signals of posterior pituitary and pituitary stalk were normal in anterior pituitary dysplasia. In all cases pituitary hyperplasia was caused by hypothyroidism. MRI results showed that anterior pituitary was enlarged, and we detected upward apophysis and obvious homogeneous enhancement. There were no pituitary stalk interruption and abnormal signal. We also observed that after hormone replacement therapy the size of pituitary gland was reduced. Anterior pituitary atrophy was observed in Rathke cleft cyst, empty sella syndrome, sellar regional arachnoid cyst and craniopharyngioma. The microstructure of hypophysis and sellar region was studied with MRI. We detected pituitary lesions, and the characteristics of various pituitary diseases of GHD in children with short stature. It was concluded that in children with GHD caused by pituitary lesions, MRI was an excellent method for early diagnosis. This method offers clinical practicability and we believe it can be used for differential diagnosis and to monitor the therapeutic effects.

Growth Hormone Therapy Benefits Pituitary Stalk Interruption Syndrome Patients with Short Stature: A Retrospective Study of 75 Han Chinese

Objective. We aim to investigate the long-term benefits of growth hormone (GH) therapy in short stature adolescents and adults with pituitary stalk interruption syndrome (PSIS), which would be beneficial for future clinical applications. Design and Methods. In this study, initial height, final height, total height gain, and GH treatment history were retrospectively investigated in 75 Chinese PSIS patients. We compared height gain between the GH treated cohort and untreated cohort and explored the impact of different GH therapy duration on height gain. Results. For GH treated patients, their final height (SDS) increased from -1.99 ± 1.91 (-6.93~2.80) at bone age (BA) of 11.2 (5.0~17.0) years to -1.47 ± 1.64 (-7.82~1.05) at BA of 16.6 (8.0~18.0) years (P = 0.016). And GH treated patients had more height gain than the untreated patients (P < 0.05). There was a significant difference between the different GH therapy duration groups (P = 0.001): GH 0 versus GH 3, P = 0.000; GH 1 versus GH 3, P = 0.028; GH 2 versus GH 3, P = 0.044. Conclusion. Adult Chinese PSIS patients with short stature benefited the most from at least 12 months of GH therapy. Although patient diagnosis age was lagged behind in the developing countries, GH treatment was still effective for them and resulted in a higher final height and more height gain.

Necrotizing Enterocolitis in the Full-Term Infant

Necrotizing enterocolitis in full-term infants is relatively rare. When seen, it is usually associated with perinatal asphyxia, sepsis, or specific forms of congenital heart disease. It can also be associated with endocrinopathies. In this review, a full-term infant was found to have necrotizing enterocolitis and persistent hypoglycemia. Evaluation for hypoglycemia revealed pan-hypopituitarism, and magnetic resonance imaging confirmed this diagnosis. Timely evaluation and early initiation of hormone replacement therapy is essential to minimize long-term morbidities and mortality associated with pan-hypopituitarism.

Pituitary gland size is a useful marker in diagnosing isolated growth hormone deficiency in short children

INTRODUCTION

Diagnosis of isolated growth hormone deficiency (IGHD) can be challenging. As short stature is common in children, confirmed diagnosis is necessary prior to commencing treatment. Pituitary hypoplasia can be seen in children with IGHD. However, confirmatory studies are lacking.

AIM

To test the application of pituitary size as a marker for IGHD in a population-matched control.

PATIENT AND METHOD

Subjects with IGHD were enrolled. Patients had brain magnetic resonance imaging, and the height and width of the pituitary were measured. Pituitary volume was calculated as (height × width)3/2. A control group was recruited.

RESULTS

Sixty patients and 130 controls were enrolled. The median and age range for the patients and controls were 11 and 3-16 years and 9 and 3-17 years, respectively. Cases had a significantly lower dimensions compared to controls (p < 0.001).

CONCLUSION

Pituitary volume can be a useful marker to compliment the diagnosis of IGHD in selected patients when population-relevant normative control data are used.

Effect of growth hormone deficiency on brain MRI findings among children with growth restrictions

OBJECTIVES

Growth hormone deficiency (GHD) is a major problem among children with short stature. In this study, the role of brain magnetic resonance imaging (MRI) in defining the underlying defects among short children with GHD is evaluated.

METHODS

In a cross-sectional study, data of 158 children were evaluated. Growth hormone (GH) levels were measured using stimulating tests and brain MRI with gadolinium contrast was applied, as well.

RESULTS

Some 25.3% of patients had GHD with a mean age of 8.01±3.40 years. MRI results showed 35 as normal, four with pituitary hypoplasia, and one with microadenoma. The MRI results were significantly associated with GH levels and presence of other endocrine disorders. There was a significant association between prenatal disorders and patients' bone age delay.

CONCLUSIONS

In patients with severe GHD and patients with multiple pituitary hormone deficiencies, MRI is more likely to be abnormal, and bone age is much delayed in patients with history of prenatal disorders.

Diagnostic pitfalls in the assessment of congenital hypopituitarism

BACKGROUND

The diagnosis of congenital hypopituitarism is difficult and often delayed because its symptoms are nonspecific.

AIM

To describe the different clinical presentations of children with congenital hypopituitarism to reduce the time for diagnosis and to begin a precocious and appropriate treatment.

STUDY DESIGN

We analyzed a cohort of five children with congenital hypopituitarism, describing their clinical, biochemical and radiological characteristics from the birth to diagnosis.

RESULTS

As first sign of the disease, all of five patients presented a neonatal hypoglycemia, associated in four cases with jaundice. In all these four cases, the clinicians hypothesized a metabolic disease delaying the diagnosis, which was performed in only two cases within the neonatal period. In the other three cases, the diagnosis was formulated at 2, 5 and 8 years of life because there was severe and precocious growth impairment.

CONCLUSIONS

It is important to suspect congenital hypopituitarism in the presence of persistent neonatal hypoglycemia associated with jaundice and of a precocious and severe reduction of the growth velocity in childhood. In all these cases, it is necessary to undertake a hypothalamic-pituitary magnetic resonance imaging scan as soon as possible, and to start appropriate treatment.

Pituitary stalk interruption syndrome in 59 children: the value of MRI in assessment of pituitary functions

Pituitary imaging abnormality is a specific indicator of hypopituitarism. This study involved a retrospective review of 59 children diagnosed with pituitary stalk interruption syndrome (PSIS). Of the 59 eligible patients, 54 were born by breech delivery, and there was a significant difference between numbers of patients with breech and head-presenting birth. In order to discuss the relationship between pituitary functions and delineation of pituitary structure in magnetic resonance imaging (MRI), a control analysis was carried out in children with PSIS. Fifty-nine children were subdivided into two groups: group I (partial PSIS, 20 cases) and group II (complete PSIS, 39 cases). There was a significantly small anterior pituitary in both groups of PSIS compared with controls (P < 0.001). The incidence of ectopic posterior pituitary (EPP) was significantly higher in group II (P < 0.001). Before and after hormone replacement therapy, pituitary functions were measured and compared with controls. The levels of growth hormone (GH), free thyroxine (FT4), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), and cortisol (COR) were significantly lower in group II (P < 0.05). The dosage of levothyroxine sodium in group II was significantly higher than in group I (P < 0.01). Conclusion. On the basis of birth history, breech presentation may a forewarning for subsequent pituitary hormone deficiencies. Grades of MRI can predict occurrence and severity of PSIS, which are also correlated with the levels of the pituitary target hormone deficiencies. Interruption of pituitary stalk and ectopic posterior pituitary both represent important markers of pituitary structure and function.

Congenital Growth Hormone Deficiency - A Review with a Focus on Neuroimaging

Growth hormone deficiency is an important cause of short stature in childhood. It is characterised by low growth velocity in childhood and is diagnosed by stimulation testing. Individuals with growth hormone deficiency may have other pituitary hormone deficits in addition to growth hormone deficiency. When multiple pituitary hormone deficiencies are present, abnormal pituitary anatomy, as visualised on magnetic resonance imaging (MRI), is a frequent finding. The classic triad (ectopic posterior pituitary, hypoplastic or aplastic anterior pituitary and absent/thin pituitary stalk) or variants of the classic triad are commonly seen in these patients. Volumetric sequencing allows all three planes of visualisation to be reconstructed in post-processing, allowing the radiologist to more fully evaluate pituitary anatomy. The normal dimensions of the pituitary gland vary by age and precise definitions of what constitutes a hypoplastic gland are not clearly defined in the medical literature. Having an experienced neuroradiologist interpret the MRI in patients with pituitary dysfunction is very important.