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Diwaker C, Thadani P, Memon SS, Sarathi V, Lila AR, Arya S, Krishnappa B, Karlekar M, Patil VA, Shah N, Bandgar T. Pituitary stalk interruption syndrome: phenotype, predictors, and pathophysiology of perinatal events. Pituitary 2022; 25:645-652. [PMID: 35749012 DOI: 10.1007/s11102-022-01243-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE There is limited data regarding Pituitary Stalk Interruption Syndrome (PSIS) from India. Moreover, the pathophysiological link between perinatal events and PSIS is unclear. We aim to elucidate the predictors of PSIS among patients with growth hormone deficiency (GHD) and perinatal events in PSIS by comparing cohorts of PSIS and genetically proven GHD without PSIS. METHODS Among 179 GHD patients, 56 PSIS and 70 genetically positive GHD (52-GHRHR, 15-POU1F1, and 3-PROP1) patients were included. Perinatal events, clinical anomalies, pituitary hormone deficiency, and imaging findings were recorded. We compared PSIS-isolated GHD (PSIS-IGHD) subgroup with GHRHR-IGHD and PSIS-combined pituitary hormone deficiency (PSIS-CPHD) subgroup with POU1F1/PROP1-CPHD. RESULTS PSIS patients (45 males, median age: 12.5 years) most commonly presented with short stature. At last follow-up (median age: 17.35 years), gonadal (during pubertal-age), thyroid and cortisol axes were affected in 81.6%, 62.5%, and 62.5%. 10/13 (77%) of PSIS children with initial IGHD diagnosis manifested hypogonadism during pubertal age. Male predominance, sporadic presentation, and clinical anomalies were significantly higher in both PSIS subgroups than in the respective genetic subgroups. Breech presentation was higher in PSIS-CPHD than POU1F1/PROP1-CPHD (44.4% vs 5.5%, p = 0.004). Neonatal hypoglycemia (22% vs. 0%, p = 0.05) and jaundice (42 vs. 5%, p = 0.004) were higher in PSIS-CPHD than PSIS-IGHD. CONCLUSION Later age at presentation and frequent hypogonadism were observed in our PSIS cohort. Male sex, sporadic presentation, clinical anomalies, and breech presentation predicted PSIS at presentation. Breech presentation in PSIS is likely due to stalk interruption rather than hormonal deficiency.
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Affiliation(s)
- Chakra Diwaker
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Puja Thadani
- University Hospitals Coventry and Warwickshire (UHCW) NHS Trust, Coventry, England, UK
| | - Saba Samad Memon
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - Anurag Ranjan Lila
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Sneha Arya
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Brijesh Krishnappa
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Manjiri Karlekar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Virendra A Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, 400012, India.
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Wang Q, Meng X, Sun Y, Liu F, Xu C, Qiao Y, Yang J, Li G, Wang Y. Hypoglycemia and jaundice in newborns with pituitary stalk interruption syndrome. Medicine (Baltimore) 2021; 100:e25843. [PMID: 34106625 PMCID: PMC8133236 DOI: 10.1097/md.0000000000025843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 04/17/2021] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Qi Wang
- Department of Paediatrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan
| | - Xiangji Meng
- Department of Neurosurgery, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences
| | - Yan Sun
- Department of Paediatrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan
| | - Fan Liu
- Department of Paediatrics, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan
| | - Chao Xu
- Department of Endocrinology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yu Qiao
- Department of Paediatrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan
| | - Jianmei Yang
- Department of Paediatrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan
| | - Guimei Li
- Department of Paediatrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan
| | - Yulin Wang
- Department of Paediatrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan
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Neonatale Cholestase. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-020-01042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Di Dato F, Capalbo D, Mirra R, Del Vecchio Blanco F, Salerno M, Iorio R. Case Report: Neonatal Cholestasis as Early Manifestation of Primary Adrenal Insufficiency. Front Pediatr 2021; 9:767858. [PMID: 34858908 PMCID: PMC8632351 DOI: 10.3389/fped.2021.767858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Neonatal cholestasis (NC) may be due to multiple surgical and non-surgical causes, some of which are potentially fatal. The list of potential causes of NC is long, and the systematic search for each of them is challenging in infants, especially when overt signs of underlying disease are lacking. Endocrinological diseases as causes of NC are rare and sometimes misdiagnosed. We report the case of an infant with prolonged cholestatic jaundice due to adrenal insufficiency suspected because of a single episode of hypoglycemia occurring at birth in the absence of clinical signs of adrenal impairment. Clinical exome analysis identified a new homozygous variant in MC2R gene as a putative responsible for familial glucocorticoid deficiency (FGD). Adrenal insufficiency should always be considered in all cholestatic infants, even in the absence of specific symptoms, since early recognition and treatment is essential to prevent life-threatening events.
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Affiliation(s)
- Fabiola Di Dato
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Donatella Capalbo
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Rita Mirra
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Mariacarolina Salerno
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Raffaele Iorio
- Section of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
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Abstract
Liver dysfunction is a common problem in the sick premature infant. The dysfunction is usually multifactorial and often underlies a combination of liver immaturity, comorbidities, and/or the presence of primary liver disease. The liver of the preterm infant has a paucity of bile ducts, low levels of many hepatic enzymes and transporters, and a small bile acid pool. Many other organ systems are immature as well and do not respond to stress the way they would later in infancy. This articles discusses how prematurity affects the liver, how it responds to secondary insults, and approaches to evaluation.
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Affiliation(s)
- Carol Jean Potter
- Nationwide Children's Hospital, The Ohio State University, 700 Childrens Drive, Columbus, OH 43205, USA.
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Vitiello L, De Bernardo M, Guercio Nuzio S, Mandato C, Rosa N, Vajro P. Pediatric liver diseases and ocular changes: What hepatologists and ophthalmologists should know and share with each other. Dig Liver Dis 2020; 52:1-8. [PMID: 31843253 DOI: 10.1016/j.dld.2019.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/29/2019] [Accepted: 11/17/2019] [Indexed: 12/11/2022]
Abstract
Several rare pediatric liver disorders are accompanied by ophthalmic signs whose awareness and early identification may be of value in confirming/accelerating their diagnosis. Many of these signs are asymptomatic and can only be detected with an ophthalmological examination. Corneal signs are described in patients with Wilson's disease, Alagille's syndrome and some liver storage diseases. Cataract plays an important role to diagnose galactosemia. Retinal involvement is seen in some peroxisomal disorders (e.g. Zellweger's syndrome), in mucopolysaccharidoses (pigmentary retinopathy), and in Niemann-Pick disease (macular cherry red spot). In mucopolysaccharidoses optic nerve can be involved as optic atrophy secondary to pigmentary retinopathy or to chronic papilledema. Children with neonatal cholestasis due to hypopituitarism may present septo-optic dysplasia. Several infectious agents have an ophthalmological/hepatic involvement in the fetal life and/or thereafter. Some mitochondrial liver diseases, such as Pearson's syndrome, present pigmentary retinopathy and a chronic progressive external ophthalmoplegia. Finally, some drugs while protecting the liver may damage the ocular system as seen with long-term glucocorticoids and Nitisinone administration. This review provides a synopsis of those conditions that hepatologists and ophthalmologists should share among themselves to better take care of patients. Synoptic tables are presented to facilitate the mutual understanding of the issues.
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Affiliation(s)
- Livio Vitiello
- Eye Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy
| | - Maddalena De Bernardo
- Eye Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy
| | - Salvatore Guercio Nuzio
- Pediatric Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy
| | - Claudia Mandato
- Department of Pediatrics, Children's Hospital Santobono-Pausilipon, Naples, Italy
| | - Nicola Rosa
- Eye Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy
| | - Pietro Vajro
- Pediatric Clinic, Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Baronissi, Italy.
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Mehta S, Brar PC. Severe, persistent neonatal hypoglycemia as a presenting feature in patients with congenital hypopituitarism: a review of our case series. J Pediatr Endocrinol Metab 2019; 32:767-774. [PMID: 31211689 DOI: 10.1515/jpem-2019-0075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/14/2019] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Shilpa Mehta
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
| | - Preneet Cheema Brar
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
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Abstract
Navigating the complexities of interpreting a liver biopsy performed on a neonate with conjugated/direct hyperbilirubinemia can be an arduous task given these biopsies are infrequently encountered. The list of entities is long and yet there are only a few histologic patterns of liver injury. The first step for the pathologist is to determine the histologic pattern, which will guide further inquiry into the useful clinical information to have while evaluating the biopsy. Ultimately, the goal is to identify those conditions that will benefit from early intervention. We begin with a review of biliary development to help understand what findings may be physiologic versus pathologic, particularly in premature infants. Then we review eight cases that cover the three most common histologic patterns of injury in patients with neonatal cholestasis: biliary obstructive, neonatal hepatitis, and paucity of intrahepatic bile ducts. The entities that serve as prototypes for these histologic patterns are covered, including biliary atresia, idiopathic neonatal hepatitis, and Alagille syndrome, along with rarer entities that have histologic overlap. The cases with accompanying tables and algorithms are intended to help place the histologic findings in the context of the overall clinical work-up, including genetic testing.
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Affiliation(s)
- Soo-Jin Cho
- Department of Pathology, University of California San Francisco, San Francisco, CA United States
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA United States.
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Bolia R, Srivastava A. Hypopituitarism Related Cholestatic Jaundice: Important to Recognise, Rewarding to Treat but Difficult to Diagnose! Indian J Pediatr 2019; 86:401-402. [PMID: 30863924 DOI: 10.1007/s12098-019-02922-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Rishi Bolia
- Division of Pediatric Gastroenterology Department of Gastroenterology, PGIMER, Chandigarh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, SGPGIMS, Raebareli Road, Lucknow, UP, India.
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