Investigation of hypothalamic-pituitary disease

Rapid ultrasensitive measurement of salivary cortisol using nano-linker chemistry coupled with surface plasmon resonance detection

Cortisol detection in saliva is of great interest for the diagnosis of various disease states and the monitoring of stress in humans. Currently, measurements are performed predominantly by radioimmunoassay (RIA) which is expensive, labour intensive, uses hazardous radioisotopes and involves extensive delays in obtaining results. A rationally designed cortisol-linker conjugate allowing high assay sensitivity was employed as a coating antigen in a microfluidic surface plasmon resonance (SPR) biosensor immunoassay for the ultrasensitive and rapid detection of salivary cortisol. Detection of cortisol is by competitive immunoassay using a secondary antibody for signal enhancement. The method requires no chemical extraction or complex sample pre-treatment despite high saliva viscosity. The cortisol assay was optimized for maximum sensitivity in buffer before being adapted for the salivary matrix, where it showed a limit of detection of 49 pg/mL. The results showed good correlation to RIA (r = 0.94). The biosensor assays showed an inter-assay coefficient of variation (CV) of 13.5% and recoveries close to 100%. The covalently immobilized sensor surface provided stable responses for more than 140 binding and regeneration cycles, enabling re-use. Cortisol in saliva was detected across the physiologically relevant range using the SPR immunobiosensor by employing a rationally designed assay format including signal enhancement for maximum sensitivity. The system can handle saliva matrix effects by use of chemical treatment during the assay to reduce non-specific binding to sensor surfaces. This sensor system provides an automated, high sensitivity analytical tool capable of yielding results in approximately 15 min. This biosensor could potentially be used for active stress-monitoring and in the diagnosis of disease.

Prevalence of GH and other anterior pituitary hormone deficiencies in adults with nonsecreting pituitary microadenomas and normal serum IGF-1 levels

OBJECTIVE

GH is usually the first pituitary hormone to be affected following a pathological insult to the pituitary; however, data on the prevalence of GH deficiency in patients with nonsecreting pituitary microadenomas and normal serum IGF-1 levels are scarce. This study aims to evaluate the prevalence of GH and other anterior pituitary hormone deficiencies, and to determine whether microadenomas per se could be associated with reduced GH response rates to GHRH-arginine stimulation.

DESIGN

Analytical, retrospective, two-site case-control study.

PATIENTS AND METHODS

Thirty-eight patients with nonsecreting pituitary microadenomas (mean size 4.2 mm) and normal serum IGF-1 levels were studied. Anterior pituitary function testing, including the GHRH-arginine test to examine GH reserve, was performed in all patients. Serum IGF-1 levels and peak GH levels in the patients that passed the GHRH-arginine test were compared with 22 age- and BMI-matched healthy controls.

RESULTS

Nineteen patients (50%) failed the GHRH-arginine test and had higher body mass index (BMI) than those that passed the GHRH-arginine test and healthy controls. Peak GH levels in patients that passed the GHRH-arginine test were lower compared to healthy controls and 19 patients (50%) had at least one other pituitary hormone deficit. A negative correlation (r = -0.42, P < 0.01) between peak GH levels and BMI was identified, but no correlations were found between peak GH and serum IGF-1 levels.

CONCLUSIONS

Our data demonstrated that a substantial number of patients with nonsecreting pituitary microadenomas failed the GHRH-arginine test despite normal serum IGF-1 levels, and had at least one other pituitary hormone deficiency, suggesting that nonsecreting microadenomas may not be clinically harmless. We therefore recommend long-term follow-up with periodic basal pituitary function testing, and to consider dynamic pituitary testing should clinical symptoms arise in these patients.

The GnRH test in the assessment of patients with pituitary and parapituitary lesions: results of a 5-year retrospective study

OBJECTIVE

To examine the utility of the GnRH (gonadotrophin-releasing hormone) test in the management of patients with pituitary and parapituitary lesions.

PATIENTS AND METHODS

A 5-year retrospective study of LH (luteinizing hormone) and FSH (follicle stimulating hormone) responses to GnRH test in patients with HP (hypothalamic-pituitary) disease in a regional endocrine centre. Serum LH and FSH concentrations were measured at baseline and at 20 and 60 min after an intravenous bolus of 100 mcg (micrograms) of GnRH. The GnRH responses were categorised by tumour size, tumour type, and gonadal status.

RESULTS

Of the 104 patients studied, 46 were male and 58 were female. There were 50 normal, 38 subnormal and 16 exaggerated LH responses compared with 34 normal 67 subnormal and three exaggerated responses for FSH. Seventy-four patients (71.2%) were hypogonadal. Normal LH responses were achieved in half of the hypogonadal subjects and normal FSH responses in more than a third. Furthermore, the LH responses were exaggerated in nine hypogonadal patients compared with three for FSH. The GnRH test could not differentiate between pituitary or parapituitary lesions either by size or type of lesion. An exception was the male non-functioning adenoma (NFA) sub-group (10 patients, all were hypopituitary, seven were hypogonadal), which demonstrated significant subnormal LH and FSH responses compared with other male and female tumour type sub-groups.

CONCLUSIONS

The data from this study indicate that the GnRH test is unhelpful in the clinical assessment of the HP axis in patients with HP disease.

Serotonergic control of TSH and PRL secretion in obese men

To evaluate whether the inhibitory control of TSH and the stimulatory control of prolactin (PRL) secretion exerted by endogenous serotonin was altered in obesity, 22 obese men and 10 normal controls were tested with TRH (200 micrograms IV bolus) in the presence (experimental test) and absence (control test) of the serotonergic agonist fenfluramine (60 mg PO 90 min before TRH). Control and experimental tests were also performed in seven male patients with subclinical hypothyroidism and were repeated in the same obese subjects after substantial weight loss. Basal TSH levels were similar in control and obese men. Normal TSH responses to TRH (peak less than or equal to 14 mU/L) were observed in all normal controls (mean peak +/- SE 9.8 +/- 0.6 mU/L). In contrast, obese men were divided into two groups: nine in whom the TRH-induced TSH rise was higher than normal (group I: mean peak = 16.5 +/- 0.5 mU/L) and 13 in whom it was normal (group II: mean peak = 10.6 +/- 0.7 mU/L). The hypothyroid men all had elevated basal and TRH-stimulated TSH levels. Basal PRL concentrations were similar in the normal controls and both groups of obese subjects. The PRL response to TRH was lower in both group I and group II obese men than in normal controls and was similar between group I and group II.(ABSTRACT TRUNCATED AT 250 WORDS)

Suprasellar germinoma--occult presentation with hypothalamic failure 18 months before diagnosis

Hormonal evidence of widespread hypothalamic failure, including diabetes insipidus, hyperprolactinaemia, growth failure, hypothyroidism, and adrenal failure, was present in a boy of 14 years. Investigation with computerised axial tomography (CT) and metrizamide encephalography failed to identify any anatomical abnormality at the time of presentation. However, 18 months later papilloedema was noted at which time a suprasellar mass and gross dilatation of the ventricular system were readily identified using CT and a germinoma was subsequently diagnosed and treated. In the light of this experience we recommend that when "idiopathic" hypothalamic failure is diagnosed, imaging procedures, including CT or nuclear magnetic resonance examinations, should be repeated on at least one occasion, after an interval of approximately 6 months.

X-ring Turner's syndrome with combined immunodeficiency and selective gonadotropin defect

A rare association of chromosomal, immunological and endocrine defects is described in a young woman with short stature, recurrent pulmonary infections and primary amenorrhea. Cytogenetic studies showed a 45, X karyotype in 65% of peripheral blood lymphocytes and 46,Xr(X) (p22q27) karyotype in the remaining 35%. Severe immunodeficiency was revealed by phenotypical and functional studies and a selective gonadotropin defect was disclosed by endocrinological investigations. An attempt is made to explain the coexistence of the three abnormal pictures.