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Abucham J, Martins M. Subclinical central hypothyroidism in patients with hypothalamic-pituitary disease: does it exist? Rev Endocr Metab Disord 2024; 25:609-618. [PMID: 38324081 DOI: 10.1007/s11154-024-09876-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/08/2024]
Abstract
Central hypothyroidism (CH) is characterized by decreased thyroid hormone production due to insufficient stimulation of an otherwise normal thyroid gland by TSH. In patients with established hypothalamic-pituitary disease, a low FT4 concentration is considered highly specific, although poorly sensitive, for the diagnosis of CH. That would be comparable to diagnosing primary hypothyroidism in patients at risk only when serum FT4 concentrations are below the reference range, missing all patients with subclinical primary hypothyroidism and preventing proper therapy in patients in which thyroxine replacement is clearly beneficial. Cardiac time intervals, especially the isovolumic contraction time (ICT), have been considered the gold standard of peripheral thyroid hormone action. Using Doppler echocardiography, we have previously shown a very high proportion of prolonged ICT in patients with hypothalamic-pituitary disease and serum FT4 levels indistinguishable from controls. As ICT decreased/normalized after thyroxine-induced increases in FT4 concentrations within the normal reference range, prolonged ICT was considered a bona fide diagnostic biomarker of subclinical CH. Those findings challenge the usual interpretation that FT4 concentrations in the mid-reference range exclude hypothyroidism in patients with hypothalamic-pituitary disease. Rather, subclinical central hypothyroidism, a state analogous to subclinical primary hypothyroidism, seems to be frequent in patients with hypothalamic-pituitary disease and normal FT4 levels. They also challenge the notion that thyroid function is usually the least or the last affected in acquired hypopituitarism. The relevance of Doppler echocardiography to correctly diagnose and monitor replacement therapy in both clinical and subclinical forms of CH should improve quality of life and decrease cardiovascular risk, as already demonstrated in patients with clinical and subclinical primary hypothyroidism.
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Affiliation(s)
- Julio Abucham
- Neuroendocrine Unit, Endocrinology Division, Escola Paulista de Medicina - Universidade Federal de São Paulo-UNIFESP, São Paulo, São Paulo, Brazil
| | - Manoel Martins
- Drug Research and Development Center, Department of Clinical Medicine, School of Medicine, Universidade Federal do Ceará-UFC, Fortaleza, Ceará, Brazil.
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2
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Alonso FH, Niedringhaus KD, Ceregatti MG, Maglaty MA. Case Report: Cytologic Description of Somatotroph Pituitary Adenoma in a Cat. Front Vet Sci 2022; 9:934009. [PMID: 35923821 PMCID: PMC9339988 DOI: 10.3389/fvets.2022.934009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
This case report describes for the first time the cytologic characteristics of a hormonally secreting pituitary adenoma in a cat. An 8-year-old female spayed domestic long-haired cat was referred with a previous diagnosis of hypersomatotropism and secondary diabetes mellitus 7 months prior. Clinical signs included weight loss, polyphagia, polyuria, and polydipsia. Serum insulin-like growth factor-1 was 340 nmol/L (RI: 12-92), and CT scan revealed a hypophyseal mass, and a presumptive diagnosis of acromegaly was made. A transsphenoidal hypophysectomy was performed. A fragment of the pituitary gland was subjected to a squash preparation and cytology revealed a neuroendocrine neoplasm characterized by anisokaryosis and prominent nucleoli. Additional cytologic findings included cell cohesiveness, indistinct cytoplasmic borders, nuclear crowding, molding, and fragmentation. A diagnosis of adenoma was based on a lack of histopathologic or imaging evidence of invasion. A week later, during post-surgical hospitalization, the patient worsened and died. Histopathology from a necropsy procedure revealed fibrinosuppurative meningitis as a post-surgical complication. Pituitary adenomas might have an aggressive cytologic appearance, despite a lack of histopathologic invasion or dissemination.
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Affiliation(s)
- Flavio H. Alonso
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
- Department of Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis
- *Correspondence: Flavio H. Alonso
| | - Kevin D. Niedringhaus
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Mariah G. Ceregatti
- Department of Veterinary Clinic and Surgery, School of Veterinary Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Marisa A. Maglaty
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
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3
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Samec B, Setnikar G, Gaberscek S, Kocjan T. Patients with Central Hypothyroidism are Less Sufficiently Treated with Levothyroxine than Patients with Primary Hypothyroidism. Exp Clin Endocrinol Diabetes 2021; 130:223-228. [PMID: 34331306 DOI: 10.1055/a-1543-8826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Contrary to patients with hypothyroidism after radioiodine (HRI) or after thyroidectomy (HTh), patients with central hypothyroidism (CH) cannot rely on thyrotropin (TSH) level to guide their treatment with L-thyroxine (L-T4). Consequently, they are at constant risk of under- or overtreatment. We aimed to establish the adequacy of L-T4 treatment in patients with CH in our cohort. METHODS Consecutive patients with CH on L-T4 treatment were compared with patients adequately treated for HRI or HTh. Levels of free thyroxine (fT4) and free triiodothyronine (fT3) were evaluated and the fT4/fT3 ratio was calculated. RESULTS Forty patients with CH, 136 patients with HRI and 43 patients with HTh were included in this study. Patients with HRI were significantly younger than patients with HTh and CH (p<0.001 for both). Levels of fT4 were significantly lower in CH than in adequately treated patients with HRI and HTh (median (range), 15.6 (12.7-21.3), 18.4 (12.2-28.8), and 18.7 (13.8-25.5) pmol/L, respectively, p<0.001 for both comparisons). Levels of fT3 did not differ significantly (p=0.521) between CH, HRI and HTh (median (range), 4.5 (2.7-5.9), 4.3 (3.2-6.2), and 4.4 (2.9-5.5) pmol/L, respectively). Accordingly, the fT4/fT3 ratio was significantly lower in the CH group than in HRI and HTh groups (median (range), 3.7 (2.5-5.2), 4.2 (1.2-7.7), and 4.4 (2.5-6.1), respectively, p<0.001 for both comparisons). CONCLUSIONS Patients with CH have lower fT4 levels and lower fT4/fT3 ratios than patients adequately treated for HRI or HTh. The cause for this difference may be the unreliable TSH levels in patients with CH.
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Affiliation(s)
- Barbara Samec
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Gaja Setnikar
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Simona Gaberscek
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Nuclear Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tomaz Kocjan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
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4
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Feldt-Rasmussen U, Effraimidis G, Klose M. The hypothalamus-pituitary-thyroid (HPT)-axis and its role in physiology and pathophysiology of other hypothalamus-pituitary functions. Mol Cell Endocrinol 2021; 525:111173. [PMID: 33549603 DOI: 10.1016/j.mce.2021.111173] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 12/16/2022]
Abstract
The hypothalamus-pituitary-thyroid axis is one of several hormone regulatory systems from the hypothalamus to the pituitary and ultimately to the peripheral target organs. The hypothalamus and the pituitary gland are in close anatomical proximity at the base of the brain and extended through the pituitary stalk to the sella turcica. The pituitary stalk allows passage of stimulatory and inhibitory hormones and other signal molecules. The target organs are placed in the periphery and function through stimulation/inhibition by the circulating pituitary hormones. The several hypothalamus-pituitary-target organ axis systems interact in very sophisticated and complicated ways and for many of them the interactive and integrated mechanisms are still not quite clear. The diagnosis of central hypothyroidism is complicated by itself but challenged further by concomitant affection of other hypothalamus-pituitary-hormone axes, the dysfunction of which influences the diagnosis of central hypothyroidism. Treatment of both the central hypothyroidism and the other hypothalamus-pituitary axes also influence the function of the others by complex mechanisms involving both central and peripheral mechanisms. Clinicians managing patients with neuroendocrine disorders should become aware of the strong integrative influence from each hypothalamus-pituitary-hormone axis on the physiology and pathophysiology of central hypothyroidism. As an aid in this direction the present review summarizes and highlights the importance of the hypothalamus-pituitary-thyroid axis, pitfalls in diagnosing central hypothyroidism, diagnosing/testing central hypothyroidism in relation to panhypopituitarism, pointing at interactions of the thyroid function with other pituitary hormones, as well as local hypothalamic neurotransmitters and gut-brain hormones. Furthermore, the treatment effect of each axis on the regulation of the others is described. Finally, these complicating aspects require stringent diagnostic testing, particularly in clinical settings with lower or at least altered à priori likelihood of hypopituitarism than in former obvious clinical patient presentations.
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Affiliation(s)
- Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark; Institute of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Denmark.
| | - Grigoris Effraimidis
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Denmark
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Kuś A, Chaker L, Teumer A, Peeters RP, Medici M. The Genetic Basis of Thyroid Function: Novel Findings and New Approaches. J Clin Endocrinol Metab 2020; 105:5818501. [PMID: 32271924 DOI: 10.1210/clinem/dgz225] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 01/06/2020] [Indexed: 12/18/2022]
Abstract
CONTEXT Genetic factors are major determinants of thyroid function. Over the last two decades, multiple genetic variants have been associated with variations in normal range thyroid function tests. Most recently, a large-scale genome-wide association study (GWAS) doubled the number of known variants associated with normal range thyrotropin (TSH) and free thyroxine (FT4) levels. EVIDENCE ACQUISITION This review summarizes the results of genetic association studies on normal range thyroid function and explores how these genetic variants can be used in future studies to improve our understanding of thyroid hormone regulation and disease. EVIDENCE SYNTHESIS Serum TSH and FT4 levels are determined by multiple genetic variants on virtually all levels of the hypothalamus-pituitary-thyroid (HPT) axis. Functional follow-up studies on top of GWAS hits has the potential to discover new key players in thyroid hormone regulation, as exemplified by the identification of the thyroid hormone transporter SLC17A4 and the metabolizing enzyme AADAT. Translational studies may use these genetic variants to investigate causal associations between thyroid function and various outcomes in Mendelian Randomization (MR) studies, to identify individuals with an increased risk of thyroid dysfunction, and to predict the individual HPT axis setpoint. CONCLUSIONS Recent genetic studies have greatly improved our understanding of the genetic basis of thyroid function, and have revealed novel pathways involved in its regulation. In addition, these findings have paved the way for various lines of research that can improve our understanding of thyroid hormone regulation and thyroid diseases, as well as the potential use of these markers in future clinical practice.
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Affiliation(s)
- Aleksander Kuś
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Layal Chaker
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alexander Teumer
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
- DZHK (German Center for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | - Robin P Peeters
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marco Medici
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
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Waguespack SG. Thyroid Sequelae of Pediatric Cancer Therapy. Horm Res Paediatr 2019; 91:104-117. [PMID: 30541010 DOI: 10.1159/000495040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 10/31/2018] [Indexed: 11/19/2022] Open
Abstract
The hypothalamic-pituitary-thyroid axis is a common site of unintended, acquired disease either during or after the treatment of cancer. Children treated with external radiation therapy are at the highest risk for developing a thyroid-related late effect, but thyroid dysfunction and second primary thyroid neoplasms can also occur after treatment with radiopharmaceutical agents such as 131I-metaiodobenzylguanidine. Increasingly recognized is the development of early thyroid dysfunction as an off-target consequence of the more novel cancer therapeutics such as the tyrosine kinase inhibitors and immune checkpoint inhibitors. Thyroid sequelae resulting from irradiation may manifest only after years to decades of follow-up, and their resultant clinical symptoms may be indolent and non-specific. Therefore, lifelong monitoring of the childhood cancer survivor at risk for thyroid disease is paramount. In this comprehensive review, the myriad thyroid adverse effects resulting from pediatric cancer treatment are discussed and an overview of screening and treatment of these thyroid sequelae provided.
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Affiliation(s)
- Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders and the Department of Pediatrics-Patient Care, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA,
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Verhoestraete P, Carpentier M, Donck J, Vandekerckhove H. Dilated cardiomyopathy and rhabdomyolysis caused by hypopituitarism: a challenging diagnosis. Acta Cardiol 2019; 75:593-597. [PMID: 31536463 DOI: 10.1080/00015385.2019.1665848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | | | - Jan Donck
- Department of Nephrology, AZ Sint-Lucas Ghent, Ghent, Belgium
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Morinaga Y, Abe I, Sakamoto K, Inoue R, Mitsutake T, Hanada H, Haraoka S, Nii K. Effectiveness of endoscopic transsphenoidal surgery for gonadotroph adenoma mimicking dementia: A case report. Intractable Rare Dis Res 2019; 8:217-220. [PMID: 31523603 PMCID: PMC6743436 DOI: 10.5582/irdr.2019.01082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
There are few reports of pituitary adenomas (PA) mimicking dementia. Delay in disease diagnosis and treatment may result in poor clinical outcome. We experienced a rare case where endoscopic transsphenoidal surgery (eTSS) effectively treated a gonadotroph adenoma mimicking dementia and report on literature considerations. We report the case of a 72-year-old man with chief complaints of cognitive decline, bradykinesia, anorexia, dressing apraxia, and vigor decline over several months. He was admitted to our hospital for scrutiny in a disoriented state. Blood tests showed hyponatremia and thyroid hormone depression. Magnetic resonance imaging showed a pituitary tumor, and preoperative endocrine stress tests showed reduced reactivities of growth hormone, adrenocorticotropic hormone/cortisol, and luteinizing hormone/follicle-stimulating hormone. Symptomatic pituitary adenoma was suspected, and eTSS was performed. The permanent pathological diagnosis was of gonadotroph adenoma. Postoperatively, the hyponatremia, cognitive decline, movement retardation, loss of appetite, dressing apraxia, and limb edema markedly improved. The patient was discharged under hydrocortisone 15 mg/day administration without complications. The endocrine stress test performed 2 months postoperatively showed secondary hypoadrenocorticism, while the other endocrine functions had normalized. No recurrence had occurred by 30 months postoperatively; the medication of hydrocortisone was gradually discontinued and the patient at the time was still being followed as an outpatient with modified Rankin Scale score 0. Secondary hypothyroidism and secondary hypoadrenocorticism due to the pituitary tumor primarily caused the condition. It is important to consider PA in the differential diagnosis of dementia, and early diagnosis and treatment can contribute to a patient's good clinical outcome.
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Affiliation(s)
- Yusuke Morinaga
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino City, Fukuoka, Japan
- Address correspondence to:Dr. Yusuke Morinaga, Department of Neurosurgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushino City, Fukuoka Prefecture 818-8502, Japan. E-mail:
| | - Ichiro Abe
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University Chikushi Hospital, Chikushino City, Fukuoka, Japan
| | - Kimiya Sakamoto
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino City, Fukuoka, Japan
| | - Ritsurou Inoue
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino City, Fukuoka, Japan
| | - Takafumi Mitsutake
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino City, Fukuoka, Japan
| | - Hayatsura Hanada
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino City, Fukuoka, Japan
| | - Seiji Haraoka
- Department of Pathology, Fukuoka University Chikushi Hospital, Chikushino City, Fukuoka, Japan
| | - Kouhei Nii
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino City, Fukuoka, Japan
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Thyroid Disorders in Homozygous β-Thalassemia: Current Knowledge, Emerging Issues and Open Problems. Mediterr J Hematol Infect Dis 2019; 11:e2019029. [PMID: 31205633 PMCID: PMC6548211 DOI: 10.4084/mjhid.2019.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/08/2019] [Indexed: 12/19/2022] Open
Abstract
Changes in thyroid function and thyroid function tests occur in patients with β-thalassemia major (TM). The frequency of hypothyroidism in TM patients ranges from 4% to 29 % in different reports. The wide variation has been attributed to several factors such as patients’ genotype, age, ethnic heterogeneity, treatment protocols of transfusions and chelation, and varying compliance to treatment. Hypothyroidism is the result of primary gland failure or insufficient thyroid gland stimulation by the hypothalamus or pituitary gland. The main laboratory parameters of thyroid function are the assessments of serum thyroid-stimulating hor-mone (TSH) and serum free thyroxine (FT4). It is of primary importance to interpret these measurements within the context of the laboratory-specific normative range for each test. An elevated serum TSH level with a standard range of serum FT4 level is consistent with subclinical hypothyroidism. A low serum FT4 level with a low, or inappropriately normal, serum TSH level is consistent with secondary hypothyroidism. Doctors caring for TM patients most commonly encounter subjects with subclinical primary hypothyroidism in the second decade of life. Several aspects remain to be elucidated as the frequency of thyroid cancer and the possible existence of a relationship between thyroid dysfunction, on one hand, cardiovascular diseases, components of metabolic syndrome (insulin resistance) and hypercoagulable state, on the other hand. Further studies are needed to explain these emerging issues. Following a brief description of thyroid hormone regulation, production and actions, this article is conceptually divided into two parts; the first reports the spectrum of thyroid disease occurring in patients with TM, and the second part focuses on the emerging issues and the open problems in TM patients with thyroid disorders.
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Persani L, Cangiano B, Bonomi M. The diagnosis and management of central hypothyroidism in 2018. Endocr Connect 2019; 8:R44-R54. [PMID: 30645189 PMCID: PMC6373625 DOI: 10.1530/ec-18-0515] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/15/2019] [Indexed: 12/26/2022]
Abstract
Central hypothyrodism (CeH) is a hypothyroid state caused by an insufficient stimulation by thyrotropin (TSH) of an otherwise normal thyroid gland. Several advancements, including the recent publication of expert guidelines for CeH diagnosis and management, have been made in recent years thus increasing the clinical awareness on this condition. Here, we reviewed the recent advancements and give expert opinions on critical issues. Indeed, CeH can be the consequence of various disorders affecting either the pituitary gland or the hypothalamus. Recent data enlarged the list of candidate genes for heritable CeH and a genetic origin may be the underlying cause for CeH discovered in pediatric or even adult patients without apparent pituitary lesions. This raises the doubt that the frequency of CeH may be underestimated. CeH is most frequently diagnosed as a consequence of the biochemical assessments in patients with hypothalamic/pituitary lesions. In contrast with primary hypothyroidism, low FT4 with low/normal TSH levels are the biochemical hallmark of CeH, and adequate thyroid hormone replacement leads to the suppression of residual TSH secretion. Thus, CeH often represents a clinical challenge because physicians cannot rely on the use of the 'reflex TSH strategy' for screening or therapy monitoring. Nevertheless, in contrast with general assumption, the finding of normal TSH levels may indicate thyroxine under-replacement in CeH patients. The clinical management of CeH is further complicated by the combination with multiple pituitary deficiencies, as the introduction of sex steroids or GH replacements may uncover latent forms of CeH or increase the thyroxine requirements.
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Affiliation(s)
- Luca Persani
- Division of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Correspondence should be addressed to L Persani:
| | - Biagio Cangiano
- Division of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marco Bonomi
- Division of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Persani L, Brabant G, Dattani M, Bonomi M, Feldt-Rasmussen U, Fliers E, Gruters A, Maiter D, Schoenmakers N, van Trotsenburg AP. 2018 European Thyroid Association (ETA) Guidelines on the Diagnosis and Management of Central Hypothyroidism. Eur Thyroid J 2018; 7:225-237. [PMID: 30374425 PMCID: PMC6198777 DOI: 10.1159/000491388] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 06/19/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Central hypothyroidism (CeH) is a rare form of hypothyroidism characterized by insufficient thyroid stimulation due to disturbed pituitary and/or hypothalamic functioning. Due to its origin and the whole clinical context, CeH represents a challenging condition in clinical practice as it is characterized by suboptimal accuracy of clinical and biochemical parameters for diagnosis and management. Since no expert consensus or guidance for this condition is currently available, a task force of experts received the commitment from the European Thyroid Association (ETA) to prepare this document based on the principles of clinical evidence. STUDY DESIGN The task force started to work in February 2017 and after a careful selection of appropriate references (cohort studies, case reports, expert opinions), a preliminary presentation and live discussion during the 2017 ETA meeting, and several revision rounds, has prepared a list of recommendations to support the diagnosis and management of patients with CeH. RESULTS Due to the particular challenges of this rare condition in the different ages, the target users of this guidance are pediatric and adult endocrinologists. Experts agreed on the need to recognize and treat overt CeH at all ages, whereas treatment of milder forms may be dispensable in the elderly (> 75 years). CONCLUSIONS Despite the lack of randomized controlled clinical trials, the experts provide 34 recommendations supported by variable levels of strength that should improve the quality of life of the affected patients and reduce the metabolic and hormonal consequences of inadequate management.
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Affiliation(s)
- Luca Persani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- *Prof. Luca Persani, MD, PhD, University of Milan and IRCCS Istituto Auxologico Italiano, San Luca Hospital, Piazzale Brescia 20, IT–20149 Milan (Italy), E-Mail
| | - Georg Brabant
- Experimental and Clinical Endocrinology Medical Clinic I – University of Lübeck, Lübeck, Germany
| | - Mehul Dattani
- Genetics and Genomic Medicine Programme, UCL GOS Institute of Child Health, London, United Kingdom
| | - Marco Bonomi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eric Fliers
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Annette Gruters
- Department for Pediatric Endocrinology and Diabetes, Charité University Medicine, Berlin, Germany
- University Hospital Heidelberg, Heidelberg, Germany
| | - Dominique Maiter
- Department of Endocrinology and Nutrition, UCL Cliniques Saint-Luc, Brussels, Belgium
| | - Nadia Schoenmakers
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - A.S. Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Takamizawa T, Satoh T, Miyamoto T, Nakajima Y, Ishizuka T, Tomaru T, Yoshino S, Katano-Toki A, Nishikido A, Sapkota S, Watanabe T, Okamura T, Ishida E, Horiguchi K, Matsumoto S, Ishii S, Ozawa A, Shibusawa N, Okada S, Yamada M. Transducin β-like 1, X-linked and nuclear receptor co-repressor cooperatively augment the ligand-independent stimulation of TRH and TSHβ gene promoters by thyroid hormone receptors. Endocr J 2018; 65:805-813. [PMID: 29794369 DOI: 10.1507/endocrj.ej17-0384] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Mutations in TBL1X, a component of the nuclear receptor co-repressor (N-CoR) and silencing mediator of retinoic acid and thyroid hormone receptor co-repressor complexes, have recently been implicated in isolated central hypothyroidism (CeH). However, the mechanisms by which TBL1X mutations affect negative feedback regulation in the hypothalamus-pituitary-thyroid axis remain unclear. N-CoR was previously reported to paradoxically enhance the ligand-independent stimulation of TRH and TSHβ gene promoters by thyroid hormone receptors (TR) in cell culture systems. We herein investigated whether TBL1X affects the unliganded TR-mediated stimulation of the promoter activities of genes negatively regulated by T3 in cooperation with N-CoR. In a hypothalamic neuronal cell line, the unliganded TR-mediated stimulation of the TRH gene promoter was significantly enhanced by co-transfected TBL1X, and the co-transfection of TBL1X with N-CoR further enhanced promoter activity. In contrast, the knockdown of endogenous Tbl1x using short interfering RNA significantly attenuated the N-CoR-mediated enhancement of promoter activity in the presence of unliganded TR. The co-transfection of N365Y or Y458C, TBL1X mutants identified in CeH patients, showed impaired co-activation with N-CoR for the ligand-independent stimulation of the TRH promoter by TR. In the absence of T3, similar or impaired enhancement of the TSHβ gene promoter by the wild type or TBL1X mutants, respectively, was observed in the presence of co-transfected TR and N-CoR in CV-1 cells. These results suggest that TBL1X is needed for the full activation of TRH and TSHβ gene promoters by unliganded TR. Mutations in TBL1X may cause CeH due to the impaired up-regulation of TRH and/or TSHβ gene transcription despite low T3 levels.
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Affiliation(s)
- Tetsuya Takamizawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Tetsurou Satoh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Tomoko Miyamoto
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yasuyo Nakajima
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takahiro Ishizuka
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takuya Tomaru
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Satoshi Yoshino
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akiko Katano-Toki
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Ayaka Nishikido
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Santosh Sapkota
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takuya Watanabe
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takashi Okamura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Emi Ishida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kazuhiko Horiguchi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Syunichi Matsumoto
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Sumiyasu Ishii
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Atsushi Ozawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Nobuyuki Shibusawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shuichi Okada
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masanobu Yamada
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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13
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Inskip PD, Veiga LH, Brenner AV, Sigurdson AJ, Ostroumova E, Chow EJ, Stovall M, Smith SA, Weathers RE, Leisenring W, Robison LL, Armstrong GT, Sklar CA, Lubin JH. Hypothyroidism after Radiation Therapy for Childhood Cancer: A Report from the Childhood Cancer Survivor Study. Radiat Res 2018; 190:117-132. [PMID: 29763379 PMCID: PMC6161838 DOI: 10.1667/rr14888.1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
While thyroid cancer risks from exposure to ionizing radiation early in life are well characterized quantitatively, the association of radiation with nonmalignant, functional thyroid disorders has been less studied. Here, we report on a risk analysis study of hypothyroidism with radiation dose to the thyroid gland and the hypothalamic-pituitary axis among survivors of childhood cancer. Utilizing data from the Childhood Cancer Survivor Study, a cohort of 14,364 five-year survivors of childhood cancer diagnosed at 26 hospitals in the U.S. and Canada between 1970 and 1986 and followed through 2009, the occurrence of hypothyroidism was ascertained among 12,015 survivors through serial questionnaires. Radiation doses to the thyroid gland and pituitary gland were estimated from radiotherapy records. Binary outcome regression was used to estimate prevalence odds ratios for hypothyroidism at five years from diagnosis of childhood cancer and Poisson regression to model incidence rate ratios (RR) after the first five years. A total of 1,193 cases of hypothyroidism were observed, 777 (65%) of which occurred five or more years after cancer diagnosis. The cumulative proportion affected with hypothyroidism (prevalence at five years after cancer diagnosis plus incidence through 30 years after cancer diagnosis) was highest among five-year survivors of Hodgkin lymphoma (32.3%; 95% CI: 29.5-34.9) and cancers of the central nervous system (17.7%; 95% CI: 15.2-20.4). The incidence rate was significantly associated with radiation dose to the thyroid and pituitary. The joint association of hypothyroidism with thyroid and pituitary dose was sub-additive for pituitary doses greater than 16 Gy. In particular, a very strong thyroid radiation dose dependence at low-to-moderate pituitary/hypothalamic doses was diminished at high pituitary doses. Radiation-related risks were higher in males than females and inversely associated with age at exposure and time since exposure but remained elevated more than 25 years after exposure. Our findings indicated that hypothyroidism was significantly associated with treatment with bleomycin (RR = 3.4; 95% CI: 1.6-7.3) and the alkylating agents cyclohexyl-chloroethyl-nitrosourea (CCNU) (RR = 3.0; 95% CI: 1.5-5.3) and cyclophosphamide (RR = 1.3; 95% CI: 1.0-1.8), with a significant dose response for CCNU ( P < 0.01). The risk of hypothyroidism among childhood cancer survivors treated with radiation depends both on direct, dose-dependent radiation-induced damage to the thyroid gland and on dose-dependent indirect effects secondary to irradiation of the hypothalamic-pituitary axis. The dose-response relationship for each site depends on dose to the other. Radiation-related risk persists for more than 25 years after treatment. Treatment with certain chemotherapy agents may increase the risk of hypothyroidism.
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Affiliation(s)
- Peter D. Inskip
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
- Retired
| | - Lene H.S. Veiga
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
- Institute for Radiation Protection and Dosimetry, Brazilian
Nuclear Energy Commission, Rio de Janeiro, Brazil
| | - Alina V. Brenner
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
| | - Alice J. Sigurdson
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
- Retired
| | - Evgenia Ostroumova
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
- International Agency for Research on Cancer, Lyon,
France
| | - Eric J. Chow
- Clinical Research and Public Health Sciences Divisions,
Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Marilyn Stovall
- Department of Radiation Physics, The University of Texas MD
Anderson Cancer Center; Houston, TX, USA
- Retired
| | - Susan A. Smith
- Department of Radiation Physics, The University of Texas MD
Anderson Cancer Center; Houston, TX, USA
| | - Rita E. Weathers
- Department of Radiation Physics, The University of Texas MD
Anderson Cancer Center; Houston, TX, USA
| | - Wendy Leisenring
- Clinical Research and Public Health Sciences Divisions,
Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude
Children’s Research Hospital; Memphis, TN, USA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude
Children’s Research Hospital; Memphis, TN, USA
| | - Charles A. Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
| | - Jay H. Lubin
- Biostatistics Branch, Division of Cancer Epidemiology and
Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD, USA
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14
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Ferrara SJ, Bourdette D, Scanlan TS. Hypothalamic-Pituitary-Thyroid Axis Perturbations in Male Mice by CNS-Penetrating Thyromimetics. Endocrinology 2018; 159:2733-2740. [PMID: 29846550 PMCID: PMC6457038 DOI: 10.1210/en.2018-00065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/22/2018] [Indexed: 02/08/2023]
Abstract
Thyromimetics represent a class of experimental drugs that can stimulate tissue-selective thyroid hormone action. As such, thyromimetics should have effects on the hypothalamic-pituitary-thyroid (HPT) axis, but details of this action and the subsequent effects on systemic thyroid hormone levels have not been reported to date. Here, we compare the HPT-axis effects of sobetirome, a well-studied thyromimetic, with Sob-AM2, a newly developed prodrug of sobetirome that targets sobetirome distribution to the central nervous system (CNS). Similar to endogenous thyroid hormone, administration of sobetirome and Sob-AM2 suppress HPT-axis gene transcript levels in a manner that correlates to their specific tissue distribution properties (periphery vs CNS, respectively). Dosing male C57BL/6 mice with sobetirome and Sob-AM2 at concentrations ≥10 μg/kg/d for 29 days induces a state similar to central hypothyroidism characterized by depleted circulating T4 and T3 and normal TSH levels. However, despite the systemic T4 and T3 depletion, the sobetirome- and Sob-AM2-treated mice do not show signs of hypothyroidism, which may result from the presence of the thyromimetic in the thyroid hormone-depleted background.
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Affiliation(s)
- Skylar J Ferrara
- Program in Chemical Biology, Department of Physiology & Pharmacology, Oregon Health and Science University, Portland, Oregon
| | - Dennis Bourdette
- Department of Neurology, Oregon Health and Science University, Portland, Oregon
| | - Thomas S Scanlan
- Program in Chemical Biology, Department of Physiology & Pharmacology, Oregon Health and Science University, Portland, Oregon
- Correspondence: Thomas S. Scanlan, PhD, Department of Physiology and Pharmacology, Program in Chemical Biology, Oregon Health and Science University, 3181 Southwest Sam Jackson Road, L334, Portland, Oregon 97206. E-mail:
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15
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de Carvalho GA, Paz-Filho G, Mesa Junior C, Graf H. MANAGEMENT OF ENDOCRINE DISEASE: Pitfalls on the replacement therapy for primary and central hypothyroidism in adults. Eur J Endocrinol 2018; 178:R231-R244. [PMID: 29490937 DOI: 10.1530/eje-17-0947] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 02/27/2018] [Indexed: 01/07/2023]
Abstract
Hypothyroidism is one of the most common hormone deficiencies in adults. Most of the cases, particularly those of overt hypothyroidism, are easily diagnosed and managed, with excellent outcomes if treated adequately. However, minor alterations of thyroid function determine nonspecific manifestations. Primary hypothyroidism due to chronic autoimmune thyroiditis is largely the most common cause of thyroid hormone deficiency. Central hypothyroidism is a rare and heterogeneous disorder characterized by decreased thyroid hormone secretion by an otherwise normal thyroid gland, due to lack of TSH. The standard treatment of primary and central hypothyroidism is hormone replacement therapy with levothyroxine sodium (LT4). Treatment guidelines of hypothyroidism recommend monotherapy with LT4 due to its efficacy, long-term experience, favorable side effect profile, ease of administration, good intestinal absorption, long serum half-life and low cost. Despite being easily treatable with a daily dose of LT4, many patients remain hypothyroid due to malabsorption syndromes, autoimmune gastritis, pancreatic and liver disorders, drug interactions, polymorphisms in DIO2 (iodothyronine deiodinase 2), high fiber diet, and more frequently, non-compliance to LT4 therapy. Compliance to levothyroxine treatment in hypothyroidism is compromised by daily and fasting schedule. Many adult patients remain hypothyroid due to all the above mentioned and many attempts to improve levothyroxine therapy compliance and absorption have been made.
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Affiliation(s)
- Gisah Amaral de Carvalho
- Department of Endocrinology and Metabolism, SEMPR, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | | | - Cleo Mesa Junior
- Department of Endocrinology and Metabolism, SEMPR, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
| | - Hans Graf
- Department of Endocrinology and Metabolism, SEMPR, Hospital de Clínicas, Federal University of Paraná, Curitiba, Brazil
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16
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Zhang Q, Zang L, Li YJ, Han BY, Gu WJ, Yan WH, Jin N, Chen K, Du J, Wang XL, Guo QH, Yang GQ, Yang LJ, Ba JM, Lv ZH, Dou JT, Lu JM, Mu YM. Thyrotrophic status in patients with pituitary stalk interruption syndrome. Medicine (Baltimore) 2018; 97:e9084. [PMID: 29480822 PMCID: PMC5943885 DOI: 10.1097/md.0000000000009084] [Citation(s) in RCA: 2] [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] [Indexed: 01/13/2023] Open
Abstract
Pituitary stalk interruption syndrome (PSIS) is associated with simultaneous or subsequent pituitary hormone deficiencies (PHDs). Although the clinical features of multiple PHDs are well known, the status of the thyrotrophic axis in PSIS has not been thoroughly investigated.The clinical data of 89 PSIS patients and 34 Sheehan syndrome (SS) patients were retrospectively analyzed.The prevalence of central hypothyroidism in the PSIS patients and the SS patients was 79.8% and 70.6%, respectively. The thyroid-stimulating hormone (TSH) levels in the PSIS patients were significantly higher in comparison with the SS patients (5.13 ± 3.40 vs 1.67 ± 1.20 mU/L, P < .05). TSH elevation (8.79 ± 3.17 mU/L) was noticed in 29 of 71 (40.85%) hypothyroid PSIS patients but not in the 24 hypothyroid SS patients. The TSH levels in the hypothyroid PSIS patients were significantly higher in comparison with the euthyroid PSIS patients (5.42 ± 3.67 vs 3.66 ± 1.50 mU/L). Thyroid hormone replacement significantly reduced the TSH levels in the PSIS patients with elevated TSH levels from 7.24 ± 0.98 to 1.67 ± 1.51 mU/L (P < .05). The logistic regression analysis suggested that TSH level was not significantly associated with pituitary stalk status and height of the anterior pituitary gland.PSIS is a newly recognized cause of central hypothyroidism. The proportion and amplitude of TSH elevations are higher in PSIS than in other causes of central hypothyroidism.
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Affiliation(s)
- Qian Zhang
- Department of Endocrinology, Chinese PLA General Hospital
- Department of Endocrinology, PLA Army General Hospital, Beijing
| | - Li Zang
- Department of Endocrinology, Chinese PLA General Hospital
| | - Yi-Jun Li
- Department of Endocrinology, Chinese PLA General Hospital
| | - Bai-Yu Han
- Department of Endocrinology, Chinese PLA General Hospital
- Department of Endocrinology, The 264 Hospital of PLA, Taiyuan, Shanxi, China
| | - Wei-Jun Gu
- Department of Endocrinology, Chinese PLA General Hospital
| | - Wen-Hua Yan
- Department of Endocrinology, Chinese PLA General Hospital
| | - Nan Jin
- Department of Endocrinology, Chinese PLA General Hospital
| | - Kang Chen
- Department of Endocrinology, Chinese PLA General Hospital
| | - Jin Du
- Department of Endocrinology, Chinese PLA General Hospital
| | - Xian-Ling Wang
- Department of Endocrinology, Chinese PLA General Hospital
| | - Qing-Hua Guo
- Department of Endocrinology, Chinese PLA General Hospital
| | - Guo-Qing Yang
- Department of Endocrinology, Chinese PLA General Hospital
| | - Li-Juan Yang
- Department of Endocrinology, Chinese PLA General Hospital
| | - Jian-Ming Ba
- Department of Endocrinology, Chinese PLA General Hospital
| | - Zhao-Hui Lv
- Department of Endocrinology, Chinese PLA General Hospital
| | - Jing-Tao Dou
- Department of Endocrinology, Chinese PLA General Hospital
| | - Ju-Ming Lu
- Department of Endocrinology, Chinese PLA General Hospital
| | - Yi-Ming Mu
- Department of Endocrinology, Chinese PLA General Hospital
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17
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Rationalization of the Irrational Neuropathologic Basis of Hypothyroidism-Olfaction Disorders Paradox: Experimental Study. World Neurosurg 2017; 107:400-408. [DOI: 10.1016/j.wneu.2017.07.180] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 07/26/2017] [Accepted: 07/29/2017] [Indexed: 01/04/2023]
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18
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Abstract
Central hypothyroidism is a rare and heterogeneous disorder that is characterized by a defect in thyroid hormone secretion in an otherwise normal thyroid gland due to insufficient stimulation by TSH. The disease results from the abnormal function of the pituitary gland, the hypothalamus, or both. Moreover, central hypothyroidism can be isolated or combined with other pituitary hormone deficiencies, which are mostly acquired and are rarely congenital. The clinical manifestations of central hypothyroidism are usually milder than those observed in primary hypothyroidism. Obtaining a positive diagnosis for central hypothyroidism can be difficult from both a clinical and a biochemical perspective. The diagnosis of central hypothyroidism is based on low circulating levels of free T4 in the presence of low to normal TSH concentrations. The correct diagnosis of both acquired (also termed sporadic) and congenital (also termed genetic) central hypothyroidism can be hindered by methodological interference in free T4 or TSH measurements; routine utilization of total T4 or T3 measurements; concurrent systemic illness that is characterized by low levels of free T4 and normal TSH concentrations; the use of the sole TSH-reflex strategy, which is the measurement of the sole level of TSH, without free T4, if levels of TSH are in the normal range; and the diagnosis of congenital hypothyroidism based on TSH analysis without the concomitant measurement of serum levels of T4. In this Review, we discuss current knowledge of the causes of central hypothyroidism, emphasizing possible pitfalls in the diagnosis and treatment of this disorder.
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Affiliation(s)
| | - Giulia Rodari
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology and Metabolic Diseases Unit, Via Francesco Sforza 35, Milan 20122, Italy
| | - Claudia Giavoli
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Endocrinology and Metabolic Diseases Unit, Via Francesco Sforza 35, Milan 20122, Italy
| | - Andrea Lania
- Department of Biomedical Sciences, Humanitas University and Endocrinology Unit, Humanitas Research Hospital, Via Manzoni 56, Rozzano 20086, Italy
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19
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García M, González de Buitrago J, Jiménez-Rosés M, Pardo L, Hinkle PM, Moreno JC. Central Hypothyroidism Due to a TRHR Mutation Causing Impaired Ligand Affinity and Transactivation of Gq. J Clin Endocrinol Metab 2017; 102:2433-2442. [PMID: 28419241 PMCID: PMC5505191 DOI: 10.1210/jc.2016-3977] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 04/12/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Central congenital hypothyroidism (CCH) is an underdiagnosed disorder characterized by deficient production and bioactivity of thyroid-stimulating hormone (TSH) leading to low thyroid hormone synthesis. Thyrotropin-releasing hormone (TRH) receptor (TRHR) defects are rare recessive disorders usually associated with incidentally identified CCH and short stature in childhood. OBJECTIVES Clinical and genetic characterization of a consanguineous family of Roma origin with central hypothyroidism and identification of underlying molecular mechanisms. DESIGN All family members were phenotyped with thyroid hormone profiles, pituitary magnetic resonance imaging, TRH tests, and dynamic tests for other pituitary hormones. Candidate TRH, TRHR, TSHB, and IGSF1 genes were screened for mutations. A mutant TRHR was characterized in vitro and by molecular modeling. RESULTS A homozygous missense mutation in TRHR (c.392T > C; p.I131T) was identified in an 8-year-old boy with moderate hypothyroidism (TSH: 2.61 mIU/L, Normal: 0.27 to 4.2; free thyroxine: 9.52 pmol/L, Normal: 10.9 to 25.7) who was overweight (body mass index: 20.4 kg/m2, p91) but had normal stature (122 cm; -0.58 standard deviation). His mother, two brothers, and grandmother were heterozygous for the mutation with isolated hyperthyrotropinemia (TSH: 4.3 to 8 mIU/L). The I131T mutation, in TRHR intracellular loop 2, decreases TRH affinity and increases the half-maximal effective concentration for signaling. Modeling of TRHR-Gq complexes predicts that the mutation disrupts the interaction between receptor and a hydrophobic pocket formed by Gq. CONCLUSIONS A unique missense TRHR defect identified in a consanguineous family is associated with central hypothyroidism in homozygotes and hyperthyrotropinemia in heterozygotes, suggesting compensatory elevation of TSH with reduced biopotency. The I131T mutation decreases TRH binding and TRHR-Gq coupling and signaling.
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Affiliation(s)
- Marta García
- Thyroid Molecular Laboratory, Institute for Medical and Molecular Genetics, La Paz University Hospital, Autonomous University of Madrid, 28046 Madrid, Spain
| | | | - Mireia Jiménez-Rosés
- Computational Medicine Laboratory, Biostatistics Unit, Autonomous University of Barcelona, 08193 Barcelona, Spain
| | - Leonardo Pardo
- Computational Medicine Laboratory, Biostatistics Unit, Autonomous University of Barcelona, 08193 Barcelona, Spain
| | - Patricia M. Hinkle
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, New York 14642
| | - José C. Moreno
- Thyroid Molecular Laboratory, Institute for Medical and Molecular Genetics, La Paz University Hospital, Autonomous University of Madrid, 28046 Madrid, Spain
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20
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Turgeon MO, Silander TL, Doycheva D, Liao XH, Rigden M, Ongaro L, Zhou X, Joustra SD, Wit JM, Wade MG, Heuer H, Refetoff S, Bernard DJ. TRH Action Is Impaired in Pituitaries of Male IGSF1-Deficient Mice. Endocrinology 2017; 158:815-830. [PMID: 28324000 PMCID: PMC5460797 DOI: 10.1210/en.2016-1788] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/06/2017] [Indexed: 11/19/2022]
Abstract
Loss-of-function mutations in the X-linked immunoglobulin superfamily, member 1 (IGSF1) gene cause central hypothyroidism. IGSF1 is a transmembrane glycoprotein of unknown function expressed in thyrotropin (TSH)-producing thyrotrope cells of the anterior pituitary gland. The protein is cotranslationally cleaved, with only its C-terminal domain (CTD) being trafficked to the plasma membrane. Most intragenic IGSF1 mutations in humans map to the CTD. In this study, we used CRISPR-Cas9 to introduce a loss-of-function mutation into the IGSF1-CTD in mice. The modified allele encodes a truncated protein that fails to traffic to the plasma membrane. Under standard laboratory conditions, Igsf1-deficient males exhibit normal serum TSH levels as well as normal numbers of TSH-expressing thyrotropes. However, pituitary expression of the TSH subunit genes and TSH protein content are reduced, as is expression of the receptor for thyrotropin-releasing hormone (TRH). When challenged with exogenous TRH, Igsf1-deficient males release TSH, but to a significantly lesser extent than do their wild-type littermates. The mice show similarly attenuated TSH secretion when rendered profoundly hypothyroid with a low iodine diet supplemented with propylthiouracil. Collectively, these results indicate that impairments in pituitary TRH receptor expression and/or downstream signaling underlie central hypothyroidism in IGSF1 deficiency syndrome.
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Affiliation(s)
- Marc-Olivier Turgeon
- Department of Anatomy and Cell Biology, McGill University, Montreal, Quebec H3A 0C7, Canada
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Quebec H3G 1Y6 Canada
| | - Tanya L. Silander
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Quebec H3G 1Y6 Canada
- Integrated Program in Neuroscience, McGill University, Montreal, Quebec H3A 2B4 Canada
| | - Denica Doycheva
- 4Leibniz Research Institute for Environmental Medicine, 40225 Düsseldorf, Germany
- Leibniz Institute on Aging–Fritz Lipmann Institute, 07745 Jena, Germany
| | | | - Marc Rigden
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, Ontario K1A 0K9, Canada
| | - Luisina Ongaro
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Quebec H3G 1Y6 Canada
| | - Xiang Zhou
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Quebec H3G 1Y6 Canada
| | - Sjoerd D. Joustra
- Department of Pediatrics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
| | - Jan M. Wit
- Department of Pediatrics, Leiden University Medical Center, 2300 RC Leiden, The Netherlands
| | - Mike G. Wade
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, Ontario K1A 0K9, Canada
| | - Heike Heuer
- 4Leibniz Research Institute for Environmental Medicine, 40225 Düsseldorf, Germany
| | - Samuel Refetoff
- Department of Medicine and
- Department of Pediatrics and Committee on Genetics, University of Chicago, Chicago, Illinois 60637
| | - Daniel J. Bernard
- Department of Anatomy and Cell Biology, McGill University, Montreal, Quebec H3A 0C7, Canada
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Quebec H3G 1Y6 Canada
- Integrated Program in Neuroscience, McGill University, Montreal, Quebec H3A 2B4 Canada
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21
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A novel "total pituitary hormone index" as an indicator of postoperative pituitary function in patients undergoing resection of pituitary adenomas. Oncotarget 2017; 8:79111-79125. [PMID: 29108291 PMCID: PMC5668024 DOI: 10.18632/oncotarget.15978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/27/2017] [Indexed: 02/02/2023] Open
Abstract
The purpose of this study was to investigate the differences between pre- and postoperative pituitary hormone levels in patients undergoing surgical resection of pituitary adenoma and to identify factors associated with preoperative hypopituitarism. Data from 81 patients with histologically confirmed functioning and non-functioning pituitary adenomas (NFPA) who underwent transsphenoidal resection from January 2011 to December 2013 were retrospectively analyzed. Logistic regression was applied to analyze factors associated with preoperative hypopituitarism. In patients with functioning pituitary adenomas, GH and PRL levels declined after the operation; TSH, FSH and LH levels returned to preoperative values after an initial decline at postoperative day 1. In contrast, with the exception of a postoperative reduction in PRL level, NFPA patients had postoperative ACTH, TSH, FSH and LH levels at 4 months follow-up that were similar to preoperative levels. Similarly, a decrease in total hormone index was observed following surgery irrespective of NFPA type and in null-cell type NFPA patients with values increasing over the 4-month follow-up period. A higher percentage of patients receiving partial resection had high PRL levels (≥200 ng/ mL) compared to those receiving complete resection. Age (P = 0.041) and male sex (P = 0.004) were significantly associated with preoperative hypopituitarism. In conclusion, the postoperative total hormone index decreased immediately following surgery in all patients with pituitary adenoma who underwent resection, and then increased over the follow-up period. The extent of surgical resection correlated with PRL levels >200 ng/mL. Age and male sex were also independent risk factors for preoperative hypopituitarism.
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Karageorgiadis AS, Lyssikatos C, Belyavskaya E, Papadakis GZ, Patronas NJ, Lodish MB, Stratakis CA. Case 1: Poor Growth With Presence of a Pituitary Lesion in an 11-year-old Boy. Pediatr Rev 2017; 38:44-45. [PMID: 28044033 PMCID: PMC6343498 DOI: 10.1542/pir.2014-0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Alexander S Karageorgiadis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD.,Department of Pediatrics, Georgetown University Hospital, Washington, DC
| | - Charalampos Lyssikatos
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Elena Belyavskaya
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Georgios Z Papadakis
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Nicholas J Patronas
- Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Maya B Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Feldt-Rasmussen U, Klose M. Central hypothyroidism and its role for cardiovascular risk factors in hypopituitary patients. Endocrine 2016; 54:15-23. [PMID: 27481361 DOI: 10.1007/s12020-016-1047-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/30/2016] [Indexed: 12/30/2022]
Abstract
Hypothyroidism is characterized by hypometabolism, and may be seen as a part of secondary failure due to pituitary insufficiency or tertiary due to hypothalamic disease. Secondary and tertiary failures are also referred to as central hypothyroidism. Whereas overt primary hypothyroidism has a well-known affection on the heart and cardiovascular system, and may result in cardiac failure, cardiovascular affection is less well recognized in central hypothyroidism. Studies on central hypothyroidism and cardiovascular outcome are few and given the rarity of the diseases often small. Further, there are several limitations given vast difficulties in diagnosing the condition correctly biochemically, and difficulties monitoring the treatment because normal thyroid-pituitary feedback interrelationships are disrupted. The present review summarizes available studies of central adult hypothyroidism and its possible influence on the cardiovascular system, describe differences from primary thyroid failure and seek evidence for performing guidelines for clinical management of this particular thyroid and hypothalamo-pituitary disorder.
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Affiliation(s)
- Ulla Feldt-Rasmussen
- Department of Medical Endocrinology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.
| | - Marianne Klose
- Department of Medical Endocrinology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Schoenmakers N, Alatzoglou KS, Chatterjee VK, Dattani MT. Recent advances in central congenital hypothyroidism. J Endocrinol 2015; 227:R51-71. [PMID: 26416826 PMCID: PMC4629398 DOI: 10.1530/joe-15-0341] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 09/17/2015] [Accepted: 09/28/2015] [Indexed: 01/23/2023]
Abstract
Central congenital hypothyroidism (CCH) may occur in isolation, or more frequently in combination with additional pituitary hormone deficits with or without associated extrapituitary abnormalities. Although uncommon, it may be more prevalent than previously thought, affecting up to 1:16 000 neonates in the Netherlands. Since TSH is not elevated, CCH will evade diagnosis in primary, TSH-based, CH screening programs and delayed detection may result in neurodevelopmental delay due to untreated neonatal hypothyroidism. Alternatively, coexisting growth hormones or ACTH deficiency may pose additional risks, such as life threatening hypoglycaemia. Genetic ascertainment is possible in a minority of cases and reveals mutations in genes controlling the TSH biosynthetic pathway (TSHB, TRHR, IGSF1) in isolated TSH deficiency, or early (HESX1, LHX3, LHX4, SOX3, OTX2) or late (PROP1, POU1F1) pituitary transcription factors in combined hormone deficits. Since TSH cannot be used as an indicator of euthyroidism, adequacy of treatment can be difficult to monitor due to a paucity of alternative biomarkers. This review will summarize the normal physiology of pituitary development and the hypothalamic-pituitary-thyroid axis, then describe known genetic causes of isolated central hypothyroidism and combined pituitary hormone deficits associated with TSH deficiency. Difficulties in diagnosis and management of these conditions will then be discussed.
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Affiliation(s)
- Nadia Schoenmakers
- University of Cambridge Metabolic Research LaboratoriesWellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Level 4, PO Box 289, Hills Road, Cambridge CB2 0QQ, UKDevelopmental Endocrinology Research GroupSection of Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, London, UK
| | - Kyriaki S Alatzoglou
- University of Cambridge Metabolic Research LaboratoriesWellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Level 4, PO Box 289, Hills Road, Cambridge CB2 0QQ, UKDevelopmental Endocrinology Research GroupSection of Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, London, UK
| | - V Krishna Chatterjee
- University of Cambridge Metabolic Research LaboratoriesWellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Level 4, PO Box 289, Hills Road, Cambridge CB2 0QQ, UKDevelopmental Endocrinology Research GroupSection of Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, London, UK
| | - Mehul T Dattani
- University of Cambridge Metabolic Research LaboratoriesWellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Level 4, PO Box 289, Hills Road, Cambridge CB2 0QQ, UKDevelopmental Endocrinology Research GroupSection of Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, London, UK
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25
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Castinetti F, Brinkmeier ML, Mortensen AH, Vella KR, Gergics P, Brue T, Hollenberg AN, Gan L, Camper SA. ISL1 Is Necessary for Maximal Thyrotrope Response to Hypothyroidism. Mol Endocrinol 2015; 29:1510-21. [PMID: 26296153 DOI: 10.1210/me.2015-1192] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ISLET1 is a homeodomain transcription factor necessary for development of the pituitary, retina, motor neurons, heart, and pancreas. Isl1-deficient mice (Isl1(-/-)) die early during embryogenesis at embryonic day 10.5 due to heart defects, and at that time, they have an undersized pituitary primordium. ISL1 is expressed in differentiating pituitary cells in early embryogenesis. Here, we report the cell-specific expression of ISL1 and assessment of its role in gonadotropes and thyrotropes. Isl1 expression is elevated in pituitaries of Cga(-/-) mice, a model of hypothyroidism with thyrotrope hypertrophy and hyperplasia. Thyrotrope-specific disruption of Isl1 with Tshb-cre is permissive for normal serum TSH, but T4 levels are decreased, suggesting decreased thyrotrope function. Inducing hypothyroidism in normal mice causes a reduction in T4 levels and dramatically elevated TSH response, but mice with thyrotrope-specific disruption of Isl1 have a blunted TSH response. In contrast, deletion of Isl1 in gonadotropes with an Lhb-cre transgene has no obvious effect on gonadotrope function or fertility. These results show that ISL1 is necessary for maximal thyrotrope response to hypothyroidism, in addition to its role in development of Rathke's pouch.
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Affiliation(s)
- F Castinetti
- Human Genetics, University of Michigan (F.C., M.L.B., A.H.M., P.G., S.A.C.), Ann Arbor, Michigan 48109; Beth Israel Deaconess Medical Center (K.R.V., A.N.H.), Harvard University, Boston, Massachusetts 02215; Aix-Marseille University (F.C., T.B.), Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, Centre National de la Recherche Scientifique, Faculté de Médecine de Marseille, and Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Hôpital de la Timone, Marseille, France 13000; and University of Rochester School of Medicine and Dentistry (L.G.), Rochester, New York 14642
| | - M L Brinkmeier
- Human Genetics, University of Michigan (F.C., M.L.B., A.H.M., P.G., S.A.C.), Ann Arbor, Michigan 48109; Beth Israel Deaconess Medical Center (K.R.V., A.N.H.), Harvard University, Boston, Massachusetts 02215; Aix-Marseille University (F.C., T.B.), Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, Centre National de la Recherche Scientifique, Faculté de Médecine de Marseille, and Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Hôpital de la Timone, Marseille, France 13000; and University of Rochester School of Medicine and Dentistry (L.G.), Rochester, New York 14642
| | - A H Mortensen
- Human Genetics, University of Michigan (F.C., M.L.B., A.H.M., P.G., S.A.C.), Ann Arbor, Michigan 48109; Beth Israel Deaconess Medical Center (K.R.V., A.N.H.), Harvard University, Boston, Massachusetts 02215; Aix-Marseille University (F.C., T.B.), Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, Centre National de la Recherche Scientifique, Faculté de Médecine de Marseille, and Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Hôpital de la Timone, Marseille, France 13000; and University of Rochester School of Medicine and Dentistry (L.G.), Rochester, New York 14642
| | - K R Vella
- Human Genetics, University of Michigan (F.C., M.L.B., A.H.M., P.G., S.A.C.), Ann Arbor, Michigan 48109; Beth Israel Deaconess Medical Center (K.R.V., A.N.H.), Harvard University, Boston, Massachusetts 02215; Aix-Marseille University (F.C., T.B.), Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, Centre National de la Recherche Scientifique, Faculté de Médecine de Marseille, and Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Hôpital de la Timone, Marseille, France 13000; and University of Rochester School of Medicine and Dentistry (L.G.), Rochester, New York 14642
| | - P Gergics
- Human Genetics, University of Michigan (F.C., M.L.B., A.H.M., P.G., S.A.C.), Ann Arbor, Michigan 48109; Beth Israel Deaconess Medical Center (K.R.V., A.N.H.), Harvard University, Boston, Massachusetts 02215; Aix-Marseille University (F.C., T.B.), Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, Centre National de la Recherche Scientifique, Faculté de Médecine de Marseille, and Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Hôpital de la Timone, Marseille, France 13000; and University of Rochester School of Medicine and Dentistry (L.G.), Rochester, New York 14642
| | - T Brue
- Human Genetics, University of Michigan (F.C., M.L.B., A.H.M., P.G., S.A.C.), Ann Arbor, Michigan 48109; Beth Israel Deaconess Medical Center (K.R.V., A.N.H.), Harvard University, Boston, Massachusetts 02215; Aix-Marseille University (F.C., T.B.), Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, Centre National de la Recherche Scientifique, Faculté de Médecine de Marseille, and Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Hôpital de la Timone, Marseille, France 13000; and University of Rochester School of Medicine and Dentistry (L.G.), Rochester, New York 14642
| | - A N Hollenberg
- Human Genetics, University of Michigan (F.C., M.L.B., A.H.M., P.G., S.A.C.), Ann Arbor, Michigan 48109; Beth Israel Deaconess Medical Center (K.R.V., A.N.H.), Harvard University, Boston, Massachusetts 02215; Aix-Marseille University (F.C., T.B.), Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, Centre National de la Recherche Scientifique, Faculté de Médecine de Marseille, and Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Hôpital de la Timone, Marseille, France 13000; and University of Rochester School of Medicine and Dentistry (L.G.), Rochester, New York 14642
| | - L Gan
- Human Genetics, University of Michigan (F.C., M.L.B., A.H.M., P.G., S.A.C.), Ann Arbor, Michigan 48109; Beth Israel Deaconess Medical Center (K.R.V., A.N.H.), Harvard University, Boston, Massachusetts 02215; Aix-Marseille University (F.C., T.B.), Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, Centre National de la Recherche Scientifique, Faculté de Médecine de Marseille, and Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Hôpital de la Timone, Marseille, France 13000; and University of Rochester School of Medicine and Dentistry (L.G.), Rochester, New York 14642
| | - S A Camper
- Human Genetics, University of Michigan (F.C., M.L.B., A.H.M., P.G., S.A.C.), Ann Arbor, Michigan 48109; Beth Israel Deaconess Medical Center (K.R.V., A.N.H.), Harvard University, Boston, Massachusetts 02215; Aix-Marseille University (F.C., T.B.), Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, Centre National de la Recherche Scientifique, Faculté de Médecine de Marseille, and Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Hôpital de la Timone, Marseille, France 13000; and University of Rochester School of Medicine and Dentistry (L.G.), Rochester, New York 14642
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Gallo-Vallejo J, Gallo-Vallejo F. Endocrinopatías durante el puerperio. Manejo. Semergen 2015; 41:99-105. [DOI: 10.1016/j.semerg.2014.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 03/15/2014] [Accepted: 03/17/2014] [Indexed: 10/25/2022]
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Mazziotti G, Mormando M, Cristiano A, Bianchi A, Porcelli T, Giampietro A, Maffezzoni F, Serra V, De Marinis L, Giustina A. Association between l-thyroxine treatment, GH deficiency, and radiological vertebral fractures in patients with adult-onset hypopituitarism. Eur J Endocrinol 2014; 170:893-9. [PMID: 24836549 DOI: 10.1530/eje-14-0097] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In this study, we aimed at evaluating the association between radiological vertebral fractures and levo-thyroxine (l-T4) replacement doses in adult patients with hypopituitarism. DESIGN Cross-sectional study. METHODS We studied 74 adult hypopituitary patients (males, 43; females, 31; mean age, 57 years; and range, 23-79) with central hypothyroidism treated with l-T4 (median daily dose: 1.1 μg/kg). All patients also had severe GH deficiency (GHD) and 38 of them were replaced with recombinant GH. Vertebral fractures were assessed by a quantitative morphometric analysis performed on thoracic and lumbar spine lateral X-ray. RESULTS Radiological vertebral fractures were found in 23 patients (31.1%) in association with untreated GHD (P=0.02), higher serum free T4 levels (P=0.03), a higher daily dose of l-T4 (P=0.005), and a longer duration of hypopituitarism (P=0.05). When GHD was treated, the prevalence of vertebral fractures was more frequent (P=0.03) in patients receiving high l-T4 doses (third tertile: >1.35 μg/kg per day) as compared with patients who were treated with lower drug doses (first tertile: <0.93 μg/kg per day). Such a difference was not observed in patients with untreated GHD who showed a higher prevalence of vertebral fractures regardless of l-T4 daily doses. Multivariate analysis showed that untreated GHD (odds ratio: 4.27, 95% CI 1.27-14.33; P=0.01) and the daily dose of l-T4 (odds ratio: 4.01, 95% CI 1.16-14.39; P=0.03) maintained a significant and independent association with vertebral fractures in patients with central hypothyroidism. CONCLUSIONS Our data suggest for the first time that a relative overtreatment with l-T4 may influence the fracture risk in some patients with hypopituitarism.
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Affiliation(s)
- G Mazziotti
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - M Mormando
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - A Cristiano
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - A Bianchi
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - T Porcelli
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - A Giampietro
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - F Maffezzoni
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - V Serra
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - L De Marinis
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
| | - A Giustina
- Chair of EndocrinologyUniversity of Brescia, A.O. Spedali Civili di Brescia, 25123 Brescia, ItalyPituitary UnitDepartment of Endocrinology, Catholic University of Rome, 00168 Rome, Italy
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Redirecting intracellular trafficking and the secretion pattern of FSH dramatically enhances ovarian function in mice. Proc Natl Acad Sci U S A 2014; 111:5735-40. [PMID: 24706813 DOI: 10.1073/pnas.1321404111] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
FSH and luteinizing hormone (LH) are secreted constitutively or in pulses, respectively, from pituitary gonadotropes in many vertebrates, and regulate ovarian function. The molecular basis for this evolutionarily conserved gonadotropin-specific secretion pattern is not understood. Here, we show that the carboxyterminal heptapeptide in LH is a gonadotropin-sorting determinant in vivo that directs pulsatile secretion. FSH containing this heptapeptide enters the regulated pathway in gonadotropes of transgenic mice, and is released in response to gonadotropin-releasing hormone, similar to LH. FSH released from the LH secretory pathway rescued ovarian defects in Fshb-null mice as efficiently as constitutively secreted FSH. Interestingly, the rerouted FSH enhanced ovarian follicle survival, caused a dramatic increase in number of ovulations, and prolonged female reproductive lifespan. Furthermore, the rerouted FSH vastly improved the in vivo fertilization competency of eggs, their subsequent development in vitro and when transplanted, the ability to produce offspring. Our study demonstrates the feasibility to fine-tune the target tissue responses by modifying the intracellular trafficking and secretory fate of a pituitary trophic hormone. The approach to interconvert the secretory fate of proteins in vivo has pathophysiological significance, and could explain the etiology of several hormone hyperstimulation and resistance syndromes.
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Goede SL, Leow MKS, Smit JWA, Dietrich JW. A novel minimal mathematical model of the hypothalamus-pituitary-thyroid axis validated for individualized clinical applications. Math Biosci 2014; 249:1-7. [PMID: 24480737 DOI: 10.1016/j.mbs.2014.01.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 01/07/2014] [Accepted: 01/09/2014] [Indexed: 11/19/2022]
Abstract
The hypothalamus-pituitary-thyroid (HPT) axis represents a complex, non-linear thyroid hormone system in vertebrates governed by numerous variables. The common modeling approach until now aims at a comprehensive inclusion of all known physiological influences. In contrast, we develop a parsimonious mathematical model that integrates the hypothalamus-pituitary (HP) complex as an endocrinologic unit based on a parameterized negative exponential function between free thyroxine (FT4) as stimulus and thyrotropin (thyroid stimulating hormone, TSH) as response. Model validation with clinical data obtained from geographically different hospitals revealed a goodness-of-fit largely ranging between 90% < R² < 99%, each HP characteristic curve being uniquely defined for each individual akin to a fingerprint. Specifically, the HP model represents the afferent feedback limb of the HPT axis while the efferent limb is mathematically depicted by TSH input to the thyroid gland which responds by secreting T4 as its chief output. The complete HPT axis thus forms a closed loop system with negative feedback resulting in an equilibrium state or homeostasis under defined conditions illustrated by the intersection of the HP and thyroid response characteristics. In this treatise, we demonstrate how this mathematical approach facilitates homeostatic set points computation for personalized dosing of thyroid medications of patients to individualized euthyroid states.
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Affiliation(s)
- Simon L Goede
- Systems Research, Oterlekerweg 4, 1841 GP Stompetoren, The Netherlands.
| | - Melvin Khee-Shing Leow
- Singapore Institute for Clinical Sciences, Brenner Centre for Molecular Medicine, A∗STAR, Singapore; Tan Tock Seng Hospital, Singapore; National University of Singapore, Singapore; Duke-NUS Graduate Medical School Singapore, Singapore.
| | - Jan W A Smit
- Department of General Internal Medicine of Radboud University Nijmegen Medical Centre, Postbus 9101, 6500 HB Nijmegen, The Netherlands.
| | - Johannes W Dietrich
- Laboratory XU44, Medical Hospital I, Bergmannsheil University Hospitals, Ruhr University of Bochum, D-44789 Bochum, NRW, Germany.
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Han S, Tie X, Qin X, Wang Y, Wu A. Frontobasal interhemispheric approach for large superasellar craniopharyngiomas: do the benefits outweigh the risks? Acta Neurochir (Wien) 2014; 156:123-30; discussion 130-1. [PMID: 24142197 DOI: 10.1007/s00701-013-1905-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 09/27/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Large suprasellar craniopharyngiomas are surgically challenging. The aim of our study was to explore the therapeutic efficacy of the frontobasal interhemispheric approach for these lesions. METHODS Twenty-nine consecutive adult patients with large suprasellar craniopharyngiomas (diameter >4 cm) who underwent the frontobasal interhemispheric approach were retrospectively evaluated. Surgical and clinical outcomes were analyzed. RESULTS Gross total removal was achieved in 23 cases (79.3%) and subtotal removal in 6 cases (20.7%). The mean follow-up period was 76.5 ± 33.2 months (range, 12-132 months). Twenty-four patients (82.7%) had improvement of the visual impairment score (VIS) after surgery. VIS was unchanged in five patients (17.3%), and no patients experienced visual deterioration. Among 23 patients who had preoperative hypopituitarism, 8 (34.8%) had an improvement. Postoperative new or aggravated hypopituitarism was observed in four patients (13.8%). Permanent diabetes insipidus was observed in ten patients (34.4%). Postoperative anosmia occurred in two earlier cases (6.9%). There was no intracranial infection or cerebrospinal fluid fistula. At last follow-up, >9% BMI gain was observed in 34.5% of patients, and 65.5% of patients returned to work. Four patients (13.8%) suffered recurrence. CONCLUSION Although the frontobasal interhemispheric approach has some disadvantages, it provides ideal access to the suprasellar region and the third ventricle with limited brain retraction. The surgically visible angle is adequate; thus, vital structures can be better protected. For large suprasellar craniopharyngiomas, the benefits of this approach can outweigh its potential risks.
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Affiliation(s)
- Sheng Han
- Department of Neurosurgery, The First Hospital of China Medical University, Nanjing street 155, Heping District, Shenyang, 110001, China
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Persani L, Bonomi M. Uncertainties in endocrine substitution therapy for central endocrine insufficiencies: hypothyroidism. HANDBOOK OF CLINICAL NEUROLOGY 2014; 124:397-405. [PMID: 25248602 DOI: 10.1016/b978-0-444-59602-4.00027-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
In patients with primary hypothyroidism (PH), L-T4 replacement therapy can safely be adjusted to the individual needs by testing serum thyrotropin (TSH) concentration exclusively. Central hypothyrodism (CeH) is a particular hypothyroid condition due to an insufficient stimulation by TSH of an otherwise normal thyroid gland. CeH is about 1000-fold rarer than PH and raises several challenges for clinicians, mainly because they cannot rely on the systematic use of the reflex TSH strategy for diagnosis or therapy monitoring. Therefore, L-T4 replacement in CeH should rely on the combined evaluation of several biochemical and clinical parameters in order to overcome the lack of accuracy of the single index. The management of CeH replacement is further complicated by the frequent combination with other pituitary deficiencies and their treatment.
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Affiliation(s)
- Luca Persani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Division of Endocrine and Metabolic Diseases, San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy.
| | - Marco Bonomi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; Division of Endocrine and Metabolic Diseases, San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy
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Persani L. Clinical review: Central hypothyroidism: pathogenic, diagnostic, and therapeutic challenges. J Clin Endocrinol Metab 2012; 97:3068-78. [PMID: 22851492 DOI: 10.1210/jc.2012-1616] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
CONTEXT Central hypothyroidism (CH) is a particular hypothyroid condition due to an insufficient stimulation by TSH of an otherwise normal thyroid gland. This condition raises several challenges for clinicians; therefore, a review of the most relevant findings on CH epidemiology, pathogenesis, and clinical management has been performed. METHODOLOGY The relevant papers were selected by a PubMed search using appropriate key words. MAIN FINDINGS CH can be the consequence of various disorders affecting either the pituitary gland or the hypothalamus, but most frequently affecting both of them. CH is about 1000-fold rarer than primary hypothyroidism. Except for the neonatal CH due to biallelic TSHβ mutations, the thyroid hormone defect is rarely as profound as can be observed in some primary forms. In contrast with primary hypothyroidism, CH is most frequently characterized by low/normal TSH levels, and adequate thyroid hormone replacement is associated with the suppression of residual TSH secretion. Thus, CH often represents a clinical challenge because physicians cannot rely on the systematic use of the "reflex TSH strategy." The clinical management of CH is further complicated by the frequent combination with other pituitary deficiencies and their substitution.
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Affiliation(s)
- Luca Persani
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
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Lopez-Serna R, Gómez-Amador JL, Barges-Coll J, Nathal-Vera E, Revuelta-Gutiérrez R, Alonso-Vanegas M, Ramos-Peek M, Portocarrero-Ortiz L. Treatment of craniopharyngioma in adults: systematic analysis of a 25-year experience. Arch Med Res 2012; 43:347-55. [PMID: 22824214 DOI: 10.1016/j.arcmed.2012.06.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 06/04/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND AND AIMS Craniopharyngioma is a rare and mostly benign epithelial tumor of the central nervous system, mostly affecting children. Considering that most of the published series of craniopharyngioma are based on pediatric populations, studies in adults gain importance based mainly on the reduced number of cases and the possible differences emerging from a mostly different histological type. We undertook this study to establish the pattern of presentation, morphological features and specific characteristics of craniopharyngioma in an adult Mexican population, as well as discussing the long-term outcome and how it may be influenced by surgical, anatomic and clinical factors. METHODS A total of 153 adult patients (16 years or older) underwent transcranial and transsphenoidal surgery between January 1985 and December 2009, all with histological confirmation of craniopharyngioma. Hypothalamic involvement, surgical complications, rate of tumor resection and endocrinological outcome were evaluated. RESULTS Seventy nine males (51.6%) and 74 females (48.4%) were included. Mean age at diagnosis was 32.4 years (range: 16-77 years). Mean initial tumor volume was 28.44 mL (range: 0.18-100.44 mL). Partial or complete hypothalamic involvement (Samii Grades III, IV and V) was found in 90.2%. The overall rate of new endocrinopathies was 37.25% after surgery (95% CI = 33.9-41.2). CONCLUSIONS Gross total removal of craniopharyngiomas with large hypothalamic involvement was related to poor neuroendocrine outcome in adults. Partial removal should be indicated, associated with adjuvant therapy, in order to improve postoperative neuroendocrine status.
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Affiliation(s)
- Raul Lopez-Serna
- Division of Neurosurgery, "Instituto Nacional de Neurologia y Neurocirugia", Mexico City, Mexico.
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Persani L, Bonomi M, Radin R, Beck-Peccoz P. Diagnostic and therapeutic challenges of acquired thyrotropic deficiency. ANNALES D'ENDOCRINOLOGIE 2012; 73:138-40. [PMID: 22541997 DOI: 10.1016/j.ando.2012.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The acquired thyrotropic deficiency (TD) is a hypothyroid condition due to an insufficient stimulation by thyrotropin (TSH) of an otherwise normal thyroid gland. This disease can be the consequence of disorders affecting either the pituitary gland or the hypothalamus, but most frequently both of them, and is generally called central hypothyroidism (CH). CH is about one thousand folds rarer than primary hypothyroidism (PH) and the thyroid hormone defect is often less severe than in primary forms. Differently to PH, the TD is most frequently characterized by low/normal TSH levels and thyroid hormone replacement is associated with the suppression of residual TSH secretion. Thus, CH diagnosis and management often represent a clinical challenge because physicians cannot rely on the systematic use of the reflex TSH determination. The clinical challenge of CH is further amplified by the frequent combination with other pituitary deficiencies.
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Affiliation(s)
- Luca Persani
- Department of Medical Sciences, University of Milan, Italy.
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Schlenker EH. Effects of hypothyroidism on the respiratory system and control of breathing: Human studies and animal models. Respir Physiol Neurobiol 2012; 181:123-31. [DOI: 10.1016/j.resp.2012.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 02/16/2012] [Accepted: 02/19/2012] [Indexed: 01/11/2023]
Affiliation(s)
- Evelyn H Schlenker
- Division of Basic Biomedical Sciences, Sanford School of Medicine of the University of South Dakota, 414 East Clark St., Vermillion, SD 57069, United States.
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Abstract
Hypothyroidism denotes deficient production of thyroid hormone by the thyroid gland and can be primary (abnormality in thyroid gland itself) or secondary/central (as a result of hypothalamic or pituitary disease). The term 'subclinical hypothyroidism' is used to define that grade of primary hypothyroidism in which there is an elevated thyroid-stimulating hormone (TSH) concentration in the presence of normal serum free thyroxine (T4) and triiodothyronine (T3) concentrations. Subclinical hypothyroidism may progress to overt hypothyroidism in approximately 2-5% cases annually. All patients with overt hypothyroidism and subclinical hypothyroidism with TSH >10 mIU/L should be treated. There is consensus on the need to treat subclinical hypothyroidism of any magnitude in pregnant women and women who are contemplating pregnancy, to decrease the risk of pregnancy complications and impaired cognitive development of the offspring. However, controversy remains regarding treatment of non-pregnant adult patients with subclinical hypothyroidism and serum TSH values ≤10 mIU/L. In this subgroup, treatment should be considered in symptomatic patients, patients with infertility, and patients with goitre or positive anti-thyroid peroxidase (TPO) antibodies. Limited evidence suggests that treatment of subclinical hypothyroidism in patients with serum TSH of up to 10 mIU/L should probably be avoided in those aged >85 years. Other pituitary hormones should be evaluated in patients with central hypothyroidism, especially assessment of the hypothalamic-pituitary-adrenal axis, since hypocortisolism, if present, needs to be rectified prior to initiating thyroid hormone replacement. Levothyroxine (LT4) monotherapy remains the current standard for management of primary, as well as central, hypothyroidism. Treatment can be started with the full calculated dose for most young patients. However, treatment should be initiated at a low dose in elderly patients, patients with coronary artery disease and patients with long-standing severe hypothyroidism. In primary hypothyroidism, treatment is monitored with serum TSH, with a target of 0.5-2.0 mIU/L. In patients with central hypothyroidism, treatment is tailored according to free or total T4 levels, which should be maintained in the upper half of the normal range for age. In patients with persistently elevated TSH despite an apparently adequate replacement dose of LT4, poor compliance, malabsorption and the presence of drug interactions should be checked. Over-replacement is common in clinical practice and is associated with increased risk of atrial fibrillation and osteoporosis, and hence should be avoided.
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Affiliation(s)
- Deepak Khandelwal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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Abstract
The thyroid gland produces thyroid hormone, which has clinically important actions practically in every system in the human body. Detailed knowledge of the physiology of the thyroid gland is critical for the proper management of thyroid disorders. The molecular biology of thyroid function is being studied in great detail. Clinically important molecules, such as the thyroid-stimulating hormone receptor and the sodium/iodide symporter, have been identified and well characterized. Such discoveries have significantly improved our understanding of thyroid physiology. As a result, new diagnostic and therapeutic approaches for the management of thyroid disorders are now available or in development.
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Affiliation(s)
- Nikolaos Stathatos
- Department of Medicine, Thyroid Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Barbesino G, Sluss PM, Caturegli P. Central hypothyroidism in a patient with pituitary autoimmunity: evidence for TSH-independent thyroid hormone synthesis. J Clin Endocrinol Metab 2012; 97:345-50. [PMID: 22090265 PMCID: PMC3275362 DOI: 10.1210/jc.2011-1591] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Acquired central hypothyroidism is rare, especially when isolated, and is typically associated with detectable, although biologically inactive, serum TSH. OBJECTIVE We describe a 56-yr-old woman with profound central hypothyroidism and partial central hypoadrenalism, in the absence of other endocrine abnormalities. In contrast to most cases of central hypothyroidism, serum TSH remained undetectable for 9 months before the initiation of thyroid hormone and hydrocortisone treatment. A test for pituitary autoantibody was moderately positive. Serum free T(4), serum T(3), and neck radioiodine uptake were low but detectable. The thyroid and pituitary glands appeared morphologically normal on neck ultrasound and head magnetic resonance imaging, respectively. SETTINGS The study was conducted in a tertiary academic medical center. CONCLUSIONS This case illustrates the variable clinical presentation of pituitary autoimmunity. The persistence of low but detectable thyroid hormone levels and radioiodine neck uptake in the absence of TSH suggests that significant TSH-independent thyroid hormone synthesis may occur in the normal thyroid.
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Affiliation(s)
- Giuseppe Barbesino
- Thyroid Unit and Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Abstract
Central hypothyroidism is defined as hypothyroidism due to insufficient stimulation by thyroid stimulating hormone (TSH) of an otherwise normal thyroid gland. It has an estimated prevalence of approximately 1 in 80,000 to 1 in 120,000. It can be secondary hypothyroidism (pituitary) or tertiary hypothyroidism (hypothalamus) in origin. In children, it is usually caused by craniopharyngiomas or previous cranial irradiation for brain tumors or hematological malignancies. In adults, it is usually due to pituitary macroadenomas, pituitary surgeries or post-irradiation. Fatigue and peripheral edema are the most specific clinical features. Diagnosis is established by the presence of normal to low-normal TSH on the background of low-normal thyroid hormones, confirmed by the thyrotropin releasing hormone stimulation test. Therapy includes use of levothyroxine titrated to improvement in symptomology and keeping free T4 in the upper limit of normal reference range.
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Affiliation(s)
- Vishal Gupta
- Department of Endocrinology, Jaslok Hospital and Research Centre, 15-Deshmukh Marg, Mumbai - 400 026, India
| | - Marilyn Lee
- Department of General Medicine/Endocrinology, Khoo Teck Puat Hospital, Singapore
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40
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Affiliation(s)
- Paolo Beck-Peccoz
- Department of Medical Sciences, University of Milan, Endocrinology and Diabetology Unit, Fondazione IRCCS Cà Granda Policlinico, Milan, Italy.
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Akdi A, Pérez G, Pastor S, Castell J, Biarnés J, Marcos R, Velázquez A. Common variants of the thyroglobulin gene are associated with differentiated thyroid cancer risk. Thyroid 2011; 21:519-25. [PMID: 21476894 DOI: 10.1089/thy.2010.0384] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Genetic factors are important in thyroid cancer susceptibility. Recently, it has been reported that there are associations of certain chromosome regions with thyroid cancer. In this case-control study, we sought to determine whether there is an association between differentiated thyroid cancer (DTC) and variants in regions of chromosome 8q. METHODS We used a case-control association design in a population of 877 individuals (398 patients with sporadic DTC and 479 healthy controls). The iPLEX technology was applied to analyze seven single-nucleotide polymorphisms (SNPs) in chromosome 8q: two SNPs that map at 8q24, previously reported as risk markers in different types of cancer, two SNPs in the thyrotropin-releasing hormone receptor gene (TRHR), and three SNPs in the thyroglobulin gene (TG). Risk assessment was done by unconditional regression analysis. RESULTS The two SNPs that map at 8q24, rs6983267 and rs1447295, and the two TRHR polymorphisms showed no association with DTC. No association was also found for the exon 33 TG polymorphism. The two TG polymorphisms in the exon 10-12 cluster, however, were associated with an increased risk of DTC (dominant model odds ratio = 1.80, 95% confidence interval = 1.30-2.50, p < 0.001). CONCLUSIONS In this study, we show for the first time that the TG gene is a susceptibility factor for thyroid cancer. Although these conclusions are based on a large population, additional studies are warranted to support these data.
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Affiliation(s)
- Abdelmounaim Akdi
- Mutagenesis Group, Genetics Unit, Department of Genetics and Microbiology, Edifici Cn, Universitat Autònoma de Barcelona, Bellaterra, Spain
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Mori M. [Clinical guideline for thyroid disease]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2011; 100:712-716. [PMID: 21618802 DOI: 10.2169/naika.100.712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Masatomo Mori
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Japan
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Pfäffle R, Klammt J. Pituitary transcription factors in the aetiology of combined pituitary hormone deficiency. Best Pract Res Clin Endocrinol Metab 2011; 25:43-60. [PMID: 21396574 DOI: 10.1016/j.beem.2010.10.014] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The somatotropic axis is the central postnatal regulator of longitudinal growth. One of its major components--growth hormone--is produced by the anterior lobe of the pituitary, which also expresses and secretes five additional hormones (prolactin, thyroid stimulating hormone, follicle stimulating hormone, luteinizing hormone, adrenocorticotropic hormone). Proper development of the pituitary assures the regulation of critical processes such as metabolic control, puberty and reproduction, stress response and lactation. Ontogeny of the adenohypophysis is orchestrated by inputs from neighbouring tissues, cellular signalling molecules and transcription factors. Perturbation of expression or function of these factors has been implicated in the aetiology of combined pituitary hormone deficiency (CPHD). Mutations within the genes encoding for the transcription factors LHX3, LHX4, PROP1, and POU1F1 (PIT1) that act at different stages of pituitary development result in unique patterns of hormonal deficiencies reflecting their differential expression during organogenesis. In the case of LHX3 and LHX4 the phenotype may include extra-pituitary manifestations due to the function of these genes/proteins outside the pituitary gland. The remarkable variability in the clinical presentation of affected patients indicates the influence of the genetic background, environmental factors and possibly stochastic events. However, in the majority of CPHD cases the aetiology of this heterogeneous disease remains unexplained, which further suggests the involvement of additional genes. Identification of these factors might also help to close the gaps in our understanding of pituitary development, maintenance and function.
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Affiliation(s)
- R Pfäffle
- Hospital for Children and Adolescents, University of Leipzig, Liebigstrasse 20a, Leipzig, Germany.
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Loder E, Cardona L. Evaluation for Secondary Causes of Headache: The Role of Blood and Urine Testing. Headache 2011; 51:338-45. [DOI: 10.1111/j.1526-4610.2010.01840.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Delayed recognition of central hypothyroidism in a neonate born to thyrotoxic mother. Indian Pediatr 2010; 47:795-6. [DOI: 10.1007/s13312-010-0104-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ramos HE, Labedan I, Carré A, Castanet M, Guemas I, Tron E, Madhi F, Delacourt C, Maciel RMB, Polak M. New cases of isolated congenital central hypothyroidism due to homozygous thyrotropin beta gene mutations: a pitfall to neonatal screening. Thyroid 2010; 20:639-45. [PMID: 20553196 DOI: 10.1089/thy.2009.0462] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Congenital central hypothyroidism (CCH) is a rare condition that is often diagnosed in late childhood in countries where neonatal screening programs rely solely on detecting thyrotropin (TSH) elevation. TSHbeta gene mutation is one of the causes of CCH. We describe two cases of c.Q49X mutation and three cases of c.C105Vfs114X mutation in exon 3 of the TSH beta-subunit gene. SUMMARY We found two different TSHbeta gene mutations in two families. In one family, we identified a missense mutation in exon 3 leading to a premature stop at position 49 (c.Q49X) in the two affected twins. In the other family, the three affected siblings had a 313delT nucleotide deletion leading to a frame shift responsible for premature termination at codon 114 (c.C105Vfs114X); neonatal screening showed very low TSH levels in all three patients. The presence of inappropriately low TSH levels at birth in the three affected members of the second family raises questions about the value of the TSH level for CCH screening. CONCLUSIONS The marked phenotypic variability in patients with the c.Q49X mutation suggests modulation by interacting genes and/or differences in the genetic background. TSHbeta gene mutations should be suspected in neonates with inappropriately low TSH levels.
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Affiliation(s)
- Helton E Ramos
- Centre des Maladies Endocriniennes Rares de la Croissance, Hôpital Necker Enfants-Malade, Assistance Publique-Hôpitaux de PARIS, Institut National de la Santé et de la Recherche Médicale U845 and Pediatric Endocrine Unit, Université Paris Descartes, Paris, France
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Yamada M, Mori M. [Diagnostic approach to thyroid diseases. 3. Central hypothyroidism]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2010; 99:720-725. [PMID: 20578357 DOI: 10.2169/naika.99.720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Mori M. [Diagnosis and treatment of thyroid diseases--the current status and an overview]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2010; 99:683-685. [PMID: 20578351 DOI: 10.2169/naika.99.683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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50
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Kasai K. 2. Application of and Problems Associated with Guidelines for the Diagnosis of Thyroid Diseases. ACTA ACUST UNITED AC 2010; 99:692-9. [DOI: 10.2169/naika.99.693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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