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McMullan P, Maye P, Root SH, Yang Q, Edie S, Rowe D, Kalajzic I, Germain-Lee EL. Hair follicle-resident progenitor cells are a major cellular contributor to heterotopic subcutaneous ossifications in a mouse model of Albright hereditary osteodystrophy. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.18.599506. [PMID: 38948860 PMCID: PMC11213030 DOI: 10.1101/2024.06.18.599506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Heterotopic ossifications (HOs) are the pathologic process by which bone inappropriately forms outside of the skeletal system. Despite HOs being a persistent clinical problem in the general population, there are no definitive strategies for their prevention and treatment due to a limited understanding of the cellular and molecular mechanisms contributing to lesion development. One disease in which the development of heterotopic subcutaneous ossifications (SCOs) leads to morbidity is Albright hereditary osteodystrophy (AHO). AHO is caused by heterozygous inactivation of GNAS, the gene that encodes the α-stimulatory subunit (Gαs) of G proteins. Previously, we had shown using our laboratory's AHO mouse model that SCOs develop around hair follicles (HFs). Here we show that SCO formation occurs due to inappropriate expansion and differentiation of HF-resident stem cells into osteoblasts. We also show in AHO patients and mice that Secreted Frizzled Related Protein 2 (SFRP2) expression is upregulated in regions of SCO formation and that elimination of Sfrp2 in male AHO mice exacerbates SCO development. These studies provide key insights into the cellular and molecular mechanisms contributing to SCO development and have implications for potential therapeutic modalities not only for AHO patients but also for patients suffering from HOs with other etiologies.
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Affiliation(s)
- Patrick McMullan
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, CT
| | - Peter Maye
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, CT
| | - Sierra H. Root
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, CT
| | - Qingfen Yang
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, CT
| | | | - David Rowe
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, CT
| | - Ivo Kalajzic
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, CT
| | - Emily L. Germain-Lee
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, CT
- Albright Center, Division of Endocrinology & Diabetes, Connecticut Children’s, Farmington, CT
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Liu J, Lu L, Wei Y, Li Y, Wang Q, Yu L, Zhuang L, Jin G, Pei X. Pseudohypoparathyroidism Type IB with Subclinical Hypothyroidism: a Pedigree Investigation and Literature Review. Diabetes Metab Syndr Obes 2024; 17:2021-2026. [PMID: 38765469 PMCID: PMC11100510 DOI: 10.2147/dmso.s458405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/03/2024] [Indexed: 05/22/2024] Open
Abstract
Pseudohypoparathyroidism (PHP) is a rare genetic disease characterized by hypocalcemia, hyperphosphatemia, and elevated parathyroid hormone (PTH) in serum. Here, we report a case of a patient with pseudohypoparathyroidism type IB (PHPIB) and subclinical hypothyroidism, analyze the clinical and genetic data of his family members, review the relevant literature, and classify and discuss the pathogenesis and clinical characteristics of each subtype. Finally, we discuss the treatment approach to improve clinicians' understanding of the disease.
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Affiliation(s)
- Jie Liu
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, People’s Republic of China
| | - Lijuan Lu
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, People’s Republic of China
| | - Yu Wei
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, People’s Republic of China
| | - Yu Li
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, People’s Republic of China
| | - Qiong Wang
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, People’s Republic of China
| | - Lei Yu
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, People’s Republic of China
| | - Langen Zhuang
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, People’s Republic of China
| | - Guoxi Jin
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, People’s Republic of China
| | - Xiaoyan Pei
- Department of Endocrinology, the First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, People’s Republic of China
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3
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Van der Biest AM, Jüppner H, Andreescu C, Bravenboer B. Epileptic seizures and abnormal tooth development as primary presentation of pseudohypoparathyroidism type 1B. BMJ Case Rep 2024; 17:e258403. [PMID: 38423572 PMCID: PMC10910484 DOI: 10.1136/bcr-2023-258403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Pseudohypoparathyroidism (PHP) is a rare genetic disorder characterised by a non-functioning PTH. Usually, the diagnosis is made following (symptomatic) hypocalcaemia. We describe a case in which epileptic seizures and abnormalities in dental development were the main clinical manifestation of PHP type 1B. This case demonstrates the importance of screening for hypocalcaemia in patients with de novo epileptic seizures. In addition, antiepileptic medications themselves may interfere with calcium-phosphate metabolism, causing or aggravating a hypocalcaemia as well. By correcting the calcium level, a resolution of these symptoms could be obtained.
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Affiliation(s)
| | - Harald Jüppner
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Ludar H, Levy-Shraga Y, Admoni O, Majdoub H, Aronovitch KM, Koren I, Rath S, Elias-Assad G, Almashanu S, Mantovani G, Hamiel OP, Tenenbaum-Rakover Y. Clinical and Molecular Characteristics and Long-term Follow-up of Children With Pseudohypoparathyroidism Type IA. J Clin Endocrinol Metab 2024; 109:424-438. [PMID: 37669316 DOI: 10.1210/clinem/dgad524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/07/2023]
Abstract
CONTEXT Pseudohypoparathyroidism type IA (PHPIA) is a rare genetic disorder characterized by hormone resistance and a typical phenotype named Albright hereditary osteodystrophy. Unawareness of this rare disease leads to delays in diagnosis. OBJECTIVE The aims of this study were to describe the clinical and molecular characteristics of patients with genetically confirmed GNAS mutations and to evaluate their long-term outcomes. METHODS A retrospective search for all patients diagnosed with PHPIA in 2 referral centers in Israel was conducted. RESULTS Nine children (8 females) belonging to 6 families were included in the study. Five patients had GNAS missense mutations, 2 had deletions, and 2 had frameshift mutations. Four mutations were novel. Patients were referred at a mean age of 2.4 years due to congenital hypothyroidism (5 patients), short stature (2 patients), or obesity (2 patients), with a follow-up duration of up to 20 years. Early obesity was observed in the majority of patients. Elevated parathyroid hormone was documented at a mean age of 3 years; however, hypocalcemia became evident at a mean age of 5.9 years, about 3 years later. All subjects were diagnosed with mild to moderate mental retardation. Female adult height was very short (mean -2.5 SD) and 5 females had primary or secondary amenorrhea. CONCLUSION Long-term follow-up of newborns with a combination of congenital hypothyroidism, early-onset obesity, and minor dysmorphic features associated with PHPIA is warranted and molecular analysis is recommended since the complete clinical phenotype may develop a long time after initial presentation.
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Affiliation(s)
- Hanna Ludar
- Pediatric Endocrinology and Diabetes Unit, Clalit Health Services, 35024 Haifa and Western Galilee District, Israel
| | - Yael Levy-Shraga
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52620 Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, 69978 Tel-Aviv, Israel
| | - Osnat Admoni
- Pediatric Endocrine Clinic, Clalit Health Services, 17673 Northern Region, Israel
| | - Hussein Majdoub
- Pediatric Endocrinology and Diabetes Unit, Clalit Health Services, 35024 Haifa and Western Galilee District, Israel
| | - Kineret Mazor Aronovitch
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52620 Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, 69978 Tel-Aviv, Israel
| | - Ilana Koren
- Pediatric Endocrinology and Diabetes Unit, Clalit Health Services, 35024 Haifa and Western Galilee District, Israel
- The Rappaport Faculty of Medicine, Technion, Institute of Technology, 32000 Haifa, Israel
| | - Shoshana Rath
- Pediatric Endocrine Clinic, Clalit Health Services, 17673 Northern Region, Israel
- Endocrinology and Diabetes Service, Tzafon Medical Center, 15208 Teveria, Israel
| | - Ghadir Elias-Assad
- Pediatric Endocrine Clinic, Clalit Health Services, 17673 Northern Region, Israel
- Pediatric Endocrine Institute, Saint Vincent Hospital, 16511 Nazareth, Israel
| | - Shlomo Almashanu
- The National Newborn Screening Program, Ministry of Health, Tel Hashomer, 52620 Ramat Gan, Israel
| | - Giovanna Mantovani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Orit Pinhas Hamiel
- Pediatric Endocrinology and Diabetes Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52620 Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, 69978 Tel-Aviv, Israel
| | - Yardena Tenenbaum-Rakover
- The Rappaport Faculty of Medicine, Technion, Institute of Technology, 32000 Haifa, Israel
- Consulting Medicine in Pediatric Endocrinology, Clalit Health Services, 18343 Afula, Israel
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Dai LZ, Lin C, Lei R, Zhang Y, Ma H. A Case of Pseudohypoparathyroidism Misdiagnosed as Idiopathic Epilepsy for 5 Years: Clinical Analysis and Follow-up Outcomes. J Int Med Res 2023; 51:3000605231215202. [PMID: 38017366 PMCID: PMC10686026 DOI: 10.1177/03000605231215202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/30/2023] [Indexed: 11/30/2023] Open
Abstract
We report a 15-year-old Chinese girl who presented with intermittent seizure episodes and had been misdiagnosed as having idiopathic epilepsy 5 years previously. Laboratory testing revealed hypocalcemia, hyperphosphatemia, and a high parathyroid hormone (PTH) concentration. She was subsequently shown to have pseudohypoparathyroidism type Ib (PHPIb) based on the results of methylation analysis of the GNAS gene, which showed a loss of methylation of the differentially methylated regions (DMR) of GNAS-AS1, GNAS-XL, and GNAS-A/B; and a gain of methylation of the DMR of the GNAS-NESP55 region. We adjusted the patient's medication by prescribing calcium and calcitriol supplements, and gradually reduced the doses of antiepileptic drugs, until they had been completely discontinued. As a result, the patient did not experience any further seizures or epileptiform symptoms; and had normal plasma calcium, phosphorus, and 25-hydroxyvitamin D concentrations and 24-hour urinary calcium excretion. In addition, her PTH concentration gradually normalized over 12 months, and no urinary stones were found on ultrasonographic examination. In conclusion, the clinical presentation of PHP is complex, and the condition is often misdiagnosed. The diagnosis and follow-up of the present patient have provide valuable insights that should contribute to informed clinical decision-making and the implementation of appropriate treatment strategies.
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Affiliation(s)
- Li-Zhen Dai
- Department of Endocrinology, Zhongshan Hospital Xiamen University, Xiamen, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Chenshi Lin
- Department of Endocrinology, Zhongshan Hospital Xiamen University, Xiamen, China
| | - Rui Lei
- Department of Endocrinology, Zhongshan Hospital Xiamen University, Xiamen, China
| | - Yan Zhang
- Department of Endocrinology, Zhongshan Hospital Xiamen University, Xiamen, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Hong Ma
- Department of Endocrinology, Zhongshan Hospital Xiamen University, Xiamen, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
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Del Sindaco G, Berkenou J, Pagnano A, Rothenbuhler A, Arosio M, Mantovani G, Linglart A. Neonatal and Early Infancy Features of Patients With Inactivating PTH/PTHrP Signaling Disorders/Pseudohypoparathyroidism. J Clin Endocrinol Metab 2023; 108:2961-2969. [PMID: 37098127 PMCID: PMC10583975 DOI: 10.1210/clinem/dgad236] [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] [Received: 01/16/2023] [Revised: 04/04/2023] [Accepted: 04/21/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND Pseudohypoparathyroidism (PHP) and related disorders newly referred to as inactivating PTH/PTHrP signaling disorders (iPPSD) are rare endocrine diseases. Many clinical features including obesity, neurocognitive impairment, brachydactyly, short stature, parathyroid hormone (PTH) resistance, and resistance to other hormones such as thyroid-stimulating hormone (TSH) have been well described, yet they refer mainly to the full development of the disease during late childhood and adulthood. OBJECTIVE A significant delay in diagnosis has been reported; therefore, our objective is to increase awareness on neonatal and early infancy presentation of the diseases. To do so, we analyzed a large cohort of iPPSD/PHP patients. METHODS We included 136 patients diagnosed with iPPSD/PHP. We retrospectively collected data on birth and investigated the rate of neonatal complications occurring in each iPPSD/PHP category within the first month of life. RESULTS Overall 36% of patients presented at least one neonatal complication, far more than the general population; when considering only the patients with iPPSD2/PHP1A, it reached 47% of the patients. Neonatal hypoglycemia and transient respiratory distress appeared significantly frequent in this latter group, ie, 10.5% and 18.4%, respectively. The presence of neonatal features was associated with earlier resistance to TSH (P < 0.001) and with the development of neurocognitive impairment (P = 0.02) or constipation (P = 0.04) later in life. CONCLUSION Our findings suggest that iPPSD/PHP and especially iPPSD2/PHP1A newborns require specific care at birth because of an increased risk of neonatal complications. These complications may predict a more severe course of the disease; however, they are unspecific which likely explains the diagnostic delay.
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Affiliation(s)
- Giulia Del Sindaco
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Jugurtha Berkenou
- AP-HP, Service d’endocrinologie et diabète de l’enfant, Hôpital Bicêtre Paris-Saclay, Le Kremlin-Bicêtre 94270, France
- AP-HP, Centre de Référence des maladies rares du métabolisme du Calcium et du Phosphate, filière OSCAR, ERN BOND, ERN for rare endocrine disorders, Plateforme d’expertise des maladies rares de Paris Saclay, Paris, France
| | - Angela Pagnano
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Anya Rothenbuhler
- AP-HP, Service d’endocrinologie et diabète de l’enfant, Hôpital Bicêtre Paris-Saclay, Le Kremlin-Bicêtre 94270, France
- AP-HP, Centre de Référence des maladies rares du métabolisme du Calcium et du Phosphate, filière OSCAR, ERN BOND, ERN for rare endocrine disorders, Plateforme d’expertise des maladies rares de Paris Saclay, Paris, France
| | - Maura Arosio
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Agnès Linglart
- AP-HP, Service d’endocrinologie et diabète de l’enfant, Hôpital Bicêtre Paris-Saclay, Le Kremlin-Bicêtre 94270, France
- AP-HP, Centre de Référence des maladies rares du métabolisme du Calcium et du Phosphate, filière OSCAR, ERN BOND, ERN for rare endocrine disorders, Plateforme d’expertise des maladies rares de Paris Saclay, Paris, France
- Université Paris Saclay, INSERM U1185, Le Kremlin-Bicêtre 94270, France
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Miñones-Suarez L, Pérez de Nanclares G, Marín-Del Barrio S, Alcázar Villar MJ, de Sotto-Esteban D, Mogas E, Rey Cordo L, Riaño-Galán I, Lumbreras Fernández J, Leis R. Nutrition recommendations for patients with pseudohypoparathyroidism. An Pediatr (Barc) 2023; 99:129-135. [PMID: 37481364 DOI: 10.1016/j.anpede.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/22/2023] [Indexed: 07/24/2023] Open
Abstract
Pseudohypoparathyroidism (PHP) is a spectrum of diseases characterized by insensitivity of target tissues to the action of parathyroid hormone and, consequently, by the presence of hyperphosphatemia and hypocalcaemia of varying severity. Early-onset obesity is a feature of PHP type 1A. This article discusses the need to establish uniform criteria to guide the nutritional management of patients with PHP. A decrease in energy expenditure calls for an adjustment of the energy content of the diet. Reducing the intake of foods rich in inorganic phosphorus helps to manage hyperphosphataemia. Targeted nutrition should be part of the treatment plan of children and adolescents with PHP, since it contributes to modulating the calcium and phosphorus metabolism imbalances characteristic of these patients.
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Affiliation(s)
- Lorena Miñones-Suarez
- Endocrinología Pediátrica, Servicio de Pediatría, Hospital Reina Sofía, Tudela, Navarra, Spain
| | - Guiomar Pérez de Nanclares
- Laboratorio de (epi)Genética Molecular, Instituto de Investigación Sanitaria Bioaraba, Hospital Universitario Araba, Vitoria, Spain
| | - Silvia Marín-Del Barrio
- Servicio de Endocrinología Pediátrica, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - María José Alcázar Villar
- Endocrinología Pediátrica, Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Diego de Sotto-Esteban
- Endocrinología Pediátrica, Servicio de Pediatría, Clínica Rotger, Palma, Baleares, Spain; Department of Medicine, University of the Balearic Islands, Palma, Baleares, Spain
| | - Eduard Mogas
- Endocrinología Pediátrica, Hospital Universitario Maternoinfantil Vall d'Hebron, Barcelona, Spain
| | - Lourdes Rey Cordo
- Endocrinología Pediátrica, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Isolina Riaño-Galán
- Endocrinología Pediátrica, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Universidad de Oviedo, CIBER de Epidemiología y Salud Pública (CIBERESP), Oviedo, Asturias, Spain.
| | - Javier Lumbreras Fernández
- Nefrología Pediátrica, Hospital Universitari Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma, Baleares, Spain
| | - Rosaura Leis
- Unidad de Gastroenterología y Nutrición Pediátrica, Hospital Clínico Universitario de Santiago, Instituto de Investigación Sanitaria de Santiago (IDIS), CIBERObn, Santiago de Compostela, La Coruña, Spain
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Díaz-Brochero C, Diaz-Tribaldos DC, Arteaga-Díaz JM, González-Villa AM, Peralta Franco JJ. Seudohipoparatiroidismo: enfermedad huérfana en endocrinología. Reporte de un caso. CASE REPORTS 2023. [DOI: 10.15446/cr.v8n2.93719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Resumen
Introducción. El seudohipoparatiroidismo (SPT) es un trastorno genético poco frecuente que se caracteriza por la resistencia a la hormona paratiroidea (PTH). En Colombia existen pocos reportes sobre esta enfermedad, por lo que la publicación del presente caso contribuye a aumentar el interés en su búsqueda en el ámbito clínico.
Presentación del caso. Hombre de 18 años con antecedente de hipotiroidismo (diagnosticado a los 4 meses de nacido), retraso del crecimiento, desarrollo puberal tardío, obesidad, braquidactilia, fracturas patológicas, osteocondroma femoral, insomnio, parestesias y estreñimiento crónico, quien asistió al servicio de endocrinología de un hospital de tercer nivel de Bogotá (Colombia) remitido luego de haber estado hospitalizado por un episodio convulsivo. En dicha hospitalización los laboratorios evidenciaron hipocalcemia, hiperfosfatemia y 25-OH vitamina D en rango de insuficiencia con niveles elevados de PTH, y los estudios imagenológicos demostraron osificaciones heterotópicas y calcificaciones de ganglios basales del cerebro. Al paciente se le realizó un estudio genético que confirmó el diagnóstico de SPT1A, por lo que se le inició manejo con suplencia de calcio, colecalciferol y quelantes de fósforo, con lo cual evolucionó satisfactoriamente. Tanto el paciente como sus familiares de primer grado recibieron asesoramiento y valoración interdisciplinaria.
Conclusiones. El SPT1A es un trastorno genético complejo poco conocido pero de alta importancia clínica dentro de los diagnósticos diferenciales de hipocalcemia que debe considerarse ya que sin el diagnóstico y tratamiento oportunos, los pacientes pueden presentar consecuencias metabólicas graves y potencialmente fatales.
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Krishnan N, McMullan P, Yang Q, Buscarello AN, Germain-Lee EL. Prevalence of Chiari malformation type 1 is increased in pseudohypoparathyroidism type 1A and associated with aberrant bone development. PLoS One 2023; 18:e0280463. [PMID: 36662765 PMCID: PMC9858345 DOI: 10.1371/journal.pone.0280463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Albright hereditary osteodystrophy (AHO) is caused by heterozygous inactivating mutations in GNAS. Patients with maternally-inherited mutations develop pseudohypoparathyroidism type 1A (PHP1A) with multi-hormone resistance and aberrant craniofacial and skeletal development among other abnormalities. Chiari malformation type 1 (CM1), a condition in which brain tissue extends into the spinal canal when the skull is too small, has been reported in isolated cases of PHP1A. It has been hypothesized to be associated with growth hormone (GH) deficiency. Given the adverse clinical sequelae that can occur if CM1 goes unrecognized, we investigated the previously undetermined prevalence of CM1, as well as any potential correlations with GH status, given the known increased prevalence of GH deficiency in PHP1A. We also investigated these metrics for low lying cerebellar tonsils (LLCT), defined as tonsillar descent less than 5 mm below the foramen magnum. In addition, we investigated possible correlations of CM1/LLCT with advanced hand/wrist bone ages and craniofacial abnormalities known to occur in PHP1A to determine whether premature chondrocyte differentiation and/or aberrant craniofacial development could be potential etiologies of CM1/LLCT through both human studies and investigations of our AHO mouse model. METHODS We examined patients with PHP1A in our clinic and noticed CM1 more frequently than expected. Therefore, we set out to determine the true prevalence of CM1 and LLCT in a cohort of 54 mutation-confirmed PHP1A participants who had clinically-indicated brain imaging. We examined potential correlations with GH status, clinical features, biological sex, genotype, and hand/wrist bone age determinations. In addition, we investigated the craniofacial development in our mouse model of AHO (Gnas E1+/-m) by histologic analyses, dynamic histomorphometry, and micro-computerized tomographic imaging (MCT) in order to determine potential etiologies of CM1/LLCT in PHP1A. RESULTS In our cohort of PHP1A, the prevalence of CM1 is 10.8%, which is at least 10-fold higher than in the general population. If LLCT is included, the prevalence increases to 21.7%. We found no correlation with GH status, biological sex, genotype, or hand/wrist bone age. Through investigations of our Gnas E1+/-m mice, the correlate to PHP1A, we identified a smaller cranial vault and increased cranial dome angle with evidence of hyperostosis due to increased osteogenesis. We also demonstrated that there was premature closure of the spheno-occipital synchondrosis (SOS), a cartilaginous structure essential to the development of the cranial base. These findings lead to craniofacial abnormalities and could contribute to CM1 and LLCT development in PHP1A. CONCLUSION The prevalence of CM1 is at least 10-fold higher in PHP1A compared to the general population and 20-fold higher when including LLCT. This is independent of the GH deficiency that is found in approximately two-thirds of patients with PHP1A. In light of potential serious consequences of CM1, clinicians should have a low threshold for brain imaging. Investigations of our AHO mouse model revealed aberrant cranial formation including a smaller cranium, increased cranial dome angle, hyperostosis, and premature SOS closure rates, providing a potential etiology for the increased prevalence of CM1 and LLCT in PHP1A.
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Affiliation(s)
- Neetu Krishnan
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Albright Center, Division of Pediatric Endocrinology & Diabetes, Connecticut Children’s, Farmington, Connecticut, United States of America
| | - Patrick McMullan
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, Connecticut, United States of America
| | - Qingfen Yang
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, Connecticut, United States of America
| | - Alexzandrea N. Buscarello
- Albright Center, Division of Pediatric Endocrinology & Diabetes, Connecticut Children’s, Farmington, Connecticut, United States of America
| | - Emily L. Germain-Lee
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, Farmington, Connecticut, United States of America
- Albright Center, Division of Pediatric Endocrinology & Diabetes, Connecticut Children’s, Farmington, Connecticut, United States of America
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, Connecticut, United States of America
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10
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Zhang J, Guan M, Zhao S, Wu S, Weng L, Sheng W. A patient with pseudohypoparathyroidism type 1A previously misdiagnosed as hereditary multiple exostosis: A case report. Exp Ther Med 2022; 24:597. [PMID: 35949342 PMCID: PMC9353500 DOI: 10.3892/etm.2022.11534] [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: 05/17/2022] [Accepted: 06/14/2022] [Indexed: 11/11/2022] Open
Abstract
Pseudohypoparathyroidism type 1A (PHP1A), a rare hereditary disorder, is featured by end-organ resistance to parathyroid hormone and Albright's hereditary osteodystrophy. Heterozygous mutation of guanine nucleotide-binding protein α stimulating (GNAS) gene causes the half decreased bioactivity of the Gsα protein levels. Due to the diverse early clinical manifestations of PHP1A, a diagnosis of PHP1A is often easily overlooked and misdiagnosis or missed diagnosis is common. The present study described a girl who was initially diagnosed with hereditary multiple exostoses, but was afterwards confirmed with PHP1A. Moreover, genetic analysis indicated a new mutation (c2277deIC) of the gene.
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Affiliation(s)
- Jie Zhang
- Department of Pediatrics, Hangzhou Children's Hospital, Hangzhou, Zhejiang 310014, P.R. China
| | - Ming Guan
- Department of Otolaryngology, Affiliated Hangzhou First People's Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, P.R. China
| | - Shiyong Zhao
- Department of Pediatrics, Hangzhou Children's Hospital, Hangzhou, Zhejiang 310014, P.R. China
| | - Suling Wu
- Department of Pediatrics, Hangzhou Children's Hospital, Hangzhou, Zhejiang 310014, P.R. China
| | - Lingwei Weng
- Department of Pediatrics, Hangzhou Children's Hospital, Hangzhou, Zhejiang 310014, P.R. China
| | - Wenbin Sheng
- Department of Pediatrics, Hangzhou Children's Hospital, Hangzhou, Zhejiang 310014, P.R. China
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11
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Debbabi W, Khelifi D, Kharrat I, Samet S. Fahr syndrome discovered in adulthood revealing a rare
GNAS
mutation in pseudohypoparathyroidism type 1a in a Tunisian family. Clin Case Rep 2022; 10:e05849. [PMID: 35600030 PMCID: PMC9109644 DOI: 10.1002/ccr3.5849] [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: 03/13/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/11/2022] Open
Abstract
Pseudohypoparathyroidism (PHP) indicates a rare heterogeneous group of disorders characterized by hypocalcemia, hyperphosphatemia, increased serum concentration of parathyroid hormone (PTH), and insensitivity to the biologic activity of PTH. One of its most common types is PHP‐1a. In this report, we present a familial PHP‐1a and a novel mutation of the GNAS gene. PHP1a is one of the rare and little‐known pathologies that can take a long time to be discovered. It associates a particular morphotype, subcutaneous calcifications and bone and renal resistance to parathormone. It is an inherited condition, which results from an abnormality in the GNAS gene. It is usually diagnosed in childhood. and few studies have addressed its natural history. Our report illustrates the natural history of a patient with PHP1A, which went undiagnosed until the age of 31 years. Through this clinical case, we emphasize the importance of a complete phosphocalcic balance in order to find and recognize the typical biochemical alterations associated with this pathology (hypocalcemia, hyperphosphatemia and high levels of PTH), the need for a detailed clinical examination because the phenotypic appearance often escapes notice and the identification of the responsible mutation in the index case is useful for screening other family members avoiding late diagnosis.
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Affiliation(s)
- Wided Debbabi
- Department of Endocrinology Faculty of Medicine of Sousse Ibn Jazzar University Hospital Kairouan University of Medicine Kairouan Tunisia
| | - Dayssem Khelifi
- Department of Endocrinology Faculty of Medicine of Sousse Ibn Jazzar University Hospital Kairouan University of Medicine Kairouan Tunisia
| | - Issam Kharrat
- Department of Endocrinology Faculty of Medicine of Sousse Ibn Jazzar University Hospital Kairouan University of Medicine Kairouan Tunisia
| | - Slim Samet
- Department of Endocrinology Faculty of Medicine of Sousse Ibn Jazzar University Hospital Kairouan University of Medicine Kairouan Tunisia
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12
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Hwang SK, Shim YJ, Oh SH, Jang KM. Early Diagnosis of Pseudohypoparathyroidism before the Development of Hypocalcemia in a Young Infant. CHILDREN 2022; 9:children9050723. [PMID: 35626900 PMCID: PMC9139394 DOI: 10.3390/children9050723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022]
Abstract
Pseudohypoparathyroidism (PHP) is a rare, heterogeneous disorder characterized by end-organ resistance to parathyroid hormone (PTH). PTH resistance causes elevated PTH levels, hypocalcemia, and hyperphosphatemia. Since hypocalcemia causes life-threatening events, early diagnosis is crucial. However, the diagnosis of PHP is elusive during infancy because PHP is usually diagnosed with hypocalcemia-induced symptoms, which develop later in childhood when calcium requirements increase. A 1-month-old girl was referred to our clinic for elevated thyroid-stimulating hormone (TSH) levels on newborn screening. When measured 1 month after levothyroxine treatment, her TSH level normalized. At 4-months-old, multiple hard nodules were noted on her trunk. A punch skin biopsy revealed osteoma cutis associated with Albright’s hereditary osteodystrophy, a major characteristic of PHP. We performed targeted sanger sequencing of the GNAS gene and detected a heterozygous variant c.150dupA (p.Ser51Ilefs*3) in both the proband and her mother, causing frameshift and premature termination mutations. The patient was diagnosed with PHP Ia when she had normal calcium, phosphorous, and PTH levels. We report the early diagnosis of PHP Ia without hypocalcemia. It emphasizes the importance of meticulous physical examination in patients with congenital hypothyroidism.
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Affiliation(s)
- Su Kyeong Hwang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu 37224, Korea;
| | - Ye Jee Shim
- Department of Pediatrics, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu 37224, Korea;
| | - Seung Hwan Oh
- Department of Laboratory Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan 50612, Korea;
| | - Kyung Mi Jang
- Department of Pediatrics, Yeungnam University School of Medicine, Yeungnam University Hospital, Daegu 42415, Korea
- Correspondence: ; Tel.: +82-53-620-3532
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13
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McMullan P, Germain-Lee EL. Aberrant Bone Regulation in Albright Hereditary Osteodystrophy dueto Gnas Inactivation: Mechanisms and Translational Implications. Curr Osteoporos Rep 2022; 20:78-89. [PMID: 35226254 DOI: 10.1007/s11914-022-00719-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This review highlights the impact of Gnas inactivation on both bone remodeling and the development of heterotopic subcutaneous ossifications in Albright hereditary osteodystrophy (AHO). Here we discuss recent advancements in understanding the pathophysiologic mechanisms of the aberrant bone development in AHO as well as potential translational implications. RECENT FINDINGS Gnas inactivation can regulate the differentiation and function of not only osteoblasts but also osteoclasts and osteocytes. Investigations utilizing a mouse model of AHO generated by targeted disruption of Gnas have revealed that bone formation and resorption are differentially affected based upon the parental origin of the Gnas mutation. Data suggest that Gnas inactivation leads to heterotopic bone formation within subcutaneous tissue by changing the connective tissue microenvironment, thereby promoting osteogenic differentiation of tissue-resident mesenchymal progenitors. Observed variations in bone formation and resorption based upon the parental origin of the Gnas mutation warrant future investigations and may have implications in the management and treatment of AHO and related conditions. Additionally, studies of heterotopic bone formation due to Gnas inactivation have identified an essential role of sonic hedgehog signaling, which could have therapeutic implications not only for AHO and related conditions but also for heterotopic bone formation in a wide variety of settings in which aberrant bone formation is a cause of significant morbidity.
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Affiliation(s)
- Patrick McMullan
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, 505 Farmington Ave, 2nd floor, Farmington, CT, 06032, USA
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, CT, USA
| | - Emily L Germain-Lee
- Department of Pediatrics, Division of Pediatric Endocrinology & Diabetes, University of Connecticut School of Medicine, 505 Farmington Ave, 2nd floor, Farmington, CT, 06032, USA.
- Department of Reconstructive Sciences, Center for Regenerative Medicine and Skeletal Development, University of Connecticut School of Dental Medicine, Farmington, CT, USA.
- Albright Center, Connecticut Children's, Farmington, CT, USA.
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14
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Brambilla I, Rossi F, Pistone C, Licari A, De Filippo M, Votto M, Tondina E, Guarracino C. Pseudohypoparathyroidism: a diagnosis to consider once a PTH elevation is detected. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022194. [PMID: 35666115 PMCID: PMC9494184 DOI: 10.23750/abm.v93is3.13072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIM Pseudohypoparathyroidism (PHP) is a rare disease, which can occur in the youth, characterized by hypocalcemia and hyperphosphatemia due to resistance to parathyroid hormone (PTH) in target organs. This condition encompasses different conditions which differ between one another by different clinical, biochemically, and genetic features. METHODS Herein we report the clinical history of a boy with PHP1B with an interesting clinical presentation. He came in fact to the attention of the Emergency Department because of a spontaneously resolving epileptic attack, lasting about 15 minutes, characterized by loss of consciousness, fall to the ground, tonic-clonic shocks, and sphincter release. Moreover, the personal history was characterized by congenital long QT syndrome (LQTS), with a documented mutation of the KCNQ1 gene, treated with beta-blockers (nadolol). RESULTS The simultaneous presence of symptomatic acute hypocalcemia and long QT syndrome undoubtedly required particular attention both in the management of the onset and in the more in-depth subsequent diagnostics. In this regard, laboratory tests and molecular analyzes have proved to be crucial in the diagnostic process. Conclusions: this case underlines the diagnostic path complexity in patients with PTH elevation and the importance of considering all the possible differential diagnoses in order to undertake a timely and correct course of treatment.
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Affiliation(s)
- Ilaria Brambilla
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federico Rossi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Carmelo Pistone
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Amelia Licari
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Maria De Filippo
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Martina Votto
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Enrico Tondina
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Carmen Guarracino
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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15
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Mandl A, Burbelo PD, Di Pasquale G, Tay YS, Welch J, Lionakis MS, Rosenzweig SD, Waldman MA, Warner BM, Walitt B, Collins MT, Balow JE, Chiorini JA, Simonds WF, Agarwal SK, Blau JE, Weinstein LS. Parathyroid Hormone Resistance and Autoantibodies to the PTH1 Receptor. N Engl J Med 2021; 385:1974-1980. [PMID: 34788508 PMCID: PMC9088239 DOI: 10.1056/nejmoa2109409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We describe two cases of acquired parathyroid hormone (PTH) resistance consequent to the development of serum PTH type 1 receptor (PTH1R) autoantibodies, which block PTH binding and signaling. Both cases were associated with other autoimmune manifestations, and one case was associated with atypical membranous glomerulonephritis. In vitro binding and signaling assays identified the presence of PTH1R-blocking IgG autoantibodies, which were not present in serum samples from patients with other renal or autoimmune disorders. (Funded by the Intramural Research Programs of the National Institute of Diabetes and Digestive and Kidney Diseases and others.).
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Affiliation(s)
- Adel Mandl
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Peter D Burbelo
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Giovanni Di Pasquale
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - You Sher Tay
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - James Welch
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Michail S Lionakis
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Sergio D Rosenzweig
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Meryl A Waldman
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Blake M Warner
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Brian Walitt
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Michael T Collins
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - James E Balow
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - John A Chiorini
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - William F Simonds
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Sunita K Agarwal
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Jenny E Blau
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
| | - Lee S Weinstein
- From the Metabolic Diseases Branch (A.M., J.W., W.F.S., S.K.A., J.E.B., L.S.W.) and the Kidney Diseases Branch (M.A.W., J.E.B.), National Institute of Diabetes and Digestive and Kidney Diseases, the Adeno-Associated Virus Biology Section (P.D.B., G.D.P., J.A.C.), Salivary Disorders Unit (B.M.W.), and Skeletal Disorders and Mineral Homeostasis Section (M.T.C.), National Institute of Dental and Craniofacial Research, the Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases (M.S.L.), the Symptom Management Branch, National Institute of Nursing Research (B.W.), and the Department of Laboratory Medicine, Clinical Center (S.D.R.), National Institutes of Health, Bethesda, MD; and Kaiser Permanente, Sacramento, CA (Y.S.T.)
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16
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McMullan P, Maye P, Yang Q, Rowe DW, Germain‐Lee EL. Parental Origin of
Gsα
Inactivation Differentially Affects Bone Remodeling in a Mouse Model of Albright Hereditary Osteodystrophy. JBMR Plus 2021; 6:e10570. [PMID: 35079678 PMCID: PMC8771002 DOI: 10.1002/jbm4.10570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/25/2021] [Accepted: 10/08/2021] [Indexed: 01/13/2023] Open
Abstract
Albright hereditary osteodystrophy (AHO) is caused by heterozygous inactivation of GNAS, a complex locus that encodes the alpha‐stimulatory subunit of heterotrimeric G proteins (Gsα) in addition to NESP55 and XLαs due to alternative first exons. AHO skeletal manifestations include brachydactyly, brachymetacarpia, compromised adult stature, and subcutaneous ossifications. AHO patients with maternally‐inherited GNAS mutations develop pseudohypoparathyroidism type 1A (PHP1A) with resistance to multiple hormones that mediate their actions through G protein‐coupled receptors (GPCRs) requiring Gsα (eg, parathyroid hormone [PTH], thyroid‐stimulating hormone [TSH], growth hormone–releasing hormone [GHRH], calcitonin) and severe obesity. Paternally‐inherited GNAS mutations cause pseudopseudohypoparathyroidism (PPHP), in which patients have AHO skeletal features but do not develop hormonal resistance or marked obesity. These differences between PHP1A and PPHP are caused by tissue‐specific reduction of paternal Gsα expression. Previous reports in mice have shown loss of Gsα causes osteopenia due to impaired osteoblast number and function and suggest that AHO patients could display evidence of reduced bone mineral density (BMD). However, we previously demonstrated PHP1A patients display normal‐increased BMD measurements without any correlation to body mass index or serum PTH. Due to these observed differences between PHP1A and PPHP, we utilized our laboratory's AHO mouse model to address whether Gsα heterozygous inactivation differentially affects bone remodeling based on the parental inheritance of the mutation. We identified fundamental distinctions in bone remodeling between mice with paternally‐inherited (GnasE1+/−p) versus maternally‐inherited (GnasE1+/−m) mutations, and these findings were observed predominantly in female mice. Specifically, GnasE1+/−p mice exhibited reduced bone parameters due to impaired bone formation and enhanced bone resorption. GnasE1+/−m mice, however, displayed enhanced bone parameters due to both increased osteoblast activity and normal bone resorption. These in vivo distinctions in bone remodeling between GnasE1+/−p and GnasE1+/−m mice could potentially be related to changes in the bone microenvironment driven by calcitonin‐resistance within GnasE1+/−m osteoclasts. Further studies are warranted to assess how Gsα influences osteoblast–osteoclast coupling. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Patrick McMullan
- Department of Pediatrics University of Connecticut School of Medicine Farmington CT USA
- Department of Reconstructive Sciences University of Connecticut School of Dental Medicine Farmington CT USA
- Center for Regenerative Medicine and Skeletal Development University of Connecticut School of Dental Medicine Farmington CT USA
| | - Peter Maye
- Department of Reconstructive Sciences University of Connecticut School of Dental Medicine Farmington CT USA
- Center for Regenerative Medicine and Skeletal Development University of Connecticut School of Dental Medicine Farmington CT USA
| | - Qingfen Yang
- Department of Pediatrics University of Connecticut School of Medicine Farmington CT USA
- Department of Reconstructive Sciences University of Connecticut School of Dental Medicine Farmington CT USA
- Center for Regenerative Medicine and Skeletal Development University of Connecticut School of Dental Medicine Farmington CT USA
| | - David W. Rowe
- Department of Reconstructive Sciences University of Connecticut School of Dental Medicine Farmington CT USA
- Center for Regenerative Medicine and Skeletal Development University of Connecticut School of Dental Medicine Farmington CT USA
| | - Emily L. Germain‐Lee
- Department of Pediatrics University of Connecticut School of Medicine Farmington CT USA
- Department of Reconstructive Sciences University of Connecticut School of Dental Medicine Farmington CT USA
- Center for Regenerative Medicine and Skeletal Development University of Connecticut School of Dental Medicine Farmington CT USA
- Albright Center, Division of Pediatric Endocrinology Connecticut Children's Farmington CT USA
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17
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Ramalho E Silva JD, da Rocha GFMA, Oliveira MJM. An intricate case of sporadic pseudohypoparathyroidism type 1B with a review of literature. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:112-116. [PMID: 33320452 PMCID: PMC10528691 DOI: 10.20945/2359-3997000000316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/17/2020] [Indexed: 11/23/2022]
Abstract
Pseudohypoparathyroidism comprehends an assorted group of genetically rare disorders that share end-organ resistance to parathyroid hormone. Genetic and epigenetic modifications on guanine nucleotide-binding protein alpha-stimulating gene locus are the most common underlying mechanisms associated with pseudohypoparathyroidism. Biochemical and molecular analysis stratify pseudohypoparathyroidism into types 1A, 1B, 1C, and 2. We describe an unusual case of sporadic pseudohypoparathyroidism type 1B. A 34-year-old Caucasian woman was admitted to the emergency department, with persistent asthenia, limb paresthesias, and tactile hyposensitivity. Her physical examination, previous personal and family histories were unsuspicious, except for mild, intermittent and self-limited complaints of paresthesia during her two pregnancies, but no detailed workup was done. No typical features of Albright hereditary osteodystrophy were observed. The initial laboratory investigation showed elevated parathyroid hormone level (311.2 pg/mL), hypocalcemia (albumin-corrected serum calcium 4.3 mg/dL), hypocalciuria, hyperphosphatemia, hypophosphaturia, and vitamin D deficiency. Combined calcium, vitamin D, and magnesium supplementation was commenced, with symptomatic and analytical improvement. Albeit resolution of vitamin D deficiency, the patient relapsed with mild and intermittent lower limb paresthesias. Pseudohypoparathyroidism was confirmed by molecular identification of the 3-kb STX16 deletion. The treatment was readjusted, and one year later, symptomatic remission was attained. Clinical and biochemical features, and their respective course, along with lack of distinctive features of Albright hereditary osteodystrophy pointed to pseudohypoparathyroidism type 1B. A careful follow-up is needed to avoid complications and recurrence. Once correction of hypocalcemia and hyperphosphatemia is achieved, with no reported complications and recurrence, a good prognosis is anticipated, comparable to the general population.
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Affiliation(s)
- José Diogo Ramalho E Silva
- Departamento de Endocrinologia e Nutrição, Centro Hospitalar de Vila Nova de Gaia/Espinho (CHVNG/E), Vila Nova de Gaia, Portugal,
| | | | - Maria João Martins Oliveira
- Departamento de Endocrinologia e Nutrição, Centro Hospitalar de Vila Nova de Gaia/Espinho (CHVNG/E), Vila Nova de Gaia, Portugal
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18
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Mendes de Oliveira E, Keogh JM, Talbot F, Henning E, Ahmed R, Perdikari A, Bounds R, Wasiluk N, Ayinampudi V, Barroso I, Mokrosiński J, Jyothish D, Lim S, Gupta S, Kershaw M, Matei C, Partha P, Randell T, McAulay A, Wilson LC, Cheetham T, Crowne EC, Clayton P, Farooqi IS. Obesity-Associated GNAS Mutations and the Melanocortin Pathway. N Engl J Med 2021; 385:1581-1592. [PMID: 34614324 DOI: 10.1056/nejmoa2103329] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND GNAS encodes the Gαs (stimulatory G-protein alpha subunit) protein, which mediates G protein-coupled receptor (GPCR) signaling. GNAS mutations cause developmental delay, short stature, and skeletal abnormalities in a syndrome called Albright's hereditary osteodystrophy. Because of imprinting, mutations on the maternal allele also cause obesity and hormone resistance (pseudohypoparathyroidism). METHODS We performed exome sequencing and targeted resequencing in 2548 children who presented with severe obesity, and we unexpectedly identified 22 GNAS mutation carriers. We investigated whether the effect of GNAS mutations on melanocortin 4 receptor (MC4R) signaling explains the obesity and whether the variable clinical spectrum in patients might be explained by the results of molecular assays. RESULTS Almost all GNAS mutations impaired MC4R signaling. A total of 6 of 11 patients who were 12 to 18 years of age had reduced growth. In these patients, mutations disrupted growth hormone-releasing hormone receptor signaling, but growth was unaffected in carriers of mutations that did not affect this signaling pathway (mean standard-deviation score for height, -0.90 vs. 0.75, respectively; P = 0.02). Only 1 of 10 patients who reached final height before or during the study had short stature. GNAS mutations that impaired thyrotropin receptor signaling were associated with developmental delay and with higher thyrotropin levels (mean [±SD], 8.4±4.7 mIU per liter) than those in 340 severely obese children who did not have GNAS mutations (3.9±2.6 mIU per liter; P = 0.004). CONCLUSIONS Because pathogenic mutations may manifest with obesity alone, screening of children with severe obesity for GNAS deficiency may allow early diagnosis, improving clinical outcomes, and melanocortin agonists may aid in weight loss. GNAS mutations that are identified by means of unbiased genetic testing differentially affect GPCR signaling pathways that contribute to clinical heterogeneity. Monogenic diseases are clinically more variable than their classic descriptions suggest. (Funded by Wellcome and others.).
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Affiliation(s)
- Edson Mendes de Oliveira
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Julia M Keogh
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Fleur Talbot
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Elana Henning
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Rachel Ahmed
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Aliki Perdikari
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Rebecca Bounds
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Natalia Wasiluk
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Vikram Ayinampudi
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Inês Barroso
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Jacek Mokrosiński
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Deepthi Jyothish
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Sharon Lim
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Sanjay Gupta
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Melanie Kershaw
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Cristina Matei
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Praveen Partha
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Tabitha Randell
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Antoinette McAulay
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Louise C Wilson
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Tim Cheetham
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Elizabeth C Crowne
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - Peter Clayton
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
| | - I Sadaf Farooqi
- From the University of Cambridge Metabolic Research Laboratories and National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge (E.M.O., J.M.K., F.T., E.H., R.A., A.P., R.B., N.W., V.A., J.M., I.S.F.), the Exeter Centre of Excellence for Diabetes Research, University of Exeter Medical School, Exeter (I.B.), Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham (D.J., M.K.), Broomfield Hospital, Chelmsford (S.L.), Hull University Teaching Hospitals NHS Trust, Hull (S.G.), East and North Hertfordshire NHS Trust Lister Hospital, Stevenage (C.M.), County Durham and Darlington NHS Foundation Trust, Darlington (P.P.), Nottingham Children's Hospital, Nottingham (T.R.), University Hospitals Dorset NHS Foundation Trust, Poole (A.M.), Great Ormond Street Hospital for Children NHS Foundation Trust, London (L.C.W.), the Translational and Clinical Research Institute, Newcastle University, and Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne (T.C.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol (E.C.C.), and the Division of Developmental Biology and Medicine, University of Manchester, Manchester (P.C.) - all in the United Kingdom
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Metwalley K, Farghaly H. Hormone resistance in children: what primary care physicians need to know. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021255. [PMID: 34487068 PMCID: PMC8477115 DOI: 10.23750/abm.v92i4.11613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/28/2021] [Indexed: 01/13/2023]
Abstract
Hormone resistance is defined as a reduced or absence of target tissues responsiveness to a hormone, where the presentation is related to either a relative lack or excess of hormones. Various disorders of hormone resistance were encountered including, Laron syndrome, nephrogenic diabetes insipidus, thyroid hormone resistance syndrome, pseudohypoparathyroidism, insulin resistance, familial glucocorticoid deficiency, pseudohypoaldosteronism, X linked hypophosphatemic rickets and androgen insensitivity syndrome. The article gives a summary that presents, in concentrated form, what the primary care physicians need to know about recognition, clinical presentation, diagnosis, and management of various hormone resistance in children.
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Affiliation(s)
- Kotb Metwalley
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt..
| | - Hekma Farghaly
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt..
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20
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Hypocalcemia as a Cause of Complex Febrile Seizures in a Toddler. Case Rep Pediatr 2021; 2021:1798741. [PMID: 34336337 PMCID: PMC8294952 DOI: 10.1155/2021/1798741] [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: 05/25/2021] [Accepted: 07/09/2021] [Indexed: 11/21/2022] Open
Abstract
A 13-month-old boy had suffered three episodes of complex febrile seizures. At this admission, there were signs of hyperexcitability, such as Trousseau sign and QTc prolongation. A point of care blood gas analysis revealed severe hypocalcemia. Therefore, prior to administering intravenous calcium gluconate, we took blood samples to investigate the etiology of this hypocalcemia: magnesium, parathormone, and 25-hydroxyvitamin D. Since both parathormone and phosphate were significantly elevated and 25-hydroxyvitamin D was within the normal range, pseudohypoparathyroidism was diagnosed. After two years of follow-up, serum calcium had normalized in our patient under supplementation of vitamin D and calcium. He had been free of convulsions, although different febrile episodes had occurred.
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21
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Shah FA, Fujikawa P, Braford M, Patel K, Rasul K. Is All Hypocalcemia Due to Low Parathyroid Hormone?: An Unusual Case of Pseudohypoparathyroidism in a Young and Healthy Patient. Cureus 2021; 13:e16243. [PMID: 34373806 PMCID: PMC8346226 DOI: 10.7759/cureus.16243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/30/2022] Open
Abstract
Pseudohypoparathyroidism is a rare disorder that is characterized by hypocalcemia and hyperphosphatemia that are unresponsive to the parathyroid hormone. We present a unique case of pseudohypoparathyroidism seen in a 33-year-old male who presented with abnormal laboratory findings including hypocalcemia, hypokalemia, hypomagnesemia, hyperphosphatemia, and positive Trousseau's sign. Pseudohypoparathyroidism is a rare phenomenon, with an estimated prevalence between 0.3 and 1.1 cases per 100,000. Genetic mutations have been noted to play a role in the presentation of pseudohypoparathyroidism. Clinical phenotypical manifestations can include brachydactyly, short stature, a stocky build, and a round face. Similar routine follow-up and treatment as traditional hypoparathyroidism is practiced. This case highlights a unique endocrinologic pathology that clinicians should be more aware of, as it can be confused with hypoparathyroidism.
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Affiliation(s)
- Farhan A Shah
- Internal Medicine, Lewis Gale Medical Center, Salem, USA
| | | | - Michalla Braford
- Internal Medicine, Edward Via College of Osteopathic Medicine, Salem, USA
| | - Kashyap Patel
- Internal Medicine, Lewis Gale Medical Center, Salem, USA
| | - Kamran Rasul
- Endocrinology and Diabetes, Lewis Gale Medical Center, Salem, USA
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22
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Kaulfers AMD, Lim WY, Bhowmick SK. Unusual Endocrinopathies in 18q Deletion Syndrome: Pseudoparathyroidism and Hyper-/Hypo-Thyroidism. AACE Clin Case Rep 2021; 7:192-194. [PMID: 34095486 PMCID: PMC8165197 DOI: 10.1016/j.aace.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To describe new and unusual endocrinopathies in children with de novo 18q deletion (18q-) syndrome. Methods We describe 2 patients who have atypical thyroid conditions and 1 who also developed symptomatic hypocalcemia. Results The first patient developed hyperthyroidism at the age of 3 years, with a free thyroxine level of 3.9 (range, 0.8-1.8) ng/dL. Thyroid peroxidase antibodies were 262 (range, 0-32) IU/mL, and thyroid-stimulating immunoglobulin antibodies were 384% (range, 0-139%). On low-dose methimazole treatment, she developed hypothyroidism. Thyroid-stimulating hormone (TSH) level was 163 (range, 0.4-4.5) mIU/mL. Moreover, she later developed growth hormone deficiency. The second patient developed hypothyroidism at the age of 4 years, with a TSH level of 46 mIU/mL. However, TSH remained elevated at levels of 10 to 24 mIU/mL for 3 years, despite appropriate treatment, suggesting TSH resistance. She then developed hypocalcemic seizures and was diagnosed with pseudohypoparathyroidism. Her total calcium level was 6.6 (range, 8.5-10.5) mg/dL and parathyroid hormone level was 432 (range, 15-65) pg/dL. Conclusion The first patient had a mixed picture of autoimmune hypothyroidism and hyperthyroidism, requiring a combination of methimazole and levothyroxine to achieve a euthyroid state. For the second patient, the mild TSH resistance was possibly the early suggestion of a parathyroid hormone resistant state. Although growth hormone deficiency and hypothyroidism are common in patients with 18q- syndrome, the occurrence of hyperthyroidism due to Graves’ disease with the coexistence of Hashimoto’s hypothyroidism is rare. Pseudohypoparathyroidism has not yet been reported in patients with 18q- syndrome.
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Affiliation(s)
| | - Whei Ying Lim
- Department of Pediatric Endocrinology, University of South Alabama, Mobile, Alabama
| | - Samar K Bhowmick
- Department of Pediatric Endocrinology, University of South Alabama, Mobile, Alabama
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23
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Tan X, Guo Y, Liu Y, Liu C, Pei L. Symptomatic spinal cord compression: an uncommon symptom in pseudohypoparathyroidism. Ann N Y Acad Sci 2021; 1503:38-47. [PMID: 33660862 DOI: 10.1111/nyas.14584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 12/27/2022]
Abstract
We describe symptomatic spinal cord compression associated with pseudohypoparathyroidism (PHP) in a young female patient and reviewed similar cases previously reported in the literature. The characteristics of these cases were analyzed from etiology, clinical subtypes, symptoms, treatment, and prognosis. Neurological examination revealed functional upper extremities with bilateral lower extremity paraplegia. Laboratory tests showed hypocalcemia, hyperphosphatemia, and elevated parathyroid hormone; high-throughput sequencing showed a heterozygous GNAS mutation in exon 12, specifically c.1006C > T (p.R336W). Imaging findings showed multilevel spinal stenosis with significant spinal cord compression at the T2-T3 level. Seventeen cases with similar characteristics were reviewed. We found that the primary clinical manifestation of these patients was bilateral lower extremity spastic paraplegia. Multilevel spinal cord compression was commonly observed, especially at the lower cervical and upper thoracic spinal cord. Most of the patients had poor surgical treatment outcome and prognosis. Clinicians should be aware of paraplegia due to spinal cord compression as a rare neurological complication in patients with PHP. Early diagnosis and treatment of PHP is one basis for preventing severe spinal cord-related complications.
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Affiliation(s)
- Xiaoping Tan
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Yang Guo
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Yan Liu
- Department of Neurology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Cong Liu
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Lina Pei
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
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24
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Purohit S, Marathe N, Amin A, Jogani A, Shaikh A. Bilateral Transcervical Femur Neck Fracture in a Case of Pseudohypoparathyroidism: A Rare Case Report and Review of Literature. J Orthop Case Rep 2021; 10:85-87. [PMID: 33585324 PMCID: PMC7857650 DOI: 10.13107/jocr.2020.v10.i07.1930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Pseudohypoparathyroidism (PHP) is an uncommon metabolic bone disorder characterized by biochemical hypocalcemia, hyperphosphatemia and raised parathyroid hormone (PTH), and target tissue unresponsiveness to the biological actions of PTH. In addition, many patients with PHP exhibit a distinctive constellation of developmental and skeletal defects. Case Report: An 11-year-old girl was brought to emergency pediatric department for the assessment of fever with generalized tonic-clonic seizure (GTCS) with inability to walk. She had hypocalcemia and hyperphosphatemia. The diagnosis of PHP was made and was started on Vitamin D3 and oral calcium. Physical examination revealed no dysmorphic features. Biochemical investigations revealed normal complete blood count, liver and renal functions, and arterial blood gas. However, serum PTH was high with slightly decreased Vitamin D3. Conclusion: As per our knowledge, this is the first reported case in literature of bilateral pathological transcervical neck femur fracture in a case of PHP following episode of GTCS. Multidisciplinary team approach with the involvement of pediatrician, endocrinologist, and orthopedic surgeon and devising a plan after thorough workup keeping in mind the infrequent presentations of hypoparathyroidism and adequate pre-operative optimization helps provide appropriate management of this rare presentation. This case report was prepared following the CARE guidelines.
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Affiliation(s)
- Shaligram Purohit
- Department of Orthopedics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Nandan Marathe
- Department of Orthopedics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Ankit Amin
- Department of Orthopedics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - A Jogani
- Department of Orthopedics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Ashraf Shaikh
- Department of Orthopedics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
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25
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Lim WY, Germain-Lee EL, Dunbar NS. Legg-Calve-Perthes disease in an 8-year old girl with Acrodysostosis type 1 on growth hormone therapy: case report. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2020; 2020:15. [PMID: 32782451 PMCID: PMC7412821 DOI: 10.1186/s13633-020-00085-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/01/2020] [Indexed: 02/08/2023]
Abstract
Background Acrodyostosis type 1 (ACRDYS1) is a rare skeletal dysplasia, and sometimes it can be misdiagnosed as pseudohypoparathyroidism type 1A (PHP1A), a subtype of Albright hereditary osteodystrophy (AHO), due to overlapping features. Growth hormone releasing hormone (GHRH) resistance with severe short stature is common in both ACRDYS1 and PHP1A (Emily L. Germain-Lee, et al. J Clin Endocrinol Metab, 88:4059-4069, 2003). Whereas growth hormone (GH) treatment has been studied in patients with PHP1a, the same is not true for the rarer ACRDYS1. Here in we report an adverse orthopedic outcome in a patient with ACRDYS1 with severe short stature treated with growth hormone. Our experience could have implications for the treatment of other patients with this disorder. Case presentation We report a case of Legg-Calve-Perthes Disease (LCPD) in an 8-year old female with ACRDYS1 treated with GH. She initially presented with marked short stature (height Z-score - 3.46) with a low normal insulin like growth factor-1 (IGF1) level, and had biochemical evidence of thyrotropin and parathyroid hormone resistance. GH therapy was initiated at 0.35 mg/kg/week leading to increased growth velocity. After 7 months on GH, she developed right knee pain. Radiographic images revealed flattening of her right femoral head consistent with LCPD. GH was discontinued. Six weeks later, radiographs revealed further collapse of the entire femoral head. Her lesion stabilized after 8 months with conservative management and she never resumed GH. Her final adult height is 4'2″ (128 cm). Conclusion Patients with ACRDYS1 on GH therapy may be at increased risk of LCPD. This has not been reported in patients with PHP1A treated with GH. Clinicians and families need to be aware of this potential complication when counseling about GH treatment.
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Affiliation(s)
- Whei Ying Lim
- Division of Pediatric Endocrinology, Connecticut Children's, 505 Farmington Avenue, Farmington, CT 06032 USA
| | - Emily L Germain-Lee
- Division of Pediatric Endocrinology, Connecticut Children's, 505 Farmington Avenue, Farmington, CT 06032 USA.,University of Connecticut School of Medicine, 200 Academic Way, Farmington, CT 06032 USA
| | - Nancy S Dunbar
- Division of Pediatric Endocrinology, Connecticut Children's, 505 Farmington Avenue, Farmington, CT 06032 USA
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Mantovani G, Bastepe M, Monk D, de Sanctis L, Thiele S, Ahmed SF, Bufo R, Choplin T, De Filippo G, Devernois G, Eggermann T, Elli FM, Ramirez AG, Germain-Lee EL, Groussin L, Hamdy NA, Hanna P, Hiort O, Jüppner H, Kamenický P, Knight N, Le Norcy E, Lecumberri B, Levine MA, Mäkitie O, Martin R, Martos-Moreno GÁ, Minagawa M, Murray P, Pereda A, Pignolo R, Rejnmark L, Rodado R, Rothenbuhler A, Saraff V, Shoemaker AH, Shore EM, Silve C, Turan S, Woods P, Zillikens MC, de Nanclares GP, Linglart A. Recommendations for Diagnosis and Treatment of Pseudohypoparathyroidism and Related Disorders: An Updated Practical Tool for Physicians and Patients. Horm Res Paediatr 2020; 93:182-196. [PMID: 32756064 PMCID: PMC8140671 DOI: 10.1159/000508985] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 05/21/2020] [Indexed: 12/12/2022] Open
Abstract
Patients affected by pseudohypoparathyroidism (PHP) or related disorders are characterized by physical findings that may include brachydactyly, a short stature, a stocky build, early-onset obesity, ectopic ossifications, and neurodevelopmental deficits, as well as hormonal resistance most prominently to parathyroid hormone (PTH). In addition to these alterations, patients may develop other hormonal resistances, leading to overt or subclinical hypothyroidism, hypogonadism and growth hormone (GH) deficiency, impaired growth without measurable evidence for hormonal abnormalities, type 2 diabetes, and skeletal issues with potentially severe limitation of mobility. PHP and related disorders are primarily clinical diagnoses. Given the variability of the clinical, radiological, and biochemical presentation, establishment of the molecular diagnosis is of critical importance for patients. It facilitates management, including prevention of complications, screening and treatment of endocrine deficits, supportive measures, and appropriate genetic counselling. Based on the first international consensus statement for these disorders, this article provides an updated and ready-to-use tool to help physicians and patients outlining relevant interventions and their timing. A life-long coordinated and multidisciplinary approach is recommended, starting as far as possible in early infancy and continuing throughout adulthood with an appropriate and timely transition from pediatric to adult care.
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Affiliation(s)
- Giovanna Mantovani
- Endocrinology Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Murat Bastepe
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - David Monk
- Biomedical Research Centre, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Luisa de Sanctis
- Pediatric Endocrinology Unit, Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy
| | - Susanne Thiele
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | - S. Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Roberto Bufo
- Italian Progressive Osseous Heteroplasia Association (IPOHA), Foggia, Italy
| | - Timothée Choplin
- K20, French PHP and Related Disorders Patient Association, Jouars-Pontchartrain, France
| | - Gianpaolo De Filippo
- APHP, Department of Medicine for Adolescents, Bicêtre Paris Saclay Hospital (HUPS), Le Kremlin-Bicetre, France
| | - Guillemette Devernois
- K20, French PHP and Related Disorders Patient Association, Jouars-Pontchartrain, France
| | - Thomas Eggermann
- Institute of Human Genetics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Francesca M. Elli
- Endocrinology Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | | | - Emily L. Germain-Lee
- Albright Center and Center for Rare Bone Disorders, Division of Pediatric Endocrinology and Diabetes, Connecticut Children’s Medical Center, Farmington, CT, USA,Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Lionel Groussin
- APHP, Department of Endocrinology, Cochin Hospital (HUPC), Paris, France,University of Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Neveen A.T. Hamdy
- Division of Endocrinology and Centre for Bone Quality, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Patrick Hanna
- INSERM U1185, Bicêtre Paris Sud – Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Olaf Hiort
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | - Harald Jüppner
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Peter Kamenický
- INSERM U1185, Bicêtre Paris Sud – Paris Saclay University, Le Kremlin-Bicêtre, France,APHP, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Platform of Expertise Paris-Saclay for Rare Diseases and Filière OSCAR, Bicêtre Paris Saclay Hospital (HUPS), Le Kremlin-Bicêtre, France,APHP, Department of Endocrinology and Reproductive Diseases, Bicêtre Paris Saclay Hospital (HUPS), Le Kremlin-Bicêtre, France
| | - Nina Knight
- Acrodysostosis Support and Research patients’ group, London, UK
| | - Elvire Le Norcy
- University of Paris Descartes, Sorbonne Paris Cité, Paris, France,APHP, Department of Odontology, Bretonneau Hospital (PNVS), Paris, France
| | - Beatriz Lecumberri
- Department of Endocrinology and Nutrition, La Paz University Hospital, Madrid, Spain,Department of Medicine, Autonomous University of Madrid (UAM), Madrid, Spain,Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Michael A. Levine
- Division of Endocrinology and Diabetes and Center for Bone Health, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Outi Mäkitie
- Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Regina Martin
- Osteometabolic Disorders Unit, Hormone and Molecular Genetics Laboratory (LIM/42), Endocrinology Division, Hospital das Clínicas HCFMUSP, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Gabriel Ángel Martos-Moreno
- Department of Endocrinology, Hospital Infantil Universitario Niño Jesús, Hospital La Princesa Institute for Health Research (IIS La Princesa), Madrid, Spain,Department of Pediatrics, Autonomous University of Madrid (UAM), Madrid, Spain,CIBERobn, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Philip Murray
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Arrate Pereda
- Molecular (Epi)Genetics Laboratory, BioAraba Research Health Institute, Araba University Hospital-Txagorritxu, Vitoria-Gasteiz, Spain
| | | | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Rebeca Rodado
- AEPHP, Spanish PHP and Related Disorders Patient Association, Almeria, Spain
| | - Anya Rothenbuhler
- APHP, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Platform of Expertise Paris-Saclay for Rare Diseases and Filière OSCAR, Bicêtre Paris Saclay Hospital (HUPS), Le Kremlin-Bicêtre, France,APHP, Endocrinology and Diabetes for Children, Bicêtre Paris Saclay Hospital (HUPS), Le Kremlin-Bicêtre, France
| | - Vrinda Saraff
- Department of Endocrinology and Diabetes, Birmingham Children’s Hospital, Birmingham, UK
| | - Ashley H. Shoemaker
- Pediatric Endocrinology and Diabetes, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen M. Shore
- Departments of Orthopedic Surgery and Genetics, Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline Silve
- APHP, Service de Biochimie et Génétique Moléculaires, Hôpital Cochin, Paris, France
| | - Serap Turan
- Department of Pediatrics, Division of Endocrinology and Diabetes, Marmara University, Istanbul, Turkey
| | - Philip Woods
- Acrodysostosis Support and Research patients’ group, London, UK
| | - M. Carola Zillikens
- Department of Internal Medicine, Bone Center Erasmus MC – University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Guiomar Perez de Nanclares
- Molecular (Epi)Genetics Laboratory, BioAraba Research Health Institute, Araba University Hospital-Txagorritxu, Vitoria-Gasteiz, Spain
| | - Agnès Linglart
- INSERM U1185, Bicêtre Paris Sud – Paris Saclay University, Le Kremlin-Bicêtre, France,APHP, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Platform of Expertise Paris-Saclay for Rare Diseases and Filière OSCAR, Bicêtre Paris Saclay Hospital (HUPS), Le Kremlin-Bicêtre, France,APHP, Endocrinology and Diabetes for Children, Bicêtre Paris Saclay Hospital (HUPS), Le Kremlin-Bicêtre, France
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