Dermatologic manifestations of endocrine disorders

Cushing Syndrome in Childhood

We describe a 15-year-old boy who presented with low back pain due to vertebral compression fractures, growth deceleration, excessive weight gain, rounded facies, dorsocervical fat pad, and hypertension. He was diagnosed as having Cushing syndrome (CS) due to primary pigmented nodular adrenocortical disease resulting in excess cortisol produced by the adrenal glands, leading to disruption of the hypothalamic-pituitary-adrenal axis. The most common cause of CS is exogenous glucocorticoids, with endogenous causes being extremely rare, often leading to delay in diagnosis or misdiagnosis. Herein, we review clinical presentation, screening for hypercortisolism, and decision-making in the diagnosis of CS, as well as therapeutic approaches. The wide range of clinical presentations in pediatric CS and the rarity of the condition can lead to difficulty in the recognition, diagnosis, and subsequent management of these patients. CS can be difficult to differentiate from more common exogenous obesity, and outpatient screening of cortisol excess is challenging. Early recognition and treatment of CS is necessary to avoid multisystemic complications, and patients with suspected endogenous CS should be referred to a tertiary care center with experienced pediatric endocrinology and surgery specialists. Further confirmatory diagnostic tests are necessary to distinguish corticotropin-independent from corticotropin-dependent forms of CS, including a high-dose dexamethasone suppression test, a corticotropin-releasing hormone stimulation test, and imaging. There can be challenges to the evaluation of CS, including complex inpatient testing and difficulty with localization on imaging. Long-term sequelae of CS, including adrenal insufficiency, obesity, hypertension, and mental health disorders, may remain despite definitive surgical treatment, meriting close follow-up with the primary care clinician and subspecialists.

Pediatric Myxedema Due to Autoimmune Hypothyroidism: A Rare Complication of a Common Disorder

In children, hypothyroidism usually presents non-specific symptoms; symptoms can emerge gradually, compromising a timely diagnosis. We report the case of a 13-year-old male, who was admitted to the hospital due to swelling of the torso and neck. Besides these symptoms, the child was healthy, except for a significant growth delay. Ultrasound evaluation and blood tests led to the diagnosis of myxedema secondary to severe hypothyroidism, which was due to autoimmune thyroiditis. Further investigations revealed pericardial effusion and pituitary hyperplasia, with hyper-prolactinemia. Treatment with levothyroxine led to edema regression and clinical, hemato-chemical and radiological improvement. After 6 months, growth velocity increased, although the recovery of growth already lost was not guaranteed. Brain MRI showed regression of pituitary hyperplasia. The diagnostic delay in this case was probably due to the patient's apparent good health, and the underestimation of growth restriction. This report underlines the importance of growth monitoring in adolescence, a critical period for identifying endocrine conditions; if undiagnosed, these conditions can lead to serious complications, such as myxedema in hypothyroidism, with potential effects beyond growth on multiple organs.

Acanthosis nigricans: To be or not to be afraid

Acanthosis nigricans (AN), a skin disorder with high prevalence, represents a dermatological condition with esthetic implications, but otherwise mild symptoms. For any clinician, it is in fact the tip of the iceberg, leading him/her to investigate what lies beneath the surface, since AN points to a systemic problem or disease: metabolic disorder (most frequently), endocrine syndrome, medication side effects, malignancy, and genetic factors. Sometimes, it is the first observed sign of a malignancy or of diabetes mellitus, especially in patients with chronic metabolic disorder; therefore, it is not to be taken lightly. The present review summarizes the information in literature regarding the etiopathogenesis of AN. We propose a new classification that aims to better organize the different types of AN, with implications on the extent and urgency of the investigation plan, as well as various therapeutic algorithms. Therapy options are also presented, both systemic treatments that target the underlying disease, and local ones for esthetic reasons.

Circ_0075932 in adipocyte-derived exosomes induces inflammation and apoptosis in human dermal keratinocytes by directly binding with PUM2 and promoting PUM2-mediated activation of AuroraA/NF-κB pathway

It remains unclear why obese persons displayed a slower wound healing rate than the normal. In this study, we found that has_circ_0075932, a single-exon circular RNA, was outstandingly expressed in human normal adipose tissue and overexpressed in burned skin of obese persons compared with that of non-obese persons. Circ_0075932 overexpression or silencing in dermal keratinocytes had no obvious effect on cell behaviors, unless dozens of times overexpression, since its basal expression level in keratinocytes is too low. However, the exosome released from circ_0075932-overexpressing adipocytes displayed a significantly promoting effect on inflammation and apoptosis in dermal keratinocytes. Then, in our mechanism exploration, we found that circ_0075932 directly bound with the RNA-binding protein PUM2, which was reported to positively regulated AuroraA kinase, thus activating the NF-κB pathway. Moreover, either silencing PUM2, silencing AuroraA, or blockade of NF-κB activation, could abrogate the promoting effect of adipocyte-derived exosomal circ_0075932 on cell inflammation and apoptosis.

Feedback, Lineages and Self-Organizing Morphogenesis

Feedback regulation of cell lineage progression plays an important role in tissue size homeostasis, but whether such feedback also plays an important role in tissue morphogenesis has yet to be explored. Here we use mathematical modeling to show that a particular feedback architecture in which both positive and negative diffusible signals act on stem and/or progenitor cells leads to the appearance of bistable or bi-modal growth behaviors, ultrasensitivity to external growth cues, local growth-driven budding, self-sustaining elongation, and the triggering of self-organization in the form of lamellar fingers. Such behaviors arise not through regulation of cell cycle speeds, but through the control of stem or progenitor self-renewal. Even though the spatial patterns that arise in this setting are the result of interactions between diffusible factors with antagonistic effects, morphogenesis is not the consequence of Turing-type instabilities.

Delayed Diagnosis of Hypothyroidism in Children: Report of 3 Cases

Introduction:

Hypothyroidism is the most common endocrine disorder in children and presented with various sign and symptoms; its diagnosis needs a high index of suspicion.

Case Presentation:

We report 3 cases with unusual presentations of hypothyroidism and with delay in diagnosis that referred to Pediatric Endocrine Outpatient Clinic in Mashhad University of Medical Sciences, Mashhad, Iran with different clinical manifestations. They had decreased Thyroxin (T4) and increased thyroid stimulating hormone (TSH) levels. One case had mental retardation and deafness, but the other two cases had normal neurodevelopment. Some additional interesting findings were as follows: short stature, delayed bone age, teeth eruption impairment, hair loss, anemia and hypercholesterolemia, persistent and long-term constipation that had led to several abdominal surgeries. After a year of hormonal replacement therapy, their growth parameters and hematological values improved.

Conclusions:

We recommend thyroid hormonal evaluation for any children with short stature, especially with delayed bone age, in order to detect and treat hypothyroidism at the right time. It seems that more attention to pediatric growth is necessary.

Systemic conditions in children associated with pigmentary changes

Systemic conditions may have pigmentary associations. Prompt recognition of these associations allows the practitioner to initiate the appropriate workup and therapy when indicated. This contribution highlights some of the clinical features of neurofibromatosis 1, LEOPARD syndrome, acanthosis nigricans, hypomelanosis of Ito, incontinentia pigmenti, CHILD syndrome, and piebaldism to assist the dermatologist in making the proper diagnosis.