Familial syndrome with panhypopituitarism, hypoplasia of the hypophysis, and poorly developed sella turcica

Palatal expansion in a patient with solitary median maxillary central incisor syndrome

The objective of this article was to report a clinical case of a patient with solitary median maxillary central incisor syndrome. He was treated with rapid maxillary expansion and evaluated with computed tomography. The boy, aged 6 years 7 months, had a single maxillary central incisor in the midline, posterior crossbite, prominent midpalatal ridge, indistinct philtrum, no incisive papilla, and no labial frenulum. No other systemic anomalies were found. Posteroanterior cephalometric radiography showed skeletal atresia of the maxilla that was corrected with rapid maxillary expansion. A Haas expander was used and activated twice per day (quarter turn per activation) for 15 days. The procedure was monitored with computed tomography to evaluate any effect on the intermaxillary suture and tooth. Although the crossbite was clinically corrected after the expansion, radiographs and tomographs showed no opening of the midpalatal suture. Rapid maxillary expansion resulted in neither midpalatal suture opening nor transverse increase of the maxillary skeletal base in this patient.

Empty sella syndrome, panhypopituitarism, and diabetes insipidus

We present an 18-month-old girl with short stature, obesity, panhypopituitarism, diabetes insipidus, and visual defects. Postmortem examination revealed brain atrophy due to a diffuse encephalopathy, numerous calcified neurons in cerebral cortex, deep telencephalic and diencephalic nuclei, diffuse neuronal necrosis in hypothalamic nuclei, moderate atrophy of optic nerves, very thin hypophyseal stalk, and empty sella with the hypophysis compressed to the dorsal aspect of the concavity. Our hypothesis is that the presence of an empty sella in a child with hypophyseal-hypothalamic abnormalities should alert physicians to the existence of hypothalamic lesions secondary to a perinatal insult. We discuss the possible pathogenesis of these findings as well as lines of evidence available in the literature.

Immunohistochemical survey of migration of human anterior pituitary cells in developmental, pathological, and clinical aspects: a review

Developmentally pathological conditions of the anterior pituitary cells include failed separation of the primary pituitary gland into sellar and pharyngeal ones, ectopic migration into the subarachnoid space, and basophil invasion into the posterior lobe although the last is a physiological phenomenon with pathological potentiality in certain circumstances. Pituitary primordium appears at about 4 weeks of gestation. One of the causes of the pituitary gland agenesis may be a formation of the primary hypothalamic ganglionic hamartoma just at the time of occurrence of the pituitary primordium, as analyzed in cases of Pallister-Hall syndrome. A double pituitary in a single individual is a rare malformation. Its pathogenesis is considered as a result of notochordal anomaly. In the 8th gestational week, the primary pituitary gland separates into sellar and pharyngeal parts. The disturbance of this histogenesis results in a rare pituitary malformation, a "pharyngosellar pituitary." Despite the failed separation in this case, differentiation of the pituitary cells proceeds and the hormone production of this malformed pituitary gland can be displayed immunohistochemically. In this case, the distribution of the different hormone producing cells was atypical, particularly in those of gonadotropic hormones and ACTH. Life-long existence of the pharyngeal pituitary is a normal anatomical state in humans. Cell differentiation (hormone production) in the pharyngeal pituitary occurs about 4-10 weeks later than in the sellar pituitary. In pharyngeal pituitary, all kinds of adenohypophyseal hormones are produced. Extracranial pituitary adenomas (with intact sellar pituitary), exclusively found in the nasopharynx, sphenoid sinus, and clivus, may occur from the pharyngeal pituitary while another tumorigenesis can develop from the residual tissue fragment in the craniopharyngeal canal. The "overshoot" of the adenohypophyseal cell migration in the distal part of the sellar pituitary is frequently observed in the leptomeninges of the peri-infundibular or peri-hypothalamic region as ectopic pituitary cell clusters that are apparently independent of the pars tuberalis. It is suggested that these cells, frequently found in "normal" individuals, may be one of the possible origins of the intracranial ectopic pituitary adenomas. However, the reason why a majority of the reported intracranial ectopic pituitary tumors are ACTH-adenomas remains unexplained, since the ectopic cells, found in "normal" individuals, consist of fairly different hormone-producing cells. A further enigmatic phenomenon is a "basophil invasion." ACTH-positive cells invade from the pars intermedia into the posterior lobe of the pituitary. This invasion increases in intensity and frequency according to increase in age. However, the invasion of ACTH cells is observed as early as in the fetal life. The invasive cells display occasionally cell atypia as well as mitotic activity. The origin of extremely rare pituitary adenomas inside the posterior lobe can be explained by the existence and proliferative activity of basophil invasion.

Solitary median maxillary central incisor, short stature, choanal atresia/midnasal stenosis (SMMCI) syndrome

This article describes a series of 21 consecutive cases, each involving a solitary median maxillary central incisor; the patients were seen in the Department of Dentistry or the Victorian Clinical Genetics Unit, Murdoch Institute, at the Royal Children's Hospital, Melbourne, from 1966 to 1997. The spectrum of anomalies and associated features present in these cases--solitary median maxillary central incisor, choanal atresia, and holoprosencephaly--is described, and the literature related to the features, including genetic studies in these conditions, is reviewed. We relate our findings in these cases to current knowledge of developmental embryology. It is hoped that the findings, together with our interpretation of them, will help to clarify understanding of solitary median maxillary central incisor syndrome. This syndrome was previously considered a simple midline defect of the dental lamina, but it is now recognized as a possible predictor of holoprosencephalies of varying degrees in the proband, in members of the proband's family, and in the family's descendants.

Hormones, lymphohemopoietic cytokines and the neuroimmune axis

The classical distinction between hormones and cytokines has become increasingly obscure with the realization that homeostatic responses to infection involve coordinated changes in both the neuroendocrine and immune systems. The hypothesis that these systems communicate with one another is supported by the ever-accruing demonstrations of a shared molecular network of ligands and receptors. For instance, leukocytes express receptors for hormones and these receptors modulate diverse biological activities such as the growth, differentiation and effector functions. Leukocyte lineages also synthesize and secrete hormones, such as insulin-like growth factor-I (IGF-I), in response to both growth hormone (GH) and also to cytokines such as tumor necrosis factor-alpha (TNF-alpha). Since hormones share intracellular signaling substrates and biological activities with classical lymphohemopoietic cytokines, neuroendocrine and immune tissues share a common molecular language. The physiological significance of this shared molecular framework is that these homeostatic systems can intercommunicate. One important example of this interaction is the mechanism by which bacterial lipopolysaccharide, by eliciting a pro-inflammatory cytokine cascade from activated leukocytes, modulate pituitary GH secretion as well as other CNS-controlled behavioral and metabolic events. This article reviews the cellular and molecular basis for this communication system and proposes novel mechanisms by which neuroendocrine-immune interactions converge to modulate disease resistance, metabolism and growth.

Thymulin, zinc and insulin-like growth factor-I (IGF-I) activity before and during recombinant growth hormone (rec-GH) therapy in children and adults with GH deficiency

Plasma thymulin (active and total) levels; IGF-I and zinc concentrations were evaluated in 9 children and in 8 adults with GH-deficiency (GHD) before and after 3-6 months of recombinant-GH treatment. Before therapy, GH deficient children had lower plasma active thymulin levels (1.0 +/- 0.3 log-2), not due to a peripheral defect in zinc saturation since plasma zinc levels were within the normal range, and total thymulin levels (1.3 +/- 0.3 log-2) than in the age-matched control group. GH therapy significantly increased active thymulin (3rd month: 3.0 +/- 0.2 log-2, 6th month: 4.0 +/- 0.2 log-2), total thymulin (3rd month: 3.3 +/- 0.3 log-2, 6th month: 4.3 +/- 0.2 log-2) and IGF-I levels (3rd month: 283.3 +/- 7.2 micrograms/L, 6th month: 411.2 +/- 44.2 micrograms/L, vs basal: 144.3 +/- 11.5 micrograms/L); at the 6th month of therapy, thymulin levels (active and total) were comparable to those found in controls. A positive correlation existed between zinc and plasma IGF-I levels (r = 0.66, p < 0.05). In adults with GHD, plasma active (1.9 +/- 0.3 log-2) and total thymulin levels (3.9 +/- 0.1 log-2), significantly lower (p < 0.01 and 0.05, respectively) than in controls before treatment, increased after GH therapy (active thymulin, 3rd month: 3.0 +/- 0.2 log-2, 6th month: 4.4 +/- 0.3 log-2; total thymulin, 3rd month: 3.9 +/- 0.3 log-2, 6th month: 4.7 +/- 0.2 log-2), being at 6th month of therapy no more different from the values recorded in the age-matched control group. In conclusion, children and adults with GHD have a marked impairment of the thymic endocrine activity, which can be restored by six months of GH treatment. The effects of GH on thymic functions may be mediated by IGF-I, through the modulation of zinc turnover, suggesting the possible existence of an interplay among GH, zinc, IGF-I and thymulin both in children and adults with GHD.

Nasal pyriform aperture stenosis and absence of the anterior pituitary gland: report of two cases

We describe two female infants with congenital nasal pyriform aperture stenosis and severe pituitary insufficiency. The anterior pituitary gland was undetectable with magnetic resonance imaging. Consanguinity of parents in both cases suggests autosomal recessive inheritance of this disorder. An early fetal developmental defect may explain this syndrome, which affects midline craniofacial structures. In patients with congenital pyriform aperture stenosis, magnetic resonance imaging of the brain and endocrine investigations should be performed for rapid diagnosis and treatment of the latter to avoid major neurologic complications.

Abnormal development of the sella turcica and lack of pituitary visualization in a patient with partial hypopituitarism

We report the case of a 17-year-old girl presenting short stature (height 149 cm, below the 3rd percentile), obesity (weight 83.5 kg, body mass index 37 kg/m2) and secondary amenorrhea, in whom endocrinological evaluation disclosed an absolute lack of GH responsiveness to both suprapituitary challenges and repetitive growth hormone releasing hormone administration together with failure of plasma gonadotropins and PRL, low under basal conditions, to rise in response to GnRH and insulin-hypoglycemia, respectively. In contrast, basal and stimulated TSH and ACTH secretions were normal. Radiological examination of the skull revealed virtual absence of the pituitary fossa due to the lack of sellar cavum and dorsum, while magnetic resonance was unable to detect any pituitary tissue. A mucosal cleft of the nasopharynx, compatible with a pharyngeal hypophysis, was disclosed at endoscopy. This is an unusual case of developmental abnormality including lack of formation of the sella turcica and incomplete caudal migration of the embryonal anterior pituitary, resulting in ectopically located--likely pharyngeal--pituitary tissue. In view of the occurrence of spontaneous menarche and of a growth impairment less severe than one would expect considering the degree of GH deficiency, it is conceivable that the ectopic pituitary tissue has lost, in time, some of its secretory ability.

Congenital panhypopituitarism of late onset

A 29-year-old male was diagnosed congenital panhypopituitarism due to pituitary hypoplasia, absence of pituitary stalk and ectopic neurohypophysis. This report, together with bibliographic review, may induce to reconsidering isolated GH failures, partial hypopituitarisms and panhypopituitarisms which have up to now been interpreted as idiopathic. The availability of new image techniques has allowed a better definition of the anatomic substrate of these alterations, and more subtle hormonal studies have pointed out, in some cases, their possible hypothalamic origin. On this basis, some of these cases may be interpreted as presenting the same alteration as those described in necropsy of newborns dead due to severe panhypopituitarism. Therefore, a unique clinical picture with various degrees of severity may be postulated.

Growth hormone-insulinlike growth factor I and immune function

Growth hormone (GH) and insulinlike growth factor I (IGF-I) may be part of a neuroendocrine immune axis that stimulates cellular proliferation of primary lymphoid organs (bone marrow, thymus) as well as stimulates activation of peripheral lymphocytes and macrophages to enhance specific immune responses. GH can also stimulate production of thymic hormones and cytokines, and in this way impact on immune function. It is not clear whether GH and IGF-I act independently or whether the action of GH is mediated by local production of IGF-I by lymphocytes. Both GH and IGF-I and their receptors are present in lymphocytes. Thus, cells of the immune system may be important targets of the GH-IGF-I axis.

[Familial panhypopituitarism]

Two Italian brothers showed identical subsequent loss of anterior pituitary function during the first decades of their life, developing panhypopituitarism. The investigations carried out indicate that in this family the etiology is hereditary in nature, being X-chromosomal recessive or autosomal recessive, with the defect located at the level of either the hypothalamus or the pituitary gland.

Adrenal hypoplasia and pituitary agenesis in a normocephalic infant, with a review of the literature

A case of adrenal hypoplasia and pituitary agenesis in a normocephalic female infant is described. Twenty-eight other cases from the world literature were reviewed. There were 18 females and 11 males. More than one affected infant was described in five families, suggesting autosomal recessive inheritance. The mode of presentation, subsequent course, pathology and possible pathogenesis are discussed.

Growth hormone deficiency in the Rothmund-Thomson syndrome

We describe the first proven occurrence of growth hormone deficiency in an individual with the Rothmund-Thomson syndrome. This was suspected because of the patient's severely retarded growth and bone age and her failure to respond normally to growth hormone stimulation testing with l-DOPA, arginine, and growth hormone releasing factor. In addition, we have briefly reviewed other genetic and malformation syndromes that have been found associated with growth hormone deficiency. We recommend that growth hormone deficiency be considered in these syndromes, especially when the growth failure is more marked than expected.

Familial hypopituitarism associated with an enlarged pituitary fossa and an empty sella

We report an 8-year follow-up of three sisters born of a consanguineous marriage and who originally presented with short stature and enlarged pituitary fossa. All have shown progressive failure of anterior pituitary hormone function. In addition, the two eldest sisters were eventually found to have an empty sella while the youngest, who initially showed an enhancing intrasellar mass consistent with a tumour, later showed an empty sella. A familial pituitary tumour developing early in childhood but subsequently undergoing involution could account for these findings.

Multicore disease in sibs with severe mental retardation, short stature, facial anomalies, hypoplasia of the pituitary fossa, and hypogonadotrophic hypogonadism

We describe a family in which two adult sibs presented with a history of congenital nonprogressive myopathy, severe mental retardation and evidence of mild generalized weakness, short stature, musculoskeletal deformities, facial anomalies, sexual infantilism, and radiologic evidence of pituitary hypoplasia. The parents were first cousins. An excess of other, apparently unrelated, genetic conditions were present in other family members. Results of histochemical and electron microscopy studies of muscle biopsies from both affected individuals were compatible with multicore disease. This newly described syndrome likely is an autosomal recessive trait and appears to be the first reported association of multicore disease with mental retardation.

Congenital hypothalamic hamartoblastoma, hypopituitarism, imperforate anus and postaxial polydactyly--a new syndrome? Part I: clinical, causal, and pathogenetic considerations

We report on six infants with a neonatally lethal malformation syndrome of hypothalamic hamartoblastoma, postaxial polydactyly, and imperforate anus. Some, but not all, patients had laryngeal cleft, abnormal lung lobulation, renal agenesis and/or renal dysplasia, short 4th metacarpals, nail dysplasia, multiple buccal frenula, hypoadrenalism, microphallus, congenital heart defect, and intrauterine growth retardation. The infants also had hypopituitarism and hypoadrenalism. All were sporadic cases, parents were not consanguineous, chromosomes were apparently normal. Family histories were unremarkable. There was insecticide and/or herbicide exposure in several of the cases, but no exposures were common to all 6 mothers. Five of the patients were born within an 8-month period, but all in different geographic locations. It is postulated that this is a previously apparently unreported syndrome of presently unknown cause.