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Thyroid Function in Adults with Prader-Willi Syndrome; a Cohort Study and Literature Review. J Clin Med 2021; 10:jcm10173804. [PMID: 34501256 PMCID: PMC8432005 DOI: 10.3390/jcm10173804] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/02/2021] [Accepted: 08/10/2021] [Indexed: 12/19/2022] Open
Abstract
Prader–Willi syndrome (PWS) is a complex genetic syndrome combining hypotonia, hyperphagia, a PWS-specific neurocognitive phenotype, and pituitary hormone deficiencies, including hypothyroidism. The low muscle mass associated with PWS causes a low energy expenditure due to a low basal metabolic rate. Combined with increased energy intake due to hyperphagia, this results in a high risk of obesity and associated cardiovascular disease. To reduce the high mortality in PWS (3% yearly), exercise is extremely important. As hypothyroidism can impair exercise tolerance, early detection is crucial. We performed a literature search for articles on hypothyroidism in PWS, measured thyroid hormone (TH) levels in 122 adults with PWS, and performed a medical file search for medication use. Hypothyroidism (low free thyroxin) was present in 17%, and often central in origin (80%). Triiodothyronine levels were lower in patients who used psychotropic drugs, while other TH levels were similar. One in six patients in our cohort of adults with PWS had hypothyroidism, which is more than in non-PWS adults (3%). We recommend yearly screening of free thyroxin and thyroid-stimulating hormone levels to avoid the negative effects of untreated hypothyroidism on basal metabolic rate, body mass index, and cardiovascular risk. Additionally, we recommend measuring TH concentrations 3–4 months after the start of growth hormone treatment.
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Persani L, Cangiano B, Bonomi M. The diagnosis and management of central hypothyroidism in 2018. Endocr Connect 2019; 8:R44-R54. [PMID: 30645189 PMCID: PMC6373625 DOI: 10.1530/ec-18-0515] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 01/15/2019] [Indexed: 12/26/2022]
Abstract
Central hypothyrodism (CeH) is a hypothyroid state caused by an insufficient stimulation by thyrotropin (TSH) of an otherwise normal thyroid gland. Several advancements, including the recent publication of expert guidelines for CeH diagnosis and management, have been made in recent years thus increasing the clinical awareness on this condition. Here, we reviewed the recent advancements and give expert opinions on critical issues. Indeed, CeH can be the consequence of various disorders affecting either the pituitary gland or the hypothalamus. Recent data enlarged the list of candidate genes for heritable CeH and a genetic origin may be the underlying cause for CeH discovered in pediatric or even adult patients without apparent pituitary lesions. This raises the doubt that the frequency of CeH may be underestimated. CeH is most frequently diagnosed as a consequence of the biochemical assessments in patients with hypothalamic/pituitary lesions. In contrast with primary hypothyroidism, low FT4 with low/normal TSH levels are the biochemical hallmark of CeH, and adequate thyroid hormone replacement leads to the suppression of residual TSH secretion. Thus, CeH often represents a clinical challenge because physicians cannot rely on the use of the 'reflex TSH strategy' for screening or therapy monitoring. Nevertheless, in contrast with general assumption, the finding of normal TSH levels may indicate thyroxine under-replacement in CeH patients. The clinical management of CeH is further complicated by the combination with multiple pituitary deficiencies, as the introduction of sex steroids or GH replacements may uncover latent forms of CeH or increase the thyroxine requirements.
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Affiliation(s)
- Luca Persani
- Division of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Correspondence should be addressed to L Persani:
| | - Biagio Cangiano
- Division of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marco Bonomi
- Division of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Benvenga S, Klose M, Vita R, Feldt-Rasmussen U. Less known aspects of central hypothyroidism: Part 1 - Acquired etiologies. J Clin Transl Endocrinol 2018; 14:25-33. [PMID: 30416972 PMCID: PMC6205405 DOI: 10.1016/j.jcte.2018.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/24/2022] Open
Abstract
Central hypothyroidism (CH) is a rare cause of hypothyroidism. CH is frequently overlooked, as its clinical picture is subtle and includes non-specific symptoms; furthermore, if measurement of TSH alone is used to screen for thyroid function, TSH concentrations can be normal or even above the upper normal reference limit. Indeed, certain patients are at risk of developing CH, such as those with a pituitary adenoma or hypophysitis, those who have been treated for a childhood malignancy, have suffered a head trauma, sub-arachnoid hemorrhage or meningitis, and those who are on drugs capable to reduce TSH secretion.
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Key Words
- ADH, antidiuretic hormone
- AT/RT, atypical teratoid/rhabdoid tumor
- CH, central hypothyroidism
- CNS, central nervous system
- CPI, conformal primary-site irradiation
- CRI, cranial irradiation
- Central hypothyroidism
- Congenital hypothyroidism
- DDMS, Dyke-Davidoff-Masson syndrome
- FSH, follicle-stimulating hormone
- FT3, free triiodothyronine
- FT4, free thyroxine
- GCT, germ cell tumor
- GH, growth hormone
- Hypopituitarism
- IGF-1, insulin growth factor-1
- LH, luteinizing hormone
- MB, medulloblastoma
- PD-1, programmed cell death-1 receptor
- PNET, primitive neuroectodermal tumor
- PRL, prolactin
- SAH, subarachnoid hemorrhage
- TBI, traumatic brain injury
- TRH, TSH-releasing hormone
- TSH, thyrotropin
- Thyrotropin deficiency
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Affiliation(s)
- Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women’s Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital Policlinico G. Martino, Messina, Italy
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Copenhagen, Denmark
| | - Roberto Vita
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Copenhagen, Denmark
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Persani L, Brabant G, Dattani M, Bonomi M, Feldt-Rasmussen U, Fliers E, Gruters A, Maiter D, Schoenmakers N, van Trotsenburg AP. 2018 European Thyroid Association (ETA) Guidelines on the Diagnosis and Management of Central Hypothyroidism. Eur Thyroid J 2018; 7:225-237. [PMID: 30374425 PMCID: PMC6198777 DOI: 10.1159/000491388] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 06/19/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Central hypothyroidism (CeH) is a rare form of hypothyroidism characterized by insufficient thyroid stimulation due to disturbed pituitary and/or hypothalamic functioning. Due to its origin and the whole clinical context, CeH represents a challenging condition in clinical practice as it is characterized by suboptimal accuracy of clinical and biochemical parameters for diagnosis and management. Since no expert consensus or guidance for this condition is currently available, a task force of experts received the commitment from the European Thyroid Association (ETA) to prepare this document based on the principles of clinical evidence. STUDY DESIGN The task force started to work in February 2017 and after a careful selection of appropriate references (cohort studies, case reports, expert opinions), a preliminary presentation and live discussion during the 2017 ETA meeting, and several revision rounds, has prepared a list of recommendations to support the diagnosis and management of patients with CeH. RESULTS Due to the particular challenges of this rare condition in the different ages, the target users of this guidance are pediatric and adult endocrinologists. Experts agreed on the need to recognize and treat overt CeH at all ages, whereas treatment of milder forms may be dispensable in the elderly (> 75 years). CONCLUSIONS Despite the lack of randomized controlled clinical trials, the experts provide 34 recommendations supported by variable levels of strength that should improve the quality of life of the affected patients and reduce the metabolic and hormonal consequences of inadequate management.
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Affiliation(s)
- Luca Persani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- *Prof. Luca Persani, MD, PhD, University of Milan and IRCCS Istituto Auxologico Italiano, San Luca Hospital, Piazzale Brescia 20, IT–20149 Milan (Italy), E-Mail
| | - Georg Brabant
- Experimental and Clinical Endocrinology Medical Clinic I – University of Lübeck, Lübeck, Germany
| | - Mehul Dattani
- Genetics and Genomic Medicine Programme, UCL GOS Institute of Child Health, London, United Kingdom
| | - Marco Bonomi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eric Fliers
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Annette Gruters
- Department for Pediatric Endocrinology and Diabetes, Charité University Medicine, Berlin, Germany
- University Hospital Heidelberg, Heidelberg, Germany
| | - Dominique Maiter
- Department of Endocrinology and Nutrition, UCL Cliniques Saint-Luc, Brussels, Belgium
| | - Nadia Schoenmakers
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-Medical Research Council Institute of Metabolic Science, Addenbrooke's Hospital and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - A.S. Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Andreassen M, Juul A, Feldt-Rasmussen U, Jørgensen N. Semen quality in patients with pituitary disease and adult-onset hypogonadotropic hypogonadism. Endocr Connect 2018; 7. [PMID: 29514896 PMCID: PMC5881434 DOI: 10.1530/ec-18-0061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Gonadotropins (luteinizing hormone (LH) and follicle-stimulating hormone (FSH)) are released from the pituitary gland and stimulate Leydig cells to produce testosterone and initiates spermatogenesis. Little is known about how and when the deterioration of semen quality occurs in patients with adult-onset gonadotropin insufficiency. DESIGN AND METHODS A retrospective study comprising 20 testosterone-deficient men (median age, 29 years) with acquired pituitary disease who delivered semen for cryopreservation before initiation of testosterone therapy. Semen variables and hormone concentrations were compared to those of young healthy men (n = 340). RESULTS Thirteen of 20 patients (65%) and 82% of controls had total sperm counts above 39 million and progressive motile spermatozoa above 32% (P = 0.05). For the individual semen variables, there were no significant differences in semen volume (median (intraquartile range) 3.0 (1.3-6.8) vs 3.2 (2.3-4.3) mL, P = 0.47), sperm concentration 41 (11-71) vs 43 (22-73) mill/mL (P = 0.56) or total sperm counts (P = 0.66). One patient had azoospermia. Patients vs controls had lower serum testosterone 5.4 (2.2-7.6) vs 19.7 (15.5-24.5) nmol/L (P = 0.001), calculated free testosterone (cfT) 145 (56-183) vs 464 (359-574) pmol/L (P < 0.001), LH 1.5 (1.1-2.1) vs 3.1 (2.3-4.0) U/L (P = 0.002) and inhibin b (P < 0.001). Levels of FSH were similar (P = 0.63). Testosterone/LH ratio and cfT/LH ratio were reduced in patients (both P < 0.001). CONCLUSIONS Despite Leydig cell insufficiency in patients with acquired pituitary insufficiency, the majority presented with normal semen quality based on the determination of the number of progressively motile spermatozoa. In addition, the data suggest reduced LH bioactivity in patients with pituitary insufficiency.
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Affiliation(s)
- Mikkel Andreassen
- Department of EndocrinologyFaculty of Health Science, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anders Juul
- Department of Growth and ReproductionFaculty of Health Science, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of EndocrinologyFaculty of Health Science, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Niels Jørgensen
- Department of Growth and ReproductionFaculty of Health Science, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Zhang Q, Zang L, Li YJ, Han BY, Gu WJ, Yan WH, Jin N, Chen K, Du J, Wang XL, Guo QH, Yang GQ, Yang LJ, Ba JM, Lv ZH, Dou JT, Lu JM, Mu YM. Thyrotrophic status in patients with pituitary stalk interruption syndrome. Medicine (Baltimore) 2018; 97:e9084. [PMID: 29480822 PMCID: PMC5943885 DOI: 10.1097/md.0000000000009084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Pituitary stalk interruption syndrome (PSIS) is associated with simultaneous or subsequent pituitary hormone deficiencies (PHDs). Although the clinical features of multiple PHDs are well known, the status of the thyrotrophic axis in PSIS has not been thoroughly investigated.The clinical data of 89 PSIS patients and 34 Sheehan syndrome (SS) patients were retrospectively analyzed.The prevalence of central hypothyroidism in the PSIS patients and the SS patients was 79.8% and 70.6%, respectively. The thyroid-stimulating hormone (TSH) levels in the PSIS patients were significantly higher in comparison with the SS patients (5.13 ± 3.40 vs 1.67 ± 1.20 mU/L, P < .05). TSH elevation (8.79 ± 3.17 mU/L) was noticed in 29 of 71 (40.85%) hypothyroid PSIS patients but not in the 24 hypothyroid SS patients. The TSH levels in the hypothyroid PSIS patients were significantly higher in comparison with the euthyroid PSIS patients (5.42 ± 3.67 vs 3.66 ± 1.50 mU/L). Thyroid hormone replacement significantly reduced the TSH levels in the PSIS patients with elevated TSH levels from 7.24 ± 0.98 to 1.67 ± 1.51 mU/L (P < .05). The logistic regression analysis suggested that TSH level was not significantly associated with pituitary stalk status and height of the anterior pituitary gland.PSIS is a newly recognized cause of central hypothyroidism. The proportion and amplitude of TSH elevations are higher in PSIS than in other causes of central hypothyroidism.
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Affiliation(s)
- Qian Zhang
- Department of Endocrinology, Chinese PLA General Hospital
- Department of Endocrinology, PLA Army General Hospital, Beijing
| | - Li Zang
- Department of Endocrinology, Chinese PLA General Hospital
| | - Yi-Jun Li
- Department of Endocrinology, Chinese PLA General Hospital
| | - Bai-Yu Han
- Department of Endocrinology, Chinese PLA General Hospital
- Department of Endocrinology, The 264 Hospital of PLA, Taiyuan, Shanxi, China
| | - Wei-Jun Gu
- Department of Endocrinology, Chinese PLA General Hospital
| | - Wen-Hua Yan
- Department of Endocrinology, Chinese PLA General Hospital
| | - Nan Jin
- Department of Endocrinology, Chinese PLA General Hospital
| | - Kang Chen
- Department of Endocrinology, Chinese PLA General Hospital
| | - Jin Du
- Department of Endocrinology, Chinese PLA General Hospital
| | - Xian-Ling Wang
- Department of Endocrinology, Chinese PLA General Hospital
| | - Qing-Hua Guo
- Department of Endocrinology, Chinese PLA General Hospital
| | - Guo-Qing Yang
- Department of Endocrinology, Chinese PLA General Hospital
| | - Li-Juan Yang
- Department of Endocrinology, Chinese PLA General Hospital
| | - Jian-Ming Ba
- Department of Endocrinology, Chinese PLA General Hospital
| | - Zhao-Hui Lv
- Department of Endocrinology, Chinese PLA General Hospital
| | - Jing-Tao Dou
- Department of Endocrinology, Chinese PLA General Hospital
| | - Ju-Ming Lu
- Department of Endocrinology, Chinese PLA General Hospital
| | - Yi-Ming Mu
- Department of Endocrinology, Chinese PLA General Hospital
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Abstract
Central hypothyroidism (CH) is a rare cause of hypothyroidism generally related to a hypothalamic-pituitary disorder or arising as an iatrogenic complication. In adults, CH may be secondary to quantitative and/or qualitative alterations in thyroid-stimulating hormone (TSH) secretion. The disease is difficult to diagnose clinically because it lacks specific clinical signs and these may be masked by other anterior pituitary hormone secretion deficiencies. In patients with long-standing and marked CH, a diagnosis may be made based on low free T4 levels and normal, low or moderately increased TSH levels. In patients with early-stage or moderate CH, exploration of the circadian TSH cycle, determination of TSH response after a TRH test or recombinant TSH injection, estimation of TSH index, or evaluation of peripheral indexes of thyroid hormone metabolism may be required to establish a diagnosis. Regarding treatment, patients should receive levothyroxine replacement therapy, but hormone objectives during follow-up need to be precisely determined in order to reduce cardiovascular risks and to improve the quality of life of patients.
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Affiliation(s)
- Solange Grunenwald
- Cardiovascular and Metabolic Unit, Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 chemin de Pouvourville, TSA 30030, 31059, Toulouse Cedex, France
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Abstract
Central hypothyroidism (CH) is a rare cause of hypothyroidism due to an insufficient stimulation of an otherwise normal thyroid gland and it is caused by either pituitary (secondary hypothyroidism) or hypothalamic (tertiary hypothyroidism) defects. The diagnosis of CH is usually suggested by the finding of lowered thyroid hormone concentrations, associated with inappropriately low/ normal TSH levels. Restoration and maintenance of euthyroidism represent the therapeutic goals in all forms of CH. On these basis, the vast majority of patients with CH is treated with standard levo-thyroxine (L-T4) therapy which is tailored according to FT4 circulating levels that should be maintained in the normal range.
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Affiliation(s)
- Andrea Lania
- Department of Medical Sciences, Fondazione Ospedale Maggiore Policlinico IRCCS, University of Milan, Milan, Italy
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