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Ferrigno R, Cioffi D, Pellino V, Savanelli MC, Klain A. Growth alterations in rare forms of primary adrenal insufficiency: a neglected issue in paediatric endocrinology. Endocrine 2023; 80:1-9. [PMID: 36309634 DOI: 10.1007/s12020-022-03236-z] [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: 09/06/2022] [Accepted: 10/15/2022] [Indexed: 11/27/2022]
Abstract
Primary adrenal insufficiency (PAI) is an endocrine disorder characterized by direct adrenal failure, with consequent glucocorticoid, and eventually mineralocorticoid, deficiency. In children, the main cause of PAI is congenital adrenal hyperplasia (CAH), due to a loss of function of adrenal steroidogenic enzymes, but also rarer forms, including autoimmune polyglandular syndrome, adrenoleucodistrophy, adrenal hypoplasia congenita, familial glucocorticoid deficiency, and Allgrove's Syndrome, may be observed. In PAI children, growth alterations represent a major issue, as both inadequate and excessive glucocorticoid replacement treatment may lead to reduced growth rate and adult height impairment. However, growth abnormalities are poorly studied in rare forms of paediatric PAI, and specific studies on growth rate in these children are currently lacking. In the present review, the currently available evidence on growth alterations in children with rare PAI forms will be summarized, with a major focus on comorbidities with a potential impact on patients' growth rate.
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Affiliation(s)
- Rosario Ferrigno
- UOSD di Endocrinologia e Auxologia, Dipartimento di Pediatria, AORN Santobono-Pausilipon, Napoli, Italy.
| | - Daniela Cioffi
- UOSD di Endocrinologia e Auxologia, Dipartimento di Pediatria, AORN Santobono-Pausilipon, Napoli, Italy
| | - Valeria Pellino
- UOSD di Endocrinologia e Auxologia, Dipartimento di Pediatria, AORN Santobono-Pausilipon, Napoli, Italy
| | - Maria Cristina Savanelli
- UOSD di Endocrinologia e Auxologia, Dipartimento di Pediatria, AORN Santobono-Pausilipon, Napoli, Italy
| | - Antonella Klain
- UOSD di Endocrinologia e Auxologia, Dipartimento di Pediatria, AORN Santobono-Pausilipon, Napoli, Italy
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Aytac G, Guven B, Aydin I, Topyildiz E, Aykut A, Durmaz A, Edeer Karaca N, Aksu G, Kutukculer N. An Extraordinary Case of Autoimmune Polyendocrinopathy-Candidiasis-Ectodermal Dystrophy (APECED) Syndrome Misdiagnosed as Juvenile Idiopathic Arthritis on Admission. Case Reports Immunol 2023; 2023:2363760. [PMID: 37144156 PMCID: PMC10154083 DOI: 10.1155/2023/2363760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/31/2023] [Accepted: 04/13/2023] [Indexed: 05/06/2023] Open
Abstract
Background APECED is a syndrome characterized by autoimmune polyendocrinopathy, candidiasis, and ectodermal dystrophy. The most observed clinical findings are chronic mucocutaneous candidiasis, hypoparathyroidism, and autoimmune adrenal insufficiency. Case Presentation. A three-year-old male patient was admitted with classical signs of juvenile idiopathic arthritis and treated with nonsteroidal anti-inflammatory drugs. During follow-up, signs of autoimmunity, candidiasis, nail dystrophy, and onychomycosis were observed. The parents were consanguineous, and targeted next-generation sequencing was performed. A homozygous mutation in the AIRE gene SAND domain (c.769C > T, p.Arg257Ter) was detected, and the patient was diagnosed with APECED syndrome. Conclusion Inflammatory arthritis is rarely described in association with APECED and is often misdiagnosed as juvenile idiopathic arthritis. In APECED cases, nonclassical symptoms such as arthritis may occur before developing classical symptoms and considering the diagnosis of APECED in patients with CMC and arthritis is useful for early diagnosis before development of complications and management of disease.
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Affiliation(s)
- Gulcin Aytac
- Ege University Faculty of Medicine, Department of Pediatric Rheumatology, Izmir, Turkey
| | - Burcu Guven
- Ege University Faculty of Medicine, Department of Pediatric Rheumatology, Izmir, Turkey
| | - Ilyas Aydin
- Ege University Faculty of Medicine, Department of Pediatric Rheumatology, Izmir, Turkey
| | - Ezgi Topyildiz
- Ege University Faculty of Medicine, Department of Pediatric Immunology, Izmir, Turkey
| | - Ayca Aykut
- Ege University Faculty of Medicine, Medical Genetics, Izmir, Turkey
| | - Asude Durmaz
- Ege University Faculty of Medicine, Medical Genetics, Izmir, Turkey
| | - Neslihan Edeer Karaca
- Ege University Faculty of Medicine, Department of Pediatric Immunology, Izmir, Turkey
| | - Guzide Aksu
- Ege University Faculty of Medicine, Department of Pediatric Rheumatology, Izmir, Turkey
- Ege University Faculty of Medicine, Department of Pediatric Immunology, Izmir, Turkey
| | - Necil Kutukculer
- Ege University Faculty of Medicine, Department of Pediatric Rheumatology, Izmir, Turkey
- Ege University Faculty of Medicine, Department of Pediatric Immunology, Izmir, Turkey
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Soyak Aytekin E, Serin O, Cagdas D, Tan C, Aksu T, Unsal Y, Yeni S, Orhan D, Ozon ZA, Tezcan I. A Patient With AIRE Mutation Who Presented With Severe Diarrhea and Lung Abscess. Pediatr Infect Dis J 2021; 40:66-69. [PMID: 33284251 DOI: 10.1097/inf.0000000000002887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) (polyglandular endocrinopathy type 1) is a rare autosomal recessive disorder caused by mutations in the autoimmune regulator gene (AIRE). The major clinical features of APECED are hypoparathyroidism, adrenal insufficiency (Addison disease), and chronic mucocutaneous candidiasis. This disease is also associated with multiple other and uncommon autoimmune (autoimmune hepatitis, autoimmune enteropathy, atrophic gastritis with or without pernicious anemia, gonadal failure, diabetes mellitus, hypothyroidism, functional hyposplenism), ectodermal (alopecia and vitiligo), and inflammatory (intestinal lung disease, nephritis) features. Here, we report a case of a 13-year-old Turkish boy who presented wih enteropathy and lung abscess. Molecular genetic analysis demonstrated a homozygous frameshift mutation (p.Asp70fs, c.208_209insCAGG) in exon 2, in AIRE gene. APECED may present with severe, life-threatening infections due to functional hyposplenism. Multidisciplinary approach, careful follow-up, and molecular genetic studies are needed.
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Affiliation(s)
- Elif Soyak Aytekin
- From the Department of Pediatrics, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - Oguzhan Serin
- Department of Pediatrics, Hacettepe University Medical School, Ankara, Turkey
| | - Deniz Cagdas
- From the Department of Pediatrics, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
| | - Cagman Tan
- Institute of Child Health, Immunology, Hacettepe University, Ankara, Turkey
| | - Tekin Aksu
- Department of Pediatrics, Division of Pediatric Hematology, Hacettepe University Medical School, Ankara, Turkey
| | - Yagmur Unsal
- Department of Pediatrics, Division of Pediatric Endocrinology and Metabolism, Hacettepe University Medical School, Ankara, Turkey
| | - Selma Yeni
- Department of Clinical Pathology, Hacettepe University Medical School, Ankara, Turkey
| | - Diclehan Orhan
- Department of Clinical Pathology, Hacettepe University Medical School, Ankara, Turkey
| | - Zeynep Alev Ozon
- Department of Pediatrics, Division of Pediatric Endocrinology and Metabolism, Hacettepe University Medical School, Ankara, Turkey
| | - Ilhan Tezcan
- From the Department of Pediatrics, Division of Pediatric Immunology, Hacettepe University Medical School, Ankara, Turkey
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Gutierrez MJ, Gilson J, Zacharias J, Ishmael F, Bingham CA. Childhood Polyarthritis As Early Manifestation of Autoimmune Polyendocrinopathy with Candidiasis and Ectodermal Dystrophy Syndrome. Front Immunol 2017; 8:377. [PMID: 28458664 PMCID: PMC5394715 DOI: 10.3389/fimmu.2017.00377] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 03/16/2017] [Indexed: 12/13/2022] Open
Abstract
Autoimmune polyendocrinopathy with candidiasis and ectodermal dystrophy (APECED) is a rare disorder of immune dysregulation caused by mutations in the autoimmune regulator (AIRE) gene. Individuals affected with APECED develop a clinical syndrome characterized by ectodermal abnormalities, autoantibody production, and organ-specific autoimmune manifestations. Inflammatory arthritis is usually not described as a part of the syndrome, and only sporadic cases are reported. We describe the case of a preschool-age girl who presented with hypoparathyroidism, hepatitis, interstitial pneumonitis, and chronic polyarthritis at 4 years of age and was found to have two compound heterozygous disease-associated mutations in the AIRE gene. We also conducted a literature review of the main characteristics of inflammatory arthritis in APECED patients. Our case and review demonstrate that (1) inflammatory arthritis, although rare, can be an early manifestation of APECED; (2) the diagnosis of APECED should be considered if mucocutaneous candidiasis, multiple organ-specific autoimmune manifestations, polyendocrinopathy, especially hypoparathyroidism or adrenal failure, or ectodermal dystrophy accompany joint symptoms; and (3) genotyping interpretation should take into account that mutations are found in the 14 exons of the gene, compound heterozygosity is common, and in some cases, only one or no mutated alleles are found.
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Affiliation(s)
- Maria J Gutierrez
- Division of Pediatric Allergy Immunology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jamie Zacharias
- Section of Allergy, Asthma and Immunology, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Faoud Ishmael
- Section of Allergy, Asthma and Immunology, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - C April Bingham
- Division of Pediatric Rheumatology, Penn State Children's Hospital, Hershey, PA, USA
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Efeitos do uso do hormônio de crescimento em crianças e adolescentes com artrite idiopática juvenil: revisão sistemática. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2016.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Frittoli RB, Longhi BS, Silva AM, Filho ADAB, Monteiro MÂRDG, Appenzeller S. Effects of the use of growth hormone in children and adolescents with juvenile idiopathic arthritis: a systematic review. REVISTA BRASILEIRA DE REUMATOLOGIA 2016; 57:100-106. [PMID: 28343613 DOI: 10.1016/j.rbre.2016.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/07/2016] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Children with juvenile idiopathic arthritis (JIA) often have impaired growth and short stature. There is evidence that the therapeutic use of growth hormone (GH) is useful and safe in these patients. OBJECTIVE To analyze the effects of GH use in patients with JIA. METHOD A systematic review of the literature over the last 18 years in Medline and Embase databases. The criteria were analyzed independently by the researchers. We used the following keywords: "growth hormone", "arthritis, juvenile", "arthritis, rheumatoid", "child" and "adolescent". RESULTS Among the 192 identified articles, 20 corresponded to the inclusion criteria. Seventeen longitudinal studies and 3 case reports were found. Most studies analyzed observed increased growth, muscle mass and bone mass using GH. Adverse effects observed were glucose intolerance, diabetes, bone deformities, osteonecrosis, reactivation of the disease and low final height. CONCLUSION The majority of studies reported positive effects after the therapeutic use of GH, but some variability in response to treatment was observed. The combination of growth hormone with other drugs seems to be a good option.
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Affiliation(s)
- Renan Bazuco Frittoli
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Laboratório de Reumatologia, Campinas, SP, Brazil
| | - Barbara Sugui Longhi
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Laboratório de Reumatologia, Campinas, SP, Brazil
| | - Amanda Meireles Silva
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Laboratório de Reumatologia, Campinas, SP, Brazil
| | - Antônio de Azevedo Barros Filho
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Unidade de Reumatologia Pediátrica, Campinas, SP, Brazil
| | | | - Simone Appenzeller
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Unidade de Reumatologia Pediátrica, Campinas, SP, Brazil; Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Unidade de Reumatologia, Campinas, SP, Brazil.
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Schreiner F, Plamper M, Dueker G, Schoenberger S, Gámez-Díaz L, Grimbacher B, Hilger AC, Gohlke B, Reutter H, Woelfle J. Infancy-Onset T1DM, Short Stature, and Severe Immunodysregulation in Two Siblings With a Homozygous LRBA Mutation. J Clin Endocrinol Metab 2016; 101:898-904. [PMID: 26745254 DOI: 10.1210/jc.2015-3382] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
CONTEXT Type 1 diabetes mellitus (T1DM) is caused by autoimmunity against pancreatic β-cells. Although a significant number of T1DM patients have or will develop further autoimmune disorders during their lifetime, coexisting severe immunodysregulation is rare. OBJECTIVE Presuming autosomal-recessive inheritance in a complex immunodysregulation disorder including T1DM and short stature in two siblings, we performed whole-exome sequencing. CASE PRESENTATION Two Libyan siblings born to consanguineous parents were presented to our diabetology department at ages 12 and 5 years, respectively. Apart from T1DM diagnosed at age 2 years, patient 1 suffered from chronic restrictive lung disease, mild enteropathy, hypogammaglobulinemia, and GH deficiency. Fluorescence-activated cell sorting analysis revealed B-cell deficiency. In addition, CD4(+)/CD25(+) and CD25(high)/FoxP3(+) cells were diminished, whereas an unusual CD25(-)/FoxP3(+) population was detectable. The younger brother, patient 2, also developed T1DM during infancy. Although his enteropathy was more severe and electrolyte derangements repeatedly led to hospitalization, he did not have significant pulmonary problems. IgG levels and B-lymphocytes were within normal ranges. RESULTS By whole-exome sequencing we identified a homozygous truncating mutation (c.2445_2447del(C)3ins(C)2, p.P816Lfs*4) in the lipopolysaccharide-responsive beige-like anchor (LRBA) gene in both siblings. The diagnosis of LRBA deficiency was confirmed by a fluorescence-activated cell sorting-based immunoassay showing the absence of LRBA protein in phytohemagglutinin-stimulated peripheral blood mononuclear cells. CONCLUSION We identified a novel truncating LRBA mutation in two siblings with T1DM, short stature, and severe immunodysregulation. LRBA mutations have previously been reported to cause multiorgan autoimmunity and immunodysfunction. In light of the variable phenotypes reported so far in LRBA-mutant individuals, LRBA deficiency should be considered in all patients presenting with T1DM and signs of severe immunodysregulation.
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Affiliation(s)
- Felix Schreiner
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Michaela Plamper
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Gesche Dueker
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Stefan Schoenberger
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Laura Gámez-Díaz
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Bodo Grimbacher
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Alina C Hilger
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Bettina Gohlke
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Heiko Reutter
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
| | - Joachim Woelfle
- Pediatric Endocrinology (F.S., M.P., B.Go., J.W.), Pediatric Gastroenterology and Hepatology (G.D.), and Pediatric Hematology and Oncology (S.S.), Children's Hospital, University of Bonn, 53113 Bonn, Germany; Center for Chronic Immunodeficiency (L.G.-D., B.Gr.), University Medical Center and University of Freiburg, 79085 Freiburg, Germany; Institute for Human Genetics (A.C.H., H.R.), University of Bonn, 53113 Bonn, Germany; and Department of Neonatology and Pediatric Intensive Care (H.R.), Children's Hospital, University of Bonn, 53113 Bonn, Germany
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Zucchini S, Iafusco D, Vannelli S, Rabbone I, Salzano G, Pozzobon G, Maghnie M, Cherubini V, Bizzarri C, Bonfanti R, D'Annunzio G, Lenzi L, Maggio MC, Marigliano M, Scaramuzza A, Tumini S, Iughetti L. Combined therapy with insulin and growth hormone in 17 patients with type-1 diabetes and growth disorders. Horm Res Paediatr 2015; 82:53-8. [PMID: 24925520 DOI: 10.1159/000360856] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 02/25/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM Combined growth hormone (GH) and insulin therapy is rarely prescribed by pediatric endocrinologists. We investigated the attitude of Italian physicians to prescribing that therapy in the case of short stature and type-1 diabetes (T1DM). METHODS A questionnaire was sent and if a patient was identified, data on growth and diabetes management were collected. RESULTS Data from 42 centers (84%) were obtained. Of these, 29 centers reported that the use of combined therapy was usually avoided. A total of 17 patients were treated in 13 centers (GH was started before T1DM onset in 9 patients and after the onset of T1DM in 8). Height SDS patterns during GH therapy in the 11 patients affected by GH deficiency ranged from -0.3 to +3.1 SDS. In the 8 diabetic patients in whom GH was added subsequently, mean insulin dose increased during the first 6 months of therapy from 0.7 ± 0.2 to 1.0 ± 0.2 U/kg (p = 0.004). HbA1c was unchanged during the first 6 months of combined therapy. CONCLUSIONS Most Italian physicians do not consider prescribing the combined GH-insulin therapy in diabetic children with growth problems. However, the results of the 17 patients identified would confirm that the combined therapy was feasible and only caused mild insulin resistance. GH therapy was effective in promoting growth in most patients and did not affect diabetes metabolic control.
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Affiliation(s)
- Stefano Zucchini
- Department of Pediatrics, S. Orsola-Malpighi Hospital, Bologna, Italy
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9
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Bratanic N, Kisand K, Avbelj Stefanija M, Battelino T, Trebusak Podkrajsek K. Clinical, Genetic and Immunological Characteristics of Paediatric Autoimmune Polyglandular Syndrome Type 1 Patients in Slovenia. Zdr Varst 2015; 54:112-8. [PMID: 27646917 PMCID: PMC4820163 DOI: 10.1515/sjph-2015-0017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 01/07/2015] [Indexed: 12/22/2022] Open
Abstract
Introduction Autoimmune polyglandular syndrome type 1 (APS-1) is an autosomal recessive disorder, caused by mutations in the AIRE gene. The major components of APS-1 are chronic mucocutaneous candidiasis (CMC), hypoparathyroidism (HP) and Addison’s disease (AD). Clinical, genetic and immunological characteristics of Slovenian paediatric APS-1 patients were investigated. Methods Existing medical records of 15 APS-1 patients were rewieved, when necessary, additional clinical and laboratory investigations were issued. AIRE gene analysis was performed to identify causative mutations, and autoantibodies against type I interferons were measured by luminescence immunoprecipitation system. Results Patients had one to eight different manifestations of the disease. CMC was present in all, HP in 12/15 (80 %) and AD in 8/15 (53 %) patients. Growth retardation, due to hyposomatotropism, growth hormone resistance, autoimmune thyroiditis, corticosteroid treatment, malabsorption or secretory failure of exocrine pancreas, was observed in altogether 7 (46 %) patients. Six different AIRE gene mutations were detected and p.R257X mutation was present in 63.3 % of pathological alleles. Antibodies against type I interferons were detected in all patients. Conclusion APS-1 is a rare disorder with a broad spectrum of clinical manifestations, which, if unrecognized or inadequately treated may be fatal. AIRE gene mutational analysis and autoantibodies against type I interferons are important in early identification of the disease. The aetiology of growth retardation was shown to be extremely diverse, frequently caused by less characteristic manifestations. APS-1 may affect patients’ quality of life in numerous ways, and may cause great psychosocial burden leading to depression and suicidal thoughts even in paediatric patients.
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Affiliation(s)
- Nina Bratanic
- University Children's Hospital, Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, Bohoriceva 20, 1000 Ljubljana, Slovenia
| | - Kai Kisand
- University of Tartu, Institute of Biomedicine and Translational Medicine, Ravila 19, 50411, Tartu, Estonia
| | - Magdalena Avbelj Stefanija
- University Children's Hospital, Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, Bohoriceva 20, 1000 Ljubljana, Slovenia
| | - Tadej Battelino
- University Children's Hospital, Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, Bohoriceva 20, 1000 Ljubljana, Slovenia; University of Ljubljana, Faculty of Medicine, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Katarina Trebusak Podkrajsek
- University of Ljubljana, Faculty of Medicine, Vrazov trg 2, 1000 Ljubljana, Slovenia; University Medical Centre Ljubljana, University Children's Hospital, Unit for Special Laboratory Diagnostics, Vrazov trg 1, 1000 Ljubljana, Slovenia
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10
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Roncalés-Samanes P, de Arriba Muñoz A, Lou Francés GM, Ferrer Lozano M, Justa Roldán ML, Labarta Aizpun JI. [Type 1 polyglandular autoimmune syndrome associated with C322fsx372 mutation]. An Pediatr (Barc) 2014; 82:e60-3. [PMID: 24582129 DOI: 10.1016/j.anpedi.2014.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 01/09/2014] [Accepted: 01/16/2014] [Indexed: 11/30/2022] Open
Abstract
Polyglandular autoimmune syndromes are rare diseases based on autoimmune mechanisms in which endocrine and non-endocrine disorders coexist. In type 1 the characteristic manifestations are chronic mucocutaneous candidiasis, hypoparathyroidism and adrenal insufficiency. A case is presented of a patient with typical clinical sequence, along with other changes, and in whom a mutation in homozygosis, C322fsX372, was detected after performing a molecular analysis of autoimmunity regulator gene (AIRE). Inheritance is autosomal recessive, associated with mutations in the AIRE gene, which encodes a protein involved in autoimmunity and immunodeficiency. For diagnosis, At least two of the three major clinical manifestations are required for a diagnosis. However, only one of them is necessary in the study of relatives of affected patients. These syndromes must be diagnosed early, given their high morbidity and mortality. Every manifestation needs to be treated, in order to maintain the quality of life.
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Affiliation(s)
- P Roncalés-Samanes
- Unidad de Endocrinología Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - A de Arriba Muñoz
- Unidad de Endocrinología Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - G M Lou Francés
- Unidad de Endocrinología Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - M Ferrer Lozano
- Unidad de Endocrinología Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - M L Justa Roldán
- Unidad de Nefrología Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - J I Labarta Aizpun
- Unidad de Endocrinología Pediátrica, Hospital Universitario Miguel Servet, Zaragoza, España
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Metabolic safety of growth hormone in type 1 diabetes and idiopathic growth hormone deficiency. J Pediatr 2013; 163:1095-8.e4. [PMID: 23746867 DOI: 10.1016/j.jpeds.2013.04.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/11/2013] [Accepted: 04/23/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate metabolic consequences of growth hormone (GH) treatment in children with type 1 diabetes. STUDY DESIGN This study is an analysis of metabolic changes in 37 patients with childhood-onset GH deficiency and type 1 diabetes, documented in the Diabetes Patienten Verlaufsdocumentationsystem database. Main outcome measures were changes in hemoglobin A1c and daily insulin requirements during GH therapy in children with GH deficiency and type 1 diabetes compared with a large cohort of adolescents with type 1 diabetes. RESULTS Thirty-seven patients with type 1 diabetes and a diagnosis of idiopathic GH deficiency after onset of diabetes were compared with 48856 patients with type 1 diabetes. After adjustment for age, sex, duration of diabetes, and migration background, a significant difference in mean daily insulin requirement was seen between the 2 groups (1.0 IU/kg/day in subjects with GH deficiency and type 1 diabetes vs 0.85 IU/kg/day in controls; P < .01) and height-SDS (-2.0 in subjects with GH deficiency and diabetes vs +0.03 in controls; P < .0001). There was no significant between-group difference in hemoglobin A1 concentration, however (8.1% ± 1.4% in patients with GH deficiency and type 1 diabetes vs 8.2% ± 1.7% in those with type 1 diabetes only; P > .05). CONCLUSION An increased daily insulin requirement should be considered in patients with type 1 diabetes treated with GH. With adequate adaptation of insulin dosage, metabolic control is not impaired during GH treatment.
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Vakili H, Cattini PA. The hidden but positive role for glucocorticoids in the regulation of growth hormone-producing cells. Mol Cell Endocrinol 2012; 363:1-9. [PMID: 22910554 DOI: 10.1016/j.mce.2012.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 07/18/2012] [Accepted: 08/01/2012] [Indexed: 11/27/2022]
Abstract
Growth hormone (GH) is a prominent metabolic factor that is targeted by glucocorticoids; however, their role in GH production remains controversial. This is explained in part by discrepancies between in vitro and in vivo, short-term versus long-term exposure and even species-specific effects. The prevailing view, however, is that glucocorticoids are negative modulators of growth and GH production. An examination of recent findings from elegant avian and gene ablation in mice studies as well as clinical case reports, suggests this is not the case. The evidence suggests that the effect of glucocorticoids on growth and GH production can be uncoupled, and reveals they play a crucial and positive role in maturation of functional somatotrophs, the GH-producing cells of the anterior pituitary. Here, we provide an overview and insights into the possible roles of glucocorticoids in the development of somatotrophs before birth as well as regulation of GH production in infancy (neonatal) and adulthood (postnatal). A fully functional glucocorticoid-signaling pathway appears to be required for establishment of somatotrophs before birth, and glucocorticoids continue to be required for maintenance of GH production in the newborn. There is evidence to suggest progenitor somatotrophs may persist after birth, and perhaps account for the ability of glucocorticoid therapy to correct some cases of GH deficiency as a result of compromised glucocorticoid signaling. Finally, there is support for positive regulation of avian, murine and human GH gene activation and/or expression by glucocorticoids, however, there appears to be no common mechanism and the contribution of direct versus indirect effects remains unclear. Thus, our observations reveal a largely hidden face of glucocorticoids, specifically, a positive role in somatotroph development and GH gene activation/expression, which may enable us to better understand the differential effect of glucocorticoids on growth and GH production in human studies.
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Affiliation(s)
- Hana Vakili
- Department of Physiology, University of Manitoba, Canada.
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Pantelis T, Nikolaos V, Zoe I, Efthymios D. Long-term followup of adolescent and young adult females with hypergonadotropic hypogonadism. Int J Endocrinol 2012; 2012:862892. [PMID: 22190931 PMCID: PMC3235457 DOI: 10.1155/2012/862892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 10/18/2011] [Indexed: 11/18/2022] Open
Abstract
The condition characterized by elevated gonadotrophins (gonadotropins elevated into the menopausal range), low sex steroids, and menstrual disorders was previously termed Premature Ovarian Failure (POF). However, over the last two years an effort has been made by many authors to have the term Primary Ovarian Insufficiency (POI) exclusively applied. Irrespective of the term, the condition concerns adolescent and young adult women under 40 years who experience cessation of menstruation for more than 3 cycles (whereas these women in the past had a rhythmic menstrual cycle) or amenorrhea for 4-6 months against the background of a previously disturbed menstrual cycle. Determining the cause of POI is difficult, and it is even harder to deal with problems arising from the paucity of estrogen as well as to draw up the plan for long-term monitoring of these patients. This paper presents long-term therapeutic management strategies concerning emotional health, hormone replacement therapy, maintenance of bone health, family planning, other associated disorders as well as possible research options for the future.
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