Idiopathic central diabetes insipidus in a large cohort of patients: the hypopituitarism ENEA rare observational (HEROS) study

Central Diabetes Insipidus (CDI) is mainly associated with structural pathologies of the hypothalamic-pituitary area. Etiologies underlying CDI are identified in most patients, however idiopathic CDI is reported in 13-17% of cases after excluding other etiologies. The Hypopituitarism ENEA Rare Observational Study (HEROS study) retrospectively collected data of patients with idiopathic CDI from 14 pituitary centers in 9 countries. The cohort included 92 patients (59 females 64%), mean age at diagnosis was 35.4 ± 20.7 years, and a mean follow up of 19.1 ± 13.5 years following CDI diagnosis. In 6 women, diagnosis was related to pregnancy. Of 83 patients with available data on pituitary imaging, 40(48%) had normal sellar imaging, and 43(52%) had pathology of the posterior pituitary or the stalk, including loss of the bright spot, posterior pituitary atrophy or stalk enlargement. Anterior pituitary hormone deficiencies at presentation included hypogonadism in 6 (6.5%) patients (5 females), and hypocortisolism in one; during follow-up new anterior pituitary deficiencies developed in 6 patients. Replacement treatment with desmopressin was given to all patients except one, usually with an oral preparation. During follow up, no underlying disease causing CDI was identified in any patient. Patients with idiopathic CDI following investigation at baseline are stable with no specific etiology depicted during long-term follow-up.

Diagnostic performance of a newly developed salivary cortisol and cortisone measurement using an LC-MS/MS method with simple and rapid sample preparation

BACKGROUND

Late-night salivary cortisol level is one of the first-line tests recommended by the Endocrine Society for the diagnosis of endogenous hypercortisolism. Most routine laboratories measure cortisol levels using immunoassay tests which fail to determine low cortisol levels accurately due to the numerous interfering substances. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method with simple and rapid sample preparation was developed for the simultaneous measurement of cortisol and cortisone and its performance in the diagnosis of endogenous hypercortisolism was evaluated.

METHODS

324 late-night saliva samples were analyzed from which 272 samples were derived from patients with a suspected diagnosis of endogenous hypercortisolism. Salivary cortisol levels were assayed using an electrochemiluminescent immunoassay (ECLIA, Cortisol II, Roche), and simultaneous measurement of cortisol and cortisone was performed using an LC-MS/MS method.

RESULTS

A strong correlation between cortisol results measured using ECLIA and LC-MS/MS (r ² = 0.892) was demonstrated. Receiver operating characteristics (ROC) analysis showed good diagnostic performance of cortisol and cortisone levels assayed using LC-MS/MS method and for cortisol measured using ECLIA.

CONCLUSIONS

Late-night salivary cortisol and cortisone are useful parameters for the diagnosis of hypercortisolism. Using samples obtained from patients where the diagnosis of hypercortisolism is extremely challenging cut-off values for midnight salivary cortisol and cortisone measured by LC-MS/MS method were established.

ACE and ACTN3 genes polymorphisms among female Hungarian athletes in the aspect of sport disciplines

The aim of the study was to determine the importance of two sport-associated gene polymorphisms, alpha-actinin-3 R577X (ACTN3) and angiotensin-converting enzyme I/D (ACE), among Hungarian athletes in different sports. The examination was carried out only on women (n = 100). Sport-specific groups were formed in order to guarantee the most homogeneous clusters. Human genomic DNA was isolated from blood, and genotyping was performed by polymerase chain reaction. To measure the differences between the participating groups, Chi-squared test was performed using Statistica 9.0 for Windows® (significance level: p < 0.05). In comparing the ACE I/D allele frequencies, significant difference was detected between water polo (I = 61.11%; D = 38.89%) and combat sports (I = 35.71%, D = 64.29%) athletes (p < 0.03). There was no statistical difference when ACE I/D alleles in combat sports and kayaking/rowing (p > 0.05) were compared. A similarity was detectable in the I allele frequencies of the water polo (61.11%) and kayaking/rowing (56.67%) groups. The ACTN3 R/X polymorphism showed no differences in comparison with the sport groups. R allele frequencies were higher in every group compared to the X allele. The potential significance of the ACE I allele in sports of an aerobic nature was not clearly confirmed among Hungarian athletes.

Characterization of particulate matter in attic and settled dusts collected from two buildings in Budapest, Hungary

We have investigated two buildings covered with Zsolnay glazed architectural ceramics in Budapest (Hungary), one located in the densely built-up area of the city centre with a high traffic rate and one in a city quarter with moderate traffic and more open space. A black crust layer, containing a large amount of artificial particulate matter with different size and chemical composition, was observed on the ceramic material of both buildings, whereas weathered glaze was detected only on the ceramics of the building situated in the city centre. In this paper, our goal is to reveal the role of the particulate matter in the degradation of architectural ceramics. For this reason the attic dust and settled dust from the roofs of the studied buildings were collected. In the attic dust, besides the natural particles of geological origin, three types of artificial particles typically with spherical shape (spherules) were also distinguished: aluminosilicate (two subtypes), carbonaceous, and iron-rich fly-ash. The appearance of gypsum crystallites around the particulate matter in association with all spherule types suggests that the particulate matter greatly contributes to the degradation process.

Ten-year cardiovascular risk assessment in university students

Cardiovascular disease (CVD) is responsible for more than half of all deaths in the European region. The aim of the study was to compare body composition, blood pressure, total cholesterol (TC) and high density lipoprotein cholesterol (HDL-C), family history, activity behaviors, and the 10-year risk of having a heart attack between 166 university students (21.62 ± 2.59 yrs) from Utah (USA) and 198 students (22.11 ± 2.51 yrs) from Hungary. Ninety-two percent of the Hungarian students and 100% of the Utah students had an estimated 10-year Framingham risk score of 1% or less. The high prevalence of low risk was primarily due to the young age of study participants, healthy body composition and non-smoking behavior. Hungarians who had higher 10-year risk of heart attack had significantly higher waist hip ratio (WHR), TC, diastolic blood pressure (DBP) and were smokers compared to those Hungarians with lower risk. The self-reported physical activity levels between the two groups of students were not different. In conclusion the young men and women who participated in this study were, for the most part healthy; however the smoking habits and the lower physical activity of the Hungarian students likely elevated their risk of CVD.

Field Tests with Sex Attractants of Diachrysia chrysitis and D. tutti (Lepidoptera: Noctuidae) at Several Sites in Hungary

Sex attractants for the sibling taxa Diachrysia chrysitis (L.) s.str. and D. tutti (Kost.) were field tested on 9 sites in Hungary. Catches with the two already described attractant blends, Z-5-10:Ac/Z-7-10:Ac in ratios 10:1 and 2:100, were similar to earlier results obtained in areas more to the west, chrysitis s.str. type males responding to the 10:1 while tutti type males to the 2:100 ratio. Substantial chrysitis s.str. catches were also obtained by the intermediate 1:1 blend. On all 9 sites the two taxa were co-occurring.

[Retrospective analysis of short-term and mid-term results of percutaneous endovascular repair in patients with abdominal aortic aneurysm]

INTRODUCTION

Endovascular abdominal aortic aneurysm repair (EVAR) is a modern and, compared to conventional open surgery, less invasive therapeutic strategy with short-term lower morbidity and mortality. The aim of our retrospective analysis was the assessment of safety, technical success, short-term and mid-term results of elective patients scheduled for total percutaneous EVAR implantation (PEVAR).

MATERIAL AND METHODS

One hundred and sixteen consecutive patients (M:F 104:12, age 71±9 years, maximum AAA diameter 60±14mm) underwent elective PEVAR between January 2009 and August 2012. All the patients were treated under local anaesthesia by total percutaneous approach via femoral access. The immediate technical success of stentgraft implantation as well as the presence of 30-day and 1-year complications and the need of reintervention rate were assessed.

RESULTS

In 115/116 patients (99.1%),immediate technical success of the procedure was recorded, with no need of conversion to open surgery; in 1 patient (0.9%) the performance technically failed due to unfavourable arterial anatomy. The mortality in 30-day follow-up was 2.6% (3 patients), during 1-year follow-up it amounted to 8.6% (10 patients), without causal relationship with stentgraft implantation. Overall event-free survival was 85% (98/116) without serious complications (mortality, MI, stroke, reintervention, severe ischemic complication) in the one-year follow-up period.

CONCLUSION

Endovascular AAA repair is a safe and feasible method with low mortality and acceptable complication rate in patients scheduled for EVAR implantation. Percutaneous approach allows for the extension of indications also for the highest-risk group of polymorbid patients. Technical feasibility and adequate periprocedural management are essential for further reduction in adverse events after PEVAR.

Compounds modifying male responsiveness to main female sex pheromone component of the currant borer,Synanthedon tipuliformis clerk (Lepidoptera: Sesiidae) under field conditions

Various blends of (E,Z)-2,13-octadecadien-1-ol acetate (E,Z2,13-18: OAc), (Z)-13-octadecen-1-ol acetate (ZOAc) (two previously identified pheromone components of the currant borer,Synanthedon tipuliformis females), (E,Z)-, (Z,Z)-3,13-octadecadien-1-ol acetates (E,Z- andZ,Z3,13-18:OAc), andZ,Z-3,13-octadecadien-1-ol (Z,Z3,13-18:OH) were evaluated in field traps in three geographic regions. MaleS. tipuliformis were attracted toE,Z2,13-18:OAc in Tasmania, New Zealand, and Hungary. Captures were not influenced by the addition ofZ13-18: OAc, tested in Tasmania and Hungary. In Hungary and New Zealand, the addition ofE,Z3,13-18: OAc toE,Z2,13-18:OAc in a ratio of 100:3 was strongly synergistic; however, in Tasmania captures were reduced. The addition ofZ,Z3,13-18: OAc toE,Z2,13-18:OAc in a ratio of 10∶1 resulted in strong inhibition of trap captures in Hungary. WhenZ,Z3,13-18: OAc was added in different ratios to a 100:3 binary mixture ofE,Z2,13-18:OAc/E,Z3,13-18:OAc in Hungary, it strongly reduced captures at, or above a ratio of 100∶3∶3 but no decrease was recorded at a ratio of 100∶3∶1. In New Zealand and Tasmania it reduced captures at a ratio of 100∶3∶1. Observations of behavioral responses of maleS. tipuliformis in Hungary to synthetic baits in the field showed thatE,Z2,13-18:OAcby itself evoked close-range approaches to the source from only 20% of males, whereas the addition ofE,Z3,13-18:OAc in a ratio of 100∶3 raised that value to 65 %. Landing on the source was significant only at sources with a 100∶3∶0.1∶3∶10 blend ofE,Z2,13-18:OAc/E,Z3,13-18: OAc/Z,Z3,13-18: OAc/Z,Z3,13-18: OH/Z13-18: OAc. A 100∶3 binary mixture ofE,Z2,13-18:OAc/E,Z3,13-18:OAc in a dose range of 10-1000 μg can be recommended for more effective field monitoring ofS. tipuliformis populations in Hungary and in New Zealand. In Tasmania, at present,E,Z2,13-18: OAc by itself is the most potent sex attractant of the species.

Behavioral activity of optical isomers of 5,9-dimethylheptadecane, the sex pheromone ofLeucoptera scitella L. (Lepidoptera: Lyonetidae)

Among the pure stereoisomers of 5,9-dimethylheptadecane, a previously identified sex pheromone component ofLeucoptera scitella L., only theS,S isomer yielded trap captures in the field. The addition of the other stereoisomers had no effect on cathes. The addition of low percentages of racemic 5,9-dimethylhexadecane, a previously identified minor component in the sex pheromone, did not influence trap catches or alter behavior of males approaching an attractant source in the field.

Novel type of sex pheromone structure identified fromStigmella malella (Stainton) (Lepidoptera: Nepticulidae)

Short-chain unsaturated chiral methyl carbinols are identified as a new class of lepidopteran pheromone components. The natural female-produced pheromone of the banded apple pigmyStigmella malella (=Nepticula malella) (Stainton) (Lepidoptera: Nepticulidae) was identified to be a mixture of (S)-(E)-6,8-nonadien-2-ol and (S)-(Z)-6,8-nonadien-2-ol. For monitoring traps, a 10:3E:Z blend at 100-1000 µg is recommended. It is suggested that pheromones with similar structures may be specific to Nepticulidae and other related microlepidopteran families.

Examining physical activity and inactivity in 9-12 years old children

Information about children's daily physical activity in Eastern-Europe is essential because of the increasing prevalence in overweight and obesity. Sixty-three children (age=11.16 ± 1.10 years; 33 boys and 30 girls) from two public elementary schools had their physical activity objectively measured using uni-axial accelerometer every 5 seconds for five consecutive days (3 weekdays, 2 weekend days). After data cleaning, 10 children were excluded from database. There were no significant differences in boys' and girls' BMI (17.6 ± 2.2 vs. 17.1 ± 2.4) and BF% (18.0 ± 5.2 vs. 19.4 ± 5.0). Children engaged in more sedentary, light, moderate, and vigorous physical activity and had higher counts per minute during weekdays compared to weekend days. There were no sex differences in moderate to vigorous physical activity (87.6 ± 22.4 vs. 93.5 ± 20.6 min and 53.6 ± 21.3 vs. 59.4 ± 22.0 min) during weekday and weekend days. Data indicated that 96% of the girls and 92% of the boys met the international physical activity guideline for children of 60 minutes of MVPA, on weekdays.

Increased sympathetic activity can cause repolarization instability in athlete's heart

Sudden cardiac death (SCD) of athletes usually occurs during warm-up or shortly after training. At this point sympathetic tone is still elevated but oxygen demand does not differ from resting levels. It is supposed not to have a primarily ischemic origin but most likely relates to repolarization abnormalities which can be associated with intracellular cAMP level caused by increased sympathetic tone. The mediators of sympathetic nervous system are the catecholamines (epinephrin, norepinephrin). Measuring QT-dispersion can show the repolarization's inhomogeneity. 27 elite soccer players, 28 triathletes and 29 non-trained control person took part in our study. It was recorded cardiac ultrasound, an ECG and taken blood before and after exercise. We found significantly higher QT-dispersion and catecholamines in soccer players compared to the triathletes and the controls. However the soccer players did not show larger athlete's heart than the triathletes. After exercise the increased repolarization inhomogeneity persisted in soccer players, but in triathletes it decreased. Increased sympathetic tone in athletes can enhance arrhythmia propensity. Our data may explain why the soccer players die of sudden cardiac death most commonly in Europe.

Bone turnover in patients with endogenous Cushing's syndrome before and after successful treatment

We investigated bone turnover and its restoration in a large number of patients in the active phase and after cure of endogenous Cushing's syndrome. Furthermore, the usefulness of serum osteocalcin and collagen breakdown products as potential markers of active Cushing's syndrome was also evaluated.

INTRODUCTION

Suppressed bone formation is one of the most characteristic features of Cushing's syndrome (CS). Despite numerous previous reports, many aspects of the disturbed bone metabolism of these patients are unexplored. In this study, we investigated the time course of bone marker changes after the cure of CS as well as correlations between bone markers and serum cortisol concentrations.

METHODS

Eighty-seven patients with CS were studied. Patients were followed up to 48 months after surgical cure. Serum osteocalcin (OC) and collagen breakdown products (CTX) were measured with immunochemiluminescence method and compared to the results of 161 healthy controls.

RESULTS

OC showed a negative, while CTX displayed a positive correlation with serum cortisol. Patients with diabetes mellitus and myopathy had significantly lower serum OC levels compared to those without these complications. The area under the curve of OC obtained by receiver-operating characteristics analysis for the discrimination of patients with CS from healthy controls was 0.9227. Postoperative OC increased rapidly from the first few days or weeks reaching its maximum at the sixth month and remained stable after the 24th postoperative month.

CONCLUSIONS

Our study demonstrated significant correlations between serum cortisol and both bone formation and resorption markers in the active phase of CS. We propose that OC may serve as a sensitive biologic marker of glucocorticoid activity in endogenous CS during its active phase and it may reflect the clinical cure of the disease.

Strong relationship between NT-proXNP levels and cardiac output following cardiac surgery in neonates and infants

BACKGROUND

NT-proXNP, a new natriuretic peptide analyte, incorporates information about the concentrations of both N-terminal pro-atrial and pro-brain natriuretic peptides (NT-proANP, NT-proBNP). We aimed to investigate whether NT-proXNP is a reliable indicator of the cardiac index (CI) and the hemodynamic state in neonates and infants undergoing an open heart surgery.

METHODS

We enrolled 26 children under the age of 1 year into this prospective study. All patients underwent an elective cardiac operation with cardiopulmonary bypass (CPB) to achieve complete biventricular repair. Peri-operative hemodynamic parameters were assessed by transpulmonary thermodilution and natriuretic peptide levels were recorded.

RESULTS

The NT-proXNP level correlated significantly with the simultaneously measured NT-proANP level (r=0.60, P<0.001), but more strongly with the NT-proBNP level (r=0.89, P<0.001) and the arithmetic sum of both (r=0.88, P<0.001). NT-proXNP had a strong correlation with CI (r=-0.85, P<0.001), the stroke volume index (r=-0.80, P<0.001) and the global ejection fraction (r=-0.67, P<0.009) throughout the post-operative period. Conventionally measured parameters such as heart rate, mean arterial pressure and pulse-pressure product exhibited weaker correlations with CI than NT-proXNP. Among laboratory values, creatinine levels correlated significantly with CI (r=-0.77, P<0.001) and NT-proXNP (r=0.76, P<0.001) during the post-operative period. A post-operative NT-proXNP level of 3079 pmol/l was diagnostic for CI <3 l/min/m(2) with 89% sensitivity and 90% specificity (area under the curve: 0.91 +/- 0.05).

CONCLUSION

NT-proXNP is a good marker of cardiac output following pediatric cardiac surgery and might be a useful tool in the recognition of a low output state.

Impact of blood glucose values in patients with and without insulin treatment following paediatric cardiac surgery

Objective: To investigate the associations of blood glucose (BG) parameters and postoperative complications following paediatric cardiac surgery in the presence and absence of insulin treatment.

Methods: Prospectively collected perioperative data on 810 consecutive patients who underwent surgery for congenital heart disease were retrospectively analysed. A combined outcome of death and multiple organ dysfunction (any two of the followings: infectious, cardiac, pulmonary, renal or neurological complications) was considered as the endpoint.

Results: In total, 110 patients developed the combined endpoint and 32 of these patients died during the perioperative period. Patients treated with insulin were younger, smaller and underwent more complex procedures. They had higher peak BG levels and higher daily BG fluctuation, however, BG parameters were not associated with adverse outcome. In patients without insulin treatment, peak BG values higher than 250 mg/dl (OR, 7.65; 95% CI, 1.06–55.17; p=0.043) and BG fluctuation exceeding the level of 150 mg/dl (10.72; 1.74–65.90 p=0.010) on the first postoperative day were independently associated with the combined endpoint.

Conclusions: Peak BG level and BG fluctuation on the first postoperative day were associated with the combined endpoint of complications and death but these results were only confined to patients without insulin treatment.

New inhibitors of glycogen phosphorylase as potential antidiabetic agents

The protein glycogen phosphorylase has been linked to type 2 diabetes, indicating the importance of this target to human health. Hence, the search for potent and selective inhibitors of this enzyme, which may lead to antihyperglycaemic drugs, has received particular attention. Glycogen phosphorylase is a typical allosteric protein with five different ligand binding sites, thus offering multiple opportunities for modulation of enzyme activity. The present survey is focused on recent new molecules, potential inhibitors of the enzyme. The biological activity can be modified by these molecules through direct binding, allosteric effects or other structural changes. Progress in our understanding of the mechanism of action of these inhibitors has been made by the determination of high-resolution enzyme inhibitor structures (both muscle and liver). The knowledge of the three-dimensional structures of protein-ligand complexes allows analysis of how the ligands interact with the target and has the potential to facilitate structure-based drug design. In this review, the synthesis, structure determination and computational studies of the most recent inhibitors of glycogen phosphorylase at the different binding sites are presented and analyzed.

Potassium channels sensitive to combination of charybdotoxin and apamin regulate the tone of diabetic isolated canine coronary arteries

AIMS

Functional roles of calcium-activated potassium channels on the mechanical activity of epicardial coronary arteries obtained from a canine model of diabetes were investigated.

METHODS

Coronary arteries were isolated from healthy, alloxan-diabetic and insulin-treated diabetic dogs. Basal tensions, contractions induced by the prostaglandin (PG) analogue, U46619, and endothelium-dependent relaxations to acetylcholine (ACh) were modified with charybdotoxin (CHTX) + apamin (APA), inhibitors of calcium-activated potassium channels, as well as with N(omega)-nitro-l-arginine (LNA) + indomethacin (INDO) to suppress the synthesis of nitric oxide (NO) and PGs. The relaxing effect of nitroprusside-sodium (SNP), an NO donor, was also determined.

RESULTS

In diabetic coronary arteries, CHTX + APA did not change while LNA + INDO elevated the basal tension. PG-induced contractions were enhanced by CHTX + APA and by LNA + INDO in all the three groups of animals. CHTX + APA decreased the maximal relaxations to ACh in a partly insulin-dependent manner. LNA + INDO abolished the endothelium-dependent relaxations to ACh. In diabetic coronary arteries, the sensitivity to SNP-induced relaxation was enhanced, insulin independently, suggesting that NO could be partly responsible for maintaining intact ACh-induced vasorelaxation.

CONCLUSION

In diabetic canine coronary artery, the vasomotor responses reflect up-regulation of calcium-activated potassium channels. This endothelial mechanism of the canine epicardial coronary artery may oppose vasoconstrictions in diabetic vascular tissue.

Skeletal differences in bone mineral area and content before and after cure of endogenous Cushing's syndrome

We examined bone densitometric data in a four-year follow-up period before and after the cure of CS. Plasma cortisol concentrations were similar, but the duration of estimated glucocorticoid excess was longer in patients with prevalent bone fractures compared to those without fractures. After therapy of CS, bone area, BMC and BMD increased significantly at the LS and femur during follow-up, but they decreased at the forearm, suggesting redistribution of bone minerals from the peripheral to the axial skeleton.

INTRODUCTION

Only a few studies report the changes in bone mineral density (BMD) after the cure of Cushing's syndrome (CS).

METHODS

Forty-one patients with Cushing's disease, 21 patients with adrenal CS and 6 patients with ectopic CS were prospectively enrolled. BMD, bone mineral content (BMC) and bone area were measured by DXA.

RESULTS

No significant correlations were found between serum cortisol concentrations and baseline bone densitometric data. After successful therapy of CS, bone area and BMD increased significantly at the lumbar spine (LS) and femur during follow-up, but they decreased at the forearm. The progressive increase in BMC at the LS had a significant negative correlation with the change of the BMC of radius in the first and second follow-up years. The change in the body mass index was an independent predictor for changes in BMC both at the LS and at the forearm at the second year of remission.

CONCLUSIONS

The regional differences and the time-dependent changes of BMC suggest that the source of marked increase in axial BMC after the cure of CS is, at least partly, due to the redistribution of bone minerals from the peripheral to the axial skeleton.

Role of slow delayed rectifier K+-current in QT prolongation in the alloxan-induced diabetic rabbit heart

AIM

In diabetes mellitus, several cardiac electrophysiological parameters are known to be affected. In rodent experimental diabetes models, changes in these parameters were reported, but only limited relevant information is available in other species, having cardiac electrophysiological properties more resembling the human, including the rabbit. The present study was designed to analyse the effects of experimental type 1 diabetes on ventricular repolarization and the underlying transmembrane potassium currents in rabbit hearts.

METHODS

Diabetes was induced by a single injection of alloxan (145 mg kg(-1) i.v.). After the development of diabetes (3 weeks), electrophysiological studies were performed using whole cell voltage clamp and ECG measurements.

RESULTS

The QT(c) interval in diabetic rabbits was moderately but statistically significantly longer than measured in the control animals (155 +/- 1.8 ms vs. 145 +/- 2.8 ms, respectively, n = 9-10, P < 0.05). This QT(c)-lengthening effect of diabetes was accompanied by a significant reduction in the density of the slow delayed rectifier K(+) current, I(Ks) (from 1.48 +/- 0.35 to 0.86 +/- 0.17 pA pF(-1) at +50 mV, n = 19-21, P < 0.05) without changes in current kinetics. No differences were observed either in the density or in the kinetics of the inward rectifier K(+) current (I(K1)), the rapid delayed rectifier K(+) current (I(Kr)), the transient outward current (I(to)) and the L-type calcium current (I(CaL)) between the control and alloxan-treated rabbits.

CONCLUSION

It is concluded that type 1 diabetes mellitus, although only moderately, lengthens ventricular repolarization. Diabetes attenuates the repolarization reserve by decreasing the density of I(Ks) current, and thereby may enhance the risk of sudden cardiac death.

Laterality disturbance and hypopituitarism. A case report of co-existing situs inversus totalis and combined pituitary hormone deficiency

The authors present the case history of a 52-yr-old male patient with a unique association of combined pituitary hormone deficiency (CPHD) and situs inversus totalis. Except for signs and symptoms of pituitary hormone deficiency, the patient had no dysmorphic features, and hearing impairment, primary mental or neurological defects were also absent. Pituitary magnetic resonance imaging (MRI) scan showed hypoplasia of the anterior lobe of the pituitary gland and an ectopic posterior pituitary lobe. Despite the presence of situs inversus totalis, the patient was right-handed and functional MRI demonstrated left-hemisphere activation during language tests. Kartagener syndrome was considered, but immunofluorescence analysis showed normal localization of the outer dynein arm protein in respiratory epithelial cells obtained from the nasal mucosa. Direct DNA sequencing of all coding exons of the pituitary transcription factor 1 (PIT1) and prophet of PIT1 (PROP1) genes failed to detect disease-causing mutations, suggesting that these genes were not involved in the development of CPHD in our patient. More interestingly, the potential role of the paired like homeodomain transcription factor 2 (PITX2) gene, which has been implicated not only in CPHD, but also in left-right patterning in animal models, was also excluded, as sequencing showed the absence of mutations in coding exons of this gene. To our knowledge, PITX2 gene mutations have not been investigated in CPHD patients who had situs inversus totalis. We conclude that in contrast to animal models, the PITX2 gene is not involved in the development of situs inversus totalis, at least not in our CPHD patient.