Syndrome of Congenital Insulin Resistance Caused by a Novel INSR Gene Mutation

Mutations in the INSR gene result in rare inherited syndromes causing insulin resistance, such as leprechaunism (Donohue syndrome), Rabson-Mendenhall syndrome and insulin resistance type A. Leprechaunism is an autosomal recessive disorder associated with extreme insulin resistance that leads to hyperinsulinemia, impaired glucose homeostasis, fasting hypoglycemia and postprandial hyperglycemia. Impaired insulin action causes prenatal and postnatal growth retardation. Lipoatrophy, dysmorphic facies, hypertrichosis, macrogenitosomia and hypertrophy of internal organs are also present. A male infant with congenital insulin resistance was born at term after a normal pregnancy with a weight of 1905 g (<3 c), a length of 48 cm (<3 c), and an Apgar score of 10. Intrauterine growth retardation, transient hypoglycemia, pneumonia, urinary tract infection and heart defects [patent foramen ovale (PFO); patent ductus arteriosus (PDA)] were diagnosed after birth. At 5 weeks of age, he was admitted to the regional hospital with severe fever, diarrhea and dehydration. Hyperglycemia was observed (672 mg/dL), and insulin was administered. He was referred to a hospital at 7 weeks of age for suspected neonatal diabetes and hypertrophic cardiomyopathy. The physical examination revealed a loud systolic heart murmur, tachycardia, tachypnea, dysmorphic facies, hypertrichosis, acanthosis nigricans, hypotonia, swollen nipples and enlarged testicles. Glycemic fluctuations (50-250 mg/dL) were observed. The serum insulin concentration was high (maximum 1200 IU/mL) at normoglycemia. Ultrasound of the heart confirmed progressive hypertrophic cardiomyopathy. Leprechaunism was confirmed by genetic analysis of INSR, in which a novel c.320C>G; p. Thr107Arg homozygous missense mutation was found in exon 2.

Difficulties in Interpreting IGF-1 Levels in Short Stature Children Born Small for Gestational Age (SGA) Treated with Recombinant Human Growth Hormone (rhGH) Based on Data from Six Clinical Centers in Poland

The assessment of IGF-1 concentrations is one of the parameters used for evaluating response to rhGH treatment. An increase in IGF-1 concentration positively correlates with growth improvement, whereas IGF-1 concentrations significantly above the reference range may increase the risk of possible side effects. The aim of this study was to evaluate the IGF-1 local reference ranges for the rhGH treatment centers concerned and to compare these values with the population reference ranges. A retrospective analysis was conducted on auxological data from 229 SGA patients who received rhGH treatment between 2016 and 2020 at six university clinical centers in Poland. The IGF-1 levels were assessed at baseline, after 12 and 24 months, and compared to the reference ranges provided by the local laboratory and to the population reference ranges. After 12 months, 56 patients (24%) presented IGF-1 values > 97th percentile for the local reference range, whereas only 8 (3.5%) did so using the population reference ranges; p < 0.001. After 24 months of treatment, the values were: 47 (33%) > 97th percentile by local vs. 6 (4.2%) by population standards; p < 0.001. Thirty-nine patients had rhGH dose reduced after 12 months, of whom twelve (25%) had IGF-1 > 97th percentile according to the local reference ranges and five (13%) > 97th percentile for the population. Our data suggest that different methods used to determine IGF-1 concentration and the different IGF-1 reference ranges result in a significant proportion of rhGH-treated children with elevated IGF-1 concentration and experiencing dose reductions, which may negatively affect growth rate.

Weight gain in type 1 diabetes during the SARS-CoV-2 pandemic. Does lockdown affect the metabolic control of pediatric patients?

BACKGROUND AND AIMS

Due to the severe acute respiratory syndrome coronavirus 2 pandemic, governments of many countries decided to implement lockdowns, which included school closures. This major lifestyle change also applied to people with diabetes. The aim of this paper was to analyze how the COVID-19 pandemic and related restrictions influenced the metabolic compensation of diabetes in the pediatric population.

METHODS

Patients with type 1 diabetes (T1D), treated by one therapeutic team, who in 2020 and 2021 paid at least two in-person visits in the outpatient clinic, were included in the study. The time in range (TIR) and HbA1c, as well as the total daily dose (TDD) of insulin and BMI from the visit before the announcement of the pandemic restrictions (March 2020) and during the lockdown (second visit after 6 months) and within the period of loosened restrictions (two visits in 2021) were analyzed.

RESULTS

A total of 185 patients with T1D were included in the study (96 boys), aged 2-18 years (11.5 ± 3.5); 135 of them (72.9%) use CSII and 142 (76.8%) use CGM or FGM. During the first months of the studied period, despite comparable (p>0.05) TIR (57.5 ± 21.4% vs. 59.9 ± 20.5%), improvement of HbA1c was noticed (7.9 ± 1.6% vs. 7.5 ± 1.4%, p=0.0336), whereas in the following months, both HbA1c and TIR were comparable. Also, the TDD increased significantly (from 37.3 ± 18.9 units/day on the first visit up to 46.8 ± 22.7 units/day on the last visit, p=0.0003); however, TDD/kg remained constant (p>0.05) (0.8 ± 0.2 units/kg/day vs. 0.8 ± 0.3 units/kg/day) possibly due to an increased BMI (19.1 ± 3.7 kg/m² vs. 20.9 ± 4.1 kg/m², p=0.0001). The percentage of basal insulin in the TDD remained stable (p>0.05) (39.7 ± 11.3% vs. 39.3 ± 13.6%). Furthermore, a significant (p=0.0001) change in the BMI percentile was noticed [from 58.9 ± 26.2 percentiles (%iles) before lockdown vs. 64.6 ± 26.0%iles on the second visit]. However, the BMI percentile returned to baseline (58.1 ± 28.4%iles) at the visit at the end of the observation period.

CONCLUSIONS

The parameters of metabolic control in pediatric patients with T1D during the pandemic period remained stable; however, weight gain and an increase in daily insulin dose have been observed, possibly due to reduced physical activity.

Soluble Klotho Is Decreased in Children With Type 1 Diabetes and Correlated With Metabolic Control

Klotho concentration may be considered as a prognostic factor in the development of chronic complications of diabetes. Moreover, decrease in sKlotho concentration may contribute to beta cell apoptosis and type 1 diabetes development. The aim of this study was to evaluate if sKlotho protein concentration in children with type 1 diabetes (T1D) and its correlation with classical risk factors of chronic complications of diabetes: dysglycemia and endothelial dysfunction.

MATERIAL AND METHODS

In a cross-section single center study the levels of soluble Klotho protein in 80 T1D (37 boys) and 34 healthy children (controls, 15 boys). Micro- and macroangiopathy were excluded and renal function was normal in all participants. Serum sKlotho, sICAM-1, sVCAM-1 and E-selectin levels were measured.

RESULTS

The concentration of sKlotho was lower in T1D than in the controls (2041.9 ± 1017.6 pg/mL vs. 2790.3 ± 1423.9 pg/mL, p=0.0113). sICAM-1, sVCAM-1 and E-selectin concentrations were comparable in patients and controls. In T1D, sKlotho was not correlated with the duration of diabetes. Klotho and E-selectin were correlated with HbA1c (r=-0.31, P=0.0066 and r=0.25, P=0.0351, respectively), but not with AVBG and blood glucose SD. Correlations of sKlotho with total cholesterol (r=0.31, P=0.0129), HDL-cholesterol (r=0.43, P=0.0011) and LDL-cholesterol (r=0.28, P=0.0412), but not with triglycerides, were found. Likewise, Klotho was not correlated with sICAM-1, sVCAM-1, and E-selectin concentrations.

CONCLUSIONS

This study reports the significantly lower level of s-Klotho in children with type 1 diabetes, correlated with HbA1c and HDL cholesterol, but not with the adhesion molecules concentrations nor the duration of the disease. Negative correlation between the levels of HbA1c and soluble Klotho may suggest its possible involvement in the development of chronic diabetes complications.

Metabolic disorders in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex disease. Depending on the used criteria the prevalence of PCOS ranges from 6 to 20%. It is necessary to exclude diseases leading to androgen excess. The participation of genetic and environmental factors is considered in the etiology of PCOS development. The highest rate of incidence of PCOS is assessed in girls who were born SGA and developed premature adrenarche later in life.The free androgen index (FAI) is concerned as the most sensitive marker of hyperandrogenaemia in PCOS although insulin resistance, anti-Müllerian hormone (AMH),and deficiency of vitamin D may intensify metabolic disturbances. The ultrasound criteria used in adolescent patients prefer the estimation of the ovarian volume or the ratio of ovarian stroma to total ovary, rather than the number of ovarian follicles. PCOS is connected with different metabolic disorders. Post-binding defect in signal transduction is responsible for insulin resistance. This defect results from an impaired activity of the kinase receptor. Moreover, the adipose tissue of PCOS women differs substantially from the tissue of the others according to morphology and function. The adipocytes produce lower amounts of adiponectin, which is an insulin-sensitizing agent. Dyspidemia with high triglycerides and low high density lipoprotein cholesterol concentrations is frequently noticed. Cardio-metabolic risk factors, insulin resistance, and endothelial dysfunction accompany PCOS from the very beginning. Oxidative stress plays a role as a link among systemic inflammation and dysfunction of endothelial cells and abnormal thecal cell action. The treatment efforts in PCOS depend on the patient's main problems. Modification of diet and lifestyle is the most important recommended advice to each woman independent of age and weight.

The assessment of skeletal status in young patients with Turner syndrome by 2 densitometric techniques: Phalangeal quantitative ultrasound and dual energy X-ray absorptiometry

BACKGROUND

Studies using dual energy X-ray absorptiometry (DXA) demonstrate a reduction in bone mineral density (BMD) in children and adolescents with Turner syndrome (TS). However, these studies do not take into account changes in bone size, which influence BMD in the case of short-statured patients. Phalangeal quantitative ultrasound (phQUS) measurements have shown an ability to reveal changes due to skeletal growth, aging, and bone and mineral disorders. There is limited data on bone mineral status in girls with TS assessed by 2 different techniques, i.e., DXA and phQUS.

OBJECTIVES

The aim of this study was to investigate the potential negative impact of TS on bone status and to assess whether densitometric values were related to former fractures.

MATERIAL AND METHODS

In 43 TS girls aged 5-18 years, we evaluated bone status by 2 different densitometric techniques, DXA and phQUS.

RESULTS

The mean lumbar spine areal bone mineral density (LS aBMD) Z-score was significantly lower than 0 (the hypothetical mean) compared to the reference population (p < 0.001). The mean LS aBMD height-adjusted Z-score did not differ significantly from 0. The amplitude-dependent speed of sound (Ad-SoS) Z-score was significantly lower than 0 compared with a Polish reference population. There were no significant differences between fractured and fracture-free patients as regards Ad-SoS Z-score and LS aBMD height-adjusted Z-score.

CONCLUSIONS

Girls with TS have normal bone density adjusted for height, but significantly decreased phQUS values. Neither DXA nor phalangeal Ad-SoS can identify young TS patients with former fractures.

LPL gene mutation as the cause of severe hypertriglyceridemia in the course of ketoacidosis in a patient with newly diagnosed type 1 diabetes mellitus

INTRODUCTION

Severe hypertriglyceridemia is a condition associated with extremely high triglycerides (TG) plasma concentrations exceeding 1000mg/dl. This condition may result in mutations in genes encoding lipoprotein lipase (LPL), apolipoprotein C2 (APOC2) and apolipoprotein A5 (APOA5) characterized by an autosomal recessive inheritance pattern.

AIM

A case report of a patient in which clinical picture of type 1 diabetes mellitus (T1DM) was accompanied by diabetic ketoacidosis (DKA) and severe hypertriglyceridemia.

CASE REPORT

A 2.5-year-old boy was admitted to the hospital with ketoacidosis (pH - 7.0, BE - 20mmol/l, HCO3 10mmol/l), glucose level of 850mg%, hyponatremia (Na 100mmol/l) and hyperlipidemia (TG 13493 mg/dl, TC 734 mg/dl). The administered treatment resulted in nearly normal glycemic values and lipid disturbances normalization. This child was diagnosed with a heterozygous mutation of the LPL gene. Currently with an intensive insulin therapy and correct metabolic control of type 1 diabetes mellitus (T1DM), this patient maintains a normal lipid profile.

CONCLUSION

In patient with T1DM the diagnosis of severe hypertriglyceridemia in the course of ketoacidosis should be based on careful interpretation of laboratory tests results. Moreover genetic tests of the patient and his/her immediate relatives blood samples should be performed.

Growth Hormone Treatment Increases Plasma Irisin Concentration in Patients with Turner Syndrome

Irisin (Ir) deficiency may be a contributing factor in metabolic disease. This study aimed to investigate the effect of supraphysiological doses of recombinant human growth hormone (rhGH) on Ir plasma concentration in relation to metabolic disorders, including obesity and other components of metabolic syndrome. We studied 36 girls with Turner syndrome (mean age 8.2 years) treated with rhGH (0.05 mg/kg/day). Anthropometric data and fasting blood levels [e. g., Ir, insulin, glucose, glycated hemoglobin (HbA1c), IGF-1, IGFBP-3, cholesterol, insulin resistance (HOMA-IR), and β-cell function (HOMA-β)] were analyzed prior to and following rhGH therapy [mean (SD) follow-up of 1.47 (0.89) years]. Insulin sensitivity (Matsuda index) was calculated before and after the glucose load. Following rhGH therapy, an increase in IGF-1 [mean (SD) of 119.40 (62.47) ng/ml to 439.08 (209.91) ng/ml, p=0.000], Ir [2.10 (1.03) μg/ml to 2.48 (0.78) μg/ml, p=0.036], HOMA-IR [median (IQR) of 0.64 (0.45-1.30) to 0.92 (0.67-2.36), p=0.0206], and HOMA-β values [45.00 (27.69-72.00) to 81.53 (51.43-132.00), p=0.0447] were observed. Multiple regression analysis yielded no associations between Ir and metabolic and hormonal parameters before rhGH treatment; however, on rhGH, the model (R²=0.56, adjusted R²⁼0.45) showed positive associations between Ir and IGF-1 standard deviation score and HbA1c, and negative associations between Ir and fasting blood glucose, HDL-cholesterol, and triglycerides. Despite manifestation of insulin resistance, rhGH application had a positive effect on Ir regulation, and restored physiological conditions of lipid and glucose metabolism.

The Influence of GnRH Analog Therapy on Growth in Central Precocious Puberty

BACKGROUND

Children with central precocious puberty (CPP) present various somatic and psychological abnormalities.

OBJECTIVES

The aim of the study was to evaluate growth changes in girls with central precocious puberty treated with GnRH analog therapy and to analyze the factors affecting the auxological response to this treatment.

MATERIAL AND METHODS

The study group consisted of 40 girls with puberty onset aged 6.0 ± 1.9 years (mean, ± SD), treated with 3.75 mg decapeptyl depot intramuscularly every 28 days. The treatment was initiated at the age of 7.5 ± 2.2 years and continued for 3.3 ± 2.3 years, until the age of 11.4 ± 0.9 years. Height (Ht), height standard deviation score (HtSDS), statural age, bone age and Ht prediction.

RESULTS

During the treatment a decline in HtSDS from 2.0 ± 1.36 to 1.24 ± 1.0 was observed (p = 0.0002); and a deceleration in the maturation of bones of 1.0 ± 0.29 year in the first year and 0.66 ± 0.33 year in the following years (p = 0.0008). The HtSDS at the end of the treatment was significantly higher than was predicted in pretreatment (1.33 ± 1.04 vs. 0.07 ± 1.39, p = 0.0005). Ht and HtSDS after treatment were positively correlated with the predicted Ht (PAH) before treatment and negatively correlated with the bone age/statural age ratio before treatment (p < 0.05). The PAH before and after treatment correlated inversely with the bone age/statural age ratio (p < 0.05). Two subgroups were analyzed according to the patients' age when therapy was introduced: group 1 included girls who were under the age of 7 when therapy was introduced, and group 2 included girls aged 7 or older. There was a statistically significant difference in the PAH SDS before treatment between these two subgroups: Group I (-) 1.3 ± 1.8 vs. Group II (-) 0.14 ± 1.2 and there was no difference in the PAH SDS after treatment: Group I (-) 0.7 ± 1.1 vs. Group II 0.31 ± 1.2.

CONCLUSIONS

The child's age at the beginning of GnRHa therapy was an important predictor of height prognosis; the therapy introduced under the age of 7 improves the PAH during treatment. Height prediction during the entire treatment period is worse in children with more advanced bone age for their statural age at the onset of treatment.

The presence of eye defects in patients with Turner syndrome is irrespective of their karyotype

OBJECTIVE

Published data on eye disorders in patients with Turner syndrome (TS) are limited. We aimed to evaluate the prevalence of eye disorders in patients with TS and assess the association with patient karyotype.

DESIGN

Cross-sectional, observational study.

PATIENTS

Eighty-two patients with TS.

MEASUREMENTS

We evaluated visual acuity (distance and proximity), intraocular pressure, optic system refraction, orthoposition, frontal eye segment, the eye fundus and colour vision. For eye fundus abnormalities, we conducted ultrasound examinations, visual field evaluations and fluorescein angiography. We statistically tested the association between the prevalence of eye disorders and karyotype.

RESULTS

50 (61%) patients had monosomy X; 9 (11%) had mosaicism with a normal 46,XX line; 21 (26%) had structural aberrations; and 2 patients (2%) had other chromosomal abnormalities. Eye disorders were diagnosed in 43 (52%) patients, with 29 (35%) patients having multiple eye defects. Defects related to impaired vision were the most common (44%), followed by strabismus (21%), changes in the posterior eye segment (6%), red-green colour deficiency (5%), changes in the anterior eye segment (5%) and nystagmus (4%). Amblyopia was diagnosed in 13 patients (16%). The most common combinations of ophthalmological defects were hypermetropia and astigmatism with or without other eye problems (12 patients). We found no association between the presence of eye defects and karyotype.

CONCLUSIONS

Detection of eye abnormalities is necessary in all patients directly after being diagnosed with TS to prevent irreversible deterioration of eye function and permanent poor vision. All girls with TS, irrespective of their karyotype, should be referred to an ophthalmologist.

Thyroidectomy in children: changing trends and surgical strategies

BACKGROUND

Surgical thyroid pathology is an uncommon problem in children and due to environmental factors may be locally-specific. Until the mid-90's, Lower Silesia had been regarded as a region of endemic goiter but since then a better system of iodine prophylaxis has been introduced.

OBJECTIVES

To assess changing trends in the epidemiology of surgical thyroid diseases in children and to examine whether they have influenced potential alterations of operative strategies during the study period.

MATERIAL AND METHODS

The medical records of all children operated on for thyroid disease between 1993 and 2010 in the university pediatric surgical center were retrospectively reviewed. The data regarding the indications for thyroidectomy, details of surgical management and outcome were collected and analyzed in three periods of time 1993-1998, 1999-2004 and 2005-2010.

RESULTS

There were 46, 63 and 41 children operated on in the analyzed periods of time, respectively, with no significant differences regarding their age and gender. Preoperative thyroid ultrasound scan showed nodular lesions within the thyroid gland in 145 children (94.7%). The frequency of unilateral and bilateral nodular lesions was basically similar throughout the whole study. There has been a significant decrease of subtotal resections from around 63% in the first period to less than 16% in the other two periods of the study. The reverse trend can be clearly seen with regard to unilateral total lobectomy. Since 1999, total lobectomy or total thyroidectomy has been performed in more than 80% of the children. Nodular goiter was the most common indication for surgical operation followed by follicular adenoma. Malignant disease was recorded in 7 children (4.6%).

CONCLUSIONS

The gradual decrease of the number of children with surgical pathology of the thyroid gland seems to reflect an effective iodine prophylaxis. Depending on the extent of thyroid disease, unilateral lobectomy, either alone or coupled with partial or total resection of the contralateral lobe should be a standard surgical procedure in children.

Ganglioneuroma in a patient with Turner syndrome

INTRODUCTION

Ganglioneuroma is a benign neuroblastal tumor that derives from immature cells of the sympathetic nerve system. It is a very rare disease and affects newborns and infants more often than adolescents and adults. The benign tumors are relatively difficult to diagnose since they usually are asymptomatic. We present a case of unusual coincidence of an ganglioneuroma and Turner syndrome (TS).

CASE REPORT

An 11.5-year-old TS patient was admitted into the hospital with good general condition. She was 7 months into growth hormone (GH) therapy. The reason for the admission was to carry out control tests. The patient had not complains or abnormalities on physical examination. On the ultrasound examination of the abdomen in the right adrenal area an adrenal tumor was identified. The ultrasound examination of the abdomen performed 13 months earlier did not show any abnormalities. Computed tomography of adrenal glands confirmed right adrenal tumor. The hormonal function of the adrenal gland was normal. The treatment with GH was terminated and the patient was urgently referred to surgical management. The right adrenal gland tumor together with a part of diaphragm was removed. On histopathological examination ganglioneuroma maturum was diagnosed. On the control MIBG examination physiological gaining of tracer in the left adrenal and in the rest tissue in the area of the right adrenal was found. Trepanobiopsy did not confirm neoplastic changes.

CONCLUSIONS

There is a necessity of careful monitoring of TS patients also in face of the possibility of disclosure previously not stated neoplasm after starting GH therapy. It is impossible to rule out that GH therapy promote growth of existing neoplasm.

[Klinefelter syndrome in a boy with symptoms of precocious puberty]

Klinefelter syndrome is one of the most frequent sex chromosomal aberration. It is usually not recognized before puberty and many patients remain never diagnosed. Delayed puberty and hypergonadotropic hypogonadism are typical in this syndrome. Early diagnosis and therapy with androgens is important for patients. We present case of 8-year old boy with Klinefelter syndrome who was admitted to our department because of precocious puberty.

Multihormonal hypopituitarism, hypothyroidism and hypoparathyroidism in a 17-years-old girl with Diamond-Blackfan anemia and secondary hemochromatosis

Congenital hypoplastic anemia (Diamond-Blakcfan syndrom) is a genetically determined disorder which is manifested in early childhood with selective deficiency of erythrocyte line in bone marrow. Severe anemia usually appears in the first six months of life. Survival depends on blood transfusions, which in consequence lead to hemochromatosis. The most common complications of transfusional hemochromatosis are hepatic cirrhosis, hypopituitarism, hypogonadism, diabetes mellitus, other endocrinopathies, and cardiomyopathy. We present the case of 17 years old girl with congenital hypoplastic anemia and multihormonal insufficiency due to secondary hemochromatosis.

[Thyroid ectopy - the presentation of four patients]

Ectopy of the thyroid gland means its incorrect location most often along the midline of the body from the foramen cecum to the mediastinum, usually in the dorsum of the tongue. In 75% of patients, the lingual thyroid is the only active thyroid tissue. ectopic thyroid is frequently incidentally diagnosed in patients without symptoms of hypothyroidism. The authors present four patients with lingual location of the thyroid treated due to congenital hypothyroidism. in two of them, an ultrasound examination revealed thyroid tissue in a proper location in front of the trachea, however, the tissue did not show jodine-131 uptake on scintigraphy performed after four week-cessation of thyroxin treatment. The ectopic tissue can undergo the same pathological alterations as in the properly located gland (single or multiple nodules, inflammation, neoplasms), therefore, the monitoring by imaging techniques seems crucial.

Complex glycerol kinase deficiency - X-linked contiguous gene syndrome involving congenital adrenal hypoplasia, glycerol kinase deficiency, muscular Duchenne dystrophy and intellectual disability (IL1RAPL gene deletion)

Contiguous gene syndromes are disorders caused by deletions of genes that are adjacent to one another. One of them is complex glycerol kinase deficiency. It is caused by partial deletion of Xp21, which includes the genes responsible for glycerol kinase deficiency, congenital adrenal hypoplasia, Duchenne muscular dystrophy and intellectual disability. There are no definite dysmorphic features for this syndrome. The diagnosis is based on clinical and laboratory findings. Symptoms depend on the size of deletion and appear almost exclusively in the male gender. Usually the first and most severe are the signs of adrenal hypoplasia, which, if not cured, may lead to death in a short time. The symptoms of glycerol kinase deficiency occur also early in life, but they may be masked by the deficiency of mineralocorticoids. Duchenne muscular dystrophy appears in childhood and is always accompanied by certain symptoms. Developmental retardation and intellectual disability occur often with complex glycerol kinase deficiency. The reasons for it are heterogeneous, but usually, there is a connection with the deletion of DMD or I L1R A P L genes. Due to the fact that loci of all genes responsible for complex glycerol kinase deficiency were determined, it is possible to carry out molecular examination, confirm clinical diagnosis and determine female carriers of the disorder.

Coincidence of Poland's syndrome with Turner's syndrome

INTRODUCTION

Poland's syndrome (PS) is an inborn defect consisting in unilateral underdevelopment of the pectoralis major muscle, homolateral anomalies of upper extremity, as well as mammary gland aplasia. PS occurrence frequency is determined as 1:7000 to 1:100 000. Turner's syndrome (TS) results from lack of one sex chromosome or its incorrect structure and occurs with a frequency of 1:2000 of female sex newborns. Coincidence of both syndromes may hypothetically occur in 1:14 000 000 of females.

CASE REPORT

A 5-year-old girl was diagnosed with a rare coincidence of PS and TS. It is the second description of PS and TS coincidence case in the literature. Low body mass, lymphatic edemas of the feet and developmental defect of the right hand in form of defective palm development and syndactyly were found after birth. At the age of 3, after digit separation procedure, she was referred to an endocrinologist because of short stature (83 cm, -3.35 SDS). Right pectoral muscle and right hand hypoplasia were found during physical examination as well as the presence of dysmorphic characteristics. The result of cytogenetic examination confirmed TS diagnosis. She began treatment with growth hormone at the age of 4.5 years.

CONCLUSIONS

Appearance of PS in female patients with TS may dub diagnostic vigilance and delay TS diagnosis. Growth deficit in girls with PS constitutes the indication for karyotype testing.

A two year observation of the process of applying recombinant IGF-1 to treat short stature in children with primary IGF-1 deficiency -- case reports of 3 patients

Growth deficiency is one of the most frequent causes of referral to Endocrinology Outpatient Clinic. IGF-1 (insulin-like growth factor 1) deficiency is one of the rarest causes of short stature. In 2009 in Poland a therapeutic programme was set up for children with severe primary IGF-1 deficiency. The authors present the data of three first polish patients qualified for the rhIGF-1 (recombinant human insulin-like growth factor 1) - mecasermin. The authors conclude that the treatment with rhIGF-1 significantly improves growth velocity in patients with IGF-1 deficiency. During two years of mecasermin treatment no serious side effects were noted.

[Lipoprotein a (Lp(a)) in patients with Turner's syndrome]

INTRODUCTION

Women with Turner syndrome (TS) more frequently develop cardiovascular disease. Abnormal lipid metabolism is a well known risk factor for ischemic heart disease.

AIM OF THE STUDY

was to evaluate serum lipid abnormalities, particularly lipoprotein (a) (Lp(a)) in patients with TS.

MATERIAL AND METHODS

The study group consisted of 65 girls with TS without clinical signs of thyroid dysfunction or diabetes mellitus. The mean age was 12.45+/-5,03 (2-21) years. X chromosome monosomy was found in 60%, mosaicism in 30.8%, structural aberration in 9.2% of the patients. Most of them (59.7%) received GH treatment, 17.5 had finished treatment prior to the study, 22.8% did not start it yet. Height SDS, BMI SDS, Lp(a), cholesterol, triglycerides, free thyroxin, TSH, insulin, IGF-I, FSH, estradiol were determined.

RESULTS

Thyroid hormone values were within normal ranges in all the patients. In 30.1% (n=20) of them the diagnosis of Hashimoto disease had been established from 1 to 8 years prior to the trial, levothyroxine was administered and euthyreosis was observed. There were significant correlations between Lp(a) and cholesterol (r = 0.37, p=0.005) and Lp(a) and LDL (r=0.48, p<0.001), but not the age, height SDS, BMI SDS and other parameters. There were no significant differences in Lp(a) levels between the groups of patients with different karyotypes. The highest Lp(a) level was observed in patients before GH treatment, the lowest after finishing the treatment but without a statistical significance. We compared the groups of patients with high Lp(a) level (>35 mg/dl) (n=12) to low Lp(a) level (<5 mg/dl) (n=29), but did not find any difference in age, height, BMI, IGF1, insulin level. Only LDL concentration was significantly higher in the first group (p=0.036).

CONCLUSIONS

High Lp(a) concentration observed in 18.5% of patients with TS could lead to atherosclerotic process development. Ultrasound monitoring of arteries is therefore advisable. Lp(a) level does not seem to be influenced by karyotype, the age or auxological parameters. However, the evaluation of the influence of GH therapy requires further investigation.

Sex chromosome pentasomy 49,XXXXY connected with hypothyroidism. Case report

49,XXXXY syndrome is a very rare sex chromosomes polysomy, which is always connected with dysmorphic appearance, hypergonadothrophic hypogonadism and mental retardation. In this report we describe the clinical, biochemical, hormonal, radiological and developmental status of the patient with 49,XXXXY syndrome, referred to our department at the age of 12 months because of underdeveloped external genitalia. Subclinical hypothyroidism and severe scoliosis could further disturb his development.

[Papillary thyroid carcinoma and meningioma in 17-year-old boy- a late effect of acute lymphoblastic leukemia treatment or a new disease? Case report and literature review]

Thyroid carcinoma and meningioma can occur as a primary malignancy (PTM) or secondary after another malignancy (STM). We presented a boy 17 years of age with thyroid carcinoma and meningioma, which were recognized during growth deficiency diagnosis, 11 years after the treatment of ALL and 10 years after the bone marrow transplantation. Children who have been successfully treated for one cancer have a higher than expected incidence rate of additional tumors and therefore they need endocrinological care.

Influence of GnRH analog therapy on body mass in central precocious puberty

THE AIM OF THE STUDY

Was to evaluate the body mass index (BMI) changes in girls with central precocious puberty (CPP) treated with a GnRH analog (GnRHa) and to analyse the factors affecting BMI.

MATERIAL AND METHODS

43 girls with puberty onset aged (mean, +/-SD) 6.1+/-1.9, treated with 3.75 mg Decapeptyl Depot i.m. every 28 days. The treatment was initiated at the age of 7.5+/-2.1 year and continued for 3.3+/-2.2 year until the age of 11.4+/-0.9 year. The height, weight and BMI data were evaluated before, during and after GnRH agonist administration. Using recommended Polish BMI cut-off values we defined overweight in children of 90th and 97th centiles and obesity above 97th centile.

RESULTS

There was no statistical difference between BMI SD score before initiation of therapy and at the end of therapy (p=0.49). 9.8% of the cohort were overweight and 22.0% were obese before treatment. At the end of the therapy 18.6% children were overweight and 14.0% obese. These differences were not statistically significant. There was no significant correlation between overweight and obesity at the end of treatment and the duration of the therapy (r=-0.17) and with the duration of CPP before introduction of GnRH therapy (r= -0.11).

CONCLUSIONS

1.Overweight and obesity are not related to long term pituitary-gonadal suppression due to GnRH analogue treatment. 2. The rate of overweight and obesity among children with CPP is higher than in the general population. Thus detailed evaluation of metabolic status of overweight children with CPP should be performed in order to prevent complications of the metabolic syndrome.

[Mosaic trisomy of chromosome 20 in a patient with congenital anomalies--10-years observation]

Trisomy 20 is one of the most often identified disorders in amniocytes, but in a postnatal analysis is detected rather rarely. We present a girl with dysmorphic features, congenital defects, tumor of a suprarenal gland, hypothyroidism and abnormal intelligence. The recognition of mosaic trisomy 20 was confirmed after cytogenetic examination of the skin fibroblast. The karyotype is described as mos 47,XX,+20/46,XX. The karyotype from peripheral blood lymphocytes, which was examined in the 1st year of life, was normal female (46,XX) and the Turner syndrome was excluded. During 10 years we observed that the dysmorphic features were increased and suggested genetic reasons of these features. In children with dysmorphic features and normal karyotype of blood lymphocytes a wide-ranged genetic counseling is necessary.

Evaluation of hearing organ in patients with Turner syndrome

Hearing loss and middle ear diseases are often reported in some of Turner patients. In most of the reports hearing organ was evaluated with the use of subjective methods. The aim of the work was subjective and objective evaluation of hearing organ with an attempt to set the correlation between the results and the genotype of the patients with Turner syndrome (Ts).

MATERIAL

51 Ts patients aged 14.3 years on average. There were 29 girls with monosomy X and 22 having mosaicism. A detailed medical history was taken in each case with attention given to the hearing loss risk factors.

METHOD

Physical ENT examination, hearing evaluation: pure tone audiometry, impedance audiometry, distortion products otoacoustic emissions (DPOAEs), brain auditory evoked potentials (BAEP). The control group consisted of 30 healthy patients.

RESULTS

Recurrent acute otitis media was reported by 19.6% of Ts patients. Pure tone audiometry was improper in 36.3% ears; conductive hearing loss was present in 11.7% ears, mixed hearing loss in 5.9% ears and the moderate sensorineural hearing loss in 18.6% ears. Impedance audiometry was impaired in 14.7% of the cases. DPOAE disturbances were present in 41.4% of Ts patients, BAEP was improper in 52.0%. The percentage of the disturbances in DOPAEs and in BAEP in patients with mosaicism was 45.4 and 40.9% while in patients with monosomy 68.9 and 62%.

CONCLUSIONS

Ts patients present predisposition to hearing disturbances. The disturbances seem to be connected with middle ear infections and with sensorineural hearing losses. Hearing loss in Ts women is not clinically apparent in most of the cases; this fact reflects the need of early evaluation and further monitoring of hearing organ in those patients. Sensorineural hearing loss seems to prevail in patients with 45,X genotype, so perhaps attention should be paid to this subgroup of Ts patients.

Congenital hypoaldosteronism associated with nails hypothrophy - case report and review of the literature

We report 15 years follow-up of a girl born with nails hypothrophy and primary hypoaldosteronism. The failure to thrive, troubles with feeding and vomiting were observed since the first weeks of life. The results of the laboratory examination confirmed isolated hypoaldosteronism. The growth velocity was diminished and short stature was present during first 4 years of life. Thyroid and pituitary disturbances were excluded. At the age of 4 the treatment with fludrocortisone was gradually discontinued without clinical manifestation of aldosteron deficiency. The child was on high sodium chloride diet. The growth velocity improved. At the age of 7,5 years pubarche, lipid and carbohydrate disturbances occurred. The bone age was adequate to chronological age. The treatment with Cortineff and diet modification were recommended. Further improving in growth velocity and lowering in salt consumption were observed. Menarche occurred at the age of 12 years 8 months with subsequent monthly bleedings. She finished growth with height SDS -2.52 (target height SDS -1.71), and BMI SDS 1.83. The nails hypothrophy still maintains.

[Multiplex minisequencing applied in detection of human functional CYP21 gene mutations]

We analyzed seven most common mutations within the CYP21B gene, responsible for congenital adrenal hyperplasia (CAH), using the minisequencing method. Functional CYP21B gene sequences were amplified with the pair of specific primers that pevented amplification of pseudogene CYP21P or pseudogene CYP21P/active CYP21 hybrids. Multiplex minisequencing (SNaPShot PCR) assay was performed with fluorescent dideoxynucleotides ([F]ddNTPs) and originally designed primers, claiming seven most common mutation sites responsible for the CAH symptoms. Using the method we detected five novel substitutions of unknown effect on the CAH course in five out of seven analyzed mutation sites. Compared to classic SNPs analyzing methods, especially single SNP detection, multiplex minisequencing is the same highly specific and sensitive but much faster one. The method is recommended for any population screened for known mutations.

[Pituitary response to GnRH analogue testing in girls with a polycystic ovary syndrome]

THE AIM of our study was to estimate the gonadotropin level after GnRH analogue injection in girls with PCOS after suppression with dexamethasone.

MATERIAL AND METHODS

57 girls with hirsutism, mean age 15.9 years, were involved in the study. The research was performed in the early and middle follicular stage. Menstrual disorders were observed in 78% of them. The patients were divided into 3 groups: I -- with clinical and laboratory symptoms of PCOS (menstruation disorders, testosterone >65 ng/ml and/or LH/FSH >2; n=29), II -- with menstruation disorders and without elevated androgen level (n=15), III -- without menstruation disorders and without elevated androgen level (n=13). Basal blood samples were drawn at 8 a.m. GnRH analogue (Relefact LH-RH) 100 microg was then given subcutaneously and blood samples were drawn every 4 hours for 24 hours.

RESULTS

Basal level of LH was the highest in group I (6,18+/-4,10 IU/l) in comparison with II (5.53+/-3.40 IU/l) and III (3.82+/-2.79 IU/l). After GnRH analogue administration mean LH concentration increased in all groups and peaked after 2 hours. Stimulated LH level was the highest in group I and differed statistically significantly from group III during the whole period of the test. The most significant difference occurred at 12 a.m. (p=0.003) and 10 a.m. (p=0.004). The FSH secretion in all tested groups was similar. It peaked, like LH, after 2 hours after GnRH analogue injection and decreased slightly during next 2 hours. A marked decrease was observed in the following period of time.

CONCLUSIONS

1. High and fast LH secretion responding to GnRH analogue indicates masculinization of the hypothalamo-pituitary axis in PCOS girls. 2. The hirsute girls without menstrual disturbances and hormonal abnormalities probably also have subtle masculinization of the pituitary response to stimulation by GnRH analogue.

[Precocious puberty caused by McCune-Albright syndrome in a girl aged 6 years and 9 months]

The McCune-Albright syndrome is characterised by polyostotic fibrous dysplasia, "cafe-au-lait" spots and autonomous hyperfunction of various endocrine organs. The authors present the case of a girl at the age of 6 years 9 months with precocious puberty (thelarche III, menarche). High estradiol level (204 pg/ml) and low gonadoptopins concentration as well as their level after GnRH administration suggested ovarian autonomy. Ovarian cysts were found on pelvic ultrasound. Other endocrine abnormalities were excluded. Single "cafe-au-lait" spot was found on the patient skin. Scintigraphy, radiography and computed tomography scans showed fibrous dysplastic bones in the right tibia and in maxillary and sphenoid sinuses.

[Precocious puberty and von Recklinghausen's disease]

Von Recklinghausen's disease belongs to a group of neurocutaneous syndromes and is characterised by skin, nerve and bone abnormalities. We present a case of von Recklinghausen's disease and precocious puberty in 7-year-old boy. At the age of three café au lait spots on the skin and an incranial tumour situated near the optic chiasm--qualified as inoperable--were discovered. At the age of 7 first signs of precocious puberty appeared (pubic hair P3 and enlargement of the testes (15 ml) and penis). Laboratory measurements included: LH 7.5 mIU/ml, FSH 1.1 mIU/ml, testosterone 183 ng/ml, assessment of bone age: 9 years. The response to LHRH stimulation was characteristic for true precocious puberty (LH 15.9 mIU/ml and FSH 1.5 mIU/ml after 30 minutes). The MRI of the brain showed a tumour of the suprasellar region with compression of pituitary stalk. True precocious puberty was diagnosed. Treatment with Diphereline was introduced. At present the boy is 9 years old and has been treated with Diphereline for 16 months. The volume of the testicles has decreased to 7 ml and loss of pubic hair was noted. The MRI does not show any progression in tumour growth. The authors would like to underline the need of close observation of children with von Reclinghausen disease with regard to possibility of uncovering true precocious puberty which is critical for rapid diagnosis and introduction of correct treatment.

[The prevalence of thyro-peroxidase antibodies and thyroid function in Turner's syndrome]

INTRODUCTION

Higher frequency of autoimmune diseases in patients with Turner's syndrome (TS) compared with the general population has been described. 5 to 10% of cases occur before adolescence. The goal of the study was to determine the prevalence of thyro-peroxidase antibodies (TPO-Ab) in correlation with karyotype, clinical symptoms and hormonal thyroid function in TS patients.

MATERIAL AND METHODS

96 girls with TS, aged 0.5-19.8 years (mean age 12.3+/-5.0) and 58 girls matched for age and BMI (control group) were analysed. The diagnosis of TS was established basing on clinical features and karyotype analysis. 54 had X monosomy, 7--isochromosome, 1--other X chromosome aberration, 11--mosaicism 45,X/46,XX, 3--45,X/47,XXX, 1--45,X/46,XX/47,XXX, 19--mosaicism with structural aberration: 12--45,X/46,X,i(Xq), 2--others, 5--with Y chromosome. In all children TSH, FT(4), FT(3), TPO-Ab, cholesterol, triglyceride levels, physical and ultrasonographic examination were performed.

RESULTS

25% of TS patients were positive for TPO-Ab. This frequency was significantly higher (p=0.0017) than that seen in the control group (5.2%). Positive titers of TPO-Ab were found: in 42% of girls with isochromosome (46,X,i(Xq) and 45,X/46,X,i(Xq)), 22.2% with X monosomy, and 17.4% with other karyotypes. The percentage of positive TPO-Ab titres increased with cumulative age of TS patients. It was 6.7% at the age of 10 years and almost doubled (12.1%) one year later. The next strong increase was observed at the age of 16 (up to 19.1%) and gradually rose to 20 years of age. Mean age of seronegative patients was significantly lower than that of seropositive patients (p=0.018). Only 2 patients manifested symptoms of hyperthyroidism requiring short period of antithyroid treatment. Others did not reveal any clinical features of thyroid dysfunction, although developed thyroid abnormalities such as elevated TSH (11.4%) or goiter (28%). Lack of correlation between TPO-Ab, thyroid hormones and lipid levels was associated with L-thyroxine supplementation, in patients with mildly elevated TSH, prior to the study.

CONCLUSIONS

Patients with TS, especially with isochromosome, have antithyroid antibodies more frequently than their co-evals. Therefore, it is important to monitor TPO-Ab from about the age of 10 years even in asymptomatic patients. However, in routine clinical practice, both the thyroid examination and TSH level (even in asymptomatic patients) should be screened yearly for early detection of subclinical hypothyroidism and risk of more severe growth retardation in girls with TS.

[Adrenal function in girls with hirsutism]

The aim of our study was to estimate the adrenal function in hirsute girls.

MATERIAL AND METHODS

57 girls with hirsutism aged from 12 to 19 years, mean age 15.95 years, were involved into the study. The research was performed in early and middle follicular stage. Menstrual disorders were observed in 78% of them. Hirsutism was estimated with Ferriman-Gallwey scale (mean value 13+/-1.58), mean BMI was 22.7. The patients were divided into 3 groups: group 1 with clinical and laboratory symptoms of PCOS, n=29; group 2 with menstrual disorders and without elevated androgen level, n=15; group 3 without menstrual disorders and without elevated androgen level, n=13.

RESULTS

17OHP level was the highest in group I (1.17+/-0.58 ng/ml). Diurnal cortisol profile was regular in all patients. After Synacthen injection cortisol level rose in all groups to the similar values at 60 min. The same stimuli induced intensive 17OHP secretion in group 1 (2.42+/-2.02 ng/ml) at 30 min statistically higher than in group 2 (1.46+/-0.95 ng/ml), (p=0.045). None had 21-hydroxysase defect. There were positive correlation between levels of 17OHP and LH (r=0.38), 17OHP and T (r=0.39), 17OHP and LH/FSH (r=0.40) CONCLUSIONS: 17OHP level in patients with PCOS is significantly higher then in other hirsute girls. High 17OHP and normal cortisol level after Synacthen administration in PCOS girls point that activity of enzymes involved in 17OHP production is augmented.

[Salt wasting syndrome caused by congenital, insufficient synthesis or aldosterone function--etiology, diagnosis and management]

Salt wasting syndrome is caused by a congenital or acquired synthesis disorder or by the aldosterone function disorder. It manifests itself by ionic disorders where the sodium and chlorine level decrease with the simultaneous potassium retention. Synthesised aldosterone is in the glomerular zone of the adrenal cortex. Symptoms of dyselectrolitemia are not distinctive, they develop within a few first days of life. The suction aversion, apathy, lack of growth or progressing, body mass loss is being noticed. The most often cause of salt wasting syndrome is the congenital cortical adrenal hyperplasia (CAH) caused by 21-hydroxylase enzyme deficit. The classic form with and without salt wasting (SW), as well as non-classic form is distinguished. The therapy of SW form depends on Hydrocortisone and Cortineff administering. The other forms of salt wasting syndrome occur not so often and these are: aldosterone synthesis deficit, dehydrogenase 3beta-hydroxysteroid deficit, lipoid cortical hyperplasia, adrenal hypoplasia congenital (AHC), adrenoleukodystrophy and pseudohypoaldosteronism. The knowledge of the symptoms and causes of salt wasting syndrome allows for the proper therapeutic management and contributes to the regular psychophysical infantile development of the children.

[Hamartoma as a reason of precocious puberty in a 15-month old boy]

Hamartoma of the hypothalamic region is known as one of the reasons of precocious puberty. The case of a 15-month old boy with hamartoma as a reason of precocious puberty is presented. The GnRH analogues were used in the therapy.

[Estimation of IGF-1 and IGFBP-3 concentrations in serum in children with diabetes type 1 and growth disorders]

The relations between diabetes type 1 and growth disturbances have been controversial. The aim of the study was to estimate the IGF-1 and IGFBP-3 levels in the group of children with diabetes type 1 and growth disturbances. The study group consisted of 22 children (10 males and 12 females) aged 11.96+/-3.38, bone aged 10.70+/-3.91, GV SDS < -0.93 below the mean for C. A. IGF-1, IGFBP-3, GH stimulation test, TSH, fT4 and HbA1 were determined. In the studied group positive correlations between: IGF-1 and IGFBP-3; IGF-1 and BMI; BMI and IGFBP-3 were determined. In children with diabetes type 1. The IGF-1 concentration was significantly higher when the sceletal age was delayed above 1 year in comparison with children with delaying of the sceletal age bellow 1 year and it was independent on results of GH stimulation tests.

[Primary or tertiary hypothyroidism as a cause of growth disturbances in 13-month old boy?]

Due to the screening examination it is possible to diagnose primary hypothyreosis at the very beginning. On the other hand, hypothyreosis may be also caused by insufficient secretion of TSH or TRH. We present a 13-month old boy (A.I.) admitted to our Department because of short stature. The child was from normal pregnancy, birth spontaneous at full term with weight 4400 g, length 56 cm, 10 points in Apgar scale, TSH - 1,87 micro IU/ml in the screening examination. The psychomotor development was normal. At the admission the height was 72 cm (below 3 c), weight - 10,1 kg, body proportions normal, atresic fontanels, 7 teeth. Additional examinations revealed: skeletal age - 3 months, blood cell count normal, biochemical examinations normal except for level of cholesterol (209 mg/dl). We found lack of the GH secretion after clonidine. TSH value was slightly above normal range. The levels of free thyroid hormones, anti-TPO antibodies and thyroid ultrasonography were normal. The TSH level was increased in the stimulation test with TRH. Result of the MR examination of the brain was normal. On the basis of the whole picture tertiary hypothyreosis can not be excluded. The normalisation of thyroid hormone levels and GH in stimulation test with glucagone was obtained after therapy with L-thyroxine.

CONCLUSION

In cases of unclear growing disorders the full diagnostics of the hypothalamic-hypophyseal-thyroid axis should be done because of the possibility of regulatory centres insufficiency.