Major circadian variations of glucose homeostasis in a patient with Rabson-Mendenhall syndrome and primary insulin resistance due to a mutation (Cys284-->Tyr) in the insulin receptor alpha-subunit

We have performed clinical, in vitro biochemical, and genetic studies of a patient with severe insulin resistance, considerable growth restriction, and Rabson-Mendenhall syndrome (patient RM-3). The blood IGF-I level was undetectable in this patient, although the GH level was moderately decreased. During the postprandial period, glycemia, ketonuria, and plasma glucagon were very elevated despite high doses of exogenous insulin (glucose levels up to 30 mmol/L). In the postabsorptive state, blood glucose was normalized with small amounts of insulin; ketonuria, and glucagon levels were reduced but remained supranormal. Erythrocytes and cultured skin fibroblasts from the patient displayed a decrease in cell surface insulin receptors (IRs). The ability of physiologic concentrations of insulin to stimulate metabolic processes was altered in patient fibroblasts. Analysis of the IR gene by denaturing gradient gel electrophoresis and direct sequencing showed a homozygous missense mutation in exon 3, replacing Cys284 by Tyr in the alpha-subunit. In conclusion, marked primary insulin resistance was evidenced in patient cells as a result of a structural alteration in the IR alpha-subunit. The in vitro studies could not account alone for the in vivo metabolic alterations because glucose homeostasis varied considerably during the day in the patient.

[Reliability of needle biopsy of solitary thyroid nodules in view of surgical indications]

To evaluate the accuracy of fine-needle biopsy in the management of the solitary thyroid nodules, 320 biopsies without aspiration were performed in 212 patients, iteratively in 91 cases. Among the 212 initial biopsies, 93 smears were found presumably benign (43.9%), 6 malignant (2.8%), 49 benign implying cytologic control (23.1%), 24 suspicious with decision to operate (11.3%), 40 inadequate (18.9%). On 67 surgical indications (malignant or suspicious cytology, or clinical data), 59 operations were performed. The 11 diagnosed cancers (5.2% of the patients; 18.6% of the operations) correspond to six malignant and five suspicious cytologies at the first or second biopsy. On 145 cases without decision to operate, 125 were clinically surveyed, with sometimes another biopsy (mean survey: 27.6 months; range: 6-80 months), and it was never necessary to modify the initial expectancy attitude. Our results, rather similar to those related by most of the previous publications, confirm that the fine-needle biopsy is a reliable and effective means for the etiologic diagnosis of thyroid nodules and the indications for operative intervention. It spares many patients from a useless operation and is worthy to take a leading place in exploring these nodules.

[Late onset hyperandrogenism caused by 3-beta-hydroxysteroid dehydrogenase deficiency]

OBJECTIVES

Clinical manifestations of hyperandrogenism, including hirsutism and acne with or without dysmenorrhoea are well recognized in late onset hyperandrogenism due to deficiency in 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD), yet the frequency of this deficiency in patients with post-puberty hirsutism is not well established. We therefore evaluated retrospectively this deficiency state in women who consulted our unit for manifestations suggestive of hyperandrogenism from 1990 to 1992.

METHODS

We included 32 women with clinical manifestations of hyperandrogenism for whom a partial deficit in 3 beta-HSD could be searched for on the basis of hormone assays. Their mean age was 27.5 years (range 14 to 46) and the clinical manifestation was hirsutism in 21 cases, acne in 13, alopecia in 5 and dysmenorrhoea in 11. Diagnostic tests included adrenal stimulation with 0.25 mg beta 1-24 corticotrophin and immunoradioassay of plasma levels of 17-hydroxypregnenolone (17-OHPreg), 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone (DHA) and cortisol (F). Pang's criteria for the diagnosis of partial deficiency in 3 beta-HSD were retained. We defined deficiency in 3 beta-HSD as certain when the 4 following criteria were present 60 minutes after stimulation: 17-OHPreg > 17.5 ng/ml; DHA > 20 mg/ml; 17-OHPreg/17-OHP > 9; 17-OHPreg/F.10(-3) > 53. Diagnosis was considered probable when only 3 criteria were met and was excluded in all other cases.

RESULTS

Positive diagnosis of deficiency in 3 beta-hydroxysteroid dehydrogenase was made in 4 of the 32 patients and probable in 4 others.

CONCLUSION

Based on our series of patients, late onset hyperandrogenism due to 3 beta-hydroxysteroid dehydrogenase deficiency would thus appear to be a relative frequent deficiency state. Since therapeutic measures can be taken, this deficiency should be carefully searched for in all young patients presenting with manifestations suggesting hyperandrogenism.

Linkage analysis of hereditary thyroid carcinoma with and without pheochromocytoma

The use of polymorphic DNA segments as markers for the gene for the multiple endocrine neoplasia (MEN) syndrome, type 2a, allows the identification of family members at high risk for developing medullary carcinoma of the thyroid and other tumors, especially pheochromocytoma. Several families have also been identified in which medullary thyroid carcinoma is inherited, but pheochromocytoma is not seen. We have analysed 18 families, 9 with MEN 2A and 9 with medullary carcinoma of the thyroid without pheochromocytoma, with probes specific for the pericentromeric region of chromosome 10 and conclude that the mutations for the two presentations are closely situated. Genetic heterogeneity of the susceptibility locus was not seen among this sample of 18 families. The genetic mutation for medullary carcinoma was in disequilibrium with the marker alleles of the two closely linked probes, IRBPH4 and MCK2. These data suggest that different mutant alleles of the same gene or closely linked mutations account for the variation in penetrance of pheochromocytoma in families with hereditary medullary thyroid carcinoma.

[Thorburn's posture. A sign of lesion of the cervical cord]

In two infants hypertonia of the scapular muscles (C5-C6 level) associated with flacid palsy in other muscles of the upper limb produced an unusual posture. This one, described in adults by Thorburn, suggests a traumatic or ischaemic lesion of the cervical cord.

[Can Acarus siro be considered an allergenic mite in children? Evaluation of 248 cases]

Among 248 allergic children we noted 44 children (21%) with strongly or moderately positive cutaneous tests (In seven out of these tested children respiratory provocation tests are very positive). They are urban children and their houses are not different from other allergic children. They are mostly boys (72%), more than 5 years old (91%), with an asthma (84%), a radiological sinusitis (45%), an hypereosinophilia (88%) and elevated total IgE (90%). 43/44 children also have positive cutaneous tests to Dermatophagoides pteronyssinus mite. Since respiratory sensitivity is exquisite, we undertook a specific hyposensitization for some patients with encouraging results.

[Role of rhinomanometry in childhood mite allergy apropos of 76 cases]

Place for Passive Anterior Rhinomanometry (PAR) in mite allergic children. PAR is a simple method to investigate chronic or recurrent rhinopathies in children. Among 59 investigations with a Dermatophagoides pteronyssinus extract, we found 27 positive responses, 3 doubtful results and 32 negative explorations. Nasal sensitization is usually important: the liminal dose is less than 250 mcg in 17/28 cases. Most children have no bronchial sensitivity. None of 14 children with negative cutaneous and RAST tests have nasal sensitivity. When cutaneous and RAST tests are both positive, 12/16 positive PAR are found. We note a nasal sensitivity in 3/5 cases with only cutaneous test positive and 12/26 cases with only RAST tests positive. For other mites a nasal sensitivity is found in 8 out of 14 explorations (Tyrophagus and Glyciphagus especially). Among all patients when cutaneous tests, RAST tests and history are doubtful for the real part played by mites in the child rhinopathy, nasal exploration allows more explicit diagnostic and therapy.

[Does immediate-type respiratory allergy occur regarding Stemphylium? Evaluation of 39 challenge tests]

Does immediate respiratory allergy with stemphylium exist? About 39 provocation tests. We present 39 children with positive cutaneous and/or RAST tests for stemphylium mold. Provocation tests individualize 19 patients (14 boys and 4 girls, 10 to 16 years old in 17/19) with a respiratory sensitivity: 6/10 by passive anterior rhinomanometry and 13/15 by bronchial tests. Clinical symptoms are asthma and spasmodic rhinitis (14/19), predominantly from june to august. We noted a mite allergy in 11 cases and a grass pollenosis in 13 children. Positive cutaneous and/or RAST tests are found for alternaria mold in 13/19 cases. We undertook a specific hyposensitization in 14 children with a three years experience in 10 cases. Tolerance is excellent. This provocation respiratory exploration shows the important role played by stemphylium mold in the etiology of recurring respiratory incidents in children.

[Does mugwort pollenosis occur in children in the northern region?]

Is Mugwort pollenosis frequent among children in North of France? In North of France where no ragweed grows, mugwort (artemisia) is after grasses and plantago, the third pollenosis in children. Among 184 children with summer clinical signs, positive cutaneous tests with a mugwort extract are noted in 40 patients (21%). RAST are positive only in 23 on 34 children with positive cutaneous test. Among the 40 children only two are less 5 years old and 26 are more 10 years old. Respiratory provocation tests confirm in 13/19 cases a sensitization of upper or lower respiratory tract. No food allergy exists among those children.

[Malignant pheochromocytoma. A case]

A case of malignant phaeochromocytoma is reported. The primary tumour was removed in 1970. Metastases were diagnosed in 1979 and management of the condition included antihypertensive treatment with alphamethylparatyrosine, antitumoral chemotherapy and surgical reduction of secreting tissue. In these rare tumours malignancy can only be confirmed by metastases, i.e. presence of chromaffin cells in loci where they are not usually found. Histology is of little value. High levels of catecholamine precursors or their metabolites in the urine may be a sign of malignancy, but some asymptomatic tumours are only revealed by metastases. Computerized tomography and radioisotope scanning with I131 metaiodobenzylguanidine are the best available methods to locate the lesions. In view of the small number of cases and of the unpredictable course (sometimes spread over many years) of malignant phaeochromocytomas, the effectiveness of treatments with alphamethylparatyrosine, chemotherapy and radiotherapy is difficult to evaluate.

[Congenital intrahepatic portacaval anastomosis: analysis of manifested glucose abnormalities]

The authors report a case of a high-flow intrahepatic portacaval shunt due to a congenital venous abnormality. Suspected by digestive echography, the abnormality was confirmed by angiography. A precise analysis of glycoregulation showed an "impaired glucose tolerance", followed by post-stimulative hypoglycemia with persistant hyperinsulinemia and lowering of the C peptide/insulin ratio. These abnormalities seem to be related to the shunt only. This observation appears as an experimental model permitting the appreciation of the disturbances in glucose metabolism related to an intrahepatic shunt without any hepatic cell disorder.

[Location of an insulinoma by transhepatic phlebography with staged insulin assays (author's transl)]

Insulinoma was easily diagnosed in a 73-year-old woman who had organic hypoglycaemia associated with hyperinsulinism, but the tumour could not be located by echotomography and computerized tomography. The state of the patient's arteries precluded arteriography. Pancreatic phlebography was carried out by the portal transhepatic route and blood was collected at different levels for plasma insulin assays. A very high gradient at the pancreatic isthmus indicated the site of the tumour, which was found on surgery to be precisely there and could be enucleated. This technique cannot be used systematically to locate insulinomas, but it is unquestionably helpful when the tumour cannot be located by other methods or when these are contra-indicated.

[Results of treatment of Graves' disease by antithyroid drugs. Report of 90 cases (author's transl)]

Ninety patients with Graves' disease were given treatment with antithyroid drugs. The first course, which is almost always immediately successful, gave in the long term 46 failures and 44 successes. Among the latter, 38 had a follow up equal or greater than one year after interruption of the course. Among the 78 cases sufficiently well followed up for the whole period of treatment (of which 21 had at least two courses of treatment), we noted 23 failures and 55 successes (70%) for which the average follow up was 61 months. If one requires a follow up equal or greater than one year after the end of treatment, we noted 47 good results out of 70 fully documented cases, i. e. 67%. The possible failures almost always occurred less than one year after the end of treatment. The delay since the last interruption of antithyroid drugs is thus of prognostic value. The result of treatment was not found to be related to any of the clinical or laboratory parameters found during the initial stage of the disease, nor with the type of antithyroid drug used. The addition of thyroid hormone to antithyroid drugs does not seem to be of any use. On the other hand, delay in starting treatment seems to favour the failure of treatment. Other interesting prognostic factors may be sought in the kinetics of TSH, the T3-suppressibility, the early radioiodine uptake, the estimation of thyrostimulating antibodies, and the study of HLA histocompatibility antigens.

[Adrenomyeloneuropathy in adults. Relationship with adrenoleukodystrophy in children (author's transl)]

The case reported concerns a man in whom appeared gradually, since the age of twenty-seven years, difficulty in walking and sexual impotence. The neurological syndrome consisted of pyramidal signs and objective sensory disorders of the lower limbs, intermittent sphincter disorders and mild mental deterioration, which was progressive. Biopsy of a sensory nerve showed rarefaction of myelinated fibres. The endocrine syndrome consisted of peripheral adrenal insufficiency, which was undoubted but with biologic evidence only. There was no response of plasma cortisol during five stimulation tests with tetracosactide and there was a gradual rise in plasma A.C.T.H. The clinical picture was thus that of an adrenomyeloneuropathy.

[Morphology of adipose tissue. Study in 102 obese subjects in reference to some clinical and biological criteria (author's transl)]

In spite of the methodological reserves that the measure of adipocyte volume and the calculation of the number of adipocytes evoke, it appeared interesting to us to study these parameters in a group of 102 obese subjects in reference to some clinical and biological criteria. The following conclusions come out of this study. The greater the obesity, the greater the adipocyte volume. There is a positive correlation between the importance of obesity and cellularity of the adipose tissue. However, this correlation is no longer found for the most obese patients, in whom adipocyte hypertrophy intervenes but no longer the multiplication of the fat cells. The onset of obesity at adolescence pairs with a number of adipocytes higher than in the other chronological forms: obesity appearing at adolescence would be thus more frequently hyperplastic. This characteristic is not discovered in the cases of obesity appearing in infancy. No relation was found between the existence of impaired glucose tolerance and mean adipocyte diameter and/or the number of adipocytes. It has been the same for the cases of hyperlipidemia.

[Platelet functions in diabetes with angiopathy (author's transl)]

Platelet functions studied in 163 unselected diabetics compared with 163 controls had the following characteristics: hyperagregation induced by ADP (1.2 muM and 0.6 muM), delayed platelet disagregation (ADP: 0.6 muM), normal agregation in the presence of collagen and thrombin. Platelet hyperagregation induced by ADP was marked in both sexes in cases of retinopathy and in women after the age of 50. By contrast, no correlation was demonstrated between the degree of hyperagregation and age, weight, the duration of diabetes, blood glucose control, lipid profile, vascular complications other than retinopathy and the nature of treatment.

[Tomodensitometry: localizing value in hypertension of adrenal origin (author's transl)]

Computarized axial tomography has shown the localization of adrenal lesions in four cases of hypertension of adrenal origin: two phaeochromocytomas, one primary hyperaldosteronism, one Cushing's syndrome. This method has the advantage of being neither invasive, nor time-consuming. Unfortunately, it cannot localize tumors smaller than two cm in diameter. It seems to be highly beneficial in phaeochromocytoma, where it can advantageously take the place of arteriography. It is less fruitful in primary hyperaldosteronism and in Cushing's syndrome because lesions are smaller.

[Mechanisms of spontaneous hypoglycaemia in the adult (author's transl)]

Hypoglycaemia increases hepatic glucose output; insulin release is suppressed and the secretion of counter regulatory hormones enhanced. Catecholamines and glucagon seem to play a major role. The brain energy content is initially preserved, but the neuronal activity exhibits a 40-60 % decrease. Neither cerebral blood flow, nor oxygen consumption are altered. In addition to glucose, other substrates are metabolized. Cerebral edema may occur. An insulin-storage defect seems to be the main abnormality in insulinoma beta cell function. The most accurate biological tests are the insulin/glucose ratio, stimulation tests and suppression tests such as fasting and insulin-induced hypoglycaemia. Ectopic release of ACTH, HCG, HLP, glucagon or gastrin, is observed in some malignant insulinomas. When inconclusive, classic localising procedures may be effected by selective venous-blood sampling. Hypoglycaemia of extra-pancreatic tumors results from glucose hyperconsumption and decreases in glucose hepatic output, lipolysis and ketogenesis, related to secretion of insulin-like peptides NSILAs or NSILAp. Rare cases of hypoglycaemia related to insulin auto-antibodies of unknown origin have been reported. Alcoholic hypoglycemia results from diminished hepatic glycogen content, alcohol dehydrogenase pathway blockade, reduction of gluconeogenesis defect in the alcohol catabolic catalase pathway and enhancement of peripheral glucose consumption.

[Adrenoleukodystrophy (Schilder-Addison's disease): a probable case in an adult (author's transl)]

Adrenoleukodystrophy (Schilder-Addison's disease) is a sex-linked recessive syndrome usually observed in children, associating neurological disorders and Addison's disease. Its outcome is death after a few years. The authors report the case of a man in whom a spastic paraparesis and a mental deterioration appeared at the age of 30 years. A biological adrenal deficiency was found: plasma cortisol and urinary 17-hydroxy-steroids and 17-ketosteroids failed to increase after synacthen stimulation; plasma ACTH level was above normal. Since two nephews of the patient suffered from adrenoleukodystrophy, the same disease is likely in the reported patient.

Relationship between plasma insulin, the size and number of adpocytes and habitual calory intake in a group of 186 obese women

In a group of 186 obese women, no correlation was found between post-glucose load insulinemia, measured at 13:00 hrs, and the degree of overweight, nor between post-glucose insulinemia and mean adipocyte diameter. Significant correlations were found between post-glucose insulinemia and daily caloric intake, and between post-protein insulinemia and mean adipocyte diameter. Post-glucose and post-protein load insulinemia were interrelated.

[A phonomecanographic test of hyperthyroidism]

Systolic intervals may be studied by phonomechanography. This provides data regarding the function of the left ventricle. In the absence of any problem of intraventricular conduction or valvular lesion, such information is particularly valuable. Thyroxine impregnation, whetHer active directly and/or by catecholamine hypersecretion, results in cardiac hyperkinesia which is reflected not only by tachycardia but also a shortening penetration time and contraction of the ventricular muscle. This shows itself within systole as a change in the relation between the duration of the pre-ejection phase (PPE) and the ejection phase. The first decreases whilst the second remains normal and their ratio changes, PPE/E changes from a normal value of 0.34 +/- 0.04 to 0.25 +/- 0.03. These tests are not only of value in diagnosis but also make it possible to observe the effects of treatment. It is certain that a true phonomechanographic syndrome of cardiac hyperkinesia may be described. The commonest, though not the only, aetiology is hyperthyroidism.