Growth impairment in a boy with late-onset congenital adrenal hyperplasia and anorexia nervosa

Treatment of congenital adrenal hyperplasia (CAH) in its salt-wasting form with appropriate doses of glucocorticoids and mineralocorticoids should promote growth, puberty and final height in a similar to normal pattern. However, the individual requirements for these drugs to normalize the hormonal profile and to achieve a physiologic growth pattern may differ. Moreover, the time of onset of puberty is also unpredictable since the course of the disease may predispose for precocity. The aim of this study was to explain the unexpected arrest of growth during puberty in a boy with late-onset CAH, who had been treated with glucocorticoid from early childhood. A short course of GnRH agonist treatment was also introduced in later years. The growth chart reflects two periods of impaired growth velocity preceded by weight loss. The reason for the first decline is difficult to prove retrospectively, but during the second episode the boy became both clinically and hormonally hypogonadal. At that time the anorexia nervosa (AN) was diagnosed according to APA DSM-IV criteria. We conclude that there were several reasons for the discontinued growth spurt and reduced final height in this boy with CAH: (a) early variant of puberty and subsequent late treatment with GnRH agonist, (b) AN possibly occurring during mid-childhood and clearly during puberty and (c) the repeated use of high doses of glucocorticoids. AN, a relatively rare disorder in boys, appears to have had a significant negative effect on this patient's growth and should be considered in the differential diagnosis in CAH children with impaired growth.

Growth hormone therapy for short children born small for gestational age

Children born small for gestational age may demonstrate continued growth retardation, resulting in persistent short stature. In the majority of the cases, this is linked with abnormal growth hormone secretion and also abnormal insulin-like growth factor levels. This review discusses the treatment of such children with recombinant human growth hormone. It illustrates the importance of starting therapy early, the dose-dependent response, and the advantages of continuous therapy and describes safety considerations.

Differences in infantile growth patterns in Turner syndrome girls with and without spontaneous puberty

OBJECTIVE

The role of prepubertal estrogen in child growth was modeled using Turner's syndrome, comparing growth patterns of girls who later did or did not enter puberty spontaneously. The hypothesis was that TS patients with normal prepubertal estrogen levels would have a different growth pattern from those with subnormal estrogen levels.

STUDY DESIGN

Growth data from 78 full-term patients with Turner's syndrome were collected retrospectively. 24/78 later developed spontaneous puberty, (+Pub), and their growth data were compared to TS patients without spontaneous puberty (-Pub). A nonlinear mixed model was fitted using the bi-exponential model.

RESULTS

The growth velocity difference between the -Pub and +Pub groups suggests an early infantile growth advantage in the -Pub group, which disappears before the end of the first year of life; growth velocity remains similar (+/- 1 cm/y) for the next 6 years and declines at age 7-8 years in the +Pub group faster than it does in the -Pub group. Bi-exponential analysis showed that both the 1st (restrictive) and 2nd exponent (forward) were different (p = 0.0003).

CONCLUSIONS

Comparison of girls with or without spontaneous puberty suggests a role for estrogen in child growth. Estrogens restrict infantile growth, as well as growth during the mid-childhood spurt.

Adult height after GH therapy in 188 Ullrich-Turner syndrome patients: results of the German IGLU Follow-up Study 2001

OBJECTIVES

We aimed to evaluate the factors influencing true adult height (HT) after long-term (from 1987 to 2000) GH treatment in Ullrich-Turner syndrome (UTS) based on modalities conceived in the 1980s.

DESIGN

Out of 347 near-adult (>16 Years) patients from 96 German centres, whose longitudinal growth was documented within KIGS (Pharmacia International Growth Database), 188 (45, X=59%; bone age >15 Years) were available for further anthropometric measurements.

RESULTS

At a median GH dose of 0.88 (10th/90th percentiles: 0.47/1.06) IU/kg per week, a gain of 6.0 (-1.3/+13) cm above the projected adult height was recorded. Variables were recorded at GH start, after 1 Year GH, puberty onset, and last visit on GH therapy. At these visits, the median ages were 11.7, 12.7, 14.2, 16.6 and 18.7 Years; and median heights, 0.4, 1.1, 1.7, 1.7 and 1.3 SDS (UTS) respectively. Height gain (DeltaHT) after GH discontinuation was 1.5 cm. Total DeltaHT correlated (P<0.001) negatively with bone age and HT SDS at GH start, but positively with DeltaHT after the first Year, DeltaHT at puberty onset, and GH duration. Final HT correlated (P<0.001) positively with HT at GH start, first-Year DeltaHT, and HT at puberty onset. Body mass index increased slightly (P<0.05), with values at start and adult follow-up correlating highly (R=0.70, P<0.001). No major side effects of GH occurred.

CONCLUSIONS

GH dosages conceived in the 1980s are safe but too low for most UTS patients. HT gain and height are determined by age and HT at GH start. Height gain during the first Year on GH is indicative of overall height gain. After spontaneous or induced puberty, little gain in height occurs.

Evidence for change of 11beta-hydroxysteroid dehydrogenase activity during infancy and childhood

The conversion of cortisol (F) to cortisone (E) is catalyzed by 11beta-hydroxysteroid dehydrogenase type 2. The present study was designed to investigate the changes of F and E plasma concentration as an indirect measurement of 11beta-hydroxysteroid dehydrogenase activity in infancy and childhood. Plasma samples were obtained from 262 healthy children and adolescents aged 1 d to 18 y. Plasma F and E were measured, using specific radioimmunoassays after extraction and automated Sephadex LH 20 chromatography. The F/E ratio was calculated to assess 11beta-hydroxysteroid dehydrogenase activity. During the first year of life, plasma F levels rose significantly (r(2) = 0,24; p = 0.01), and thereafter no further increase was seen until adulthood (r(2) = 0.01; p = 0.86). In contrast, plasma E significantly decreased during the first year of life (r(2) = -0.35; p<0.001) and stayed unchanged thereafter (r(2) = 0.02; p = 0.81). As a consequence, the F/E ratio rose significantly during the first year (r(2) = 0.67; p<0.001) but did not change afterward (r(2) = 0.001; p = 0.99). During the first year of life, there is a change from the predominance of E, with low mineralocorticoid receptor affinity, to F, with high mineralocorticoid receptor affinity. This shift corresponds to the declining plasma concentrations of aldosterone during infancy. The changes may indicate a not yet recognized, significant change of 11beta-hydroxysteroid dehydrogenase isoenzyme activity or alterations in the secretion of F and E, which may be of relevance for the development of arterial blood pressure in infancy.

Longitudinal analysis of growth over the first 3 years of life in Turner's syndrome

OBJECTIVE

To evaluate longitudinal growth in Turner's syndrome (TS) over the first 3 years of life.

METHODS

Growth of 47 patients with TS was compared with that of 40 age-matched control girls by using an analysis according to the Infancy-Childhood-Puberty and bi-exponential models.

RESULTS

A mean of 1.2 SDs were lost before birth and a total of 3.0 SDs were lost by age 3 years. According to the Infancy-Childhood-Puberty model, intrauterine growth retardation contributed -1.24 SDs, a 5-month delay in childhood growth spurt contributed -0.96 SDs, and slow childhood growth contributed an additional -0.8 SDs by age 3 years. The bi-exponential analysis disclosed a quasi-linear first exponent and a confining second exponent, which merged at age 18 months in control subjects and 24 months in patients with TS. The first exponent confers an average annual growth rate of 8.4 cm/y in control subjects and 6.7 cm/y in patients with TS.

CONCLUSIONS

Intrauterine growth retardation and the initial 3 years of life contribute most of the deficit in the final height of patients with TS. These data provide a reference of standards for longitudinal growth in patients with TS at age 3 months to 3 years.

The early mineralocorticoid effector mechanism, the sodium-proton exchanger, is sensitized in lymphocytes from patients with Cushing's syndrome

OBJECTIVE

In-vitro binding of aldosterone to mineralocorticoid receptors on human mononuclear leucocytes and its effects on the intracellular sodium and potassium concentrations, the sodium-proton exchanger and cell volume of human mononuclear leucocytes have been described for normals. In the present paper this easily accessible human cell model was studied in Cushing's syndrome to detect abnormalities of the mineralocorticoid effector mechanism.

DESIGN

The rate of cell swelling in isotonic sodium propionate reflecting the activity of the sodium-proton exchanger and the stimulatory activity of 1.4 nM aldosterone were determined in a Coulter Channelyzer.

PATIENTS

Nine female patients with pituitary-dependent (7) and adrenal hypercortisolism (2) were included in the study.

MEASUREMENTS

Compared with controls from matched normals, the cell volume of human mononuclear leucocytes in a physiological buffer was significantly increased in the patients. The increment of cell size in isotonic sodium propionate was elevated in the presence of 1.4 nM aldosterone only.

RESULTS

These findings are equivalent to an excess stimulation of the sodium-proton exchanger by aldosterone in these patients. Plasma cortisol was inversely correlated with the cell swelling in propionate.

CONCLUSIONS

These data indicate that the early mineralocorticoid effector mechanism in human mononuclear leucocytes from patients with Cushing's syndrome has an increased sensitivity to aldosterone compared with that from normals. This could reflect an adaptation of the cellular electrolyte metabolism to the decreased mineralocorticoid activity balancing the increased glucocorticoid activity. If representative of other cell systems, e.g. renal tubular cells, these findings would identify accompanying electrolyte disorders in these patients not as a side-effect of glucocorticoids, but as a result of an increased sensitivity to endogenous mineralocorticoids.

A new method for the determination of serum iron: potentiostatic coulometry with the Ferrochem 3050

Potentiostatic coulometry allows the fast determination of iron in serum samples of 50 microliters serum or less. Precision, accuracy, specificity and practicability of the method were evaluated using the Ferrochem 3050, and found to be favourable. This method can therefore be recommended to all laboratories in which small sample volumes have to be analysed.