Splice site mutations in GH1 detected in previously (Genetically) undiagnosed families with congenital isolated growth hormone deficiency type II.

BACKGROUND: Congenital isolated growth hormone deficiency (IGHD) is a rare endocrine disorder that presents with severe proportionate growth failure. Dominant (type II) IGHD is usually caused by heterozygous mutations of GH1. The presentation of newly affected family members in 3 families with dominant IGHD in whom previous genetic testing had not demonstrated a GH1 mutation or had not been performed, prompted us to identify the underlying genetic cause. METHODS: GH1 was sequenced in 3 Caucasian families with a clinical autosomal dominant IGHD. RESULTS: All affected family members had severe growth hormone (GH) deficiency that became apparent in the first 2 years of life. GH treatment led to a marked increase in height SDS. So far, no other pituitary dysfunctions have become apparent. In the first family a novel splice site mutation in GH1 was identified (c.172-1G>C, IVS2-1G>C). In two other families a previously reported splice site mutation (c.291+1G>A, IVS3+1G>A) was found. CONCLUSION: These data show that several years after negative genetic testing it was now possible to make a genetic diagnosis in these families with a well-defined, clearly heritable, autosomal dominant IGHD. This underscores the importance of clinical and genetic follow-up in a multidisciplinary setting. It also shows that even without a positive family history, genetic testing should be considered if the phenotype is strongly suggestive for a genetic syndrome. Identification of pathogenic mutations, like these GH1 mutations, has important clinical implications for the surveillance and genetic counseling of patients and expands our knowledge on the genotype-phenotype correlation.

Recognition of heat shock protein 60 epitopes in children with type 1 diabetes.

BACKGROUND: Treatment with a specific HSP60 epitope in new onset of type 1 diabetes (T1D) patients has been shown to preserve endogenous insulin production. Previously, recognition of pan HLA-DR-binding HSP60 epitopes in various autoimmune diseases was found; this study investigated recognition of these epitopes in newly diagnosed T1D patients and correlated findings to the occurrence of a partial remission. METHODS: Peripheral blood mononuclear cells of 18 children with T1D were prospectively collected at disease onset and a few months after diagnosis. Epitope-specific T-cell proliferation and cytokine production (intracellular and in culture supernatants) were measured. Results were compared with 31 longstanding T1D patients and ten healthy controls. RESULTS: Although HSP60 epitope-specific T-cell proliferative responses were detected, overall proliferative responses were low. At onset, epitope-specific intracellular IFN-γ production was higher in T1D patients compared with healthy controls (p < 0.05). At follow-up, both IL-10 and IFN-γ production were higher in those without a partial remission than in those with a partial remission (both p < 0.05). Also, IL-10 and IFN-γ production were higher compared with onset for patients without a PR (both p < 0.01). In supernatants of HSP60 epitope-specific T-cell cultures, no substantial differences in cytokine production were found between T1D patients with and without a partial remission, either at onset or a few months after onset. As patient numbers were small, results should be interpreted with caution. CONCLUSIONS: Pan-DR-binding HSP60 peptides induced low peptide-specific proliferative responses and peptide-specific production of some, mainly intracellular, cytokines in T1D patients. Recognition did not differ significantly between patient groups and various time points.

[Antipsychotics and metabolic abnormalities in children and adolescents: a review of the literature and some recommendations]. / Antipsychotica en metabole afwijkingen bij kinderen en adolescenten; een literatuuroverzicht en aanbevelingen voor de praktijk.

BACKGROUND: Adult patients with schizophrenia and bipolar disorder have an increased risk of developing the metabolic syndrome. This is due to their psychiatric illness and to the use of antipsychotic drugs. Children and adolescents are being treated more and more with antipsychotics. The risk of metabolic abnormalities in this age group remains unclear. AIM: To investigate the relationship between psychotic disorders in childhood and metabolic abnormalities and to study the influence of the use of both typical and atypical antipsychotics on this relationship. METHOD: The PubMed database was searched for relevant articles published between 2000 and June 2009. RESULTS: So far, research into the relationship between psychiatric disorders and metabolic abnormalities in children and adolescents has been inadequate. The normal values and meaning of the components of the metabolic syndrome in children and adolescents have not yet been firmly established. Children and adolescents who use antipsychotics run a significantly higher risk of weight gain. The younger the child, the greater the risk. There are no data about the risk of developing diabetes mellitus type 2. The influence of typical antipsychotics on these conditions has not been investigated. CONCLUSION: The risk of significant weight gain due to the use of atypical antipsychotics is greater in younger children. The 'metabolic syndrome' concept is not applicable to children and adolescents. Very little is known about metabolic risks in the long term. Caution is called for in the prescription of antipsychotics for children and adolescents and further research is needed.

[Follow-up of adult women with Turner's syndrome in a cohort study in Utrecht]. / Follow-up van volwassen vrouwen met het syndroom van Turner bij een Utrechts cohort.

OBJECTIVE: To evaluate the follow-up of adult women with Turner's syndrome. DESIGN: Cross-sectional study using questionnaires. METHOD: In August 2005 questionnaires were sent to 5 adult women with Turner's syndrome who were known to the Wilhelmina Children's Hospital in Utrecht, The Netherlands. The questions concerned morbidity, follow-up and levels of satisfaction with care and the provision of information about Turner's syndrome. Case notes were also examined. RESULTS: 38 questionnaires were returned, 19 from women aged 17-25 and 19 from women aged 26-42. 7 women had been without medical care for some time and 4 women were not receiving any medical care at the time of the study. The remaining women were being monitored by a general practitioner or one or more medical specialists. 6 of the 38 women were under the care of a cardiologist. 5 women had hypertension. 8 women had a renal malformation and, 5 of them were not having any renal follow-up. 8 women had undergone bone mineral density measurements in the preceding 5 years. The women between 17-25 years of age were more satisfied with the transfer of medical care from childhood to adulthood than those between 26-42 years of age. Most women felt they were well informed about Turner's syndrome. CONCLUSION: Medical care for adult women with Turner's syndrome in our study group was less than optimal. Cardiovascular risks in particular needed more attention. We advocate a multidisciplinary approach for the follow-up of women with Turner's syndrome.

An amino-terminal DAX1 (NROB1) missense mutation associated with isolated mineralocorticoid deficiency.

CONTEXT: Mutations in DAX1 (dosage-sensitive sex reversal-adrenal hypoplasia congenita critical region on the X chromosome gene 1; NR0B1) cause X-linked adrenal hypoplasia congenita, a disease characterized by primary adrenal failure, testicular dysgenesis, and gonadotropin deficiency. Most DAX1 mutations are deletions, nonsense, or frameshift mutations that markedly impair its transcriptional activity. Missense mutations have been restricted to the carboxy-terminal domain and are associated with more variable clinical phenotypes. OBJECTIVE: The objective was to identify novel clinical phenotypes associated with DAX1 missense mutations. PATIENTS AND DESIGN: We investigated the genetic basis of isolated mineralocorticoid deficiency in a patient who carries a unique missense mutation (W105C) in the amino-terminal region of DAX1. RESULTS: The W105C DAX1 mutation in the proband was present in three asymptomatic hemizygous males, but it was not detected in the general population. Using in vitro studies of DAX1 expression and function in transfected cells, we demonstrate that the mutant DAX1 protein exhibits mild loss of function, whether studied for genes it represses or for genes it activates. Structure-function studies suggest that the W105C and other mutations in the aminoterminus are compensated by the presence of repeated LXXLL motifs that mediate DAX1 interactions with other proteins. CONCLUSIONS: We describe the first missense mutation in the aminoterminus of DAX1 and conclude that mutations in this region may be partially compensated by redundant functional domains. Mild DAX1 mutations may be a cause of isolated mineralocorticoid deficiency.

[From gene to disease; congenital adrenal hypoplasia and the DAX-1 gene]. / Van gen naar ziekte; congenitale bijnierschorshypoplasie en het DAX-1-gen.

Congenital adrenal hypoplasia is an X-linked disorder resulting in adrenocortical deficiency, failure to complete puberty due to hypogonadotrophic hypogonadism, and infertility. The disease is caused by mutations in the DAX-1 gene. The DAX-1 protein is a transcription inhibitor; it represses the transcription of other, as yet mostly unknown, genes. Mutation analysis can confirm a clinical diagnosis of congenital adrenal hypoplasia. An early diagnosis might prevent critical damage due to an adrenal crisis in an undiagnosed patient. Molecular testing can be used for carrier detection and genetic counselling.

[When is a tall child too tall?]. / Wanneer zijn lange kinderen te lang?

3 children presented with tall stature. A 14-year-old girl of 179.6 cm was found to be within her target height range and was treated with oestrogen. A 15.5-year-old boy of 199,5 cm was beyond his target height range and was found to have a 47,XYY karyo- type; growth was inhibited with epiphysiodesis. A 12-year-old girl of 178.5 cm and very long legs was beyond her target height range but was found to have homocysteinaemia, a contraindication for hormonal- growth inhibition. her final height was 192 cm. Children growing above the 98th percentile of the growth curve are considered too tall. Most children with tall stature are constitutionally tall and remain within their target height range; no additional investigation is needed. In contrast, growth above this range or disproportionate growth and/or the presence of dysmorphic features in the child or parents warrants further investigation and may reveal important diagnoses. Height prediction based on bone age reading plays a key role in the management of tall children. Treatment with sex steroids may be used in an attempt to limit final height, but some conditions underlying tall stature are a contraindication for this treatment.

Laparoscopic identification and removal of focal lesions in persistent hyperinsulinemic hypoglycemia of infancy.

BACKGROUND: Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is a heterogeneous condition. A number of children have focal lesions, and removal of these lesions is curative. However, these lesions are difficult to detect, even during surgery. A laparoscopic approach is beneficial. METHODS: Two children with PHHI underwent laparoscopic pancreatic inspection at 32 and 29 days of age, respectively. RESULTS: In both children, a lesion was easily found in the head of the pancreas. The lesions looked more lobular, had a more pronounced blood supply, and appeared to have a firmer texture than the remaining pancreas. Enucleation was curative. CONCLUSION: A laparoscopic approach seems to be ideal for patients with PHHI not only because of the magnification but also because of the delicate surgery it allows and the avoidance of major abdominal wall problems.

Lung function abnormalities in children with type I diabetes.

Recent developments in intrabronchial administration of insulin raise lung function in patients with type I diabetes as important issue. Several studies in adults report abnormalities of lung function of these patients. The aim of this study was to investigate lung function in children with type I diabetes. Twenty-seven children with type I diabetes performed measurement of airway obstruction (forced flow-volume curves), lung volumes and airway resistance (bodyplethysmography) and of pulmonary carbon monoxide diffusion capacity Mean age (+/- SD) of the children was 12.8 +/- 5 years. Mean time between the detection of type I diabetes and the lung function tests was 5.5 years with a variation from I to 17 years. The total airway resistance (Raw) was significantly higher compared to the reference values (P < 0.001). The other lung function parameters were not significantly different from reference values (P > 0.05). In this relatively small study no relationship between lung function abnormalities and age, the duration of disease or level of HbA1c was observed. Our data show that increase of airway resistance do occur in children withtype I diabetes. Progressive abnormalities in lung function might interfere with the promising results of treatment with intrabronchial administration of insulin.

Genotype versus phenotype in families with androgen insensitivity syndrome.

Androgen insensitivity syndrome encompasses a wide range of phenotypes, which are caused by numerous different mutations in the AR gene. Detailed information on the genotype/phenotype relationship in androgen insensitivity syndrome is important for sex assignment, treatment of androgen insensitivity syndrome patients, genetic counseling of their families, and insight into the functional domains of the AR. The commonly accepted concept of dependence on fetal androgens of the development of Wolffian ducts was studied in complete androgen insensitivity syndrome (CAIS) patients. In a nationwide survey in The Netherlands, all cases (n = 49) with the presumptive diagnosis androgen insensitivity syndrome known to pediatric endocrinologists and clinical geneticists were studied. After studying the clinical phenotype, mutation analysis and functional analysis of mutant receptors were performed using genital skin fibroblasts and in vitro expression studies. Here we report the findings in families with multiple affected cases. Fifty-nine percent of androgen insensitivity syndrome patients had other affected relatives. A total of 17 families were studied, seven families with CAIS (18 patients), nine families with partial androgen insensitivity (24 patients), and one family with female prepubertal phenotypes (two patients). No phenotypic variation was observed in families with CAIS. However, phenotypic variation was observed in one-third of families with partial androgen insensitivity resulting in different sex of rearing and differences in requirement of reconstructive surgery. Intrafamilial phenotypic variation was observed for mutations R846H, M771I, and deletion of amino acid N682. Four newly identified mutations were found. Follow-up in families with different AR gene mutations provided information on residual androgen action in vivo and the development of the prepubertal and adult phenotype. Patients with a functional complete defective AR had some pubic hair, Tanner stage P2, and vestigial Wolffian duct derivatives despite absence of AR expression. Vaginal length was functional in most but not all CAIS patients. The minimal incidence of androgen insensitivity syndrome in The Netherlands, based on patients with molecular proof of the diagnosis is 1:99,000. Phenotypic variation was absent in families with CAIS, but distinct phenotypic variation was observed relatively frequent in families with partial androgen insensitivity. Molecular observations suggest that phenotypic variation had different etiologies among these families. Sex assignment of patients with partial androgen insensitivity cannot be based on a specific identified AR gene mutation because distinct phenotypic variation in partial androgen insensitivity families is relatively frequent. In genetic counseling of partial androgen insensitivity families, this frequent occurrence of variable expression resulting in differences in sex of rearing and/or requirement of reconstructive surgery is important information. During puberty or normal dose androgen therapy, no or only minimal virilization may occur even in patients with significant (but still deficient) prenatal virilization. Wolffian duct remnants remain detectable but differentiation does not occur in the absence of a functional AR. In many CAIS patients, surgical elongation of the vagina is not indicated.

Fetal sex determination from maternal plasma in pregnancies at risk for congenital adrenal hyperplasia.

OBJECTIVE: To determine first-trimester fetal sex by isolating free fetal DNA from maternal plasma. METHODS: The index case was a pregnant woman who previously delivered a girl with congenital adrenal hyperplasia. The SRY gene as a marker for the fetal Y chromosome was detected in maternal serum and plasma by quantitative polymerase chain reaction analysis. Simultaneously, we performed the same test in 25 and 19 women in the first and second trimester, respectively, and compared plasma results with fetal gender as assessed by prenatal karyotyping or as seen at ultrasound or birth. RESULTS: In 44 of 45 patients at gestational ages ranging from 8 3/7 to 17 3/7 weeks, we correctly predicted fetal sex using quantitative polymerase chain reaction analysis of the SRY gene in maternal plasma. In one case, the test result was inconclusive. Overall, fetal sex was correctly predicted in 97.8% of cases (95% confidence interval 88.2%, 99.9%). CONCLUSION: Amplification of free fetal DNA in maternal plasma is a valid technique for predicting fetal sex in early pregnancy. In case of pregnancies at risk for congenital adrenal hyperplasia, the technique allows restriction of dexamethasone treatment to female fetuses resulting in a substantial decrease of unnecessary treatment and invasive diagnostic tests.

Short stature as the only presenting feature in a patient with an isodicentric (Y)(q11.23) and gonadoblastoma. A clinical and molecular cytogenetic study.

A 13-year-old phenotypically female patient presented with short stature (height SDS -2.6), but without any Turner stigmata or other dysmorphic features. Chromosome analysis showed mosaicism for an isodicentric (idic) (Y)(q11.23) containing cell line and a 45,X cell line. Subsequent gonadectomy revealed a left streak ovary and a right ovary of abnormal appearance, which on histological examination appeared to contain a gonadoblastoma. DNA analysis showed that the proposed critical region of the gonadoblastoma locus on the Y chromosome was contained within the patient's idic (Y). Conclusion. The case described here shows that patients with 45,X/46,X, isodicentric (Yp) mosaicism and a female phenotype (1) can lack external virilisation but still have a gonadoblastoma and (2) do not necessarily have Turner stigmata but can present with only short stature. This case also underlines the importance of karyotyping patients with unexplained short stature to enable gonadectomy if Y-derived material is detected.

[Children with craniopharyngioma, a 'benign' brain tumor with a high morbidity]. / Kinderen met een craniofaryngioom, een 'goedaardige' hersentumor met grote morbiditeit.

The craniopharyngioma is a histologically benign tumour, mainly occurring in childhood. Neurosurgical treatment, in some of these patients in combination with external radiotherapy, results in a fair prognosis for children with craniopharyngioma. However, the central localisation of this tumour in the brain, damage of surrounding structures due to tumour growth, as well as the adverse effects of treatment will result in substantial morbidity in many patients. The first patient, a 13-year-old boy, presented with symptoms and signs of increased intracranial pressure. Following operation he was treated with radiotherapy, and up to 4 years after the operation there was no tumour recurrence. However, he experienced endocrine, visual, hypothalamic and intellectual disturbances due to the disease and its treatment. The second patient, a 6-year-old girl, presented with hydrocephalus due to the tumour, but also had growth retardation. After operation and radiotherapy, she had visual, endocrine, and intellectual dysfunction, but there were no signs of tumor recurrence. The third patient, an 12-year-old boy, already had growth retardation several years before he presented with neurological dysfunction. He received no postoperative radiation, as all tumour tissue could be removed. He had visual, hypothalamic, endocrine and intellectual disturbances but until nearly 6 years after the operation, there was no tumour recurrence. The morbidity due to the tumour and its treatment has a negative impact on the patient's quality of life. A multidisciplinary treatment and follow-up of these children cannot avoid this morbidity but may result in a timely observation of problems and thereby prevent unnecessary damage.

17Beta-hydroxysteroid dehydrogenase-3 deficiency: diagnosis, phenotypic variability, population genetics, and worldwide distribution of ancient and de novo mutations.

17Beta-hydroxysteroid dehydrogenase-3 (17betaHSD3) deficiency is an autosomal recessive form of male pseudohermaphroditism caused by mutations in the HSD17B3 gene. In a nationwide study on male pseudohermaphroditism among all pediatric endocrinologists and clinical geneticists in The Netherlands, 18 17betaHSD3-deficient index cases were identified, 12 of whom initially had received the tentative diagnosis androgen insensitivity syndrome (AIS). The phenotypes and genotypes of these patients were studied. Endocrine diagnostic methods were evaluated in comparison to mutation analysis of the HSD17B3 gene. RT-PCR studies were performed on testicular ribonucleic acid of patients homozygous for two different splice site mutations. The minimal incidence of 17betaHSD3 deficiency in The Netherlands and the corresponding carrier frequency were calculated. Haplotype analysis of the chromosomal region of the HSD17B3 gene in Europeans, North Americans, Latin Americans, Australians, and Arabs was used to establish whether recurrent identical mutations were ancient or had repeatedly occurred de novo. In genotypically identical cases, phenotypic variation for external sexual development was observed. Gonadotropin-stimulated serum testosterone/androstenedione ratios in 17betaHSD3-deficient patients were discriminative in all cases and did not overlap with ratios in normal controls or with ratios in AIS patients. In all investigated patients both HSD17B3 alleles were mutated. The intronic mutations 325 + 4;A-->T and 655-1;G-->A disrupted normal splicing, but a small amount of wild-type messenger ribonucleic acid was still made in patients homozygous for 655-1;G-->A. The minimal incidence of 17betaHSD3 deficiency in The Netherlands was shown to be 1: 147,000, with a heterozygote frequency of 1:135. At least 4 mutations, 325 + 4;A-->T, N74T, 655-1;G-->A, and R80Q, found worldwide, appeared to be ancient and originating from genetic founders. Their dispersion could be reconstructed through historical analysis. The HSD17B3 gene mutations 326-1;G-->C and P282L were de novo mutations. 17betaHSD3 deficiency can be reliably diagnosed by endocrine evaluation and mutation analysis. Phenotypic variation can occur between families with the same homozygous mutations. The incidence of 17betaHSD3 deficiency is 0.65 times the incidence of AIS, which is thought to be the most frequent known cause of male pseudohermaphroditism without dysgenic gonads. A global inventory of affected cases demonstrated the ancient origin of at least four mutations. The mutational history of this genetic locus offers views into human diversity and disease, provided by national and international collaboration.

Growth hormone treatment in a child with Williams-Beuren syndrome: a case report.

UNLABELLED: Growth retardation is a consistent finding in Williams-Beuren syndrome. The cause of short stature in this syndrome is unknown. Endocrine studies have failed to reveal abnormalities in the growth hormone-insulin-like growth factor I axis. We report a boy with confirmed Williams-Beuren syndrome, who was found to have classical growth hormone deficiency and responded well to growth hormone therapy. CONCLUSION: Although growth hormone deficiency is not likely to be a common cause of short stature in Williams-Beuren syndrome, we nevertheless recommend evaluation of the growth hormone-insulin-like growth factor I axis in all cases.

[A twelve-year old girl with diabetes mellitus type 2]. / En 12-jarig meisje met diabetes mellitus type 2.

A 12-year-old very obese girl was referred for hyperglycaemia. She had no complaints apart from a recent vaginal candidiasis. Non-insulin-dependent diabetes mellitus (type 2 diabetes) was diagnosed. She was started on a hypocaloric diet and on an oral hypoglycaemic agent (metformin 500 mg/day). This case illustrates the importance of awareness of the existence of type 2 diabetes in childhood and adolescence.

Rectal hydrocortisone during stress in patients with adrenal insufficiency.

OBJECTIVE: Patients with glucocorticoid deficiency need lifelong glucocorticoid replacement treatment. During acute stressful events, steroid dosage must be increased several times, which is often problematical in children. This study investigated the reliability of rectal hydrocortisone administration as an alternative to the intramuscular route. STUDY DESIGN: Serum cortisol was assessed during stress in normal children to determine the concentration that should be achieved after rectal hydrocortisone. Subsequently, serum cortisol concentrations were measured three hours after administering a suppository containing hydrocortisone 100 mg/m2 to 57 patients with adrenocortical insufficiency. In eight patients, the time dependency of the cortisol rise after rectal administration was established. RESULTS: In 51 previously healthy children admitted to hospital with an acute stressful condition, the mean serum cortisol concentration was 1092 nmol/l. Rectal hydrocortisone in patients with adrenocortical insufficiency resulted in a mean serum cortisol concentration of 1212 nmol/l three hours after insertion of the suppository containing hydrocortisone. In 14 of 57 children, serum cortisol was < 1000 nmol/l and in eight children it was below 600 nmol/l. One hour after administration, the mean cortisol concentration had reached 1000 nmol/l. This was sustained for more than four hours. CONCLUSION: Rectal hydrocortisone is a safe alternative to parenteral administration in the self management of Addisonian prone conditions. However, because eight of 57 children did not achieve concentrations > 600 nmol/l, its use is recommended only after previously documenting an adequate serum cortisol concentration three hours after receiving a test dose.