An Intron 9 CYP19 Gene Variant (IVS9+5G>A), Present in an Aromatase-Deficient Girl, Affects Normal Splicing and Is Also Present in Normal Human Steroidogenic Tissues.

BACKGROUND/AIMS: Splicing CYP19 gene variants causing aromatase deficiency in 46,XX disorder of sexual development (DSD) patients have been reported in a few cases. A misbalance between normal and aberrant splicing variants was proposed to explain spontaneous pubertal breast development but an incomplete sex maturation progress. The aim of this study was to functionally characterize a novel CYP19A1 intronic homozygote mutation (IVS9+5G>A) in a 46,XX DSD girl presenting spontaneous breast development and primary amenorrhea, and to evaluate similar splicing variant expression in normal steroidogenic tissues. METHODS: Genomic DNA analysis, splicing prediction programs, splicing assays, and in vitro protein expression and enzyme activity analyses were carried out. CYP19A1 mRNA expression in human steroidogenic tissues was also studied. RESULTS: A novel IVS9+5G>A homozygote mutation was found. In silico analysis predicts the disappearance of the splicing donor site in intron 9, confirmed by patient peripheral leukocyte cP450arom and in vitro studies. Protein analysis showed a shorter and inactive protein. The intron 9 transcript variant was also found in human steroidogenic tissues. CONCLUSIONS: The mutation IVS9+5G>A generates a splicing variant that includes intron 9 which is also present in normal human steroidogenic tissues, suggesting that a misbalance between normal and aberrant splicing variants might occur in target tissues, explaining the clinical phenotype in the affected patient.

[Bone mineral density of children and adolescents with congenital hypothyroidism]. / Densidade mineral óssea de crianças e adolescentes com hipotireoidismo congênito.

UNLABELLED: A cross sectional study was made on 60 patients (9.9 +/- 1.8 yr-old) with congenital hypothyroidism (CH) (group A): 40 girls (23 prepubertal) and 20 boys (18 prepubertal). Control group (group B) was constituted of 28 healthy children (10.4 +/- 2.1 yr-old): 18 girls (8 prepubertal) and 10 boys (9 prepubertal). AIMS: To evaluate bone mineral density (BMD) and content (BMC) and to correlate them with chronological and bone age (BA), sex, sexual maturation, l-T4 dose, TSH, TT4, FT4, and CH etiology. BA, total body BMD, and BMC (DXA) were obtained of both groups. TSH, TT4, and FT4 were measured in patients only. BMD was lower in group A (0.795 +/- 0.075 g/cm(2) vs. 0.832 +/- 0.092; p = 0.04) and higher in pubertal than in prepubertal girls (p = 0.004). There was no significant difference between BMD and BMC related to sex and CH etiology. Our data demonstrated that BMD was significantly lower in children with CH, different from what has been published in the literature.

Densidade mineral óssea de crianças e adolescentes com hipotireoidismo congênito / Bone mineral density of children and adolescents with congenital hypothyroidism

Realizou-se estudo transversal com 60 pacientes (9,9 ± 1,8 anos) com hipotireoidismo congênito (HC) (grupo A): 40 meninas (23 pré-púberes) e 20 meninos (18 pré-púberes), com grupo controle (grupo B) constituído por 28 indivíduos (10,4 ± 2,1 anos): 18 meninas (8 pré-púberes) e 10 meninos (9 pré-púberes). OBJETIVOS: Avaliar a densidade (DMO) e o conteúdo mineral ósseo (CMO) e correlacioná-los com idade cronológica e óssea (IO), sexo, maturação sexual, dose de l-T4, TSH, TT4, FT4, e etiologia do HC. IO, DMO e CMO de corpo total (DXA) foram obtidos dos 2 grupos; TSH, TT4 e FT4, apenas dos pacientes. DMO foi menor no grupo A (0,795 ± 0,075 g/cm² vs. 0,832 ± 0,092; p = 0,04) e maior nas meninas púberes do que nas pré-púberes (p = 0,004). Não houve diferença significativa de DMO e CMO quanto ao sexo e etiologia do HC. Nosso estudo mostra que a DMO foi significativamente menor no grupo com HC, diferente dos dados da literatura.

A cross sectional study was made on 60 patients (9.9 ± 1.8 yr-old) with congenital hypothyroidism (CH) (group A): 40 girls (23 prepubertal) and 20 boys (18 prepubertal). Control group (group B) was constituted of 28 healthy children (10.4 ± 2.1 yr-old): 18 girls (8 prepubertal) and 10 boys (9 prepubertal). AIMS: To evaluate bone mineral density (BMD) and content (BMC) and to correlate them with chronological and bone age (BA), sex, sexual maturation, l-T4 dose, TSH, TT4, FT4, and CH etiology. BA, total body BMD, and BMC (DXA) were obtained of both groups. TSH, TT4, and FT4 were measured in patients only. BMD was lower in group A (0.795 ± 0.075 g/cm² vs. 0.832 ± 0.092; p = 0.04) and higher in pubertal than in prepubertal girls (p = 0.004). There was no significant difference between BMD and BMC related to sex and CH etiology. Our data demonstrated that BMD was significantly lower in children with CH, different from what has been published in the literature.

Childhood adrenocortical tumours: a review.

Childhood adrenocortical tumour (ACT) is not a common disease, but in southern Brazil the prevalence is 15 times higher than in other parts of the world. One hundred and thirty-seven patients have been identified and followed by our group over the past four decades. Affected children are predominantly girls, with a female-to-male ratio of 3.5:1 in patients below 4 years of age. Virilization alone (51.6%) or mixed with Cushing's syndrome (42.0%) was the predominant clinical picture observed in these patients. Tumours are unilateral, affecting both glands equally. TP53 R337H germline mutations underlie most childhood ACTs in southern Brazil. Epidemiological data from our casuistic studies revealed that this mutation has ~10% penetrance for ACT. Surgery is the definitive treatment, and a complete resection should always be attempted. Although adjuvant chemotherapy has shown some encouraging results, its influence on overall outcome is small. The survival rate is directly correlated to tumour size; patients with small, completely excised tumours have survival rates close to 90%, whereas in those patients with inoperable tumours and/or metastatic disease it is less than 10%. In the group of patients with large, excisable tumours, half of them have an intermediate outcome. Recent molecular biology techniques and genomic approaches may help us to better understand the pathogenesis of ACT, the risk of developing a tumour when TP53 R337H is present, and to predict its outcome. An ongoing pilot study consisting of close monitoring of healthy carriers of the TP53 R337H mutation - siblings and first-degree relatives of known affected cases - aims at the early detection of ACTs and an improvement of the cure rate.

Tratamento do tumor do córtex adrenal na infância / Treatment of childhood adrenocortical tumor

O tumor do córtex adrenal (TCA) na infância é raro. Entretanto, no Paraná sua incidência é 15 vezes maior do que a observada em outros países. A mutação germinativa R337H TP53, presente em mais de 95 por cento dos nossos pacientes, provavelmente está relacionada à maior incidência. Cento e vinte e cinco pacientes foram tratados no período de 1966 a 2003. A cirurgia é o único tratamento curativo. Em nossa experiência, tumores no estádio I, ausência de spillage durante a cirurgia e ausência de trombo são parâmetros relacionados à maior sobrevida. Dados preliminares mostram que a associação de etoposídeo, doxorrubicina, cisplatina e mitotano produziu remissão completa do tumor e/ou das metástases em alguns pacientes. Os efeitos colaterais destas drogas são comuns e pode ocorrer insuficiência adrenocortical. As doses de reposição de glicocorticóides e mineralocorticóides devem ser 2 a 3 vezes maiores que as doses fisiológicas.

[Treatment of childhood adrenocortical tumor]. / Tratamento do tumor do córtex adrenal na infância.

Adrenocortical tumors (ACT) in children are uncommon. However, the incidence of these tumors in Paraná is 15 times higher than that worldwide. A germline mutation, R337H TP53, present in more than 95% of our patients, is probably the reason for the higher incidence in our state. A hundred twenty-five patients were treated in the period of 1966 to 2003. Surgery is the only curative treatment. In our experience, disease stage I, absence of spillage during surgery and absence of intravenous thrombus are associated with better survival rates. Preliminary data with the combination of etoposide, doxorubicin, cisplatin, and mitotane have shown that in some patients a complete remission is observed both of the tumor and metastasis. Side effects due to these drugs are common and adrenal insufficiency may occur. Glucocorticoid and mineralocorticoid reposition should be done with 2 to 3 times the physiological doses.

Amplification of the steroidogenic factor 1 gene in childhood adrenocortical tumors.

Southern Brazil has one of the highest incidences of childhood adrenocortical tumors (ACTs), occurring 10-15 times more frequently than worldwide estimates. The reasons for this increase remain elusive. In an attempt to further characterize the genetic changes in childhood ACTs, we recently detected a consistent gain of 9q (or a portion of it) in eight of nine cases of pediatric ACTs and amplification of 9q34 in the majority of these cases using comparative genomic hybridization. Other studies involving both childhood and adult ACTs have corroborated these findings. To follow up on these results, we examined whether the steroidogenic factor 1 (SF-1) gene, which is located in this chromosomal region and plays an important role in the development and function of the adrenal cortex is amplified in these ACT cases. We detected increased copy number of the SF-1 gene in all eight cases with 9q gain, suggesting an association between an increased copy number of the SF-1 gene and adrenocortical tumorigenesis.

Câncer de tireóide na infância e adolescência: relato de 15 casos / Thyroid cancer in childhood and adolescence: report of 15 cases

Tumores tireoideanos são raros na infância e adolescência. Foram revisados os prontuários de quinze pacientes (8 do sexo feminino) com idades entre 5,8 e 15,2 anos, atendidos na Unidade de Endocrinologia Pediátrica (UEP) do HC-UFPR entre fevereiro de 1988 e março de 2003. Nódulo cervical anterior foi a queixa inicial mais freqüente. Dez pacientes eram portadores de carcinoma papilífero (CP), quatro apresentavam carcinoma medular (CMT; dos quais, três com NEM-2B) e um, carcinoma folicular. Dois pacientes com NEM-2B apresentam mutação de novo (Met918Thr) do proto-oncogene RET. PAAF, efetuada em dez pacientes, foi positiva para neoplasia em cinco deles. Todos os pacientes foram submetidos a tireoidectomia total. Terapia adjuvante com 131I foi realizada em dez pacientes. Dois pacientes faleceram por doença não relacionada ao tumor. Nove pacientes não apresentam evidência clínica ou laboratorial do tumor; um (CP) apresentou recidiva 5 anos após o tratamento inicial e três (1 CP, 2 CMT) ainda têm evidência da doença. Nossos dados estão de acordo com a literatura em relação ao prognóstico e manifestações clínicas. Entretanto, a prevalência de CMT (27 por cento), a distribuição por sexo e os resultados da PAAF diferem da maioria das casuísticas publicadas, o que pode ser atribuído ao número de casos aqui relatado.

Tumores do córtex adrenal na infância / Childhood adrenocortical tumors

O tumor do córtex adrenal (TCA) na infância é raro. Entretanto, no Paraná sua incidência é 15 vezes maior do que a observada em outros países. Descrevemos as características clínicas, laboratoriais, tratamento e evolução de 125 pacientes atendidos em uma única instituição no Paraná. A média de idade ao diagnóstico foi de 4,3 anos, com uma relação feminino:masculino de 2,6:1. As formas clínicas mais comuns foram virilização isolada (51,2 por cento) e virilização e síndrome de Cushing (42 por cento). Em 4,8 por cento dos casos, os tumores foram não-funcionantes. Dois pacientes (1,6 por cento) apresentaram síndrome de Cushing isolado e 1 (0,8 por cento) síndrome de Conn. Hipertensão arterial ocorreu em 56 por cento dos pacientes. O único tratamento curativo é a cirurgia. Os dados da nossa casuística mostram que estádio clínico 1 do TCA, ausência de trombo intra-venoso e ausência de spillage durante a cirurgia estão associados a uma maior sobrevida.

[Childhood adrenocortical tumors]. / Tumores do córtex adrenal na infância.

Adrenocortical tumors (ACT) in children are uncommon. However, the incidence of these tumors in Paraná, Brazil, is 15 times higher than that worldwide. We describe the clinical, laboratory and treatment characteristics and outcome of 125 patients treated in a single institution in the State of Paraná. The median age at diagnosis was 4.3 years, with a female:male ratio of 2.6:1. The most common forms of presentation were isolated virilization (51.2%) and virilization and Cushing's syndrome (42%). Nonfunctioning tumors comprised 4.8% of the cases. Two patients (1.6%) had isolated Cushing's syndrome and 1 (0.8%) had Conn's syndrome. Fifty-six percent presented hypertension. Surgery is the only curative treatment. Our data show that disease stage 1, absence of spillage during surgery and absence of intravenous thrombus were associated with better survival rates.

[Thyroid cancer in childhood and adolescence--report of 15 cases]. / Câncer de tireóide na infância e adolescência--relato de 15 casos.

Thyroid tumors are rare in childhood and adolescence. A retrospective analysis was done of fifteen patients (8 female) with thyroid carcinoma attended in the Pediatric Endocrinology Unit of the HC-UFPR, from February 1988 to March 2003. The most frequent initial complaint was an anterior cervical nodule. Ten patients were papillary carcinoma (PTC) bearers, four had medullary carcinoma (MTC; three of them with MEN-2B) and one had follicular carcinoma. Two patients with MEN-2B have de novo proto-oncogene RET mutation (Met918Thr). Fine needle aspiration (FNA) was performed in ten patients and was malignancy positive in only five of them. All patients underwent total thyroidectomy. Adjuvant radioiodine (131I) therapy was made in ten patients. Two patients died from unrelated diseases. Nine patients presented no clinical or laboratorial evidence of disease; one (PTC) developed recurrence 5 years after initial treatment and three (1 PTC, 2 MTC) have disease evidence yet. Our prognosis and clinical manifestations data are according to the literature. However, MTC prevalence (27%), sex distribution and FNA results differ from the majority of published casuistics, that can be attributed to the number of cases reported here.

Evaluation of sensorimotor polyneuropathy in children and adolescents with type I diabetes: associations with microalbuminuria and retinopathy.

To investigate diabetic polyneuropathy, we measured peroneal motor conduction velocity, sural sensory nerve conduction velocity and vibratory sense threshold (biothesiometry) in 28 children and adolescents with insulin-dependent diabetes (type 1), and in 28 age- and sex-matched, normal controls. Age varied from 8 to 19 yr (mean +/- SD = 13.04 +/- 2.61); age at the onset of diabetes from 9 months to 12 yr (4.53 +/- 2.42 yr); and the duration of diabetes from 5 to 16 yr (8.48 +/- 2.98). Eight patients (28%) fulfilled the minimal criteria for the diagnosis of polyneuropathy. Four of these patients showed symptoms while three had clinical signs of neuropathy. Eight patients had abnormal, sural sensory nerve conduction velocities. The presence of polyneuropathy did not correlate with the duration of diabetes or degree of metabolic control of diabetes. The prevalence of microvascular complications (microalbuminuria and retinopathy) was 32%. The presence of microvascular complications did not correlate with metabolic control but did with the duration of diabetes. The relationship between polyneuropathy and microvascular complications was 34%.

Tratamento do hipertireoidismo na infância e adolescência / Treatment of hyperthyroidism in infancy and adolescence

A doença de Graves (DG) é responsável por mais de 90 por cento dos casos de hipertireoidismo em crianças . Na DG, o hipertireoidismo é causado por anticorpos estimuladores dirigidos contra o receptor do TSH, conhecidos como TRAb (TRAb, Thyrotropin Receptor Antibody), que mimetizam os efeitos do TSH. O hipertireoidismo pode, ainda, ser devido a mutaçöes nos genes do receptor do TSH ou da sub-unidade alpha da proteína G e secreçäo inadequada de TSH, ao passo que tireotoxicose pode ser causada por tireoidite de Hashimoto ou tiroidite sub-aguda. O tratamento inicial da DG é feito com drogras antitireoidianas (DAT)e o tratamento definitivo com DAT, tireoidectomia ou 131I. Nenhum oferece segurança, efetividade e eutireoidismo permanente, beta-bloqueadores podem ser usados para diminuir os sinais adrenérgicos. As DAT inibem a síntese de T3 e T4 e agem sobre o sistema imune; o propiltiouracil (PTU) diminui a conversäo periférica de T3 e T4. Recomenda-se PTU, 5-10mg /Kg/dia, em três tomadas; ou metimaµg/m2/dia) deve ser adicionada quando se obtém o eutireoidismo. A taxa de remissäo é muito baixa. efeitos adversos leves (rash cutâneo, náusea, cefaléia, artralgias)säo mais frequentes, enquanto os mais graves (hepatite, vasculite, purpura fulminans e agranulocitose) raros. A recidiva pode ser tratada como novo ciclo de DAT, tireoidectomia ou 131I. A taxa de mortalidade com a cirurgia é baixa (0,08 por cento) e o índice de cura éde 80 por cento. O 131I é seguro e econômico. Ultimamente tem sido utilizado com maior frequência como primeira opçäo de terapia definitiva em vários países. Doses elevadas säo utilizadas para se obter ablaçäo total da glândula. Repete-se o 131I se necessário. O hipotireoidismo (pós-cirurgia ou 131I) deve ser adequadamente tratado com L-tiroxina. A cirurgia e o 131I säo indicados nos hipertireoidismo por mutaçöes nos genes do receptor do TSH ou da subunidade alfa da proteína G. A cirurgia é a melhor opçäo nos tumores produtores de TSH. Na síndrome de resistência ao hormônio tireoidiano, T3 ou ácido tri-iodotiroacético (TRIAC) têm sido empregados. Causas de tireotoxicose por ruptura folicular säo manejadas apenas com beta-bloqueadores.