Adrenal insufficiency in a man with non-classical 21-hydroxylase deficiency: consequence or coincidence?

Deficiency of the adrenal enzyme 21-hydroxylase, which is required for cortisol synthesis, appears in two forms: a rare classical variant with severe enzyme deficiency, usually presenting in neonates with ambiguous genitalia (from androgen overproduction) or adrenal crisis (from glucocorticoid and mineralocorticoid underproduction), and a common (1% of the general population) non-classical variant with mild enzyme deficiency, usually presenting in young adults with findings of androgen excess but without clinical evidence of decreased steroid hormone production. We describe a 22-year-old man who had clinical and biochemical findings consistent with adrenal insufficiency, including a favorable response to hydrocortisone replacement, in whom elevated serum levels of the cortisol precursor 17-hydroxyprogesterone were diagnostic of non-classical 21-hydroxylase deficiency and in whom no other cause of adrenal insufficiency could be identified. These findings raise the possibility that non-classical 21-hydroxylase deficiency, an extremely frequent disorder which is generally thought to be without significant morbidity, might cause or contribute to adrenal insufficiency in adults.

Estrogen regulation of the nuclear 1,25-dihydroxyvitamin D3 receptor in rat liver and kidney.

We previously identified a receptor protein for 1,25-dihydroxyvitamin D3 in rat liver nuclei. The present studies were undertaken to investigate the ontogenesis of the hepatic nuclear vitamin D receptor (nVDR) and the estrogen regulation of this receptor in the liver, small intestine, and kidneys. The hepatic nVDR was significantly elevated in adult female rats compared to prepubertal female rats, while in male rats, this increase was not observed. Oophorectomized rats contained significantly less hepatic nVDR than did intact female rats. Administration of estradiol to castrated male or oophorectomized rats increased the hepatic nVDR. Further studies demonstrated that the increase in the hepatic nVDR was observed only after 2 weeks of estradiol treatment and was positively correlated with circulating estradiol concentrations. Castration of male rats did not alter the hepatic nVDR compared to intact male rats nor did testosterone administration to castrated male rats for 4 weeks change the hepatic nVDR concentration. Unlike the liver, intact female rats contained significantly less renal nVDR than did kidneys from intact male or castrated male rats. Estradiol administration to oophorectomized rats significantly decreased the renal nVDR. Renal nVDR concentrations correlated inversely with the serum concentration of estradiol. Castration of male rats had no effect on the renal nVDR. Intestinal nVDR concentrations were unaffected by castration of male rats or by treatment of castrated male rats with estrogen for up to 4 weeks. These results indicate that estradiol increases the nVDR in liver, decreases the nVDR in kidney and does not change the nVDR in the intestine. Physiological concentrations of testosterone do not regulate the nVDR in these tissues. Estradiol regulation of this receptor is organ specific and, therefore, conclusions about the regulation of the nVDR in one tissue cannot be extrapolated to other tissues.

In vitro dissolution of calcium carbonate preparations.

Calcium supplements are widely used for the treatment of osteoporosis. The bioavailability of these preparations is unknown. Because poor tablet dissolution accounts for a majority of drug bioavailability problems, we determined the in vitro dissolution at 30, 60, and 90 minutes of 27 commercially available calcium carbonate supplements using the method of the U.S. Pharmacopoiea. At 30 minutes, five preparations (18%) were more than 75% dissolved, four (15%) between 33 and 74%, and the remaining 18 (67%) were less than 33% dissolved. After 90 minutes, 17 (63%) of the preparations were less than 50% dissolved. Dissolution correlated negatively with the weight of filler (noncalcium carbonate material in the tablet) (rs = -0.51, P less than 0.01) but not with tablet hardness or cost. Similar to previous studies, we also found no correlation of dissolution with the stated calcium content, chemical source of calcium carbonate (oyster shell or chemical precipitate), or retail source. We conclude that there is a wide range of in vitro dissolution among the calcium carbonate preparations tested, and that the filler is an important determinant of the dissolution of these tablets. These results raise concern about the bioavailability of the calcium in these preparations and may have important implications for the therapeutic use of the various calcium carbonate supplements.

Identification and partial characterization of multiple forms of biologically active EGF in rat milk.

Milk from lactating Sprague-Dawley rats was assayed for epidermal growth factor (EGF)-like activities. A homologous radioimmunoassay (RIA) indicated the presence of immunoreactive material that competed in a nonparallel fashion with submandibular gland rat EGF (sm-r-EGF). The activity in the milk was extracted using antibodies to sm-r-EGF covalently linked to acrylamide beads. This activity was characterized by RIA, nondenaturing polyacrylamide gel electrophoresis, enzymatic digestion, radioreceptor assay, and ability to stimulate incorporation of [3H]thymidine into cultured fibroblasts. The presence of three distinct immunoreactive forms of EGF in rat milk were detected that competed with 125I-labeled r-EGF for binding to the EGF receptor and stimulated DNA synthesis in growth-arrested fibroblasts. Two of the forms are converted to the sm-r-EGF species by tryptic digestion as determined by RIA and migration rates in a nondenaturing polyacrylamide gel. The biological activities are stable to heating in 0.1 M acetic acid and also are stable at pH 9.0. Levels of r-EGF equivalents in milk were low at time of birth (6.3 +/- 1.7 ng/ml) and rose to 35.4 +/- 14.6 by days 4 to 6.

Intracellular processing of epidermal growth factor by early wound healing cells.

Epidermal growth factor (EGF) is a potent 53-amino-acid residue polypeptide that has been implicated in normal wound healing. Although past studies have shown that locally applied EGF accelerates wound healing, these studies have not examined intracellular events related to the processing of the growth factor. The objective of this study was to characterize both initial and later postbinding intracellular processing of EGF by a responsive cell line (osteoblasts) that is important in the healing of wounds. Cloned mouse calvarial osteoblasts (MC-3TC-E1) were incubated with radiolabeled EGF, with and without preincubation with nonlabeled EGF, for specific time intervals. Cell-associated radioactivity was characterized by nondenaturing polyacrylamide gel electrophoresis. Results showed that EGF is processed as three distinct species and that the relative proportions of these species are altered at later time periods when compared with initial processing. The patterns, similar to those reported for human fibroblasts, indicate a possible common pathway for the mitogenic signal in cells associated with the early events of wound healing. In addition, these data represent the first direct evidence that preexposure of cells to nonlabeled EGF alters the processing of radiolabeled EGF. This is significant, because cells must be exposed to EGF for 5 to 8 hours to elicit a growth response. Such data may help to explain the "lag phase" of wound healing.

The effects of lactation on bone mineral content in healthy postpartum women.

Bone mineral contents were estimated by dual photon absorptiometry of the lumbar spine (L2-L4) and single photon absorptiometry of the mid- and distal radius in 19 healthy women on their second postpartum day and at 6 months postpartum. All bone mineral measurements were performed by one technician, and the single and dual photon absorptiometry results were read by one observer. Daily oral calcium intakes were estimated from dietary histories obtained by a dietitian. Twelve women who breast-fed exclusively throughout the first 6 months postpartum were compared with seven formula-feeding women who did not breast-feed or who breast-fed for less than 3 months postpartum. No differences were found in age, parity, height, weight, or daily calcium intake between the breast- and formula-feeding women. Breast-feeding women had a significant decrease (averaging 6.5%) in bone mineral of the lumbar spine at 6 months postpartum as compared with 2 days postpartum (1.14 +/- 0.03 versus 1.22 +/- 0.03 g/cm2, mean +/- SEM; P less than .001), whereas no significant change occurred in the formula-feeding women at 6 months (1.24 +/- 0.03 versus 1.26 +/- 0.04 g/cm2). At 6 months postpartum, the breast-feeding women had a significantly lower mean bone mineral content of the lumbar spine than did formula-feeding women (P less than .05). No significant changes were noted in bone mineral content of the mid- or distal radius in either group of women during the period of evaluation. We conclude that during the first 6 months postpartum, breast-feeding is associated with bone mineral loss from the lumbar spine, but not from the mid- or distal radius.

A 1,25-dihydroxyvitamin D3 receptor-like protein in mammalian and avian liver nuclei.

The actions of 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3] are thought to be mediated through receptor proteins which have been described in a variety of avian and mammalian tissues, but not in the liver. To determine if a binding protein for 1,25-(OH)2D3 is present in this tissue, rat liver was homogenized in a low ionic strength buffer containing 10 mM Tris (pH 7.4), 2.2 m sucrose, 3 mM calcium chloride, 0.2% Triton X-100, and 0.04% Trasylol (sucrose buffer) and centrifuged over a 10-ml cushion of sucrose buffer at 61,000 x g for 80 min at 4 C. The resultant nuclear pellet was extracted in a 26 mM Tris (pH 7.4) buffer containing 0.3 M potassium chloride, 5 mM dithiothreitol, 1 mM EDTA, and 10 mM sodium molybdate. Saturable 1,25-(OH)2D3 binding was identified in high salt extracts of rat liver nuclei and was eliminated by treatment with trypsin. This liver binding protein cosediments on high salt 5-20% sucrose density gradients with the 1,25-(OH)2D3 receptor protein from intestine and is distinct from the 6.OS tissue binding protein for 25-hydroxyvitamin D3. Perfusion of rat liver with PBS to remove receptor-positive blood cells before isolation of the nuclei did not change 1,25-(OH)2D3 binding. The nuclear protein bound 1,25-(OH)2D3 more avidly than either 24,25-(OH)2 D3 or 25-hydroxyvitamin D3. Saturation analysis of 1,25-(OH)2D3 binding revealed an apparent equilibrium dissociation constant of 20.6 +/- 2.2 pM (mean +/- SEM) at 4 C and a maximum binding capacity of 49.0 +/- 14.6 fmol/extract from 1.0 mg DNA. The 1,25-(OH)2D3-binding binding protein was present in liver nuclei isolated from mice, rabbits, and chicks and in nuclei isolated from cultured rat hepatocytes. The ligand specificity, sedimentation coefficient, limited binding capacity, trypsin sensitivity, and nuclear location of the hepatic 1,25-(OH)2D3-binding protein are similar to those of 1,25-(OH)2D3 receptors described in other tissues and suggest that the liver may be a target organ for [1,25-(OH)2D3] action.

Inhibition of EGF processing in responsive and nonresponsive human fibroblasts.

We have examined the proteolytic processing of radiolabeled epidermal growth factor (EGF) in EGF growth-responsive human foreskin fibroblasts (HFF) versus EGF nonresponsive human fetal lung fibroblasts (HFL). Previous studies (Schaudies et al., 1985) have shown that both cell lines demonstrate similar binding affinities and numbers of binding sites, as well as similar rates of internalization and degradation of the bound, radiolabeled hormone. We have used nondenaturing electrophoresis to compare how these two cell lines process EGF at its carboxy terminus. EGF lacking either one [des-(53)-EGF] or six [des (48-53)-EGF] carboxy terminal amino acids could be distinguished by this method. Chloroquine or leupeptin were added to the incubation system in an attempt to accentuate potential differences in hormonal processing between the responsive and nonresponsive cell lines. In the absence of inhibitors, the responsive and nonresponsive cells generated similar distributions of processed forms of EGF after 30-minutes incubation. However, after 4-hours incubation in the constant presence of 125I-EGF, the electrophoretic profiles of extracted hormone were substantially different. The radiolabel within the responsive cells, as well as that released from them, migrated predominantly at the dye front, indicating complete degradation of EGF. In contrast, the majority of the radiolabel within the nonresponsive cells migrated as partially processed forms of hormone, while the released radiolabel migrated at the dye front. Addition of chloroquine to either cell line inhibited processing of EGF beyond removal of the carboxyl terminal arginine residue. Both intact 125I-EGF, and 125I-EGF lacking the carboxyl terminal arginine were released from chloroquine-treated cells in a ratio equal to that present in the intact cells. Incubations in leupeptin, proteolysis of EGF beyond the des-(48-53)-EGF was blocked; however, no large-molecular-weight species were released from the cells under these conditions.

Hypocalcemia with osteoblastic metastases in patient with prostate carcinoma. A cause of secondary hyperparathyroidism.

A 68 year old man with prostatic carcinoma and extensive painful osteoblastic metastases was discovered to have hypocalcemia (serum calcium 7.1 mg/dl) without evidence of hypoalbuminemia, renal failure or malabsorption. Baseline studies revealed hypocalciuria (24 hour urine calcium less than 5 mg/day), normal serum phosphate (3.4 mg/dl), low tubular reabsorption of phosphate (68 percent), undetectable serum calcitonin, normal serum 25-hydroxyvitamin D, slightly elevated serum parathyroid hormone level and increased urinary cyclic AMP (8.87 mumol/g creatinine). These studies were compatible with secondary hyperparathyroidism. The intravenous administration of parathyroid extract produced no further change in urinary phosphate but a 25-fold increase in nephrogenous cyclic AMP. Three days administration of intramuscular parathyroid extract slowly and temporarily restored serum calcium to normal levels while increasing urinary cyclic AMP and phosphate. Chemotherapy with cyclophosphamide and 5-fluorouracil rendered the patient free of pain while reducing serum acid and alkaline phosphatase levels and restoring serum total and ionized calcium and urinary cyclic AMP excretion to normal.

Pregnancy in the Turner syndrome with only 45,X chromosomal constitution.

A 31-year-old white female, 127 cm tall and with other findings of the Turner syndrome, had had normal menses and had become pregnant at ages 23 and 26 years. Chromosomal analyses of several tissues, including both ovaries, revealed only 45,X karyotypes. Both of her daughters had 46,XX karyotypes in lymphocytes. This patient and nine other reported cases of fertile, apparently nonmosaic 45,X women illustrate an extreme of ovarian function in the Turner syndrome and raise questions about the absolute need for XX oocytes in ovarian development. The possibility of pregnancy must be considered in all patients with Turner syndrome, a relatively common chromosomal disorder.

Skeletal responsiveness in pseudohypoparathyroidism. A spectrum of clinical disease.

Three cases of pseudohypoparathyroidism with roentgenographic evidence of hyperparathyroid bone disease are described. Renal resistance to exogenous parathyroid hormone (PTH), the hallmark of pseudohypoparathyroidism, was documented by markedly blunted or absent urinary phosphate and cyclic AMP responses to parathyroid extract. At the time of diagnosis all patients were hypocalcemic and hyperphosphatemic with elevated serum alkaline phosphatase levels and subperiosteal resorption noted on skeletal films. Bone biopsy in one patient revealed a histologic appearance consistent with hyperparathyroidism. Serum PTH levels, measured in two patients while they were hypocalcemic, were elevated. None of the patients had short stature, brachydactyly, subcutaneous calcification or mental deficiency. These cases are compared to the 15 well-documented cases previously reported. The presently available information on pseudohypoparathyroidism indicates a variable skeletal response to PTH mediated by several factors extrinsic to bone and suggests that pseudohypoparathyroidism with hyperparathyroid bone disease is one extreme of a clinical spectrum of skeletal responsiveness to PTH. This disorder is part of an expanding clinical picture which makes pseudohypoparathyroidism a diagnostic consideration in any patient with unexplained hypocalcemia, hyperphosphatemia, elevated alkaline phosphatase levels or metabolic bone disease.

Changes in brain levels of cyclic nucleotides and gamma-aminobutyric acid in barbiturate dependence and withdrawal.

Rats exposed to chronic intake of sodium barbital maintained high circulating levels of barbital in blood and brain and exhibited increased sensitivity ot audiogenic convulsions during the withdrawal period. Levels of gamma-aminobutyric acid (GABA), glutamate, guanosine 3',5'-monophosphate (cyclic GMP) and adenosine 3',5'-monophosphate (cyclic AMP) were measured in selected brain regions after sacrifice with high power microwave inactivation. Cyclic GMP during chronic barbital administration was significantly lower than controls in most brain regions, especially the hindbrain. During the withdrawal period cyclic GMP in the cerebellum was significantly increased, while returning at least to control levels in all other regions. GABA throughout the brain tended to be reduced during barbital dependence, while cyclic AMP and glutamate levels remained unchanged in all groups. These results indicate a possible role for cyclic GMP in the mediation of the central nervous system response during barbiturate dependence and withdrawal.

Regional levels of cyclic AMP in rat brain: pitfalls of microwave inactivation.

Techniques of in-vivo microwave irradiation to inactivate brain enzymes in rats were varied as to exposure configuration and output power. The rate at which metabolism was stopped was studied in various regions of the rat brain, using changes in levels of cyclic AMP and phosphodiesterase activity. Exposure times required to obtain stabilized levels of cyclic AMP varied in different brain regions, i.e., hypothalamus, cortex and cerebellum. Levels of cyclic AMP in selective regions of the brain decreased as more rapid inactivation was achieved. The authors identify important sources of variability of present microwave inactivation systems and the need for improved control of signficant microwave parameters.