Pituitary stalk interruption syndrome: A rare case report and literature review.

RATIONALE: Pituitary stalk interruption syndrome (PSIS) is a congenital pituitary anatomical defect. It is characterized by the triad of thin or interrupted pituitary stalk, absent or ectopic posterior lobe, and hypoplastic or aplastic anterior lobe. Moreover, this condition is considered rare. PATIENT CONCERNS: A 23-year-old male patient presented with a history of short stature and hypogonadism. Laboratory assessment revealed low thyroxine, cortisol, and adrenocorticotropic hormone levels, which are consistent with adrenal insufficiency without hypoglycemia. The insulin-induced hypoglycemia tolerance test finding indicated growth hormone (GH) deficiency. Moreover, magnetic resonance imaging revealed an interrupted pituitary stalk, ectopic posterior pituitary, and hypoplastic anterior pituitary. This triad of symptoms was indicative of PSIS. DIAGNOSIS: INTERVENTIONS:: The patient was deficient in adrenaline, thyroxine, gonadal steroid, and GH. Thus, glucocorticoid replacement therapy was initiated, followed by euthyrox, androgen, and human chorionic gonadotropin treatment. Calcium tablets, calcitriol, and alendronate sodium were used for the management of osteoporosis. The patient was 164 cm tall, and his bone age was approximately 15 years old. However, owing to a poor economic condition, the family did not proceed with GH therapy. OUTCOMES: The patient did not present with adrenal or hypothyroidism crisis after receiving poly-hormonal replacement therapy. His secondary sexual characteristics began to develop. However, owing to a short treatment window period, the patient could not receive the required treatment. Hence, whether the patient would have a normal fertility function needs to be confirmed. LESSONS: PSIS is a rare disease with various clinical characteristics. During the neonatal period and infancy, the signs and symptoms of PSIS are often not evident. Therefore, diagnosis is delayed. The early detection of hormone deficiency and treatment initiation can affect both the quality of life and the prognosis of patients with PSIS. Thus, the diagnosis and treatment of this disease must be improved to help patients achieve a better quality of life and to prevent reproductive health problems.

A new imaging entity consistent with partial ectopic posterior pituitary gland: report of six cases.

BACKGROUND: Abnormal posterior pituitary development including ectopic location has been associated with endocrine manifestations of anterior pituitary dysfunction. OBJECTIVE: We describe an unreported clinical and radiologic entity we call partial ectopic posterior pituitary for which associated endocrine consequences are not known. MATERIALS AND METHODS: We selected pediatric head MRI examinations from 2005 to 2017 based on the finding of a double midline sellar and suprasellar bright spot on T1-weighted sequence. Medical history, physical examination, pituitary hormonal profile and bone age evaluation were extracted from the medical record of the selected patients. An experienced pediatric neuroradiologist reviewed head MRIs, which were performed on 3-tesla (T) magnet and included at least sagittal T1-weighted imaging centered on the sella turcica obtained with and without fat suppression. RESULTS: In six cases, two midline bright spots were identified on T1-weighted sequences obtained both with and without fat suppression. While one spot was located at the expected site of the neurohypophysis in the posterior sella, the second one was in the region of the median eminence, suggesting partial ectopic posterior pituitary gland. Growth hormone deficiency, either isolated (n=1) or combined with thyroid stimulating hormone deficiency (n=1) was found. None of the children had clinical signs of posterior pituitary dysfunction. CONCLUSION: We describe an unreported imaging entity suggesting partial ectopic posterior pituitary gland in six children. Anterior pituitary hormone deficiencies might be detected in those children and long-term follow-up could provide additional information on the development of other pituitary hormone deficiencies.

Ectopic Posterior Pituitary, Polydactyly, Midfacial Hypoplasia and Multiple Pituitary Hormone Deficiency due to a Novel Heterozygous IVS11-2A>C(c.1957-2A>C) Mutation in the GLI2 Gene

A novel heterozygous IVS11-2A>C(c.1957-2A>C) mutation in the GLI2 gene is reported. There was an extremely distinct phenotypical expression in two siblings and their father. The index case was a boy who developed cholestasis and hypoglycaemia in the neonatal period. He had bilateral postaxial polydactyly, mid-facial hypoplasia, high palatal arch, micropenis, and bilateral cryptorchidism. Laboratory examination revealed a diagnosis of multiple pituitary hormone deficiency. There was severe anterior pituitary hypoplasia, absent pituitary stalk and ectopic posterior pituitary on magnetic resonance imaging which suggested pituitary stalk interruption syndrome with no other midline structural abnormality. Molecular genetic analysis revealed a novel heterozygous splicing IVS11-2A>C(c.1957-2A>C) mutation detected in the GLI2 gene. His father and a six-year-old brother with the identical mutation also had unilateral postaxial polydactyly and mid-facial hypoplasia although there was no pituitary hormone deficiency. This novel heterozygous GLI2 mutation detected appears to present with an extremely variable clinical phenotype, even in related individuals with an identical mutation, suggesting incomplete penetrance of this GLI2 mutation.

Diabetes insipidus.

Diabetes insipidus (DI) is a disorder characterized by excretion of large amounts of hypotonic urine. Central DI results from a deficiency of the hormone arginine vasopressin (AVP) in the pituitary gland or the hypothalamus, whereas nephrogenic DI results from resistance to AVP in the kidneys. Central and nephrogenic DI are usually acquired, but genetic causes must be evaluated, especially if symptoms occur in early childhood. Central or nephrogenic DI must be differentiated from primary polydipsia, which involves excessive intake of large amounts of water despite normal AVP secretion and action. Primary polydipsia is most common in psychiatric patients and health enthusiasts but the polydipsia in a small subgroup of patients seems to be due to an abnormally low thirst threshold, a condition termed dipsogenic DI. Distinguishing between the different types of DI can be challenging and is done either by a water deprivation test or by hypertonic saline stimulation together with copeptin (or AVP) measurement. Furthermore, a detailed medical history, physical examination and imaging studies are needed to ensure an accurate DI diagnosis. Treatment of DI or primary polydipsia depends on the underlying aetiology and differs in central DI, nephrogenic DI and primary polydipsia.

Bilateral Optic Disc Pits With Posterior Pituitary Ectopia.

Posterior pituitary ectopia has been reported previously in association with optic nerve hypoplasia, as a variant of septo-optic dysplasia. We describe a 14-year-old boy with posterior pituitary ectopia and bilateral optic disc pits. He had hypopituitarism and a reduction in visual acuity to 20/40 in each eye, owing to loss of foveal ganglion cells. Optic pits and posterior pituitary ectopia may have occurred together in the same subject by chance, but the rarity of both conditions suggests a possible association.

High-resolution heavily T2-weighted magnetic resonance imaging for evaluation of the pituitary stalk in children with ectopic neurohypophysis.

BACKGROUND: In anterior pituitary deficiency, patients with non visible pituitary stalk have more often multiple deficiencies and persistent deficiency than patients with visible pituitary stalk. OBJECTIVE: To compare the diagnostic value of a high-resolution heavily T2-weighted sequence to 1.5-mm-thick unenhanced and contrast-enhanced sagittal T1-weighted sequences to assess the presence of the pituitary stalk in children with ectopic posterior pituitary gland. MATERIALS AND METHODS: We retrospectively evaluated the MRI data of 14 children diagnosed with ectopic posterior pituitary gland between 2010 and 2014. We evaluated the presence of a pituitary stalk using a sagittal high-resolution heavily T2-weighted sequence and a 1.5-mm sagittal T1-weighted turbo spin-echo sequence before and after contrast medium administration. RESULTS: A pituitary stalk was present on at least one of the sequences in 10 of the 14 children (71%). T2-weighted sequence depicted the pituitary stalk in all 10 children, whereas the 1.5-mm-thick T1-weighted sequence depicted 2/10 (20%) before contrast injection and 8/10 (80%) after contrast injection (P=0.007). CONCLUSION: Compared with 1.5-mm-thick contrast-enhanced T1-weighted sequences, high-resolution heavily T2-weighted sequence demonstrates better sensitivity in detecting the pituitary stalk in children with ectopic posterior pituitary gland, suggesting that contrast injection is unnecessary to assess the presence of a pituitary stalk in this setting.

The Missing Link: A Case of Absent Pituitary Infundibulum and Ectopic Neurohypophysis in a Pediatric Patient with Heterotaxy Syndrome.

We report a case of absent pituitary infundibulum and ectopic neurohypophysis in a 4-year-old patient presenting clinically with hypopituitarism as well as heterotaxy syndrome complicated by global developmental delay and growth retardation. The clinical and laboratory workup of our patient suggested underlying hypopituitarism related to either congenital or acquired pathology, necessitating MRI to distinguish between them. We explain the various structural causes of hypopituitarism and detail how to predict the MRI findings and treatment, based on a fundamental understanding of the anatomy and pathophysiology of the hypothalamic pituitary axis and distinguishing anterior versus posterior pituitary hormone derangements. We also discuss two important theories widely acknowledged in the literature to explain congenital hypopituitarism: 1. Head trauma typically during birth resulting in a stretch injury to the infundibulum. 2. Congenital fetal maldevelopment of midline structures.

Two novel heterozygous missense variations within the GLI2 gene in two unrelated Argentine patients.

Several heterozygous GLI2 gene mutations have been reported in patients with isolated GH deficiency (IGHD) or multiple pituitary hormone deficiency (MPHD) with or without other malformations. The primary aim of this study was to analyze the presence of GLI2 gene alterations in a cohort of patients with IGHD or MPHD and ectopic/absent posterior pituitary. The coding sequence and flanking intronic regions of GLI2 gene were amplified and directly sequenced from gDNA of 18 affected subjects and relatives. In silico tools were applied to identify the functional impact of newly found variants (Polyphen2, SIFT, Mutation Taster). We identified two novel heterozygous missense variations in two unrelated patients, p.Arg231Gln and p.Arg226Leu, located in the repressor domain of the protein. Both variations affect highly conserved amino acids of the Gli2 protein and were not found in the available databases. In silico tools suggest that these variations might be disease causing. Our study suggests that the GLI2 gene may be one of the candidate genes to analyze when an association of pituitary hormone deficiency and developmental defects in posterior pituitary gland. The highly variable phenotype found suggests the presence of additional unknown factors that could contribute to the phenotype observed in these patients.

Two novel heterozygous missense variations within the GLI2 gene in two unrelated argentine patients / Two novel heterozygous missense variations within the GLI2 gene in two unrelated Argentine patients

Several heterozygous GLI2 gene mutations have been reported in patients with isolated GH deficiency (IGHD) or multiple pituitary hormone deficiency (MPHD) with or without other malformations. The primary aim of this study was to analyze the presence of GLI2 gene alterations in a cohort of patients with IGHD or MPHD and ectopic/absent posterior pituitary. The coding sequence and flanking intronic regions of GLI2 gene were amplified and directly sequenced from gDNA of 18 affected subjects and relatives. In silico tools were applied to identify the functional impact of newly found variants (Polyphen2, SIFT, Mutation Taster). We identified two novel heterozygous missense variations in two unrelated patients, p.Arg231Gln and p.Arg226Leu, located in the repressor domain of the protein. Both variations affect highly conserved amino acids of the Gli2 protein and were not found in the available databases. In silico tools suggest that these variations might be disease causing. Our study suggests that the GLI2 gene may be one of the candidate genes to analyze when an association of pituitary hormone deficiency and developmental defects in posterior pituitary gland. The highly variable phenotype found suggests the presence of additional unknown factors that could contribute to the phenotype observed in these patients.

Mutaciones heterocigotas en el gen GLI2 fueron previamente comunicadas como causa de déficit aislado de hormona de crecimiento (IGHD) o déficit múltiple de hormonas hipofisarias (MPHD), con o sin otras malformaciones. El objetivo del estudio fue analizar la presencia de alteraciones en el gen GLI2 en un grupo de pacientes con IGHD o MPHD acompañado de neurohipófisis ectópica o ausente. La secuencia codificante y las regiones intrónicas flanqueantes del gen GLI2 fueron amplificadas y secuenciadas de manera directa a partir de ADN genómico extraído de sangre periférica proveniente de 18 sujetos afectados y sus familiares. Se utilizaron herramientas informáticas para predecir el impacto funcional de las nuevas variantes encontradas (Polyphen2, SIFT, Mutation Taster). Identificamos dos nuevas variantes heterocigotas con pérdida de sentido en dos pacientes no relacionados, p.Arg231Gln y p.Arg226Leu, localizadas en el dominio represor de la proteína. Estas variantes afectan aminoácidos altamente conservados en la secuencia proteica de GLI2 y no se encuentran informadas en las bases de datos disponibles. Las herramientas informáticas utilizadas sugieren que estas variantes pueden ser la causa del desarrollo de la enfermedad. Nuestro resultados indican que el gen GLI2 es uno de los genes candidatos a estudiar cuando existe una asociación entre déficit de hormonas hipofisarias y alteraciones en el desarrollo de la neurohipófisis. Se sugiere la existencia de otros factores adicionales que podrían contribuir a la variabilidad del fenotipo observado.

A case of presumably Rathke's cleft cyst associated with postoperative cerebrospinal fluid leakage through persisting embryonal infundibular recess.

Persisting embryonal infundibular recess (PEIR) is a rare anomaly of the third ventricular floor. Only eight cases have been published. In this report, a case of presumably Rathke's cleft cyst associated with cerebrospinal fluid leakage caused by PEIR is described. An 81-year-old woman underwent endoscopic transsphenoidal surgery for the intra- and supra-sellar cystic lesion. Intraoperatively a hole was confirmed over the sella turcica connecting the sellar cyst and the infundibular recess. Liquorrhea did not occur throughout the procedure. A computed tomography (CT) scan obtained immediately after surgery disclosed accumulation of air in the third and lateral ventricles, in addition to the intra- and supra-sellar region. Air accumulation resolved spontaneously after bed rest for 11 days and she was discharged without neurological deficits. However, she required the second transsphenoidal surgery to repair the sellar floor because of bacterial meningitis caused by liquorrhea on the postoperative day 23. A postoperative 3-tesla magnetic resonance image revealed a deep infundibular recess connecting the sella turcica and the third ventricle, which was considered to be PEIR. To the best our knowledge, this is the first reported case describing the intraoperative findings of PEIR.

Análise molecular do gene HES1 em pacientes portadores de hipopituitarismo congênito / Molecular analysis of the HES1 gene in patients with congenital hypopituitarism

Estudos em modelos animais transgênicos possibilitaram o conhecimento de parte dos genes envolvidos na embriogênese hipofisária e da etiologia genética do hipopituitarismo em humanos. Entretanto, a etiologia da maior parte dos casos de hipopituitarismo congênito, principalmente os associados à neuro-hipófise ectópica (NE), ainda é pouco definida. Mutações no gene PROP1 são a causa genética mais comum de hipopituitarismo descritas até o momento, mas estão sempre associadas à neuro-hipófise tópica. Estudos destinados a esclarecer o mecanismo molecular da mutação do gene Prop1 em camundongos demonstraram a participação da via de sinalização Notch e de seus componentes, dentre eles, o gene Hes1. O HES1 é um gene que codifica um fator de transcrição que participa de estágios precoces do desenvolvimento hipofisário e está envolvido com a morfogênese da neuro-hipófise. A avaliação do camundongo com nocaute em homozigose deste gene acarreta uma hipoplasia da adeno-hipófise e ausência da neuro-hipófise; e sua expressão constitutiva está associada ao hipopituitarismo. Como a NE é um achado comum no hipopituitarismo congênito e o gene HES1 pode estar relacionado a sua fisiopatologia, a região codificadora do gene HES1 foi avaliada em 192 pacientes com hipopituitarismo congênito. A variante alélica c.578G > A (p.G193D) em heterozigose foi encontrada em um paciente com hipopituitarismo congênito associado à NE. A avaliação da predição in silico do efeito funcional da variante pela ferramenta MutationTaster sugere que a troca do aminoácido glicina, altamente conservado entre os mamíferos, por ácido aspártico, seja deletéria. No estudo da segregação familiar, quatro irmãos aparentemente normais apresentam a mesma variante, sendo que dois deles possuem alterações discretas na imagem da hipófise. Em conclusão, esta é uma nova variante alélica descrita no gene HES1, ausente em grandes bancos de dados e controles saudáveis da população brasileira, mas presente em irmãos não...

Studies of transgenic animal models have allowed for the discovery of genes involved in human pituitary embryogenesis and the genetic etiology of hypopituitarism. However, the genetic causes of most cases of congenital hypopituitarism, especially those associated with an ectopic posterior pituitary, remain poorly defined. Mutations in the gene PROP1 are the most common genetic causes of hypopituitarism described to date, and are always associated with an ectopic posterior pituitary. Studies to elucidate the molecular mechanisms of Prop1 mutations in mice have demonstrated the involvement of the Notch signaling pathway, including its downstream target Hes1. The HES1 gene encodes a transcription factor that participates in early stages of pituitary development and is involved in posterior pituitary morphogenesis. Hes1 knockout mice exhibit a hypoplastic anterior pituitary and absence of a posterior pituitary. Conversely, constitutive expression of Hes1 is associated with hypopituitarism. Since an ectopic posterior pituitary is commonly found in congenital hypopituitarism and the HES1 gene may be related to its pathophysiology, the coding region of gene HES1 was screened in 192 patients with congenital hypopituitarism. A heterozygous allelic variant c.578G >A (p.G193D) was identified in a patient with congenital hypopituitarism associated with an ectopic posterior pituitary. Assessment by MutationTaster, a bioinformatic tool for in silico prediction of functional effect of missense variants, suggests that substitution of glycine (a highly conserved amino acid in this position among mammals) for aspartic acid is deleterious. In the genetic study of family members, we identified four apparently normal siblings with the same variant, two of which have discrete changes in their pituitary MRI. In conclusion, we described a new allelic variant in the gene HES1, absent in large databases and healthy Brazilian controls, but present in the unaffected...

Screening of LHX2 in patients presenting growth retardation with posterior pituitary and ocular abnormalities.

BACKGROUND: In humans, pituitary hormone deficiency may be part of a syndrome including extra-pituitary defects like ocular abnormalities. Very few genes have been linked to this particular phenotype. In the mouse, Lhx2, which encodes a member of the LIM (Lin-11, Isl-1, and Mec-3) class of homeodomain proteins, was shown to be expressed during early development in the posterior pituitary, eye, and liver, and its expression persists in adulthood in the central nervous system Lhx2(-/-) mice display absence of posterior pituitary and intermediate lobes, malformation of the anterior lobe, anophthalmia, and they die from anemia. METHODS: We tested the implication of the LHX2 gene in patients presenting pituitary hormone deficiency associated with ectopic or nonvisible posterior pituitary and developmental ocular defects. A cohort of 59 patients, including two familial cases, was studied. Direct sequencing of the LHX2 coding sequence and intron/exon boundaries was performed. LHX2 transcriptional activity on several pituitary promoters (AGSU, PRL, POU1F1, and TSHB) was tested in vitro. RESULTS: Six heterozygous sequence variations were identified, among which two are novel missense changes (p.Ala203Thr and p.Val333Met). In vitro, LHX2 activates transcription of TSHB, PRL, and POU1F1 promoters in the HEK293 cell line. A synergistic action of POU1F1 and LHX2 was also shown on these promoters. The two missense variations were tested and no significant difference was observed, leading to the conclusion that they are not deleterious. CONCLUSIONS: These results suggest that if LHX2 is involved in pituitary hormone deficiency associated with posterior pituitary and ocular defects, it would be a rare cause of this disease condition.

The pituitary stalk transection syndrome: multifaceted presentation in adulthood.

The pituitary stalk transection syndrome was characterized after introducing the MRI scan in the evaluation of children with hypopituitarism. Its prevalence and natural history into adulthood have not been clearly established. We present 4 cases of stalk transection syndrome diagnosed by the adult endocrinologist that reflect its pleiotropic manifestations. In all cases, MRI showed pathognomonic findings with small anterior pituitary, diminutive or absent infundibulum and ectopic posterior pituitary at the median eminence. Clinical presentation occurred in childhood or the second decade of life. The hormonal deficits were variable in severity and onset, with adrenal insufficiency diagnosed in the second and forth decade in three patients, and absent in another. Growth hormone deficiency was diagnosed before age 10 in three cases and at age 20 in one case with normal spontaneous linear growth. Hypothyroidism had onset in the first or second decade of life and hypogonadism was diagnosed during work-up for lack of pubertal development in all cases. The pituitary stalk transection syndrome should be considered in patients who were previously thought to have idiopathic GH deficiency or multiple pituitary hormone deficiencies. Presence of MRI characteristics compatible with the pituitary stalk transection syndrome should prompt a full pituitary hormonal evaluation. Long-term follow-up by the adult endocrinologist is warranted as new hormone deficiencies might appear later in life.

[Hypoplasia adrenal congenita of anencephalic type: two cases with pituitary abnormalities and review of literature]. / L'hypoplasie surrénale congénitale de type anencéphalique: deux cas avec anomalies hypophysaires, sans mutation de DAX-1 et SF-1 et revue de la littérature.

Hypoplasia adrenal congenita is an extremely uncommon disease of early onset. This condition can be lethal in the absence of treatment. Some forms are due to the congenital adrenal hypoplasia of anencephalic type whose origin is even unknown. Here, we present two cases of congenital adrenal hypoplasia of anencephalic type with pituitary abnormalities. The two male newborns died because adrenal insufficiency in the neonatal period. The adrenal glands were hypoplastic with a histological structure of anencephalic type Immunocytochemical study of the pituitary revealed an absence of the gonadotrophs. No mutation of DAX 1 and SF-1 was found.

Análise dos genes GHRH e GL12 em pacientes com deficiência de hormônio do crescimento congênita / GHRH and GLI2 genes analysis in patients with congenital growth hormone deficiency

Introdução: Alterações em genes relacionados com a secreção de GH ou a organogênese hipofisária foram identificadas em pacientes com deficiência de hormônio do crescimento (DGH) congênita. Entretanto, poucos casos de DGH têm sua etiologia esclarecida. O GHRH é um candidato óbvio para explicar a deficiência isolada de GH (DIGH). Na literatura, os estudos de análise do GHRH não conseguiram identificar mutações, porém são antigos e utilizaram uma metodologia com limitações. A maioria dos pacientes com deficiência hipotálamo-hipofisária múltipla (DHHM) apresenta neuroipófise ectópica sugerindo a importância do estudo de genes que atuam no início do desenvolvimento hipofisário, com expressão inclusive no infundíbulo. O GLI2 é um fator de transcrição na sinalização Sonic Hedgehog, envolvido com o início da embriogênese hipofisária, expresso na bolsa de Rathke primordial e no diencéfalo ventral. Previamente, mutações no GLI2 foram encontradas em pacientes com holoprosencefalia, e também alterações hipofisárias. Objetivos: Analisar o GHRH em 151 pacientes com DIGH (42 brasileiros e 109 encaminhados de centros internacionais) e analisar o GLI2 em 180 pacientes brasileiros com DIGH ou DHHM por PCR e sequenciamento automático dos genes; e descrever o fenótipo dos pacientes com mutações identificadas. Resultados: No GHRH foram identificadas seis variantes em heterozigose com previsão benigna pelas análises in silico. A análise do GLI2 identificou três mutações novas em heterozigose com códon de parada prematuro (p.L788fsX794, p.L694fsX722 e p.E380X), e geração de proteínas truncadas, com perda do domínio responsável pela ativação transcricional. A mutação p.L788fsX794 foi identificada numa paciente com baixa estatura, polidactilia, epilepsia e hipoglicemias. Apresentava deficiência de GH, TSH, ACTH, prolactina, LH e FSH. Na investigação familiar foi diagnosticada DIGH em dois tios e DHHM numa prima. Estes familiares, além de sua mãe e outros parentes maternos também...

Introduction: Alterations in genes related to GH secretion and pituitary organogenesis have been identified in patients with congenital GH deficiency (GHD). However, in only few cases of GHD the etiology has been established. GH-releasing hormone (GHRH) is an obvious candidate to explain isolated GH deficiency (IGHD). Previous reports in the literature did not identify mutations in GHRH, however, the methodology used was limited. Most patients with combined pituitary hormone deficiency (CPHD) have an ectopic posterior pituitary lobe (EPP) suggesting the study of genes involved in early pituitary development and also expressed in the infundibulum. GLI2 is a transcription factor in Sonic hedgehog signaling expressed in the primordial Rathkes pouch and ventral diencephalon during early pituitary development. Previously, GLI2 mutations were found in patients with holoprosencephaly and pituitary abnormalities. Aim: Analyse GHRH in 151 patients with IGHD (42 Brazilian and 101 from international centers) and GLI2 in 180 Brazilian patients with IGHD or CPHD by PCR and automatic sequencing, and describe the phenotype of patients with mutations. Results: In GHRH, six heterozygous variants that are benign according to in silico analysis were identified. GLI2 study revealed three novel heterozygous mutations leading to premature stop codons (p.L788fsX794, p.L694fsX722 e p.E380X) and truncated proteins, without the transcriptional activator domain. p.L788fsX794 was identified in a girl with short stature, polydactyly, epilepsy and hypoglycemia. She had GH, TSH, ACTH, prolactina, LH and FSH deficiencies. Two uncles had IGHD and one cousin CPHD. These relatives, the mother and other maternal relatives had polydactyly and carried the mutation. p.L694fsX722 was identified in a boy with short stature due to GHD who also had cleft lip and palate. His healthy father also carried the mutation. p.E380X was identified in an infant with delayed development, hypoglycemia, polyuria...