Coexistent primary empty sella syndrome and hyperprolactinemia. Report of 11 cases.

The series involved 11 women with concurrent hyperprolactinemia and primary empty sella syndrome. Eight had amenorrhea and six had galactorrhea. All 11 patients had intact hypothalamic-pituitary function, except for having elevated prolactin levels that ranged from 33 to 498 ng/mL. One patient had primary hypothyroidism. Radiologic investigations included sellar polytomography in eight cases, computed tomography of the head in eight cases, bilateral carotid angiography in six cases, and pneumoencephalography in three cases. Of eight patients undergoing transsphenoidal exploratory surgery, one had a pituitary microadenoma and an empty sella while seven had only an empty sella with a flattened pituitary gland. Conventional histologic methods (seven cases) and immunocytologic studies (three cases) of the pituitary gland showed no abnormalities. The cause of this syndrome is unknown. It should be recognized that hyperprolactinemia, with or without galactorrhea-amenorrhea, may occur in association with an empty sella in the absence of an associated pituitary tumor.

A critical evaluation of energy expenditure estimates based on individual O2 consumption/heart rate curves and average daily heart rate.

To test the applicability of indirect estimation of daily energy expenditure from average daily heart rate (HR) and individual O2-intake/heart rate (VO2/HR) regression lines in subjects with metabolic disorders, VO2/HR regression lines were determined on 2 consecutive days in 17 subjects (five healthy, five with obesity, five with untreated thyrotoxicosis, two with anorexia nervosa). Daily energy expenditure was calculated by means of the average 24 h HR. Generally, there was a high correlation coefficient for the relationship between VO2 and HR, but the slopes and intercepts varied considerably from day to day, leading to poor agreement between duplicate estimates of energy expenditures, and not infrequently to physiologically meaningless values. Further studies, comprising determination of the VO2/HR regression lines in three different body positions on 7 different days in one experienced test subject showed great variability of the VO2/HR regression lines, both in the same position and in different positions. The applied procedure seems unsuitable for metabolic studies in individual patients who engage in ordinary daily activities with low energy expenditure.

Atypical measles syndrome: unusual hepatic, pulmonary, and immunologic aspects.

The atypical measles syndrome is a relatively new disease that was first recognized 15 years ago. Initially, it occurred in children who were exposed to wild measles virus several years after they were immunized with killed measles vaccine. It was characterized by a two- to three-day prodrome of high fever, cough, headache, and myalgia followed by a rash that resembled Rocky Mountain spotted fever, scarlet fever, or varicella and associated with roentgenographic evidence of pneumonia with or without pleural effusion. This report highlights three unusual manifestations of this syndrome: 1) transient hepatitis, 2) persistence of pulmonary lesions for several years, and 3) occurrence of excessively high measles hemagglutination-inhibition antibody titers. Today, this syndrome occurs predominantly in adolescents and young adults.

Live attenuated rubella virus vaccine: comparison of responses to HPV-77-DE5 and RA 27/3 strains.

The responses of seronegative adults to two live attenuated rubella virus vaccines were compared. Of 50 women who received the HPV-77-DE5 strain, 49 (98%) had an antibody response; the geometric mean antibody titer (GMT) was 1:38 at two to five months and 1:59 at six to 14 months. Of 66 women and three men who received the RA 27/3 strain all (100%) had an antibody response; the GMT was 1:55 at two to five months and 1:75 at six to 14 months. The incidence of mild to moderate transient clinical reactions, occurring in approximately one-fourth of those vaccinated, was similar for both groups. The serologic response to both vaccines was excellent.

Vertical transmission of HIV in New York State: a basis for statewide testing of newborns.

Infants (n = 313) of HIV-infected mothers were enrolled (mean age 1.9 weeks, range 0-8 weeks) in a 3-year prospective study of vertical transmission. Fifty-six infants (17.9%) had laboratory and clinical evidence of HIV infection. Polymerase chain reaction (PCR) provided early and reliable identification of infected infants. Thirty-one of the 56 infected infants had specimens submitted when the infants were 4 weeks of age or less and 30 (97%) tested PCR positive. This percentage increased to 100% by 8 weeks of age when 51 of the 56 infected infants had specimens tested for that time period. Immune complex dissociation (ICD) antigen testing was a sensitive method for diagnosis of infection but only in infants older than 1 month. p24 antigen testing, although free of false positives, is less sensitive than either of the other methods. Among surrogate markers of HIV infection, elevation of soluble CD8 levels precedes an increase in immunoglobulin levels or a decline in CD4 T lymphocytes. Vertical transmission is significantly lower in Central and Western New York State than other regions. Transmission is significantly higher in low birthweight babies and in infants whose mothers have CD4 counts < 500. This study provided the basis for establishing a Pediatric HIV PCR Testing Service for the early diagnosis of HIV infection in neonates.

Influence of dopaminergic inhibition on serum levels of thyrotrophin and prolactin in patients with hypothyroidism before and after prolonged oral administration of TRH.

Forty mg TRH/day given orally for 3 weeks to 8 patients with mild primary hypothyroidism decreased serum TSH from a mean of 4.0 ng/ml +/- 1.2 (SE) to 2.0 ng/ml +/- 0.4 (49%), and their mean incremental TSH response to iv TRH was equally reduced from 8.6 ng/ml +/- 2.5 to 4.0 ng/ml +/- 1.9 (46%). In the same patients serum Prl was 8.2 ng/ml +/- 2.2 before oral TRH treatment and 6.6 ng/ml +/- 1.5 (81%) after treatment, and the mean incremental Prl response to iv TRH was reduced from 43.5 ng/ml +/- 5.0 to 35.9 ng/ml +/- 7.5 (83%). The oral administration of 10 mg of the dopamine antagonist metoclopramide increased mean serum TSH from 0.6 ng/ml +/- 0.1 (SE) to 0.7 ng/ml +/- 0.1 (120%) in euthyroid subjects and from 4.0 ng/ml +/- 1.2 to 5.7 ng/ml +/- 1.6 (145%) in patients with primary hypothyroidism, and mean serum Prl from 8.6 ng/ml +/- 0.8 to 109.5 ng/ml +/- 24.3 (1251%) and from 8.2 ng/ml +/- 2.2 to 119.6 ng/ml +/- 45.5 (1460%), respectively. The incremental TSH responses to iv TRH increased 2.3-fold in euthyroid subjects pre-treated with metoclopramide, while no change was observed in the TSH responsiveness in patients with primary hypothyroidism following metoclopramide pre-treatment. In the euthyroid subjects metoclopramide treatment had no effect on the Prl response to iv TRH.(ABSTRACT TRUNCATED AT 250 WORDS)

Lack of effect of somatostatin on thyroid gland function in Graves' disease.

Five women with Graves' disease, 26-52 years of age, with serum concentrations of triiodothyronine (T3) 4.8-9.2 nmol/l and thyroxine (T4) 200-320 nmol/l were studied. A 26 h infusion of cyclic somatostatin (Bachem), 6 mg in isotonic saline solution was administered. Radioactive iodine i.v. (125I or 131I) was given immediately after the start of this infusion. Serum T3, T4 and conversion rate (CR% = PBRI: total RI X 100) were determined four times during the infusion, then daily for a week. The same studies, related to an injection of radioiodine, were performed during a control week when no somatostatin was administered. Arginine-stimulated insulin and growth hormone (hGH) concentrations were considerably lowered by the somatostatin infusion. No difference in serum T3, T4 or CR between the week that started with somatostatin infusion and the control week was observed. Twelve-26 h after the somatostatin infusion started, all patients experienced gastrointestinal symptoms, which lasted 2-6 h after somatostatin withdrawal. Somatostatin in the dose given does not inhibit thyroid gland function in Graves' disease.

Excessive sensitivity to the hyponatremic effect of chlorpropamide in a patient with diabetes mellitus and anterior pituitary insufficiency.

A 67-year-old diabetic woman with undiagnosed anterior pituitary insufficiency developed hyponatremic coma within 5 weeks after initiation of chlorpropamide therapy. A provocation test with 500 mg chlorpropamide orally led within five hours to hyponatremia and sopor with high urinary sodium excretion. This rapid development of the hyponatremic syndrome excludes water retention due to ADH as the dominant cause. It is more probable that known defects in renal sodium conservation, brought about by the anterior pituitary failure, have been potentiated by chlorpropamide.

Iodine induced thyrotoxicosis in apparently normal thyroid glands.

Two male patients aged 36 and 52 years with thyrotoxicosis revealed a serum T3 of 2.8 and 6.5 nmol/l and a serum T4 of 166 and 238 nmol/l, respectively. Both had been exposed to iodine (2-10 mg daily) for 2-12 months before thyrotoxicosis was diagnosed. Urinary iodine excretion was high, 5000 and 10,000 nmol/24 h (624-1250 microgram). The uptake of 131I in the thyroid glands were low, none had goitre. Their iodine intake was interrupted, urinary iodine excretion gradually decreased, and T3 and T4 in serum concomitantly normalized. They were clinically and biochemically euthyroid 9 and 11 weeks after withdrawal. After 14 and 22 weeks they had normal thyroid uptake of 131I, and thyroid scans showed glands of normal size and configuration. TRH-stimulation and a T3-suppression tests became normal. ESR was not elevated in any of the cases, thyroid antibodies against thyroglobulin and follicular cell microsomes were absent and TSAb was undetectable durng the thyrotoxic stage. Thus no evidence of any pre-existing and/or pre-disposing pathological condition in the thyroid glands were found. The mechanism for the iodine-induced thyrotoxicosis in such cases remains obscure.

Effect of prolonged oral administration of TRH on plasma levels of thyrotrophin and prolactin in normal individuals and in patients with primary hypothyroidism.

Forty mg TRH/day was given orally for 3 weeks to 10 euthyroid women and 10 women with primary hypothyroidism on low replacement doses of thyroxine. Once weekly oral TRH was replaced by an iv TRH-test (0.4 mg) with measurement of serum concentration of TSH, prolactin (PRL), thyroxine (T4), triiodothyronine (T3) and cholesterol. In the normal group, mean serum T4 concentration increased after one week and remained elevated. Serum TSH concentration showed a slight tendency to decline. Maximal rise in TSH concentration after iv TRH (deltaTSH) fell from a mean of 4.0 ng/ml to 1.4 ng/ml within one week and stayed low. T3, cholesterol, PRL and deltaprl were normal and unchanged throughout. In the hypothyroid group T4, T3, cholesterol, PRL and deltaPRL were not influenced by the TRH administration. In 2 patients (with the highest serum T4 concentrations) serum TSH concentration was normal and resistant to iv TRH. Of the 8 patients with elevated TSH, basal level and deltaTSH did not change in 2 (with subnormal T4 levels and the highest TSH levels). In the other 6 (with intermediate T4 levels) basal TSH fell from a mean of 10.1 ng/ml to 4.2 ng/ml, and deltaTSH from 10.0 ng/ml to 3.3 ng/ml after three weeks. It is concluded that in addition to feed-back effect of thyroid hormones, the pituitary response to long-term administration of TRH is determined by other factors. Among these may be reduced pituitary TRH receptor capacity and the activity of the TSH producing cells.

[Pituitary apoplexy after injection of pituitary-hormone releasing hormones]. / Hypofysaer apopleksi etter injeksjon av hypotalamiske frigjørende hormoner.

Pituitary apoplexy often occurs spontaneously in adenomas. A few cases have been reported after testing anterior pituitary function by means of intravenous injections of a mixture of gonadotropin-releasing hormone and thyrotropin-releasing hormone, or gonadotropin-releasing hormone alone. In these cases the development of visual field defects has necessitated surgical intervention, which confirmed pituitary apoplexy. We describe a patient with a pituitary macroadenoma. He developed symptoms and signs of pituitary apoplexy immediately after intravenous injection of a mixture of hypothalamic releasing hormones. His visual fields remained normal, and he recovered spontaneously.

Actions of thyrotropin-releasing-hormone on gastrointestinal function in man. I. Inhibition of glucose and xylose absorption from the gut.

We studied serum glucose levels following a peroral glucose test in 6 healthy subjects on 2 alternate days in random order; with or without an i.v. TRH infusion for 3 hours (0.66 mg/hour). TRH infusion reduced serum glucose levels following oral glucose in all 6 subjects investigated. Serum insulin levels were reduced accordingly. Furthermore, serum xylose levels following peroral xylose were studied in the same 6 subjects. TRH infusion i.v. reduced serum xylose levels in all 6 subjects studied. I.v. glucose tolerance tests with or without an i.v. TRH infusion (0.66 mg/h) for 3 hours were studied in 4 healthy subjects. No change in serum glucose or insulin levels following TRH infusion was observed. We conclude that an i.v. infusion of TRH reduces serum levels of glucose following a peroral xylose load. TRH thus has marked actions on gastro-intestinal function in man inhibiting and/or retarding the absorption of glucose and xylose from the gut.

Appearance of trabecular bone in the femoral neck (Singh index). Relation to vertebral bone mass post mortem.

In 89 consecutive cases trabecular bone mass of the second or third lumbar vertabra was subjectively estimated in post mortem specimens, using frontal section 1 cm in thickness. The trabecular appearance of the femoral neck (Singh index) at radiography and the thickness of the femoral cortical bone were also determined. Agreement between vertebral bone mass and either of the two radiologic indices was present in only two thirds of the cases, and most often these indices underestimated the presence of vertebral osteoporosis. The results indicate that neither of these radiologic indices can be used for clinical guidance of the diagnosis of vertebral osteoporosis in the individual case.

Primary hypothyroidism followed by hyperthyroidism. Five case reports.

Five patients are described, who developed primary hypothyroidism between 25 and 57 years of age. They were all adequately treated with L-thyroxine. Graves' disease developed six months to 34 years later. Two had TSH binding inhibiting immunoglobulin (TBII) in their serum at this stage. All were treated with carbimazole, and 3 have experienced relapse upon withdrawal. Our patients are discussed in relation to the 16 cases previously reported. The pathogenesis of this condition is open to speculation.

Rapid diagnosis of varicella-zoster virus infections by countercurrent immunoelectrophoresis.

A simple, accurate, and rapid method for laboratory diagnosis of varicella-zoster virus (VZV) infections using countercurrent immunoelectrophoresis (CIE) is described. CIE uses zoster convalescent-phase serum to detect VZV antigen in vesticular fluid. Eighty-six patients were studied, 58 with VZV infections and 28 with vesicular or bullous rashes due to causes other than VZV infection. All patients with documented VZV infection had positive CIE tests for VZV, and the controls were uniformly negative. VZV antigen could be detected up to 15 (varicella) or 16 (zoster) days after the onset of rash. The sensitivity of CIE for detection of VZV antigen was compared with results of viral isolation, immune adherence hemmagglutination, and an indirect enzyme-linked immunosorbent assay.