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Susan Ahern Division of Endocrinology, UCLA School of Medicine, Ventura, California, USA

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Mark Daniels Division of Pediatric Endocrinology, Children’s Hospital of Orange County, Orange, California, USA

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Amrit Bhangoo Division of Pediatric Endocrinology, Children’s Hospital of Orange County, Orange, California, USA

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Summary

In this case report, we present a novel mutation in Lim-homeodomain (LIM-HD) transcription factor, LHX3, manifesting as combined pituitary hormone deficiency (CPHD). This female patient was originally diagnosed in Egypt during infancy with Diamond Blackfan Anemia (DBA) requiring several blood transfusions. Around 10 months of age, she was diagnosed and treated for central hypothyroidism. It was not until she came to the United States around two-and-a-half years of age that she was diagnosed and treated for growth hormone deficiency. Her response to growth hormone replacement on linear growth and muscle tone were impressive. She still suffers from severe global development delay likely due to delay in treatment of congenital central hypothyroidism followed by poor access to reliable thyroid medications. Her diagnosis of DBA was not confirmed after genetic testing in the United States and her hemoglobin normalized with hormone replacement therapies. We will review the patient’s clinical course as well as a review of LHX3 mutations and the associated phenotype.

Learning points:

  • Describe an unusual presentation of undertreated pituitary hormone deficiencies in early life

  • Combined pituitary hormone deficiency due to a novel mutation in pituitary transcription factor, LHX3

  • Describe the clinical phenotype of combined pituitary hormone deficiency due to LHX3 mutations

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Charlotte S Schömig Department of Pediatrics, University of Cologne, Cologne, Germany

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Marie-Ève Robinson Division of Endocrinology, Department of Pediatrics, McGill University Health Center, Montreal, Canada

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Julia E von Oettingen Division of Endocrinology, Department of Pediatrics, McGill University Health Center, Montreal, Canada

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Summary

Congenital hypothyroidism requires prompt treatment to prevent adverse health outcomes. Poor intestinal levothyroxine absorption can complicate management. We present a case of a term female newborn with necrotizing enterocolitis (NEC) requiring subtotal ileum resection. Congenital hypothyroidism was diagnosed by newborn screening. Treatment was complicated by intestinal malabsorption of levothyroxine. Intravenous levothyroxine substitution restored euthyroidism and supraphysiologic PO doses subsequently maintained a euthyroid state. After several months, the required levothyroxine dose was weaned down to typical recommended dosing. In conclusion, small bowel resection secondary to NEC may lead to malabsorption of oral levothyroxine. An intravenous levothyroxine dose of approximately 50% typical PO dosing is effective in providing rapid normalization of free T4 and TSH. High PO doses may be required to maintain euthyroidism. Close thyroid function monitoring and immediate therapy adjustment are essential as the individual absorption may vary widely. Normal absorption levels may be regained due to adaption of the neonatal intestines.

Learning points:

  • In neonates with malabsorption after ileum resection intravenous levothyroxine replacement should be used to provide normalization of free T4 and TSH.

  • Very high doses of up to 500% usual oral levothyroxine may be required to maintain euthyroidism. The estimated degree of malabsorption can be used to determine the initial dose.

  • Close thyroid function monitoring and immediate therapy adjustment are essential as the absorption and intestinal adaption may vary widely.

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Ricardo A Macau Nephrology Department, Hospital Garcia de Orta

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Tiago Nunes da Silva Endocrinology Department, Hospital Garcia de Orta, Almada, Portugal

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Joana Rego Silva Nephrology Department, Hospital Garcia de Orta

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Ana Gonçalves Ferreira Endocrinology Department, Hospital Garcia de Orta, Almada, Portugal

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Pedro Bravo Nephrology Department, Hospital Garcia de Orta

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Summary

Lithium-induced nephrogenic diabetes insipidus (Li-NDI) is a rare and difficult-to-treat condition. A study in mice and two recent papers describe the use of acetazolamide in Li-NDI in 7 patients (a case report and a 6 patient series). We describe the case of a 63-year-old woman with bipolar disorder treated with lithium and no previous history of diabetes insipidus. She was hospitalized due to a bowel obstruction and developed severe dehydration after surgery when she was water deprived. After desmopressin administration and unsuccessful thiazide and amiloride treatment, acetazolamide was administrated to control polyuria and hydroelectrolytic disorders without significant side effects. To our knowledge, this is the third publication on acetazolamide use in Li-NDI patients.

Learning points:

  • Treatment of lithium-induced nephrogenic diabetes insipidus might be challenging.

  • Vasopressin, amiloride and thiazide diuretics have been used in lithium-induced nephrogenic diabetes insipidus treatment.

  • Acetazolamide might be an option to treat lithium-induced nephrogenic diabetes insipidus patients who fail to respond to standard treatment.

  • The use of acetazolamide in lithium-induced nephrogenic diabetes insipidus must be monitored, including its effects on glomerular filtration rate.

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Ayanthi A Wijewardene Departments of Medicine

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Sarah J Glastras Departments of Endocrinology, Diabetes & Metabolism, Royal North Shore Hospital, Sydney, Australia
Kolling Institute of Medical Research
Sydney Medical School, University of Sydney, Sydney, Australia

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Diana L Learoyd Departments of Endocrinology, Diabetes & Metabolism, Royal North Shore Hospital, Sydney, Australia
Sydney Medical School, University of Sydney, Sydney, Australia

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Bruce G Robinson Departments of Endocrinology, Diabetes & Metabolism, Royal North Shore Hospital, Sydney, Australia
Sydney Medical School, University of Sydney, Sydney, Australia

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Venessa H M Tsang Departments of Endocrinology, Diabetes & Metabolism, Royal North Shore Hospital, Sydney, Australia
Sydney Medical School, University of Sydney, Sydney, Australia

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Summary

Medullary thyroid cancer (MTC) is a rare neuroendocrine tumour that originates from the parafollicular cells of the thyroid gland. The most common presentation of MTC is with a single nodule; however, by the time of diagnosis, most have spread to the surrounding cervical lymph nodes. Cushing’s syndrome is a rare complication of MTC and is due to ectopic adrenocorticotrophic hormone (ACTH) secretion by tumour cells. Cushing’s syndrome presents a challenging diagnostic and management issue in patients with MTC. Tyrosine kinase inhibitors (TKI) previously used for the management of metastatic MTC have become an important therapeutic option for the management of ectopic ACTH in metastatic MTC. The article describes three cases of ectopic ACTH secretion in MTC and addresses the significant diagnostic and management challenges related to Cushing’s syndrome in metastatic MTC.

Learning points:

  • Medullary thyroid cancer (MTC) is a rare neuroendocrine tumour.

  • Cushing’s syndrome is a rare complication of MTC that has a significant impact on patients’ morbidity and mortality.

  • Tyrosine kinase inhibitors (TKI) provide an important therapeutic option for the management of ectopic ACTH in metastatic MTC.

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T O’Shea Department of Endocrinology, Adelaide and Meath Hospitals, incorporating the National Children’s Hospital, Tallaght, Dublin, Ireland

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R K Crowley Department of Endocrinology, Adelaide and Meath Hospitals, incorporating the National Children’s Hospital, Tallaght, Dublin, Ireland

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M Farrell Departments of Neuropathology

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S MacNally Departments of Neurosurgery, National Neurosciences Centre, Beaumont Hospital, Beaumont, Dublin, Ireland

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P Govender Department of Radiology, Adelaide and Meath Hospitals, incorporating the National Children’s Hospital, Tallaght, Dublin, Ireland

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J Feeney Department of Radiology, Adelaide and Meath Hospitals, incorporating the National Children’s Hospital, Tallaght, Dublin, Ireland

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J Gibney Department of Endocrinology, Adelaide and Meath Hospitals, incorporating the National Children’s Hospital, Tallaght, Dublin, Ireland

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M Sherlock Department of Endocrinology, Adelaide and Meath Hospitals, incorporating the National Children’s Hospital, Tallaght, Dublin, Ireland

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Summary

Meningioma growth has been previously described in patients receiving oestrogen/progestogen therapy. We describe the clinical, radiological, biochemical and pathologic findings in a 45-year-old woman with congenital adrenal hyperplasia secondary to a defect in the 21-hydroxylase enzyme who had chronic poor adherence to glucocorticoid therapy with consequent virilisation. The patient presented with a frontal headache and marked right-sided proptosis. Laboratory findings demonstrated androgen excess with a testosterone of 18.1 nmol/L (0–1.5 nmol) and 17-Hydroxyprogesterone >180 nmol/L (<6.5 nmol/L). CT abdomen was performed as the patient complained of rapid-onset increasing abdominal girth and revealed bilateral large adrenal myelolipomata. MRI brain revealed a large meningioma involving the right sphenoid wing with anterior displacement of the right eye and associated bony destruction. Surgical debulking of the meningioma was performed and histology demonstrated a meningioma, which stained positive for the progesterone receptor. Growth of meningioma has been described in postmenopausal women receiving hormone replacement therapy, in women receiving contraceptive therapy and in transsexual patients undergoing therapy with high-dose oestrogen and progestogens. Progesterone receptor positivity has been described previously in meningiomas. 17-Hydroxyprogesterone is elevated in CAH and has affinity and biological activity at the progesterone receptor. Therefore, we hypothesise that patients who have long-standing increased adrenal androgen precursor concentrations may be at risk of meningioma growth.

Learning points:

  • Patients with long-standing CAH (particularly if not optimally controlled) may present with other complications, which may be related to long-standing elevated androgen or decreased glucocorticoid levels.

  • Chronic poor control of CAH is associated with adrenal myelolipoma and adrenal rest tissue tumours.

  • Meningiomas are sensitive to endocrine stimuli including progesterone, oestrogen and androgens as they express the relevant receptors.

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Etienne Larger Department of Diabetology, Hôpital Bichat and University Paris Denis Diderot, Paris, France

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Nicolai J Wewer Albrechtsen Department of Biomedical Sciences
Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

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Lars H Hansen Department of Molecular Signaling, Hagedorn Research Institute, Gentofte, Denmark

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Richard W Gelling Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

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Jacqueline Capeau Inserm UMR_S 938, Centre de Recherche Saint-Antoine, Paris, France
Sorbonne University, UPMC, University of Paris 6, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France

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Carolyn F Deacon Department of Biomedical Sciences
Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

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Ole D Madsen Global Research External Affairs, Novo Nordisk A/S, 2760 Måløv, Denmark

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Fumiatsu Yakushiji Department of Internal Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
Department of Education Planning and Development, Faculty of Medicine, Toho University, Tokyo, Japan

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Pierre De Meyts Global Research External Affairs, Novo Nordisk A/S, 2760 Måløv, Denmark

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Jens J Holst Department of Biomedical Sciences
Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

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Erica Nishimura Metabolic Disease Research, Novo Nordisk A/S, Måløv, Denmark

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Summary

Glucagon stimulates hepatic glucose production by activating specific glucagon receptors in the liver, which in turn increase hepatic glycogenolysis as well as gluconeogenesis and ureagenesis from amino acids. Conversely, glucagon secretion is regulated by concentrations of glucose and amino acids. Disruption of glucagon signaling in rodents results in grossly elevated circulating glucagon levels but no hypoglycemia. Here, we describe a patient carrying a homozygous G to A substitution in the invariant AG dinucleotide found in a 3′ mRNA splice junction of the glucagon receptor gene. Loss of the splice site acceptor consensus sequence results in the deletion of 70 nucleotides encoded by exon 9, which introduces a frame shift and an early termination signal in the receptor mRNA sequence. The mutated receptor neither bound 125I-labeled glucagon nor induced cAMP production upon stimulation with up to 1 µM glucagon. Despite the mutation, the only obvious pathophysiological trait was hyperglucagonemia, hyperaminoacidemia and massive hyperplasia of the pancreatic α-cells assessed by histology. Our case supports the notion of a hepato–pancreatic feedback system, which upon disruption leads to hyperglucagonemia and α-cell hyperplasia, as well as elevated plasma amino acid levels. Together with the glucagon-induced hypoaminoacidemia in glucagonoma patients, our case supports recent suggestions that amino acids may provide the feedback link between the liver and the pancreatic α-cells.

Learning points:

  • Loss of function of the glucagon receptor may not necessarily lead to the dysregulation of glucose homeostasis.

  • Loss of function of the glucagon receptor causes hyperaminoacidemia, hyperglucagonemia and α-cell hyperplasia and sometimes other pancreatic abnormalities.

  • A hepato–pancreatic feedback regulation of the α-cells, possibly involving amino acids, may exist in humans.

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Roghieh Molaei Langroudi Diagnostic Radiology Department, Poursina Hospital, Guilan University of Medical Sciences, Guilan, Iran

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Fatemeh Ghazanfari Amlashi Guilan Endocrinology and Metabolism Research Center, Razi Hospital, Rasht, Guilan, Iran and

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Mohammad Hassan Hedayati Emami Department of Endocrinology, Guilan Endocrinology and Metabolism Research Center, Razi Hospital, Rasht, Guilan, Iran

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Summary

Background: Spontaneous ovarian hyperstimulation syndrome (sOHSS) can occur following hypothyroidism. Ultrasonography facilitates diagnosis and monitoring of this syndrome. We describe ovarian sonographic changes in a hypothyroid patient with sOHSS after treatment with levothyroxine (l-T4).

Case presentation: A 15-year-old girl presented with abdominal pain and distension for a few months. On examination, she had classical features of hypothyroidism. Abdominal and pelvic ultrasound revealed enlarged ovaries with multiple thin-walled cysts and mild ascitic fluid. On follow-up, abdominal ultrasound showed significant reduction of ovary size after 6 weeks of initiation of l-T4. Normal ovary size with complete regression of ovarian cysts was seen after 4 months.

Conclusion: Serial ultrasound in sOHSS associated with hypothyroidism showed regression of ovarian cysts and ovarian volume after 4 months whereas in other studies, it is reported to happen in various durations, presumably according to its etiology.

Learning points

  • OHSS can rarely occur due to hypothyroidism.

  • This type of OHSS can be simply treated by l-T4 replacement, rather than conservative management or surgery in severe cases.

  • Ultrasound follow-up shows significant regression of ovarian size and cysts within 6 weeks of initiation of l-T4.

  • Ultrasound follow-up shows normal ovarian size with complete resolution of ovarian cysts 4 months after treatment.

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