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Maria P Yavropoulou 1st Propaedeutic Department of Internal Medicine, LAIKO General Hospital of Athens

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Efstathios Chronopoulos 2nd Orthopaedic Department, Konstantopouleio General Hospital

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George Trovas Laboratory for Research of the Musculoskeletal System, Th Garofalidis, National and Kapodistrian University of Athens, Athens, Greece

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Emmanouil Avramidis 2nd Orthopaedic Department, Konstantopouleio General Hospital

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Francesca Marta Elli Endocrinology Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy

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Giovanna Mantovani Endocrinology Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy

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Pantelis Zebekakis 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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John G Yovos 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece

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Summary

Pseudohypoparathyroidism (PHP) is a heterogeneous group of rare endocrine disorders characterised by normal renal function and renal resistance to the action of the parathyroid hormone. Type 1A (PHP1A), which is the most common variant, also include developmental and skeletal defects named as Albright hereditary osteodystrophy (AHO). We present two cases, a 54- and a 33-year-old male diagnosed with PHP who were referred to us for persistently high levels of serum calcitonin. AHO and multinodular goitre were present in the 54-year-old male, while the second patient was free of skeletal deformities and his thyroid gland was of normal size and without nodular appearance. We performed GNAS molecular analysis (methylation status and copy number analysis by MS-MLPA) in genomic DNA samples for both patients. The analysis revealed a novel missense variant c.131T>G p.(Leu44Pro) affecting GNAS exon 1, in the patient with the clinical diagnosis of PHP1A. This amino acid change appears to be in accordance with the clinical diagnosis of the patient. The genomic DNA analysis of the second patient revealed the presence of the recurrent 3-kb deletion affecting the imprinting control region localised in the STX16 region associated with the loss of methylation (LOM) at the GNAS A/B differentially methylated region and consistent with the diagnosis of an autosomal dominant form of PHP type 1B (PHP1B). In conclusion, hypercalcitoninaemia may be encountered in PHP1A and PHP1B even in the absence of thyroid pathology.

Learning points:

  • We describe a novel missense variant c.131T>G p.(Leu44Pro) affecting GNAS exon 1 as the cause of PHP1A.

  • Hypercalcitoninaemia in PHP1A is considered an associated resistance to calcitonin, as suggested by the generalised impairment of Gsα-mediated hormone signalling.

  • GNAS methylation defects, as in type PHP1B, without thyroid pathology can also present with hypercalcitoninaemia.

Open access
Davi da Silva Barbirato Wolfgang C. Pfeiffer Laboratory of Environmental Biogeochemistry, Federal University of Rondônia (UNIR), Rio de Janeiro, Brazil

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Mariana Fampa Fogacci Wolfgang C. Pfeiffer Laboratory of Environmental Biogeochemistry, Federal University of Rondônia (UNIR), Rio de Janeiro, Brazil

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Mariana Arruda Department of Internal Medicine and Endocrine Section, Medical School and Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

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Monique Oliveira Rodrigues Division of Graduate Periodontics, Department of Dental Clinic, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
Faculdades São José, Rio de Janeiro, Brazil

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Leonardo Vieira Neto Department of Internal Medicine and Endocrine Section, Medical School and Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

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Summary

Osteopetrosis (OP) comprehends a rare group of conditions, presenting on radiographs increased bone density, deriving from irregularities in osteoclast differentiation or function. In the autosomal dominant osteopetrosis (ADO), some patients stay asymptomatic for some time, or only develop mild symptoms. The dental surgeon is often the first to presuppose the disease during routine imaging examinations, referring the patient to a specialized medical group. Furthermore, osteomyelitis is one of the major OP complications, and should be refrained through frequent dental monitoring. Signals of cortical interruption, sclerotic sequestra or periosteal new bone formation, should be looked for in these patients. Their dental management is complex and procedures encompassing bone tissue, such as implant procedures, tissue regenerations, tooth extractions, maxillofacial surgeries and orthodontic treatments, when elected, should be avoided. This case report describes a case of ADO with a diagnosis of moderate generalized chronic periodontitis, not statistically related to plaque index. This is the first case to describe such a condition, in which the systemic component and the altered bone metabolism seem to be related to the loss of periodontal apparatus, independent of the biofilm. Concerning prevention, we can reinforce the need for frequent dental monitoring to avoid further interventions in those cases.

Learning points:

  • This paper reports a case in which the systemic component and the altered bone metabolism seem to have been related to the loss of periodontal attachment apparatus, independent of the biofilm.

  • The periodontal damage observed in the OP patient was not related to the dental plaque, which leads us to suggest that the cases of periodontitis in OP patients should be diagnosed as periodontitis as a manifestation of systemic diseases.

  • The periodontitis prevention should be longed for in OP patients thus, we propose that doctors responsible for patients with OP refer them to a dental service as soon as possible and that dentists should be aware of the preventive dentistry value as well as the most appropriate dental management for those cases.

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Dinesh Giri Alder Hey Children’s NHS Foundation Trust, Liverpool, UK

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Prashant Patil Alder Hey Children’s NHS Foundation Trust, Liverpool, UK

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Rachel Hart Liverpool Women’s NHS Foundation Trust, Liverpool, UK

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Mohammed Didi Alder Hey Children’s NHS Foundation Trust, Liverpool, UK

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Senthil Senniappan Alder Hey Children’s NHS Foundation Trust, Liverpool, UK

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Summary

Poland syndrome (PS) is a rare congenital condition, affecting 1 in 30 000 live births worldwide, characterised by a unilateral absence of the sternal head of the pectoralis major and ipsilateral symbrachydactyly occasionally associated with abnormalities of musculoskeletal structures. A baby girl, born at 40 weeks’ gestation with birth weight of 3.33 kg (−0.55 SDS) had typical phenotypical features of PS. She had recurrent hypoglycaemic episodes early in life requiring high concentration of glucose and glucagon infusion. The diagnosis of congenital hyperinsulinism (CHI) was biochemically confirmed by inappropriately high plasma concentrations of insulin and C-peptide and low plasma free fatty acids and β-hydroxyl butyrate concentrations during hypoglycaemia. Sequencing of ABCC8, KCNJ11 and HNF4A did not show any pathogenic mutation. Microarray analysis revealed a novel duplication in the short arm of chromosome 10 at 10p13–14 region. This is the first reported case of CHI in association with PS and 10p duplication. We hypothesise that the HK1 located on the chromosome 10 encoding hexokinase-1 is possibly linked to the pathophysiology of CHI.

Learning points:

  • Congenital hyperinsulinism (CHI) is known to be associated with various syndromes.

  • This is the first reported association of CHI and Poland syndrome (PS) with duplication in 10p13–14.

  • A potential underlying genetic link between 10p13–14 duplication, PS and CHI is a possibility.

Open access
Rossella Mazzilli Andrology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University of Rome “Sapienza”, Via di Grottarossa 103500189, Rome, Italy

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Michele Delfino Andrology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University of Rome “Sapienza”, Via di Grottarossa 103500189, Rome, Italy

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Jlenia Elia Andrology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University of Rome “Sapienza”, Via di Grottarossa 103500189, Rome, Italy

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Francesco Benedetti Andrology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University of Rome “Sapienza”, Via di Grottarossa 103500189, Rome, Italy

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Laura Alesi Genetics Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University of Rome “Sapienza”, Via di Grottarossa 103500189, Rome, Italy

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Luciana Chessa Genetics Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University of Rome “Sapienza”, Via di Grottarossa 103500189, Rome, Italy

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Fernando Mazzilli Andrology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, University of Rome “Sapienza”, Via di Grottarossa 103500189, Rome, Italy

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Summary

We report the case of a 19-year-old boy, presenting several congenital malformations (facial dysmorphisms, cardiac and musculoskeletal abnormalities), mental retardation, recurrent respiratory infections during growth and delayed puberty. Although previously hospitalised in other medical centres, only psychological support had been recommended for this patient. In our department, genetic, biochemical/hormonal and ultrasound examinations were undertaken. The karyotype was 49,XXXXY, a rare aneuploidy with an incidence of 1/85 000–100 000, characterised by the presence of three extra X chromosomes in phenotypically male subjects. The hormonal/biochemical profile showed hypergonadotropic hypogonadism, insulin resistance and vitamin D deficiency. The patient was then treated with testosterone replacement therapy. After 12 months of treatment, we observed the normalisation of testosterone levels. There was also an increase in pubic hair growth, testicular volume and penis size, weight loss, homeostatic model assessment index reduction and the normalisation of vitamin D values. Moreover, the patient showed greater interaction with the social environment and context.

Learning points

  • In cases of plurimalformative syndrome, cognitive impairment, recurrent infections during growth and, primarily, delayed puberty, it is necessary to ascertain as soon as possible whether the patient is suffering from hypogonadism or metabolic disorders due to genetic causes. In our case, the diagnosis of hypogonadism, and then of 49,XXXXY syndrome, was unfortunately made only at the age of 19 years.

  • The testosterone replacement treatment, even though delayed, induced positive effects on: i) development of the reproductive system, ii) regulation of the metabolic profile and iii) interaction with the social environment and context.

  • However, earlier and timely hormonal replacement treatment could probably have improved the quality of life of this subject and his family.

Open access
A Deeb Paediatric Endocrinology Department, Mafraq Hospital, PO Box 2951, Abu Dhabi, United Arab Emirates

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O Afandi Medical School, Gulf University, Ajman, United Arab Emirates

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S Attia Paediatric Endocrinology Department, Mafraq Hospital, PO Box 2951, Abu Dhabi, United Arab Emirates

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A El Fatih Biochemistry Laboratory Department, Shaikh Khalifa Medical Center, Mafraq Hospital, Abu Dhabi, United Arab Emirates

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Summary

3-M syndrome is a rare autosomal recessive disorder caused by mutations in the CUL7, OBSL1 and CCDC8 genes. It is characterised by growth failure, dysmorphic features and skeletal abnormalities. Data in the literature show variable efficacy of GH in the treatment of short stature. We report four Emirati siblings with the condition. The index case is a 10-year-old boy with characteristic features, including prenatal and postnatal growth failure, a triangular face, a long philtrum, full lips and prominent heels. Genetic testing confirmed a novel mutation (p.val88Ala) in the CUL7 gene. The parents are healthy, first-degree cousins with nine children, of whom two died in the first year of life with respiratory failure. Both had low birth weight and growth retardation. The boy's older sibling reached an adult height of 117 cm (−6.71 SDS). She was never treated with GH. He was started on GH treatment at 7 years of age, when his height was 94 cm (−5.3 SDS). 3-M syndrome should be considered in children with short stature who have associated dysmorphism and skeletal abnormalities. The diagnosis is more likely to occur in families that have a history of consanguinity and more than one affected sibling. Death in early infancy due to respiratory failure is another clue to the diagnosis, which might have a variable phenotype within a family. Genetic testing is important for confirming the diagnosis and for genetic counselling. GH treatment might be beneficial in improving stature in affected children.

Learning points

  • 3-M syndrome should be considered in families that have more than one sibling with short stature, particularly if there is consanguinity.

  • Syndrome phenotype might be variable within a family with the same mutation.

  • Genetic analysis is helpful in confirming diagnosis in the presence of variable siblings' phenotype.

  • GH treatment might be useful in improving stature in 3-M syndrome.

Open access
Hanna Remde
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Elke Kaminsky Laboratory for Molecular Genetics, Hamburg, Germany

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Mathias Werner Institute of Pathology, HELIOS Klinikum Emil von Behring, Stiftung Oskar-Helene-Heim, Berlin, Germany

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Marcus Quinkler Endocrinology in Charlottenburg, Stuttgarter Platz 1, Berlin, D 10627, Germany

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Summary

We report of a male patient aged 32 years who presented with primary hyperparathyroidism. Three parathyroid glands were resected. At the age of 46 years, nervus facialis irritation was noted, and an MRI scan incidentally revealed a non-functioning pituitary adenoma with affection of the chiasma opticum. The patient underwent transsphenoidal operation resulting in pituitary insufficiency postoperatively. At the same time, primary hyperparathyroidism reoccurred and a parathyroid adenoma located at the thymus was resected. The mother of the patient died early due to multiple tumors. The patient was suspected to have multiple endocrine neoplasia type 1 (MEN1) and genetic analysis was performed. In addition, on clinical examination, multiple exostoses were noticed and an additional genetic analysis was performed. His father was reported to have multiple osteochondromas too. MEN1 was diagnosed in the patient showing a novel heterozygote mutation c.2T>A in exon 2, codon 1 (start codon ATG>AAG;p.Met1?) of the MEN1 gene. In genetic mutational analysis of the EXT1 gene, another not yet known mutation c.1418-2A>C was found in intron 5 of the EXT1 gene (heterozygotic). In conclusion, we report novel mutations of the EXT1 and the MEN1 genes causing hereditary multiple osteochondromas and MEN1 in one patient.

Learning points

  • It is important to ask for the patient's family history in detail.

  • Patients with MEN1 are characterized by the occurrence of tumors in multiple endocrine tissues and nonendocrine tissues, most frequently parathyroid (95%), enteropancreatic neuroendocrine (50%), and anterior pituitary (40%) tissues.

  • Familiar MEN1 has a high degree of penetrance (80–95%) by the age over 50; however, combinations of the tumors may be different in members of the same family.

  • Patients with EXT1 gene mutations should be monitored for possible transformation of bone lesions into osteochondrosarcoma.

Open access