bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the Molecular Pathogenesis of Adrenocortical Tumors by Whole-Genome Sequencing
Authors: Neininger Kerstin , May Patrick , Altieri Barbara , Lippert Juliane L , Roomp Kirsten , Dalmazi Guido Di , Canu Letizia , Ceccato Filippo , Riester Anna , Herterich Sabine L , Fassnacht Martin , Schneider Jochen G , Ronchi Cristina L
Published: May 2021

Pathogenesis of autonomous steroid secretion and adrenocortical tumorigenesis remains partially obscure. Our aim was to identify novel genetic alterations in adrenocortical adenomas (ACA) without somatic mutations in known driver genes. Whole-genome sequencing was performed on 26 ACA/blood-derived DNA pairs without driver mutations in PRKACA, GNAS and CTNNB1 genes at previous WES (ENSAT study JCEM 2016). These included 12 cortisol-producing adenomas with Cushing syndrome (CS-CPAs), 7 with mild autonomous cortisol secretion (MACS-CPAs), and 7 endocrine-inactive ACAs (EIAs). Seven adrenocortical carcinomas (ACC) were added to the cohort. We developed a bioinformatics pipeline for a comprehensive genome analysis and to reveal differences in variant distribution. Strelka, VarScan2 and ANNOVAR software and an in-house confidence score were used for variant calling and functional annotation. Combined Annotation-Dependent-Depletion (CADD) values were used to prioritize pathogenic variants. Additional focus relied on variants in pathogenically known pathways (Wnt/β-catenin, cAMP/PKA pathway). NovoBreak algorithm was applied to discover structural variations. Two hypermutated CS-CPA samples were excluded from further analysis. Using different filters, we detected variants in driver genes not observed at WES (one p.S45P in CTNNB1 and one p.R206L in PRKACA in two different CS-CPAs). In total, we report 179,830 variations (179,598 SNVs; 232 indels) throughout all samples, being more abundant in ACC (88,954) compared to ACA (CS-CPAs: 31,821; MACS-CPAs: 35,008; EIAs: 29,963). Most alterations were in intergenic (>50%), followed by intronic and ncRNA intronic regions. A total of 32 predicted pathogenic variants were found in both coding (CADD values ≥ 15) and non-coding (CADD values ≥ 5) regions. We found 3,301 possibly damaging and recurrent variants (intergenic mutations removed) (CS-CPAs: 1,463; MACS-CPAs: 1,549; EIAs: 1,268; ACC: 1,660), mostly accumulated in intronic regions. Some of these were detected in members of the Wnt/β-catenin (CS-CPAs: 6; MACS-CPAs: 2; EIA: 1) and cAMP/PKA (CS-CPAs: 6; MACS-CPAs: 7; EIA: 4) pathways (e.g. ADCY1, ADCY2, GNA13, PDE11A). We also found a slightly higher number of structural variations in EIA (3,620) and ACC (3,486) compared to CS-CPAs (977) and MACS-CPAs (2,119). In conclusion, still unrevealed genetic alterations, especially in intronic regions, may accompany early adrenal tumorigenesis and/or autonomous cortisol secretion.
Anastrozole Improves Near Adult Height in Boys With Compromised Height Potential, as Monotherapy or in Combination With a GnRH Analogue
Authors: Papadimitriou Dimitrios T , Dermitzaki Eleni , Papagianni Maria , Kleanthous Kleanthis , Papadimitriou Anastasios , Mastorakos George
Published: May 2021

Background: Bone maturation depends mainly on locally produced estrogens by aromatization. Third generation aromatase inhibitors (AIs) are being widely used off-label to improve predicted adult height (PAH) in boys as well as in girls, either as monotherapy or in combination with growth hormone and/or puberty inhibition. They induce reverse binding inhibiting the activity of aromatase (a cytochrome P450 enzyme), which catalyzes the conversion of androstenedione and testosterone to estrone and estradiol, respectively. While numerous studies have shown that AIs delay bone maturation and improve PAH, data on near-adult height (NAH) of children treated with AIs are lacking. Aims: To compare results on NAH of boys treated with anastrozole either as monotherapy or in combination with pubertal inhibition (for at least 1yr at onset). Methods: 159 boys with advanced bone age (BA) and PAH <170 cm that received anastrozole 1 mg/day p.o. either as monotherapy (n=76, group A) or as co-therapy with a GnRH analogue for at least 1yr and then as monotherapy (n=83, group B) until bone age of 15-16 yrs were included. Data on boys that reached NAH (BA at least 16 yrs with height velocity <2 cm/yr) were analyzed: group A, n=16 with PAH 167.3 and TH 170.9 and group B, n=10 with PAH 165.5 and TH 171.7 cm. Measurements were made on the same height meter by the same examiner. The choice of therapeutic intervention was made randomly. Groups A and B did not differ in terms of age at intervention onset, TH or PAH. During treatment, they underwent a 6-month follow-up that included clinical examination, BA, and laboratory tests at 8:00 hrs (general blood count, lipid chart, LH, FSH, testosterone, estradiol, estrone, and complete calcium metabolism), with lumbar spine DEXA (Dual Energy X-ray Absorptiometry) and X-ray performed annually. Results: The duration of anastrozole treatment was 3.9 yrs in group A, and 4.6 yrs in group B (where the GnRHa was administered for at least 1 yr) and the median age at intervention onset was 11.04 and 11.8 yrs, respectively. Both groups had a statistically significant gain in NAH with no difference between them: for group A 3.6 cm (+0.53 SD, p=0.002) and for group B 4.8 cm (+0.71 SD, p=0.0007). Thus, distance from TH was finally 0 cm for group A and -1.5 cm (0.19 SD) for group B. According to the definition of NAH, the adult height of the two groups is expected to be about 2% higher. Follow-up showed no side effects on their biochemical or lipid profile, bone density and vertebral architecture. Conclusions: Anastrozole therapy is safe and effective in improving adult height in boys with advanced puberty and poor height prediction, either as monotherapy or in combination with pubertal inhibition.
Characteristics Associated With Diabetes Device Use Among Youth With Type 1 Diabetes
Authors: Chen Charlotte , Tinsley Liane , Volkening Lisa , Anderson Barbara , Laffel Lori M
Published: May 2021

Type 1 diabetes (T1D) is a common illness of childhood, requiring lifelong, daily complex management to prevent acute and chronic complications. Studies have shown that use of insulin pumps and continuous glucose monitors (CGM) offers benefit for glycemic control. However, such device use is not universal in adolescents. We aimed to compare baseline socio-demographic and diabetes characteristics associated with diabetes technology (pump and CGM) uptake and continued use in 13-17 year old teens with T1D. Data were derived from a multicenter clinical trial aimed at optimizing self-care and glycemic control in teens with T1D. Socio-demographic and diabetes data were collected quarterly by parent-youth interview and electronic medical record review prospectively over 18 months. Chi-square and t-tests compared characteristics of device and non-device users (pump vs no pump; CGM vs no CGM). The study sample comprised 301 teens (41% male) with mean±SD age 15.0±1.3 years, T1D duration 6.5±3.7 years, and A1c 8.5±1.1%. Most (65%) used a pump at entry or initiated pump therapy during the study; 35% used injection therapy at entry or stopped pump therapy. In contrast, 27% used a CGM at entry or started a CGM during the study, while 73% never used or stopped using CGM. Device users at entry and those who began use had similar characteristics, as did those who never used and those who discontinued device use. Pump users were more likely to use CGM than non-pump users (36% vs 10%, p<.0001). Neither age, sex, nor T1D duration was related to pump or CGM use. Pump users (vs non-pump users) were less likely to have another medical condition (44% vs 59%, p=.01) and more likely to be non-Hispanic white (83% vs 61%, p=.0001); have family annual household income ≥$150,000 (34% vs 19%, p=.0003), private health insurance (92% vs 74%, p<.0001), a parent with college education or higher (67% vs 46%, p=.0005), and a 2-parent household (88% vs 78%, p=.03). Pump users also had lower z-BMI (0.73±0.80 vs 0.97±0.79, p=.01), performed more frequent daily BG monitoring (4.8±1.8 vs 3.9±2.0, p<.0001), and were less likely to have HbA1c ≥9% at initial and last visits (25% vs 43%, p=.005; 31% vs 49%, p=.01). CGM users (vs non-CGM users) were more likely to be non-Hispanic white (88% vs 70%, p=.009); have family annual household income ≥$150,000 (44% vs 23%, p=.0001), a parent with college education or higher (78% vs 53%, p=.0004), and private health insurance (95% vs 82%, p=.005). CGM users also performed more frequent daily BG monitoring (5.2±1.9 vs 4.2±1.9, p=.0002) and were less likely to have HbA1c ≥9% after 18 months (27% vs 42%, p=.03). In summary, we found distinct socio-demographic and diabetes-specific factors associated with device use in adolescents with T1D. These findings provide an opportunity to address barriers associated with device non-use in order to expand device implementation, especially in underserved adolescents with T1D.
22q13 Duplication in Newborn With Dysmorphic Features: The Role of SOX10 in Disorders of Sex Development
Authors: Hammoud Batoul , Baldauff Natalie Marie Hecht , Yatsenko Svetlana , Witchel Selma Feldman
Published: May 2021

Background: The 46,XX testicular disorder of sex development (DSD), also known as 46,XX male reversal, is a rare form of DSD and clinical phenotype shows complete sex reversal from female to male. The sex-determining region Y (SRY) gene can be identified in most 46,XX testicular DSD patients; however, approximately 20% are SRY-negative. Here we present a 2 week old with discrepant prenatal karyotype and infant phenotype.

Case: This 2-week-old had dysmorphic features (bitemporal narrowing, broad and flat nasal bridge, bilateral epicanthal folds) and multiple congenital anomalies; IUGR, hypertelorism, cleft lip and palate, ASD, small kidneys, sacral dimple. Physical exam revealed palpable inguinal masses and microphallus without hypospadias. Postnatal karyotype showed a 46,XX chromosome complement with duplication of 22q13-qter. He was negative for SRY gene by FISH. Microarray analysis confirmed the duplication encompassing the SOX10 gene. Lab evaluation showed LH 10.81 mIU/ml, FSH 3.21 mIU/ml and total testosterone 241 ng/dl. These values are consistent with activation of the hypothalamic–pituitary–gonadal axis during the neonatal period in males.

Conclusion: Our case along with previous cases supports the existence of a gene on chromosome 22q that can trigger testis determination in the absence of SRY. Potential mechanisms responsible for ovotesticular disorder in the XX (SRY−) individual could involve activation of testis specifying genes in the absence of SRY and/or inadequate expression of pro-ovary/anti-testis genes such as SOX 8 and SOX9. SOX10, a gene closely related to SOX9 and SOX8, and its overexpression has been suggested as a candidate for 46,XX DSD. Over-expression of SOX10 in mice resulted in the XX DSD. The spectrum of sex reversal phenotypes and gonadal asymmetry

seen in the Sox10 transgenic mice closely mirrors the range of gonadal and reproductive tract anomalies seen in cases of partial duplication of human chromosome 22q13. Although SRY-negative 46,XX testicular DSD is a rare condition, an effort to make an accurate diagnosis is important for the provision of proper genetic counseling and for guiding patients in their long-term management.
A Case of Autoantibody Negative Pediatric Diabetes Mellitus With Marked Insulin Resistance Concomitant With COVID-19: A Novel Form of Disease?
Authors: Martinez Alfonso Hoyos , Hicks Kelly Anne , Moorjani Tracy Patel , Bell Jennifer , Lin Yuezhen
Published: May 2021

Background: SARS-CoV-2 uses the angiotensin-converting enzyme 2 (ACE2) receptor to enter human cells. This receptor is avidly expressed in the pancreatic islets, suggesting the virus may target β-cell function. 17% of adults with COVID-19 have evidence of pancreatic injury. There is a direct relation between insulin resistance and COVID-19 severity and mortality with patients with higher insulin resistance presenting with higher inflammatory response. Fulminant type 1 diabetes (fT1D) has abrupt onset of symptoms with insulinopenia without evidence of autoimmunity, usually preceded by viral illness. Clinical case: A 12-year-old Hispanic male presented with a week history of polyuria, polydipsia, headache, and fatigue but no weight loss, fever, cough, anosmia, or diarrhea. Laboratory testing revealed new onset diabetes with DKA with HbA1C 11.3%, blood pH 7.04, glucose 381 mg/dL, C-peptide 0.6 ng/mL, β-hydroxybutyrate 8.2 mmol/L, and a positive nasopharyngeal PCR for SARS-CoV-2 but no elevation of inflammatory markers (CRP, ESR and ferritin). There was evidence of mild pancreatic injury (lipase 179 U/L, n:15-110 U/L), and all autoantibodies for autoimmune diabetes were negative. He was pubertal (Tanner 3), non-obese (BMI Z score -0.3) and without acanthosis nigricans. Past medical and family history were non-contributory. He was treated with IV insulin at 0.1 u/kg/h until DKA resolved within 24 h then transitioned to subcutaneous insulin at 1 u/kg/day. He did not have signs of systemic inflammatory response, need for respiratory support, or glucocorticoids but had persistent hyperglycemia prompting an increase of insulin dosing and resumption of IV insulin. His insulin requirements continued to increase up to 4 u/kg/d with sustained hyperglycemia indicative of an exceptional state of insulin resistance. On Day 6 of admission metformin was initiated, on Day 9 insulin requirements declined and he was discharged on an insulin regimen close to 1.5 u/kg/d. Eventually metformin was discontinued on Day 20 after diagnosis without rebound in insulin requirements. On Day 28 he had improved glycemic control (HbA1c 8.8%) at insulin doses more appropriate for his age and pubertal status (0.9 u/kg/d). Clinical lessons: We report a case of autoantibody negative diabetes with pancreatic injury and marked insulin resistance unrelated to systemic inflammatory response associated with COVID-19. The clinical presentation was reminiscent of fT1D with the exception of exceptional insulin resistance. This is perhaps a novel form of diabetes mellitus not otherwise classified. Although the pathophysiology remains obscure, it is plausible that it is mediated by direct islet injury. Notably, there was a discordance between the severity of illness and insulin resistance suggesting an intrinsic effect of SARS-CoV-2 on glucose hemostasis.
Investigating the Role of Cholesterol and Lipid Trafficking in Mitotane Resistance in Adrenocortical Carcinoma
Authors: Warde Kate , Lim Yi-Jan , Beuschlein Felix , Hantel Constanze , Dennedy Michael Conall
Published: May 2021

Introduction: Adrenocortical Carcinoma (ACC) is a rare aggressive cancer which carries a poor prognosis. Adjuvant mitotane improves survival but is limited by poor response rates and resistance following tumour recurrence. Mitotane’s efficacy has been attributed to intracellular accumulation of toxic free cholesterol (FC) predominantly through inhibition of cholesterol storage through SOAT1. Yet SOAT1 specific inhibitors demonstrate inferior efficacy to mitotane in inducing ACC cell death. We hypothesize that mitotane’s efficacy to induce toxic FC accumulation in ACC cells is also mediated through enhanced breakdown of stored cholesterol within intracellular lipid droplets (LDs). Methodology: ATCC-H295R (mitotane sensitive) and MUC-1 (mitotane resistant) ACC cells were evaluated for neutral lipid content using BODIPY493/503 under baseline and cholesterol loaded conditions using Amnis ImageStream, additionally cells were treated with mitotane (H295R - 20, 40, 50µM; MUC1 - 50, 100, 200µM) for 6hr. Analysis of LDs using CE-BODIPY and FA-BODIPY identified cholesterol ester (CE) and triacylglycerol (TAG)-containing LDs, respectively. Lipid droplet-associated proteins (LDAPs) Perilipin (PLIN) 1–4 and hormone sensitive lipase (HSL) were evaluated using western blotting and PCR. Lipid uptake receptors; SRB1, LDLR, LRP1 and CD36 were measured by flow cytometry. Results: Mitotane treatment, within therapeutic range, decreased staining for LDs significantly in H295R. This was also reflected by decreased expression of LDAPs, PLIN1 and PLIN3. The decrease in H295R LDs was associated with increased activation of HSL (pHSL and LIPE). However, this effect was only evident in MUC-1 at supratherapeutic mitotane (200µM). H295R and MUC-1 demonstrated similar overall LD numbers at baseline and under cholesterol supplementation. Expression of PLIN3 was high in both cell lines, while PLIN1, PLIN2 and PLIN4 demonstrated distinct LD profiles in each. Investigation of LD content showed that H295R preferentially store CEs while MUC-1 store only TAG, irrespective of cholesterol-loading. Mitotane treatment significantly reduces both CE and TAG LDs in H295R and MUC-1. Expression of lipid uptake receptors also demonstrated significant variability between cell lines including SRB1 and LRP1. Conclusion: We highlight that lipolysis through LD breakdown and activation of HSL represents a putative additional mechanism for mitotane induced FC cytotoxicity in ACC. We also demonstrate significant differences in cholesterol handling and LDAPs between mitotane sensitive and mitotane resistant models, in particular, the absence of CE LDs in MUC-1. We therefore propose a mechanism of resistance to mitotane through absent CE storage. Further understanding of cholesterol and lipid handling in ACC offers novel therapeutic exploitation, especially in the setting of mitotane resistant disease.
A Case Series of Four Preterm Intrauterine Growth Restricted Babies With Transient Hyper-Insulinemic Hypoglycemia and Cholestasis
Authors: Rana Pratibha , Rodrigues Megan , Mahajan Chaitali N , Nyp Michael F , Vishal Pandey
Published: May 2021

Background: Premature infants with intrauterine growth restriction (IUGR) are predisposed to stress related hyper Insulinemic hypoglycemia (HIH). These babies are at risk for other prematurity related complications including direct hyperbilirubinemia. However, association of HIH with this has not been described, and transient cholestasis in HIH infants has not been reported. We present 4 such infants with perinatal stress related HIH who had cholestasis that resolved with time. Case series: In our retrospective review of these preemies with IUGR who had developed HIH, we found that 4 infants developed direct hyperbilirubinemia. Their gestational ages at birth ranged between 26 to 27 weeks, with birth weights between 527 to 642 grams. These infants had received total parenteral nutrition (TPN) for durations ranging between 12 to 19 days of life (DOL). HIH was established in them at variable ages between 55 to 75 DOL, based on an exaggerated glycemic response to glucagon. Of these, 1 baby was not started on Diazoxide due to underlying fluid overload. His HIH resolved by DOL 182. Two babies responded to therapy and while one remained on this till its resolution at 9 months age, another had the Diazoxide discontinued due to acute respiratory worsening leading to readmission. HIH in the latter resolved by 109 DOL. Fasting The last baby developed fluid overload early in therapy leading to its discontinuation without establishing response. Hypoglycemia in these infants resolved by ages between 4 to 9 months of life. Interestingly direct hyperbilirubinemia was noted by age 16 to 59 DOL. In all infants, the diagnosis of HIH was established after the onset of cholestasis. Extensive work up for hyperbilirubinemia ruled out any organic pathology. This transient cholestasis was noted to have resolved by ages 80 to 115 DOL. Conclusion: It appears from our experience in these premature infants, cholestasis may be associated with HIH. Its diagnosis preceded the establishment of HIH. We noted that HIH diagnosis was delayed by around 30 days after the onset of intermittent hypoglycemia. Both the cholestasis and HIH were transient. Whether the cholestasis may prognosticate the development of HIH or is indicative of transient HIH needs to be investigated. Any association between the two needs to be studied to address a common causality. IUGR babies with conjugated hyperbilirubinemia develop a mild and transient HI state which is self-resolving. Due to transient nature of this HIH in these IUGR babies with cholestasis, a genetic work up for HIH may be deferred.
Involvement of JAK-STAT-SOCS3 Pathway in the Regression of Mice X-Zone of Adrenal Cortex
Authors: Auricino Thais Barabba , Bento Eduarda Correa , Pacicco Lotfi Claudimara Ferini
Published: May 2021

Previously, we showed that the histological markers of the mice X-zone of adrenal cortex were still present in adult male and female postpartum SF1/SOCS3KO mice. Abnormal distribution of lipid droplets along the adrenal cortex and reduced ACTH-induced corticosterone secretion were observed in SF1/SOCS3KO mice (1). Here we have examined the adrenals of the SF1/SOCS3KO male and virgin female at 3, 8, 15 and 30 weeks through morphological and molecular analysis. Hematoxylin-eosin stains showed X-zone retention in the SF1/SOCS3KO mice adrenals regardless of the postnatal age analyzed. CYP17A1-positive cells were immunolocalized in the X-zone of SF1/SOCS3KO mice that were confirmed by immunoblotting. A fetal adrenal enhancer (FAdE) and Pik3c2g and 20αHSD genes expression were analyzed by RT-PCR, and these genes were present in the male SF1/SOCS3KO mice up to the age of 8 and 15 weeks, but not in the control mice. Therefore, we showed retention of X-zone in the adrenal cortex of SOCS3KO mice up to the age of 30 week, which suggest the involvement of JAK/STAT/SOCS3 signaling pathway in the differentiation process of adrenal cortex. Reference: (1) Pedroso et al., J Endocrinol.2017 Dec;235(3):207–222.
Challenges in the Diagnosis and Consequential Management of Patients 46, XY DSD
Authors: Berrezueta Paula Espinoza , Ejaz Sehar , Bakhsh Ismaeel
Published: May 2021

Background: Disorders of sex development (DSD) are clinical conditions that cause an incongruity between the chromosomal and phenotypic sex of an individual. A high variable group of congenital disorders can arise depending upon the timing and location of defect involved in sex determination and differentiation. 46, XY DSD occurs in 1:20,0000 male births; with external genitalia ranging from ambiguous to normal female. Such conditions can be psychologically stressful for patients and their families and have been historically difficult to diagnose, especially at genetic level. Failure to diagnose exact mutation may make the therapeutic approach, genetic counseling and risk assessment even more challenging. Clinical case: Full term baby is born to non -consanguineous parents after an uneventful pregnancy. Mother denied any history of acne/hirsutism, hormone or substance use during pregnancy. At birth, external genitalia showed non-rugated labia majora with posterior fusion, absence of labia minora and vaginal opening. Enlarged clitoris/ Penile like structure measuring 1.5 cm with palpable corpora and hypospadias was present. No palpable gonads were appreciated. No other dysmorphic features were present and rest of the physical exam was unremarkable. Cosyntropin stim test on day 4 of life showed appropriate adrenal response. Pelvic ultrasound and MRI showed an elongated structure posterior to the bladder presumably uterus with no identifiable gonads. Chromosome analysis revealed an XY karyotype. FISH for SRY and microarray were unremarkable. Further testing at 4 weeks of life showed sub optimal elevation of Gonadotropins and Testosterone. Female gender was assigned due to parents’ preference and endocrine/ Urology recommendations. The 46,XY DSD genetic panel including testing for non-syndromic DSD, steroid abnormalities, skeletal dysplasia syndromes, and multiple malformation syndromes was unremarkable. Conclusion: Although a number of cytogenetic or single-gene defects have been associated with DSD, the true incidence of pathogenic variants has not been established. Many cases of 46, XY DSD remain unexplained likely due to an unidentified pathogenic variant of genes not routinely included in the panel or not yet identified to be associated with DSD. Without a clear diagnosis, genetic counseling and risk assessment is difficult. Parents should be informed about future options regarding sexual development, hormonal therapy and surgical treatments available. The determination of social sex must be made in consideration of underlying possible etiology, phenotypic sex, ethnic traditions, sexual identity and the acceptance of the assigned social sex by the parents. The affected child and his/her family must be followed throughout life to determine the patient’s adjustment to his/her social sex.
Mutational Profile of Metastatic Pheochromocytoma and Paraganglioma
Authors: Choi Yun Mi , Lim Jinyeong , Jeon Min Ji , Lee Yu-Mi , Sung Tae-Yon , Hong Eun-Gyoung , Lee Ji-Young , Jang Se Jin , Kim Won Gu , Song Dong Eun , Chun Sung-Min
Published: May 2021

Background: In pheochromocytoma and paraganglioma (PPGL), germline and somatic mutations in one of the known susceptibility genes are present in about 60% of tumors. However, the genetic events that drive the malignant progression of the disease are yet poorly understood. We aimed to evaluate the mutational profiles of metastatic PPGLs by targeted next-generation sequencing (NGS) to characterize the genetic events in metastatic PPGLs. Methods: Among the previously reported metastatic PPGL series from Asan Medical Center (AMC), Seoul, Korea, fifteen patients with available formalin-fixed, paraffin embedded (FFPE) archival samples for targeted exome sequencing were enrolled in this study. We also analyzed accessible data of aggressive PPGLs from The Cancer Genome Atlas (TCGA) and compared with findings of AMC samples. Results: A total of 115 germline and 34 somatic variants were identified in AMC cohort. Tumors of AMC cohort had median 0.58 per megabase tumor mutation burden. Most frequently mutated mutations were SDHB germline mutation (27%), and SETD2, NF1, HRAS somatic mutations (13%). Genes are subtyped into pseudohypoxia group (n=5), kinase group (n=5) and unknown (n=5) group. In unknown subgroup, two samples showed ATRX mutations and one accompanied SETD2 mutation. In copy number variation analysis, the most frequently observed pattern was deletion of 1p arm where SDHB is present. In survival analysis, SDHB mutation and pseudohypoxia subtype was significantly associated with poor prognosis. Conclusion: The analysis of NGS from patients with metastatic PPGLs demonstrated rare genetic events as well as well-known mutations. The pseudohypoxia subtype presented poor prognosis than kinase or unknown subtypes. Subjects who had no deletion in 1p arm showed favorable treatment response. Further studies to discover driver events and markers of metastasis are warranted.
Mitotane in the Treatment of Adrenocortical Carcinoma: Metabolic and Endocrine Disruption
Authors: Cortez Samuel , Sprague Jennifer Eryn , McNerney Kyle
Published: May 2021

Background: Mitotane is a well-known adrenocytolitic agent resulting in adrenal insufficiency. However, little is known about its multiple and complex metabolic and endocrine effects.

Clinical Case: Patient is a 6 year 9 month old female who presented with acne, pubic hair and rapid weight gain. Initial evaluation showed elevated testosterone (64 ng/dL), 17-OH-progesterone (236 ng/dL), DHEA-S (922 mcg/dL), and random cortisol (30.9 mcg/dL) with suppressed ACTH (<2.0 pg/mL). She had an inappropriate lack of suppression after a 1 mg overnight dexamethasone suppression test (cortisol 49 mcg/dL, nl <2 mcg/dL). Abdominal CT showed large necrotic-appearing right adrenal mass (10.7x8.8x15 cm) with no metastasis. Surgical excision was complicated by intraoperative rupture. Pathology confirmed stage III right adrenal cortical carcinoma. Patient was started on etoposide, cisplatin, doxorubicin, and mitotane as adjuvant therapy. 6 days after surgery, her DHEA-S and cortisol levels were undetectable. She was started on glucocorticoid replacement therapy with hydrocortisone at 18 mg/m2/day. Due to severe nausea, she was switched to dexamethasone 5 mg/m2/day (245 mg/m2/day dose equivalent to hydrocortisone). However, the patient developed hypotension, increased nausea and emesis and was switched back to hydrocortisone. The patient’s clinical course was complicated by hyperlipidemia with total cholesterol 215 mg/dL, HDL 48 mg/dL and LDL 150 mg/dL, as well as central hypothyroidism with low FT4 (0.8 ng/dL) and an inappropriately low normal TSH (0.31 mcIU/mL). She was started on levothyroxine with a final dose of 2.6mcg/kg/day to achieve euthyroid state. Mineralocorticoid deficiency has been reported in a small number of case reports of mitotane use. Our patient continues to demonstrate adequate mineralocorticoid function based on her normal electrolytes, aldosterone and plasma renin activity level.

Conclusion: Mitotane exerts multiple clinically relevant metabolic and endocrine effects. Patients treated with mitotane should be monitored for complications including mineralocorticoid deficiency, central hypothyroidism, and hyperlipidemia. Dexamethasone must be avoided because of the rapid inactivation by CYP4503A4 leading to adrenal crisis. Typical glucocorticoid replacement dose must be doubled due to induction of CYP3A4 activity that leads to glucocorticoid inactivation.
Successful Use of Intragastric Dextrose in a Unique Presentation of Congenital Hyperinsulinism
Authors: Gurnurkar Shilpa , Patel Unnati , Lord Katherine , Vyas Neha
Published: May 2021

Introduction: Congenital hyperinsulinism (HI) is the most common cause of persistent hypoglycemia in infants and can pose challenges if unresponsive to diazoxide. HI can be caused by monogenic mutations or can be associated with genetic syndromes. Macrocephaly Capillary malformation (MCAP) is a rare overgrowth syndrome, caused by heterozygous variants in the PIK3CA gene. A small number of pathologic variants in this gene have been reported to cause HI.

Clinical Case: A 4-month-old boy presented with a hypoglycemic seizure while fasting for an MRI. His history was notable for being born LGA and having macrocephaly, segmental infantile hemangioma, and ventriculomegaly requiring VP shunt. Critical labs were consistent with HI: plasma glucose (PG) of 23 mg/dL (54-117), inappropriately detectable insulin (2.7 mIU/mL) and c-peptide (1.6 ng/mL), low beta hydroxybutyrate (0.1 mmol/L) and low free fatty acids (0.16 mmol/L), and a positive glucagon stimulation test (increase in PG from 48 to 101 mg/dL in 30 minutes). Diazoxide was started at 5 mg/kg/day and titrated to 15 mg/kg/day, but he was unable to maintain PG >70 mg/dL. He was deemed unresponsive and the diazoxide was discontinued. His intravenous glucose infusion rate (GIR) was 14.4 mg/kg/min. An octreotide trial (8 mcg/kg/day) revealed a robust response: PG 64 mg/dL before initial dose, 105 mg/dL 3 hours later. However, he developed tachyphylaxis to the octreotide and it was discontinued. To further evaluate the etiology of his HI, he underwent an 18F-DOPA PET scan, which showed diffuse uptake. Genetic sequencing for the 9 known HI genes was negative. At 6-months-old, he was evaluated by genetics who based on his clinical features diagnosed him with MCAP.

After failure of diazoxide and octreotide therapies, he was slowly transitioned from IV dextrose to continuous intragastric dextrose (IGD) using D20W. He was managed with a GIR of 10 mg/kg/min during the day (while receiving bolus feeds) and 5 mg/kg/min while on continuous feeds overnight. The continuous IGD allowed him to maintain euglycemia and develop his oral feeding skills. By 17-months-old, feeds by mouth improved and GIR had decreased to 6.5 mg/kg/min during the day and 2.5 mg/kg/min overnight. Genetic analysis eventually revealed a heterozygous p.Glu365Lys (c.1093 G>A) variant in the PIK3CA gene as the likely cause of the HI.

Conclusion: Genetic syndromes should be considered in infants with persistent hyperinsulinism and multiple congenital anomalies. Clinical work-up may provide important clues to the diagnosis. Diazoxide unresponsive HI can be treated with continuous IGD to prevent hypoglycemia-induced brain damage. Continuous IGD likely leads to better oral skills and decreased oral aversion compared to using continuous formula feeds.
The “Eyes” Have It. Ophthalmological Findings of Bilateral Cataract in a Boy with Hypoparathyroidism
Authors: Ruan Juejue , Zhang Lei , Yang Jun , Feldt Matthew M , Yan Yun
Published: May 2021

Background: Hypoparathyroidism is a relatively rare pediatric endocrine disorder in which parathyroid hormone (PTH) production is low or absent, resulting in low serum calcium and high phosphorus. In children, hypoparathyroidism is either congenital or acquired and is often associated with a genetic syndrome. Clinical manifestations include neuromuscular hyperexcitability, tetany, cardiac arrhythmias, and seizure. Radiographic findings include basal ganglia calcifications. In adult literature, ophthalmological findings of lenticular opacities and cataract have also been reported in hypoparathyroidism. Due to the rarity of this condition, there is a paucity of ophthalmological findings in children. We report a pediatric case with severe hypocalcemia, recurrent generalize seizures, intracranial calcifications and bilaterally cataracts secondary to hypoparathyroidism. Case: A 7-year-old boy, from a remote area in China, presented to a local hospital with one-year history of paresthesia in hands and feet. Initial lab evaluation revealed hypocalcemia with serum calcium of 1.76 mmol/L (2.03-2.68). Oral calcium supplement was started but symptoms progressively worsened. He was transferred to a tertiary hospital for further evaluation. On admission, physical exam was significant for positive Chvostek and Trousseau signs and lab evaluation showed serum calcium: 1.28 mmol/L (2.15-2.57), phosphorus: 4.2 mmol/L (0.95-1.75), magnesium: 0.97 mmol/L (0.73-1.06), PTH: 2.2 pg/mL (8.7-79), and 25(OH)Vit D: 97.1 mmol/L (36-126). Multiple symmetrical calcifications were found in the frontal lobe and basal ganglia. Ophthalmology consultation revealed bilateral cataracts with impaired vision. Trio whole exome sequencing with copy number variation testing reveled no pathogenic or likely pathogenic copy number and sequence level variants. He was diagnosed with idiopathic acquired hypoparathyroidism. The seizure disorder, intracranial calcification, and bilateral cataracts were attributed to severe and prolonged hypocalcemia secondary to hypoparathyroidism. He had a second episode of seizure after he was admitted, and seizure resolved after treated with midazolam and IV calcium gluconate. He was started on 1,25 (OH)2 vitamin D. Clinical symptoms resolved and he became biochemically eucalcemic with titrated therapy. Summary: Although lenticular changes have been observed in adults with hypoparathyroidism since the 1950’s, hypoparathyroidism and resulting cataract formations are relatively rare. Proposed mechanism of cataract formation in hypoparathyroidism is prolonged hypocalcemia resulting in membrane damage in the aqueous humor and subsequent sodium content increase in the lens. To our knowledge there are no prior pediatric reports of cataracts associated with hypoparathyroidism and signifies the importance of ophthalmologic referral and evaluation.
Antenatal Markers Related to Fetal Growth Restriction Can Predict Childhood Systolic Blood Pressure
Authors: Perchard Reena , Garner Terence , Whatmore Andrew James , Stevens Adam , Higgins Lucy , Johnstone Edward , Clayton Peter Ellis
Published: May 2021

Background: Being born small for gestational age (SGA) is linked with higher systolic blood pressure (SBP). Fetuses with growth restriction (FGR) may be either SGA or appropriate size for gestational age at birth. However, it is not known which factors contributing to size at birth influence the relationship with SBP. Aim. To determine whether antenatal markers of FGR can predict the upper quartile of childhood SBP. Methods: Brachial SBP was measured for 75 children aged 3-6 years from the Manchester BabyGRO Study, using a Tensiomed®Arteriograph with a child-sized cuff. SBP quartiles were generated. Participants were born to mothers who had attended a specialised clinic, following identification of higher FGR risk based on abnormal maternal serology (pregnancy associated plasma protein-A, β-human chorionic gonadotrophin, α-fetoprotein, Inhibin-A). Antenatal ultrasound data at 23 weeks gestation were obtained. Uterine artery Doppler (UtAD) notching was assigned a rank (0=absent, 1=unilateral, 2=bilateral). Random forest (RF) is a machine learning approach that generates many independent, uncorrelated decision trees based on multiple variables. This was used to determine the relative importance of antenatal variables in prediction of upper quartile of childhood SBP. Variables included in the model were maternal body mass index (BMI), parity, ethnicity (black/white/asian/mixed), maternal SBP and diastolic BP (DBP), maternal serology relating to FGR risk, UtAD pulsatility index, resistance index and notching rank (all measures of uteroplacental blood flow resistance), placental size measurements, 23 week estimated fetal weight (EFW) centile, ∆23w EFW-birthweight centile and birthweight SDS. A receiver operating characteristic (ROC) curve was generated, providing an area under the curve (AUC). A variable of importance (VIP) score was calculated for each marker that was significant in the model. All analyses were conducted in R (version 3.6). Results: RF analysis demonstrated antenatal markers relating to FGR risk predict the upper quartile of childhood SBP with an AUC 0.97. The top five ranked variables were maternal DBP (VIP score 14.0), birthweight SDS (11.5), parity (9.9), notching rank (9.5) and ∆23w EFW-birthweight centile (9.1). Conclusion: Maternal and antenatal markers, as well as birthweight SDS are linked with the upper quartile of SBP at 3-6 years. Antenatal markers were within the top five ranked and could help identify those babies at risk of higher SBP in childhood.
Design and Baseline Demographics of a Five-Year, Multi-National Observational Cohort Study of Children With Achondroplasia (ACHieve Study)
Authors: Ward Leanne M , de Bergua Josep Maria , Robinson Marie-Eve , Zhang Ying , Decker Carl , Giwa Adebola , Charlton R William
Published: May 2021

Background: Achondroplasia (ACH) is the most common form of dwarfism occurring in 1 in 22,000 births (95% CI 18,500 to 26,000). This skeletal dysplasia is caused by a gain-of-function mutation in the fibroblast growth factor receptor 3 (FGFR3) gene located on chromosome 4p16.3 and results in sustained activation of the FGFR3 pathway leading to impaired chondrogenesis and endochondral bone formation. Both typical childhood growth patterns and the impaired linear growth of ACH are modulated by the delicate balance between growth-inhibiting FGFR3/mitogen-activated phosphokinase and growth-promoting c-type natriuretic peptide/natriuretic peptide receptor B.

Individuals with ACH frequently develop clinically significant comorbidities, many with onset during childhood. Currently, there are no therapies addressing the underlying pathology. Most available treatments are surgical with goals to alleviate the symptoms from specific comorbidities (i.e. foramen magnum and spinal stenosis or recurrent otitis media). Since the available therapies do not address the underlying etiology, individuals with ACH often undergo multiple surgeries and myriad other forms of supportive care throughout their lives. The precise timing of comorbidity onset and the natural history of many of the skeletal dysplasia features are incompletely defined. This information is needed to inform the design and conduct of pathology-targeted intervention studies.

Aim: The purpose of this study is to gather information about the precise timing of comorbidity onset, the longitudinal growth trajectory, and the evolution of body proportionality in children with ACH.

Methods and Future Results: The ACHieve study (NCT03875534) is a multi-center, longitudinal, observational cohort study in children with ACH from birth up to 8 years at enrollment. In this non-therapeutic study, children are evaluated every six months for up to 5 years in 25 centers from North America, Europe and Oceania. The first patient was enrolled in 2019 and a total of 84 children have been enrolled to date. At each assessment, children undergo comprehensive anthropometric studies, (including body proportionality measurements and recumbent or standing height) and information on the timing and nature of ACH-related comorbidities and their treatments are collected. Additional information about the baseline demographics, including sex, age distribution, race/ethnicity, and height standard deviation scores will be presented at the time of conference.

Conclusions: The ACHieve study will provide additional insight into the natural history of growth, body proportionality, and comorbidities in children with ACH. These observations will serve as a benchmark for future intervention trials targeting the pathology of the underlying skeletal dysplasia.
Health-Related Quality of Life in Cushing Disease: Discrepancy Between Parent and Child Reports
Authors: Keil Margaret F , Leahu Adela , Stratakis Constantine A
Published: May 2021

Background: Previously we reported impairment in quality of life (QoL) measures in children with Cushing disease (CD) by parent proxy; however, little is known about QoL measures from the affected child’s perspective. Method: Prospective study of 48 (26 females, Age:11.5±3.0 yr.) children diagnosed with CD. Prior to treatment, the Child Health Questionnaire (CHQ) was used to assess QoL by parent (proxy) and child report. Results: In children with active CD, there was a discrepancy between parent and child responses for mental health and self-esteem subscales. Child responses were significantly lower than parent responses (lower scores indicate poorer function) for mental health (56 ± 2 vs. 67 ± 2, p<0.001) and self-esteem (32.8 ±3 vs. 60.5 ±3, p<0.001). No significant differences were found between parent vs.child report for other subscale scores of the CHQ. Conclusion: This is the first study to compare child vs. parent report of health-related quality of life children with active CD. Parent reports underestimated the impact of CD on quality of life measures for mental health and self-esteem. It is important for clinicians to obtain information about health-related quality of life from the child’s perspective in order to guide management and take precautionary measures to alleviate negative outcomes.
Prevalence and Risk Factors of Hypothalamic-Pituitary Dysfunction in Infant and Toddler Brain Tumor Survivors
Authors: Lebbink Chantal A , Ringers Tiara P , Schouten-van Meeteren Antoinette Y N , van Iersel Laura , Clement Sarah C , Boot Annemieke M , Claahsen-van der Grinten Hedi L , Janssens Geert O R , van Vuurden Dannis G , Michiels Erna M , Han K Sen , van Trotsenburg A S Paul , Vandertop W Peter , Kremer Leontien C M , van Santen Hanneke M
Published: May 2021

Background: Childhood brain tumor survivors (CBTS) are at risk for hypothalamic-pituitary (HP) dysfunction, mainly caused by radiation exposure or tumor involvement of the HP-region. The risk for HP dysfunction (HPD) may vary between different age groups due to maturation of the brain and differences in oncologic treatment protocols. The aim of this study was to determine the prevalence and risk factors of HPD in infant (IBTS) and toddler brain tumor survivors (TBTS) compared to older childhood brain tumor survivors (OCBTS).

Patients and Methods: A retrospective analysis in a nationwide cohort of CBTS was performed. Prevalence and risk factors for HPD were compared between IBTS (aged 0-1 years at diagnosis), TBTS (aged 1-3 years at diagnosis) and OCBTS (aged >3-18 years at diagnosis).

Results: In 718 included CBTS, with a median follow-up time of 7.9 years, overall no differences in percentage of HPD were found between the three age groups. Treatment with radiotherapy (RT) (OR 15.41; 95%CI 8.33 to 28.48), suprasellar tumor location (OR 46.62; 95%CI 19.64 to 110.66) and younger age (OR 1.09; 95%CI 1.02 to 1.15) were associated with HP dysfunction. Because IBTS were significantly less often treated with RT, subanalyses were performed for all CBTS not treated with radiation (n=459). In non-irradiated CBTS, IBTS and TBTS were significantly more frequently diagnosed with TSH-, ACTH- and ADH deficiency, compared to ECBTS. IBTS and TBTS showed significantly more weight gain (p<0.0001) and smaller height SDS (p=0.001) during follow-up.

Conclusion: Infant and toddler brain tumor survivors seem to be more vulnerable to develop HP dysfunction than when compared to older children. These results emphasize the importance of special infant and toddlers brain tumor treatment protocols and endocrine surveillance in children treated for a brain tumor at young age.
The Association of Insulin-Like Growth Factor-1 With Bone Mineral Density in Survivors of Childhood Acute Leukemia
Authors: Ahn Moon Bae , Kim Sung Eun , Lee Na Yeong , Kim Seul Ki , Kim Shin Hee , Cho Kyoung Soon , Kyoung Cho Won , Ho Jung Min , Suh Byung-Kyu
Published: May 2021

Background: The purpose of the current study is to investigate bone mineral deficit of children in survivors of childhood acute leukemia and examine the association of insulin-like growth factor-1 (IGF-1) with bone mineral density (BMD) status and the presence of osteoporosis. Methods: In a cross-sectional study of children diagnosed with different types of acute leukemia at age between 6 months and 18 years, serum IGF-1 and IGFBP-3, were assessed in relation to lumbar spine BMD (LSBMD) by using dual-energy x-ray absorptiometry and non-traumatic vertebral fracture by lateral thoracolumbar spine radiographs. Standard deviation scores (SDS) were calculated based on the age- and gender-adjusted population mean. Results: Among 189 children after completion of acute leukemia treatment, 22 (11.6%) children had LSBMD SDS less than -2.0 while 80 (42.3 %) children were diagnosed with osteoporosis. Mean areal BMD and LSBMD SDS of the subjects were 0.862±0.197 g/cm2 and -0.6±1.6, respectively. IGF-1 and IGFBP-3 were lower in children with LSBMD lower than -2.0 (P<0.05) and those with osteoporosis (P<0.05). LSBMD SDS showed linear correlation with serum IGF-1 (P=0.041). Low serum IGF-1 level (OR=0.724, P=0.042) and elder age of leukemia diagnosis (OR=1.089, P=0.023) were suggested risk factor of the occurrence of osteoporosis. Conclusions: Substantial number of survivors from childhood acute leukemia undergo bone mineral deficits, and serum IGF-1 status could be a prognostic factor associated with bone mass acquisition and future occurrence of osteoporosis.