bluuebunny/crossref_metadata_2025_split huggingface dataset:
PCOCheck AMH ELISA: A Clinical Case Report to Resolve Miss-Matched Antral Follicle Counts (AFC) to Serum AMH
Authors: Kumar Ajay , Kalra Bhanu , Alpadi Kannan , Green Katherine , Wittmaack Frank 
Published: May 2021

Abstract
Introduction: At times clinicians wonder why a subject’s Anti-Mullerian Hormone (AMH) does not correlate to the antral follicle count (AFC). AMH is secreted as a full-length protein and undergoes proteolytic cleavage at amino acid 451 to become biologically active. Additional proteolytic processing takes place at aa229. This processing, which may differ between individuals with different clinical conditions, exposes new antigenic sites which affect AMH measurements. Moreover, AMH epitopes might be masked by protein interaction in the circulation.
Clinical Case: A 24-year-old woman gravida 0 presented with metrorrhagia for several months. The bleeding pattern was unresponsive to a trial of oral contraceptive pills, and they were discontinued. The patient’s history is remarkable for a microprolactinoma, managed with dopamine agonist. She has facial acne, but no hirsutism. Her BMI is 24 kg/m2. Laboratory studies revealed normal testosterone (27 ng/mL) and DHEAS (64 mcg/dL). Her prolactin was 1.1 ng/mL Thyroid function tests were in the normal range. hCG was negative. A random progesterone was 12 ng/mL, consistent with an ovulatory cycle. Her ovarian assessment showed FSH of 6.6 IU/L, LH of 6.7 IU/L, estradiol of 51 pg/mL, Inhibin B of 139 pg/mL, all in the normal range. Transvaginal pelvic ultrasound determined the ovarian volumes to be 8 and 6 mL, respectively, with a basal antral follicle count of 15 per side. This would have predicted a normal AMH level in this patient. However, AMH levels were repeatedly found to be low (0.05 to 0.1 ng/mL) using the pro-Mature AMH assay. As this patient was interested in future fertility, additional studies to further investigate her AMH production were carried out.
AMH Measurement: Novel AMH ELISAs with antibody epitopes specific to Pro-Mature, Mature-Mature and Pro-Pro were used to analyze the sample. The observed AMH concentration by Pro-AMH ELISA, Mature-Mature ELISA and PCOCheck ELISAs were 0.1 ng/mL, 0.14 ng/mL, and 4.99 ng/mL, respectively. AMH Pro-Pro assay (PCOCheck) uses a linear epitope two-sided antibody that is not impacted by post-translational modifications, known AMH mutations or conformational changes due to thermal instability.
Conclusions: The AMH measurements indicate that the patient’s serum may not contain pro-mature associated form of AMH or the C-fragmented AMH in circulation. This may be due to mutated AMH in the C-terminus and can result in C-truncation. This subject’s AMH is mostly fragmented and contains enriched pro-region AMH, which was measured by PCOCheck ELISA.
The Teaching: Tests such as PCOCheck ELISA, targeted to specific regions of AMH will provide clinicians better tools for patient management. Such tests will also help resolve the observed AMH discrepancies with AFC using legacy AMH tests. PCOCheck ELISA can be a valuable tool for assessment of ovarian reserve or polycystic ovary syndrome (PCOS).
Early Treatment of Hypothalamic Hypogonadism With LH-RH Analog Improved the Long-Term Prognosis of Hypogonadism of Adult-Onset Craniopharyngioma
Authors: Iwabuchi Masayasu 
Published: May 2021

Abstract
Object: Craniopharyngiomas frequently grow on the cisternal surface of the hypothalamic region. The survival rate for childhood craniopharyngioma has been improving with more long-term survivors. Long-term survivors of childhood craniopharyngioma suffer a number of impairments, which include visual loss, endocrinopathy, hypothalamic dysfunction, cerebrovascular problems, neurologic and neurocognitive dysfunction. GnRH neurons in hypothalamus that send axons to portal blood system in median eminence fire in coordinated, repetitive, episodic manner, producing distinct pulses of GnRH in the portal blood system. In 2001, we experienced the case of hypothalamic hypogonadism after the radical surgery of craniopharyngioma located in the right basal ganglia and hypothalamus. During the operation, pituitary gland and stalk were preserved. The patient had developed panhypopituitarism and hypothalamic hypogonadism after transcranial surgery. The diagnosis of oligospermia and asthenospermia was made. We hypothesized that the hypogonadism was due to the lack of distinct pulses of GnRH after the surgery. The aim of this program was to demonstrate the efficacy of the pulsatile subcutaneous LH-RH therapy for the recovery of gonadal function from hypothalamic hypogonadism and to observe the long-term prognosis after recovery.
Method: After a diagnosis of hypothalamic hypogonadism, low dose LH-RH treatment was given to a 29-year-old male with small portable automatically-timed infusion pump, connected to a subcutaneous (s.c.) catheter. Gonadorelin acetate was prepared to the concentration of 0.8mg/ml. Sixteen micrograms of LH-RH s.c. was given every 120 min. Serum levels of gonadotropin and testosterone were monitored. The treatment was continued until his gonadal function normalized. Long-term follow up was continued after low dose LH-RH treatment.
Result: After the six months of pulsatile LH-RH treatment, serum level of testosterone turned normal. Then the treatment was paused in 2003. His wife became pregnant with in-vitro fertilization (IVF) in 2007 and gave birth in 2008. Moreover, his wife became pregnant naturally without IVF in 2009 and gave birth in 2010, suggesting the recovery from oligospermia and asthenospermia of her husband. Early recovery from hypothalamic hypogonadism maintained normal gonadal function in 2020.
Clinical Lessons: We demonstrated a case of successful treatment of the hypothalamic hypogonadism after the surgery of craniopharyngioma. The pulsatile subcutaneous LH-RH therapy is efficacious for the case with the lack of the distinct pulses of GnRH after radical surgery of craniopharyngioma. Early treatment of hypothalamic hypogonadism with LH-RH analog improved the long-term prognosis of hypogonadism of adult-onset craniopharyngioma.
Ectopic Cushing’s From Metastatic Prostate Cancer
Authors: Bloomer Zachary , Teague Jennifer , Vietor Nicole 
Published: May 2021

Abstract
Objective: Ectopic ACTH production from malignancy is a rare etiology of Cushing’s syndrome. The most common tumors associated with this syndrome include small cell lung cancer, pancreatic neuroendocrine tumors, pheochromoctoma, thymic carcinoma, and bronchial carcinoma. Metastatic prostate cancer does not commonly produce ACTH. Here, we present a rare case of Cushing’s syndrome due to metastatic prostate cancer.
Case Report: Patient is a 64 year old man with a 2 year history of castrate-resistant prostate cancer who was admitted for the 2nd time in 1 month for profound weakness and new onset hypokalemia. Initial analysis revealed hypertension with systolic blood pressure in the 150s, potassium in the mid 2s, an ACTH level of &gt;1000pg/mL, and a 24-hr urine cortisol of almost 10,000mcg/24hrs. This was confirmed on repeat analysis. Metyrapone was initiated for treatment of hypercortisolemia and systemic chemotherapy with Cisplatin/Irinotecan was started to treat metastatic prostate cancer. ACTH and 24-hr urine cortisol levels returned to normal within a few weeks of therapy. The patient was able to discontinue Metyrapone following systemic chemotherapy treatment. Subsequent labs following discontinuation of metyrapone confirmed ongoing resolution of hypercortisolemia.
Conclusion: This case represents an extremely rare cause of Cushing’s syndrome. Metastatic prostate cancer can rarely produce ACTH and cause clinical Cushing’s syndrome. Ectopic Cushing’s syndrome is often due to very aggressive tumors and is associated with a poor prognosis. Rapid recognition and treatment of this condition can be lifesaving.
Involvement of NR5A1 and NR5A2 in the Regulation of Steroidogenesis by Clock Gene and BMPs by Human Granulosa Cells
Authors: Suyama Atsuhito , Iwata Nahoko , Soejima Yoshiaki , Nakano Yasuhiro , Yamamoto Koichiro , Nada Takahiro , Otsuka Fumio 
Published: May 2021

Abstract
We previously reported that the expression levels of Clock gene are linked to the expression levels of steroidogenetic enzymes in human granulosa cells (EJ 2019). However, the downstream molecules of the Clock gene actions in the regulation of ovarian steroidogenesis have yet to be elucidated. In the present study, we investigated the roles of the transcription factors, NR5A1 (also known as SF-1) and NR5A2 (LRH-1), which play key roles in the reproductive function as well as steroidogenesis by focusing on the functional link between Clock gene and bone morphogenetic protein (BMP) signaling using human granulosa KGN cells. First of all, we examined the effects of BMPs/growth differentiation factor (GDF) on forskolin (FSK)-induced steroidogenesis. As a result, FSK-induced mRNA levels of StAR and P450scc, but not P450arom, were potently suppressed by treatments with BMP-6, -9, -15 and GDF-9. The expression levels of NR5A1 and NR5A2 mRNA were also upregulated by FSK treatment, while the BMP-target gene Id-1 mRNA levels were stimulated by the treatment with BMPs. Of interest, treatments with BMPs/GDF increased FSK-induced NR5A1 mRNA levels but suppressed FSK-induced NR5A2 mRNA levels by granulosa cells. The expression levels of NR5A1 mRNA were positively correlated with the changes of P450arom and 3βHSD mRNA, whereas the expression levels of NR5A2 mRNA were correlated with that of StAR and P450scc mRNA. In addition, the expression levels of NR5A1 and NR5A2 mRNAs were positively correlated with the levels of Clock mRNA. In particular, Clock mRNA levels showed highly positive correlation with the levels of NR5A2 mRNA compared with NR5A1 mRNA. Of note, Id-1 mRNA levels were positively correlated with the levels of NR5A1 mRNA, but negatively correlated with that of NR5A2 mRNA. Furthermore, the inhibition of Clock gene expression by siRNA attenuated the expression levels of NR5A1 and NR5A2 mRNA, resulting in decreased mRNA levels of StAR and P450arom in the presence of FSK. Thus, the present results suggested a novel mechanism by which Clock expression is functionally linked to the expression of NR5A1 and NR5A2, the latter of which is further regulated by BMP signaling by granulosa cells. The interaction among Clock, NR5A1/NR5A2 and BMPs may be involved in the fine tuning of steroidogenesis by ovarian follicles.
Leptin Secreted in the Testicular Microenvironment Promotes the Endogenous Function of Leydig Cells Through Hedgehog Signaling Pathway
Authors: Arora Himanshu , Parmar Madhumita , Khodamoradi Kajal , Qureshi Rehana , Hare Joshua M , Ramasamy Ranjith 
Published: May 2021

Abstract
Objective: Testosterone deficiency (TD) is a common health concern, affecting around 1 in 5 men globally. However, the factors responsible for TD remain largely unknown. Leydig cells produce testosterone in the testes under the pulsatile control of luteinizing hormone (LH) from the pituitary gland. Leydig stem cells (LSC) have the potential to differentiate into adult Leydig cells, which can increase testosterone levels; however, the factors promoting differentiation are unknown. In the present study we evaluated the paracrine factors released from the testicular microenvironment (TME) (comprised of Sertoli and peritubular myoid cells) that modulate the differentiation of Leydig stem cells to adult Leydig cells. Additionally, we explored the underlying mechanism of action of these paracrine factors.
Methods: Tissue samples were obtained from a total of 13 men with testicular failure, who underwent testis biopsies for sperm retrieval. Using an IRB approved protocol, about 10mg of testicular tissue from each sample were processed for LSC isolation, culturing, and characterization. Cytokine antibody array was performed to identify the paracrine factors released by Sertoli and peritubular myoid cells using unsorted and CD146+ve sorted cells. The cells were treated with hedgehog signaling agonist and antagonist to validate the specificity of paracrine factors identified. Immunostaining was performed to evaluate changes at the protein level. Flow cytometry was performed to study the shift in the population of cells post leptin treatment. GraphPad Prism (GraphPad Software) was used for statistical analysis.
Results: This study revealed that the TME plays an instrumental role in Leydig stem cell differentiation and testosterone production through regulation of the desert hedgehog (DHH) signaling pathway. TME-secreted leptin induces LSC differentiation and increases testosterone production. However, these effects are inversely concentration-dependent: positive at low leptin doses and negative at higher leptin doses. Mechanistically, leptin acts on LSCs upstream of DHH in a unidirectional fashion, as DHH gain or loss of function was shown to have no effects on Leptin levels.
Conclusions: These findings identify leptin as a key paracrine factor released by cells within the TME that modulate LSC differentiation and testosterone production from adult Leydig cells, a finding that is key to developing new niche therapies for TD.
P53 Gain-of-Function Mutants and Steroids in Ovarian Cancer Cell Metastasis
Authors: Candelaria Nicholes , Padmanabhan Achuth , Lanz Rainer , Wong Kwong , Richards JoAnne S 
Published: May 2021

Abstract
High-grade serous ovarian cancer (HGSOC) is a heterogeneous disease for which there currentlyis no cure. Because p53 is mutated in &gt;90% of all ovarian cancer, we studied specific gain-of-function (GOF) p53 mutants and steroid hormones for tumor morphology and metastasis in vivo. For this, we analyzed ALST (WT p53), SKOV3 (p53 null), TYK-NU (p53-R175H), OVCAR3 (p53-R248Q) and OVCA420 (p53-R273H) cell line xenografts in Foxn1-/- mice. ALST cells failed tometastasize, likely due to the known apoptotic effects of WT p53. SKOV3 and the p53-GOF celllines metastasized to the omentum and exhibited distinct morphologies: SKOV3, epithelial-like;TYK-Nu, vascular-like; OVCAR3, epithelial/mesenchymal; and OVCA420 epithelial exclusive. Despite different morphologies and p53 status, each tumor type contained large, Polyploid GiantCancer Cells (PGCCs) that are stem-like cells undergoing endoreplication. A specificphosphorylated, active form of β−catenin (pCTNNB1-S31/S37/T41; pCTNNB1) co-localizedselectively with GOF p53 and the mitotic stress regulatory kinase pMSK1-T581 in mitotic cells andPGCCs, indicating that in addition to GOF p53 mutants, pCTNNB1 and pMSK1 play a role intumor progression. To determine if ALST cells could be rendered metastatic, the p53 GOFmutants R175H and R273H were stably expressed in these cells. Remarkably, the ALST(WT/R273H) cells, but not the ALST (WT/R175H) cells, formed solid tumors on the ovary, visceralfat and uterus; but not on the omentum where OVCA420 (p53-R273H) cells formed tumors. TheALST (WT/R273H) tumors harbored discreet populations of pCTNNB1+ mitotic cells and PGCCsand exhibited distinct growth-promoting responses to estradiol while showing growth-inhibitoryeffects of DHT and nuclear AR in the tumor-associated stromal cells. Stably expressing p53-R175H or p53-R273H GOF mutants in SKOV3 (p53 null) cells enhanced tumor progression withthe R273H mutant being most aggressive. The parental SKOV3 tumors also contained pCTNNB1that was associated with mitotic cells and PGCCs. In the SKOV3 p53-R175H cells - and moreimpressively in the p53-R273H cells - pCTNNB1 co-localized with p53 in PGCCs. Whereas ESR1staining was diffuse in the ALST-R273H cells, it was nuclear in the SKOV3 cell lines. However,tumor promotion by estrogen and inhibition by DHT were observed in each SKOV3 cell line,suggesting that stromal cells may also contribute to the steroid dependent effects. Collectively, 1)elevated levels of specific phosphorylated forms of CTNNB1 and MSK1 identify mitotic cells andPGCCs within the tumors and new targets for therapeutic approaches; 2) knowing the status ofp53, and the presence and localization of pCTNNB1 and pMSK1 and steroid hormone receptorsin ovarian tumors suggest combinatorial approaches should be considered to combat the mostlethal gynecological cancer. NIH-CA181808; NIH-HD097321 (JSR).
Upregulation of Aryl Hydrocarbon Receptor in Granulosa Cells by Endoplasmic Reticulum Stress Contributes to the PCOS Pathophysiology
Authors: Kunitomi Chisato , Harada Miyuki , Azhary Jerilee M K , Kusamoto Akari 
Published: May 2021

Abstract
Studies have demonstrated that endocrine disrupting chemicals (EDC) are involved in the pathophysiology of PCOS, and aryl hydrocarbon receptor (AHR) mediates the cellular effect of EDC by inducing xenobiotic metabolizing enzymes including cytochrome P450 1B1 (CYP1B1). However, recent studies suggest the novel role of AHR in various diseases, including obesity and cancer progression, independent from the EDC metabolism. We previously demonstrated that endoplasmic reticulum (ER) stress, a newly recognized local factor, contributes to PCOS pathology by affecting diverse functions of granulosa cells. We hypothesized that ER stress induces the expression of AHR and activates its downstream signaling in granulosa cells, irrespective of the presence of EDCs, thereby promoting PCOS pathogenesis. At first, we determined the upregulation of AHR, AHR nuclear translocator (ARNT), and AHR target gene cytochrome P450 1B1 (CYP1B1) in the granulosa cells of PCOS patients and model mice by immunohistochemical staining and qPCR. We examined CYP1B1 as a representative AHR target gene. Treatment of cultured human granulosa-lutein cells (GLCs) with tunicamycin (ER stress inducer) upregulated the expression of AHR, ARNT and CYP1B1. Knockdown of AHR decreased the tunicamycin-induced expression and activity of CYP1B1, suggesting the intermediary role of AHR in upregulation of AHR activity by ER stress. To confirm the role of AHR in vivo, we administered the AHR antagonist CH223191 to PCOS model mice. The administration of the antagonist restored estrous cycling and decreased the number of atretic antral follicles, concomitant with downregulation of AHR and CYP1B1 in granulosa cells. Taken together, this study indicates that AHR and downstream signaling are activated by ER stress in GLCs of PCOS. Moreover, downregulation of local AHR expression and activation restores a normal reproductive phenotype in a PCOS mouse model. Our findings demonstrate that AHR activated by ER stress in the follicular microenvironment contributes to PCOS pathology, and that AHR represents a novel therapeutic target for PCOS.
Changes in Clinical Presentation and Perioperative Management of Pheochromocytomas and Paragangliomas: A Four-Decade Experience in a Academic Center
Authors: Uslar Thomas , Francisco Ignacio San , Olmos Roberto Ignacio , Macchiavello Stefano Pietro , Zuñiga Alvaro , Rojas Pablo , Garrido Marcelo , Huete Alvaro , Medez Gonzalo , Cifuentes Joaquin , Castro Fernando , Zemelman Jose Tomas , Olivari Daniela , Fardella Carlos E , Arteaga Eugenio , Ruiz-Tagle Jose Miguel Dominguez , Valdes Gloria , Tagle Rodrigo , Baudrand Rene 
Published: May 2021

Abstract
Objective: Latin American reports on pheochromocytomas and paragangliomas (PPGL) are scarce. Recent studies have shown changes in both clinical presentation and management of these patients. We aimed to assess the main characteristics of PPGL patients in a single academic center over the last four decades. Experimental design: Cohort study. Patients and methods: Demographic, clinical, biochemical, genetic and perioperative data from 105 PPGL patients were retrospectively and prospectively collected over the 1980–2019 period. Patients were categorized into four groups (14 patients in the 1st, 25 patients in the 2nd, 27 patients in the 3th and 39 patients in the 4th decade) according to the date of diagnosis. Results: The mean age at diagnosis was 46±19 years, and the tumor size was 5.3±2.2 cm, female gender was 63%, bilateral tumor of 15%, paragangliomas 9% and metastatic disease in 15%. The aforementioned parameters remained stable across the four decades. During the study period we observed significant increases in doxazosin dosing (2.7±2.6 mg vs. 8.0±4.5 p&lt;0.003) and laparoscopic procedures (28% vs. 84% p&lt;0.001) along with a decrease in the length of hospital stay (10.0±8.9 vs. 3.8±1.7 days p=0.007). Among the 24 genetic tests performed, we identified 59% germline mutations. The most frequent mutations were RET (18%) and SDHX (18%), followed by VHL (14%), MAX (5%) and NF1 (4%). Notably, in the last decade we observed a dramatic increase in the proportion of incidental PPGL diagnosis (0% vs. 53% p&lt;0.001) and genetic testing analyses (0 vs. 19 p&lt;0.001). When comparing incidental diagnosis (n=25) versus clinically suspicious cases(n=50), incidentalomas had fewer adrenergic symptoms (38 vs. 62%; p&lt;0.001), and lower rates of hypertension (64 vs. 80%; p=0.01), hypertension crises (28 vs. 44%; p=0.02), functionality (79 vs. 100%; p=0.01) and total catecholamines and/or metanephrine levels (8.4 vs. 12.5 fold above the upper normal limit; p=0.04). Conclusions: The implementation of a multidisciplinary program increased diagnosis and genetic testing and also optimized anesthesia and surgical procedure, translating into a notorious improvement in perioperative outcomes. In addition, we observed a change in the clinical presentation of PPGL in recent decades with a
marked increase in incidental cases, which highlights the importance of early diagnosis and treatment.
A Rare Case of Autoimmune Progesterone Disease
Authors: Padmanaban Preethi 
Published: May 2021

Abstract
Background: Autoimmune progesterone disease is a rare disease, with fewer than 200 reported cases. Unfortunately, there are no published estimates of incidence or prevalence.
Clinical Case: A 24 year-old woman with no significant past medical history presented with sudden and new onset swelling of the lips which was unresponsive to Benadryl and prednisone. Swelling eventually progressed into blistering over the lips, oral, pharyngeal mucosa and tongue. She was admitted to the hospital for suspicion of Steven Johnson syndrome and was discharged after resolution of skin and oral lesions following treatment. She presented again in 3 months with full body rash and blisters now involving oral and vaginal mucosa. She underwent biopsy of these lesions during this admission and findings were suspicious for drug eruption vs erythema multiforme. Unfortunately, inciting drug or event could not be associated even with pathological diagnosis. She continued to have mucocutaneous flare every month for the next 8 months with multiple hospitalizations and was treated with antibiotics during these admissions. Over the course of her evaluation, it was noted that her symptoms seemed to coincide with her menstrual cycles. Her IUD was removed and she was started on OCPs but her symptoms persisted without any improvement. She underwent intradermal progesterone challenge test at tertiary center for ongoing cyclical dermatitis and tested positive for progesterone sensitivity. She was diagnosed with Autoimmune Progesterone dermatitis. She had to ultimately undergo total abdominal hysterectomy and bilateral salphingo-oophorectomy as she failed OCPs and had adverse effects to progesterone desensitization including full body rash and blisters. Post operatively, she has been started on IM depot injections of estrogen and vaginal estrogen cream.
Conclusion: Autoimmune progesterone disease also known as progesterone dermatitis or progesterone hypersensitivity is not associated with other autoimmune diseases and usually affects women of reproductive age. It is a rare disorder with variable presentation and often overlaps with other forms of dermatosis. It is commonly underdiagnosed or misdiagnosed and appropriate treatment is often delayed. High clinical suspicion for symptoms of cyclical nature is necessary for making the diagnosis.