Isolated adrenocorticotropic hormone deficiency presenting with psychomotor retardation

Abstract

Isolated adrenocorticotropic hormone defi ciency (IAD) is a rare pituitary disease in childhood and is considered to be a differential diagnosis in cases of ketotic hypoglycemia. 1 Although a few patients have an infl ammation or organic lesion in the pituitary gland, the etiology of this disorder has remained unclear in the majority of cases. Adrenocorticotropic hormone (ACTH) is produced from the ACTH precursor, proopiomelanocortin (POMC), by prohormone convertase 1 (PC1), and POMC gene expression requires a cell-restricted transcription factor, TPIT. Recently, mutations in the TPIT gene have been reported in cases of early onset IAD, 2 -5 and loss-of-function mutations of the POMC gene have been found in patients with ACTH defi ciency, obesity and hair pigmentation. 6 Furthermore, PC1 gene mutation has been described in a woman with both ACTH and gonadotropin defi ciency. 7 We describe a sporadic case of congenital IAD with psychomotor retardation and report our investigations of the TPIT , POMC , and PC1 genes in the patient. Case reportThe patient was a 3-year-old Japanese boy who had been born at term weighing 3574 g, by normal vaginal delivery after an uncomplicated pregnancy. Apgar score was 9 and 10 at 1 and 5 min, respectively. The mother had a past history of hyperthyroidism and epilepsy, and his parents were unrelated. There were no neonatal or infant deaths in his family history. He exhibited neither persistent jaundice nor hypoglycemic episodes in the neonatal period. After 9 months of age, he sometimes exhibited drowsiness in the morning, which was resolved after drinking milk. Because he was barely able to sit independently and was not able to stand even with support at 10 months of age, he was admitted to Tsukuba Medical Center Hospital for examination. Laboratory tests, brain magnetic resonance imaging (MRI), electroencephalography and auditory brainstem response were all within normal limits. Chromosomal analysis indicated the 46,XY karyotype. During an episode of acute gastroenteritis at 3 years of age, the diagnosis of ketotic hypoglycemia was fi rst established because of consciousness disturbance, with a blood glucose level of 41 mg/dL and ketonuria; his condition rapidly improved with i.v. glucose infusion. At the same time, the level of plasma cortisol was low and the patient was hospitalized for further examination. On admission his height was 98 cm (+0.5 SD), bodyweight 15 kg (+0.3 SD), and head circumference 50 cm (−0.1 SD). He showed no facial dysmorphism, minor anomalies, dyspigmentation, hepatomegaly, or neurological abnormalities. He could walk without support but could not run, climb stairs, or speak even two-word sentences. His developmental quotient was 38, equivalent to 15 months of age. Laboratory tests ( Table 1 ) showed reduced plasma ACTH, cortisol, and urine 17-hydroxycorticosteroids (17-OHCS), and no circadian cycle of cortisol secretion was found. The plasma level of corticotropin-releasing hormone (CRH) measured by radioimmunoassay was within a normal range. Anti-pituit...

Isolated Adrenocorticotropic Hormone Deficiency Presenting as an Acute Neurologic Emergency in a Peripubertal Girl

“…In addition, a transient form of IAD has been described in patients after traumatic brain injury (TBI) 19 . Neurological manifestations of IAD -which were observed in our patient -have also been described, and patients have been reported presenting with delirium 20 , involuntary movements 21 , and psychomotor retardation 22 . However, to our knowledge, this is the first reported case of a patient with isolated ACTH deficiency presenting outside of the newborn period with new-onset seizure activity.…”

Clinical, Biological and Genetic Analysis of 8 Cases of Congenital Isolated Adrenocorticotrophic Hormone (ACTH) Deficiency

“…Almost all patients had had difficulty at school that disappeared once they began their Hydrocortisone® replacement therapy. Nozue et al [4] reported the case of a patient with isolated ACTH deficiency and psychomotor retardation, suggesting the specific role of the hypoglycemia and/or low blood pressure. Shulman et al [11] also reported symptoms that may mimic gastrointestinal illness or a psychiatric disorder, particularly behaviour changes or depression.…”

“…Metherell et al [3] reported 7 cases, 4 of whom were less than one year old, with two different mutations in 2 of them, and 3 of whom were over 5 years old. Nozue et al [4] reported one Japanese case and collected 7 more cases, they included 3 early onset and 5 late onset forms. Mutations in the TPIT gene are associated only with the early onset form [2] .…”