Children born small for gestational age (SGA).

SGA (small for gestational age) is a child born with birth weight and/or length (BW/BL) under two standard deviations (2 SDS) for the gestational age and sex of the population. ~5% of all newborn children are SGA. A broad spectrum of factors are found to be causative: maternal, placental, foetal, metabolic, and genetic. In the newborn period the SGA children are at greater risk of life-threatening conditions: hypoglycaemia, hypercoagulability, necrotic enterocolitis, direct hyperbilirubinemia, hypotension, etc. Approximately 10 percent of SGA children do not achieve catch-up growth and remain short (≥-2 SDS) into adulthood. SGA people have an increased incidence of metabolic syndrome, coronary artery disease, stroke, low bone density and osteoporosis. SGA children aged more than 4 years with no evidence of spontaneous catch-up and with a height≥2.5 SD are considered for growth hormone (GH) treatment.

Four generations in a family with neurofibromatosis 1: precocious puberty and optic nerve tumor (OPT).

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder with varied clinical manifestations. The proband is a 6-year-old boy with signs of precocious puberty. His penis was 10 cm, testicles 8 ml, pubic hair P2-3, and the genital skin was hyperpigmented. Multiple cafe au lait spots well above 5 mm were noticeable on his skin, as well as hard subcutaneous nodules, mostly on his trunk. His intelligence and hearing are normal. He has no history of seizures. Laboratory analysis showed: LH LH 1.4 mIU/ml, FSH 6.2 mIU/ml, testosterone 183 ng/ml. Bone age was 9 years. LHRH stimulation was characteristic of true precocious puberty (LH 9.8 mIU/ml and FSH 8.9 mIU/ml after 30 minutes). The MRI of the brain showed a tumor of the suprasellar region with compression of the pituitary stalk. At present the boy is 6 years old and has been treated with triptoreline acetate for 3 months. The volume of the testicles has decreased to 7 ml and a slight loss of pubic hair was noted. In addition, his mother and his grandfather exhibited dermal masses, and focal cutaneous and subcutaneous growths. The great-grand father had had the same cutaneous changes and died at the age of 75 from unrelated causes. It has already been well documented that NF is associated with an increased risk of malignancy and precocious puberty. Hence, we emphasize the need for a close and regular clinical follow-up of the OPT, puberty and patterns of growth.

Type I Gaucher disease (GDI) in three siblings: enzyme replacement treatment (ERT) required.

(Full text is available at http://www.manu.edu.mk/prilozi). This is a family of three children, born to healthy Macedonian parents after uneventful pregnancies and delivery. The index child was an eight-year-old girl admitted for abdominal discomfort and distension: the spleen was 14cm below the costal margin (BCM), the liver 8cm BCM. No bone pain or pathology was reported. There was mild pancytopaenia (hemoglobin 11.2 gm/L; WBC counts 4.6 x 10;3; platelets 70 x 10;3). Liver function tests, renal ultrasound, bone scan, and a chest radiograph were within normal limits. Bone marrow analysis in this child and her two brothers (11 and 6.5 years old) revealed Gaucher cells. Both brothers had only mild anaemia, but the older brother had been splenectomized prior to diagnosis of GD1. Enzyme analysis revealed low activity (2.59, 1.62, and 2.55 nmol/h/mg protein, respectively); plasma chitotriosidase levels were also elevated. Genetic testing revealed homozygosity for the N370S/N370S mutation in all three siblings. In the absence of available enzyme replacement treatment (ERT), the girl was splenectomized. Removing an important immune organ (the spleen) introduces further risk for the patients. In addition, this does not solve the bone involvement characteristic for GD. ERT should be introduced for all GD1 patients in Macedonia. Key words: Gaucher disease, N370S mutation, siblings, enzyme replacement therapy.

Growth hormone deficiency (GHD) and small for gestational age (SGA): genetic alterations.

Short stature associated with GH deficiency has been estimated to occur in about 1 in 4000 to 1 in 10,000 in various studies. In the last decade new genetic defects have been described in all the levels of the growth hormone-releasing hormone (GH-RH)-GH-IGF (insulin-like growth factor) axis. Genetic defects in the GHRH and in various parts of the Insulin-like growth factor system have been demonstrated. Genetic defects causing isolated GH deficiency (GHD), as well as multiple pituitary hormonal deficiencies have been analysed in detail. Signalling molecules and transcription factors leading to the development of the pituitary gland have been discovered and their function recognized. In animal models and in humans the importance of the transcription factors HESX1, PROP1, POU1F1, LHX3, LHX4, TBX19, SOX2 and SOX3 has been extensively studied. Genetic alterations of those transcription factors dictate the highly variable phenotype: from isolated hypopituitarism to multiple pituitary hormonal deficiencies with or without malformations (e.g. septo-optic dysplasia or holoprosencephaly). Small for gestational age (SGA) children are increasingly recognized to be a heterogeneous group in which new mechanisms of growth retardation and metabolic disturbances have been proposed. Since SGA is considered to be the main reason for the short stature in 10% of short adults this is a large group with a great potential for novel insights into mechanisms of growth and metabolic disturbances. A group of signalling proteins are involved in prenatal (SGA) growth retardation: IRS-1, PDK1, AKT1, and S6K1. In addition, an attractive modern theory supposes that a disturbed mother-placenta-foetus relation results in the activation of the so-called "thrifty phenotype" of which the IGF system is a vital part. The mechanisms assure short-term postnatal survival in conditions of deficient nutritional supply. However, as a consequence, the abundant postnatal nutritional supply and the "thrifty phenotype" result in increased adult risk of metabolic syndrome, diabetes mellitus type 2 (DM2) and cardiovascular disease. The manuscript reviews in brief genetic alterations in humans leading to growth hormone deficiency (GHD), multiple pituitary hormone deficiencies (MPHD) and SGA.