Female pseudohermaphroditism and inefficient peak bone mass in an untreated subject affected by 21-hydroxylase congenital adrenal hyperplasia.

Here we describe a subject with congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21-CAH), in its classical virilizing form, who presented at birth ambiguous genitalia and subsequently was assigned by the parents as male. At the age of 8 years, he underwent a two-step surgical correction of hypospadia and at 22 years old, uterus and ovaries were removed and a bilateral testicular prothesis was surgically placed in scrotum. He refused any chronic glucocorticoid therapy, that was given only acutely to prevent adrenal crises during stress, trauma surgery or severe illness. The patient is now 38 years old, he is genotypically female but phenotypically male, with high endogenous levels of androgen, all of adrenal origin, and with an apparent male sexual life. He had severe osteopenia, probably due to the lack of estrogen/androgen-induced increase in bone mineral density, although periferal estrogen conversion was normal. His skeletal mass, in fact, normally acquired during adolescence and early adult life, could in this case be inefficient, for the precocious pseudopuberty, that caused an inefficient peak bone mass in adolescence period.

Dysregulation of adrenal 11 beta-hydroxylase activity in hypertensive subjects: usefulness of the ACTH 1-17 stimulation test.

BACKGROUND AND AIM: The aim of this study was to determine the validity of our previous hypothesis of adrenal 11 beta-hydroxylase (11-OH) dysregulation in "essential" low-renin hypertension. METHODS AND RESULTS: A comparison was made between 30 hypertensive patients and 30 age-matched controls (NC) in basal conditions and after ACTH stimulation (ACTH 1-17) test. The 11-deoxycortisol (S) and deoxycorticosterone (DOC) integrated areas under the curve (AUCs) of stimulus were significantly higher in the hypertensives (p < 0.001) and pointed to adrenal 11-OH dysregulation. CONCLUSIONS: The ACTH 1-17 test detects impairment of 11-OH activity of probable genetic origin. The relative mineralocorticoid excess thus provoked could be an additional cause of "essential" low-renin hypertension.

Prevalence of coeliac disease in patients with thyroid autoimmunity.

The occurrence of autoimmune thyroid disorders among patients with coeliac disease (CD) is well documented, but the exact prevalence of CD among patients with autoimmune thyroid diseases (ATD) is as yet unclear. We screened 150 newly diagnosed patients with ATD by serum endomysial antibody detection (EmA). In 5 subjects (3.3%) EmA positivity was found; all underwent jejunal biopsy. On gluten-free diet an excellent clinical and histological response was recorded with an improvement of hypothyroidism and reduction of the thyroxine dosage. Our data suggest a significant high prevalence (3.3%) of CD in patients with ATD, in particular with Hashimoto's thyroiditis.

Unusual association of thyroiditis, Addison's disease, ovarian failure and celiac disease in a young woman.

The coexistence of autoimmune endocrine diseases, particularly autoimmune thyroid disease and celiac disease (CD), has recently been reported. We here present a 23-year-old woman with a diagnosis of hypothyroidism due to Hashimoto's thyroiditis, autoimmune Addison's disease, and kariotypically normal spontaneous premature ovarian failure. Considering the close association between autoimmune diseases and CD, we decided to search for IgA anti-endomysium antibodies (EmA) in the serum. The positivity of EmA and the presence of total villous atrophy at jejunal biopsy allowed the diagnosis of CD. On a gluten-free diet the patient showed a marked clinical improvement accompanied, over a 3-month period, by a progressive decrease in the need for thyroid and adrenal replacement therapies. After 6 months, serum EmA became negative and after 12 months a new jejunal biopsy showed complete mucosal recovery. After 18 months on gluten-free diet, the anti-thyroid antibodies titre decreased significantly, and we could discontinue thyroid substitutive therapy. This case emphasizes the association between autoimmune polyglandular disease and CD; the precocious identification of these cases is clinically relevant not only for the high risk of complications (e.g. lymphoma) inherent to untreated CD, but also because CD is one of the causes for the failure of substitute hormonal therapy in patients with autoimmune thyroid disease.

[Analysis of ocular saccadic movements with a fatigue test and neostigmine in Graves' ophthalmopathy]. / Analisi dei movimenti oculari saccadici con test all'affaticamento ed alla neostigmina nell'oftalmopatia di Graves.

BACKGROUND: Aim of this study was to investigate the frequency of association between Myasthenia Gravis (MG) and Graves Ophthalmopathy (GO) using the responses to diagnostic tests for MG (fatigue and neostigmine tests) by measuring horizontal saccadic eye movements (SEM). METHODS: For this paper a random investigation was performed on eleven patients, affected by Graves' disease (GD) at the department of Molecular and Clinical Endocrinology and Oncology and department of Neurology of University of Federico II of Naples, for one year. Eleven patients (11 F), were subjected to endocrinological and ophthalmological examinations (TSH IRMA, TT3-RIA, TT4-RIA, TgAb, TPOAb, orbit ultrasonography or computed tomographic scans) and computerized analysis of saccadic eye movements (SEM); the fatigue and neostigmine tests were performed by means of SEM analysis in seven of this patients. RESULTS: Our results have reported that a positive response to the diagnostic tests for MG is present in 41.6% of hyperthyroid patients with GO, further supporting the hypothesis of a common autoimmune pathogenesis is present between these pathologies. CONCLUSIONS: SEM analysis may be a useful adjunct in the diagnosis of GO.

Success of glucocorticoid replacement therapy on fertility in two adult males with 21-CAH homozygote classic form.

A normal gonadal maturation with normal fertility are some of the major goals of long-term replacement therapy in adult males with Congenital Adrenal Hyperplasia (CAH). We describe here two young men, G.O. (case A, 23 years old) and S.S.(case B, 24 years old), both with a well defined diagnosis of CAH due to 21-hydroxylase deficiency classic homozygote form (21-CAH). In case A the diagnosis of the 21-CAH classic virilizing form was made at 3 years of age. The patient has undergone glucocorticoid therapy and is now 170 cm tall; all his hormonal findings are within the normal range. The semen analysis has shown a good fertility potential, with a slight modification when the patient decided to discontinue the therapy. In case B the diagnosis of the 21-CAH salt wasting form was performed at 9 days of age. The patient was initially treated with i.v. normal saline solution and a daily i.m. injection of hydrocortisone and, subsequently, with mineral and glucocorticoid replacement therapy po. A satisfactory adult stature (165 cm) was attained. The patient is still on therapy, with a good hormonal profile. The semen analysis has shown an apparently normal fertility. In conclusion, our experience in adult males with 21-CAH, who have been administered prompt and adequate replacement therapy, shows that these patients can attain normal quality of life, satisfactory growth and development, normal sexual maturation and activity, and adequate sperm fertilizing ability, thereby supporting the usefulness of continuing this therapy during adult age.

Usefulness of a chromatographic method to detect circulating antithyroid hormone autoantibodies in canine serum.

Antithyroid hormone autoantibodies (THBA), described in both humans and animals, result in variable interference when thyroid hormone plasma levels are measured by immunoassays. We previously described a quick chromatographic method to detect circulating THBA in humans. In the present experience, we applied the method on canine sera (10 normal dogs and 3 dogs affected by hypothyroidism) to detect the THBA presence in a dog (no. 13) with clinical evidence of hypothyroidism, in spite of apparently extremely high values of thyroid hormone. After a short incubation of samples with 125I-T3 and 125I-T4 in presence of 8-anilino-1-naphtalenesulfonic acid, samples were eluted and radioactivity values counted. Eluate radioactivity values > 10% and > 30% were considered positive for THBA presence for antiT3 and antiT4 detection, respectively. High radioactivity values were detected in dog serum no. 13 and, therefore, it was considered positive for THBA presence. The Scatchard plot analysis revealed the presence of a monoclonal autoantibody with the highest affinity for T3 and an additional tenfold lower affinity for T4. In conclusion, our chromatographic method allows the detection and the characterization of THBA in species different from humans, with species specific differences in thyroid hormone metabolism; thus, taking into account the rarely availability of canine serum TSH and anti-thyroglobulin antibody immunoassay detection methods, it was possible to correctly diagnose the hypothyroidism in a dog with apparently extremely high values of thyroid hormones due to THBA interference.

Hypothalamic-pituitary-adrenal axis and immune system.

Complex and bidirectional relationships operate between the hypothalamic-pituitary-adrenal (HPA) axis and the immune system (IS) and either in vivo or in vitro evidence supports a physiological role of the HPA axis-IS network. A part of the well-known pharmacological effects of glucocorticoid hormones (GC) as immunodepressive agents, the direct effects of many HPA axis hormones on IS functions are actually documented also in physiologic conditions. Conversely, numerous IS soluble mediators are reported to affect the HPA axis functions at various steps of HPA axis regulation, in both physiologic and pathologic conditions. Stress and aging may represent two paradigmatic conditions to show the relevance of the bidirectional network between HPA axis and IS, as in both HPA activation and IS impairment are frequently coexistent. Finally, in the context of the wide spectrum of HIV-related HPA axis abnormalities, a case of a Cushing's syndrome associated to an acquired immunodeficiency syndrome (AIDS-related complex) in a 24-year-old homosexual drug abuser is reported.