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Brito VN, Canton APM, Seraphim CE, Abreu AP, Macedo DB, Mendonca BB, Kaiser UB, Argente J, Latronico AC. The Congenital and Acquired Mechanisms Implicated in the Etiology of Central Precocious Puberty. Endocr Rev 2023; 44:193-221. [PMID: 35930274 PMCID: PMC9985412 DOI: 10.1210/endrev/bnac020] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Indexed: 01/20/2023]
Abstract
The etiology of central precocious puberty (CPP) is multiple and heterogeneous, including congenital and acquired causes that can be associated with structural or functional brain alterations. All causes of CPP culminate in the premature pulsatile secretion of hypothalamic GnRH and, consequently, in the premature reactivation of hypothalamic-pituitary-gonadal axis. The activation of excitatory factors or suppression of inhibitory factors during childhood represent the 2 major mechanisms of CPP, revealing a delicate balance of these opposing neuronal pathways. Hypothalamic hamartoma (HH) is the most well-known congenital cause of CPP with central nervous system abnormalities. Several mechanisms by which hamartoma causes CPP have been proposed, including an anatomical connection to the anterior hypothalamus, autonomous neuroendocrine activity in GnRH neurons, trophic factors secreted by HH, and mechanical pressure applied to the hypothalamus. The importance of genetic and/or epigenetic factors in the underlying mechanisms of CPP has grown significantly in the last decade, as demonstrated by the evidence of genetic abnormalities in hypothalamic structural lesions (eg, hamartomas, gliomas), syndromic disorders associated with CPP (Temple, Prader-Willi, Silver-Russell, and Rett syndromes), and isolated CPP from monogenic defects (MKRN3 and DLK1 loss-of-function mutations). Genetic and epigenetic discoveries involving the etiology of CPP have had influence on the diagnosis and familial counseling providing bases for potential prevention of premature sexual development and new treatment targets in the future. Global preventive actions inducing healthy lifestyle habits and less exposure to endocrine-disrupting chemicals during the lifespan are desirable because they are potentially associated with CPP.
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Affiliation(s)
- Vinicius N Brito
- Discipline of Endocrinology & Metabolism, Department of Internal
Medicine, University of Sao Paulo Medical School, University of Sao
Paulo, Sao Paulo 01246 903, Brazil
| | - Ana P M Canton
- Discipline of Endocrinology & Metabolism, Department of Internal
Medicine, University of Sao Paulo Medical School, University of Sao
Paulo, Sao Paulo 01246 903, Brazil
| | - Carlos Eduardo Seraphim
- Discipline of Endocrinology & Metabolism, Department of Internal
Medicine, University of Sao Paulo Medical School, University of Sao
Paulo, Sao Paulo 01246 903, Brazil
| | - Ana Paula Abreu
- Division of Endocrinology, Diabetes and Hypertension, Department of
Medicine, Brigham and Women’s Hospital, Harvard Medical School,
Boston, MA 02115, USA
| | - Delanie B Macedo
- Discipline of Endocrinology & Metabolism, Department of Internal
Medicine, University of Sao Paulo Medical School, University of Sao
Paulo, Sao Paulo 01246 903, Brazil
- Division of Endocrinology, Diabetes and Hypertension, Department of
Medicine, Brigham and Women’s Hospital, Harvard Medical School,
Boston, MA 02115, USA
- Núcleo de Atenção Médica Integrada, Centro de Ciências da Saúde,
Universidade de Fortaleza, Fortaleza 60811 905,
Brazil
| | - Berenice B Mendonca
- Discipline of Endocrinology & Metabolism, Department of Internal
Medicine, University of Sao Paulo Medical School, University of Sao
Paulo, Sao Paulo 01246 903, Brazil
| | - Ursula B Kaiser
- Division of Endocrinology, Diabetes and Hypertension, Department of
Medicine, Brigham and Women’s Hospital, Harvard Medical School,
Boston, MA 02115, USA
| | - Jesús Argente
- Hospital Infantil Universitario Niño Jesús, Department of Endocrinology and
Department of Pediatrics, Universidad Autónoma de Madrid, Spanish PUBERE Registry,
CIBER of Obesity and Nutrition (CIBEROBN), Instituto de Salud Carlos III, IMDEA
Institute, Madrid 28009, Spain
| | - Ana Claudia Latronico
- Discipline of Endocrinology & Metabolism, Department of Internal
Medicine, University of Sao Paulo Medical School, University of Sao
Paulo, Sao Paulo 01246 903, Brazil
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Gohil A, Eugster EA. Gonadotropin-Releasing Hormone Analogs for Treatment of Central Precocious Puberty in Children Younger than 2 Years of Age. J Pediatr 2022; 244:215-218. [PMID: 34942182 DOI: 10.1016/j.jpeds.2021.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/24/2021] [Accepted: 12/02/2021] [Indexed: 11/28/2022]
Abstract
Although gonadotropin-releasing hormone analogs are the standard of care for the treatment of central precocious puberty, they are not approved for children/< age 2 years. We reviewed experience with the use of gonadotropin-releasing hormone analogs in 47 children younger than age 2 years, which revealed efficacy and safety comparable with that in older children.
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Affiliation(s)
- Anisha Gohil
- Division of Endocrinology & Diabetes, Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN.
| | - Erica A Eugster
- Division of Endocrinology & Diabetes, Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN
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Filippo GD, Gaudino R, Calcaterra V, Villani A, Bozzola E, Bozzola M. Incidental pineal gland cyst in girls with early onset of puberty. Ital J Pediatr 2022; 48:44. [PMID: 35313951 PMCID: PMC8935686 DOI: 10.1186/s13052-022-01235-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 02/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background The causes of an early onset of puberty are still not clearly defined and may vary from subject to subject. In girls, even if 90% of early puberty is idiopathic, magnetic resonance imaging (MRI) of the brain is performed to exclude secondary causes of precocious puberty, in particular pathological lesions as hypothalamic tumours (hamartoma). In some cases, other intracranial lesions are considered as incidental findings. Aim of the study is evaluating the prevalence of abnormal intracranial lesions detected by brain magnetic resonance imaging MRI with particular focus on the prevalence of pineal gland cysts in the diagnostic work-up of girls with central precocious puberty (CPP) as onset before 8 years and central early puberty (CEP) as onset before 10 years. Material and methods MRI data of girls referred from January 2010 to December 2015 to the Pediatric Endocrinology Unit of University of Pavia for early onset of breast development were collected. Results We collected 123 MRI data of girls referred to the Pediatric Endocrinology Unit of University of Pavia for early onset of breast development in the study period. Out of them, 25 (20.3%) had cerebral abnormalities and 15 (12.2%) had pineal gland cysts. No significant differences were noted in auxological, ultrasound and hormonal parameters at diagnosis among girls with or without pineal cysts. Patients have been observed for at least three years after the discontinuation of therapy. None of our patients had an unfavorable evolution. Conclusions Although pineal cysts seem to be not involved in the onset of puberty, the relevance of the finding remains controversial. Our study wants to provide further insight into the incidence of pineal cysts in pubertal advances. Of note, pineal cysts are often asymptomatic and do not evolve over time.
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Management of Central Precocious Puberty in Children with Hypothalamic Hamartoma. CHILDREN-BASEL 2021; 8:children8080711. [PMID: 34438602 PMCID: PMC8392575 DOI: 10.3390/children8080711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/17/2021] [Accepted: 08/17/2021] [Indexed: 12/01/2022]
Abstract
Hypothalamic hamartoma (HH) is a rare, congenital, and benign lesion of the tuber cinereum, typically presenting with central precocious puberty (CPP), gelastic seizure, and developmental delay. This study aimed to investigate CPP in HH patients and compare clinical features between before and after gonadotropin-releasing hormone (GnRH) agonist treatment. A total of 30 HH patients under 18 years of age who visited Severance Children’s Hospital between January 2005 and May 2020 were retrospectively reviewed. Fourteen patients were male (46.7%) and sixteen (53.3%) were female, with a mean age at diagnosis was4.2 ± 2.9 years. During follow-up, 24 patients (80.0%) were diagnosed with CPP, 15 patients (50.0%) had gelastic seizure, and 13 patients (43.3%) had developmental delay. The gelastic seizure was significantly associated with sessile type HH rather than pedunculated type HH (85.7% vs. 18.8%, p = 0.001). After GnRH agonist treatment, discrepancies between bone age and chronological age decreased (3.3 ± 1.3 years to 2.0 ± 1.7 years, p = 0.002). Additionally, height standard deviation score for bone age was increased, and predicted adult height increased significantly in females, while males showed an increasing trend. Clinical symptoms of HH were closely associated with the location of HH, and GnRH agonist treatment was safe and effective in the management of CPP caused by HH.
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Khawaja AM, Pati S, Ng YT. Management of Epilepsy Due to Hypothalamic Hamartomas. Pediatr Neurol 2017; 75:29-42. [PMID: 28886982 DOI: 10.1016/j.pediatrneurol.2017.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 06/28/2017] [Accepted: 07/01/2017] [Indexed: 11/18/2022]
Abstract
A hypothalamic hamartoma consists of hyperplastic heterotopic tissue growing in a disorganized fashion. These lesions occur in about one per 50,000 to 100,000 people. Hypothalamic hamartomas can cause intrinsic epileptogenesis leading to gelastic seizures. Surrounding cortical structures may also develop secondary epileptogenesis. Persistent seizures caused by hypothalamic hamartomas can be debilitating and result in significant cognitive and behavioral impairment. Early recognition and treatment is important in controlling seizures and in preventing further cognitive deterioration. Some patients experience improved cognition and behavior following early treatment, suggesting that hypothalamic hamartomas represent a reversible epileptic encephalopathy. The outcome of epilepsy associated with these lesions has significantly evolved with the availability of new treatment techniques and an improved understanding of its pathogenesis. Increasing evidence supporting the role of hypothalamic hamartomas as a cause of gelastic seizures and secondary epileptogenesis has led to more frequent use of surgery as the definitive treatment. Several minimally invasive procedures have been devised, including neuroendoscopic approaches and different stereotactic radio and laser ablation techniques. Each of these techniques can lead to unique adverse events. We review the various classification schemes used to characterize hypothalamic hamartomas and the recommended surgical approaches for each subtype. We also review the literature for currently available treatment modalities and compare their efficacy in controlling seizures and their safety profiles.
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Affiliation(s)
- Ayaz M Khawaja
- Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Sandipan Pati
- Department of Neurology, University of Alabama at Birmingham Hospital, Birmingham, Alabama.
| | - Yu-Tze Ng
- Department of Pediatrics, Baylor College of Medicine, The Children's Hospital of San Antonio, San Antonio, Texas
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Castinetti F, Brue T, Morange I, Carron R, Régis J. Gamma Knife radiosurgery for hypothalamic hamartoma preserves endocrine functions. Epilepsia 2017; 58 Suppl 2:72-76. [PMID: 28591475 DOI: 10.1111/epi.13760] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2016] [Indexed: 11/26/2022]
Abstract
Gamma Knife radiosurgery (GK) is an effective treatment for hypothalamic hamartoma. No precise data are available on the risk of endocrine side effects of this treatment. In this study, 34 patients with hypothalamic hamartoma (HH) were followed prospectively at the Department of Endocrinology, La Timone Hospital, Marseille, France, for a mean follow-up of >2 years (mean ± standard deviation [SD] 3.6 ± 2 years). Initial pre- and post-GK radiosurgery evaluations were performed, including weight, body mass index (BMI), and a complete endocrinological workup. At diagnosis, eight patients presented with central precocious puberty at a mean age of 5.4 ± 2.4 years. At the time of GK (mean age 18.2 ± 11.1 years), two patients previously treated with surgery presented with luteinizing hormone/follicle-stimulating hormone (LH/FSH) deficiency. After GK, only one patient presented with a new thyrotropin-stimulating hormone (TSH) deficiency, 2 years after the procedure. The other pituitary axes remained normal in all but two patients (who had LH/FSH deficiency prior to GK). There was no significant difference between pre- and post-GK mean BMI (26.9 vs. 25.1 kg/m2 , p = 0.59). To conclude, in this group of 34 patients, GK did not induce major endocrinologic side effects reported with all the other surgical techniques in the literature. It is, thus, a safe and effective procedure in the treatment of hypothalamic hamartoma.
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Affiliation(s)
- Frederic Castinetti
- Department of Endocrinology, Assistance Publique Hôpitaux de Marseille, La Timone Hospital, Aix-Marseille University, Marseille, France
| | - Thierry Brue
- Department of Endocrinology, Assistance Publique Hôpitaux de Marseille, La Timone Hospital, Aix-Marseille University, Marseille, France
| | - Isabelle Morange
- Department of Endocrinology, Assistance Publique Hôpitaux de Marseille, La Timone Hospital, Aix-Marseille University, Marseille, France
| | - Romain Carron
- Department of Functional Neurosurgery, Assistance Publique Hôpitaux de Marseille, La Timone Hospital, Aix-Marseille University, Marseille, France
| | - Jean Régis
- Department of Functional Neurosurgery, Assistance Publique Hôpitaux de Marseille, La Timone Hospital, Aix-Marseille University, Marseille, France
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Harrison VS, Oatman O, Kerrigan JF. Hypothalamic hamartoma with epilepsy: Review of endocrine comorbidity. Epilepsia 2017; 58 Suppl 2:50-59. [PMID: 28591479 DOI: 10.1111/epi.13756] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2016] [Indexed: 12/22/2022]
Abstract
The most common, and usually the only, endocrine disturbance in patients with hypothalamic hamartoma (HH) and epilepsy is central precocious puberty (CPP). The mechanism for CPP associated with HH may relate to ectopic generation and pulsatile release of gonadotropin-releasing hormone (GnRH) from the HH, but this remains an unproven hypothesis. Possible regulators of GnRH release that are intrinsic to HH tissue include the following: (1) glial factors (such as transforming growth factor α[TGFα) and (2) γ-aminobutyric acid (GABA)-mediated excitation. Both are known to be present in surgically-resected HH tissue, but are present in patients with and without a history of CPP, suggesting the possibility that symptoms related to HH are directly associated with the region of anatomic attachment of the HH to the hypothalamus, which determines functional network connections, rather than to differences in HH tissue expression or pathophysiology. CPP associated with HH presents with isosexual development prior to the age of 8 years in girls and 9 years in boys. It is not uncommon for CPP with HH to present in children at an earlier age in comparison to other causes of CPP, including in infancy. Surgical resection of the HH can be effective for treating CPP, but is reserved for patients with intractable epilepsy, since GnRH agonists are widely available and effective treatment. Other endocrine disturbances with HH are rare, but can include growth hormone deficiency, hypothyroidism, and adrenal insufficiency. Diabetes insipidus is commonly encountered postoperatively, but is not observed with HH prior to surgical intervention.
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Affiliation(s)
- Victor S Harrison
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Oliver Oatman
- Division of Endocrinology and Hypothalamic Hamartoma Program, Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
| | - John F Kerrigan
- Pediatric Neurology Division and Hypothalamic Hamartoma Program, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, U.S.A
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Silva CAA, Brunner HI. Review: Gonadal functioning and preservation of reproductive fitness with juvenile systemic lupus erythematosus. Lupus 2016; 16:593-9. [PMID: 17711894 DOI: 10.1177/0961203307077538] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Increased survival of children with juvenile systemic lupus erythematosus (jSLE) and improved prognosis have led to a change in the long-term health issues arising for jSLE patients. Preservation of gonadal functioning and fertility are of increasing importance for young adults with jSLE. Events during childhood, such as exposure to alkylating agents, may compromise the reproductive potential. Even in the absence of gonadotoxic therapies, fertility may be decreased through organs specific involvement with jSLE. Strategies to preserve the reproductive potential of girl and boys with jSLE are discussed. Lupus (2007) 16, 593—599.
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Affiliation(s)
- C A A Silva
- Pediatric Rheumatology Unit, Children's Hospital, and Division of Rheumatology of University of São Paulo, São Paulo, Brazil
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Bessa DS, Macedo DB, Brito VN, França MM, Montenegro LR, Cunha-Silva M, Silveira LG, Hummel T, Bergadá I, Braslavsky D, Abreu AP, Dauber A, Mendonca BB, Kaiser UB, Latronico AC. High Frequency of MKRN3 Mutations in Male Central Precocious Puberty Previously Classified as Idiopathic. Neuroendocrinology 2016; 105:17-25. [PMID: 27225315 PMCID: PMC5195904 DOI: 10.1159/000446963] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/18/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Recently, loss-of-function mutations in the MKRN3 gene have been implicated in the etiology of familial central precocious puberty (CPP) in both sexes. We aimed to analyze the frequency of MKRN3 mutations in boys with CPP and to compare the clinical and hormonal features of boys with and without MKRN3 mutations. METHODS This was a retrospective review of clinical, hormonal and genetic features of 20 male patients with idiopathic CPP evaluated at an academic medical center. The entire coding regions of MKRN3, KISS1 and KISS1R genes were sequenced. RESULTS We studied 20 boys from 17 families with CPP. All of them had normal brain magnetic resonance imaging. Eight boys from 5 families harbored four distinct heterozygous MKRN3 mutations predicted to be deleterious for protein function, p.Ala162Glyfs*14, p.Arg213Glyfs*73, p.Arg328Cys and p.Arg365Ser. One boy carried a previously described KISS1-activating mutation (p.Pro74Ser). The frequency of MKRN3 mutations among these boys with idiopathic CPP was significantly higher than previously reported female data (40 vs. 6.4%, respectively, p < 0.001). Boys with MKRN3 mutations had typical clinical and hormonal features of CPP. Notably, they had later pubertal onset than boys without MKRN3 abnormalities (median age 8.2 vs. 7.0 years, respectively, p = 0.033). CONCLUSION We demonstrated a high frequency of MKRN3 mutations in boys with CPP, previously classified as idiopathic, suggesting the importance of genetic analysis in this group. The boys with CPP due to MKRN3 mutations had classical features of CPP, but with puberty initiation at a borderline age.
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Affiliation(s)
- Danielle S. Bessa
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Delanie B. Macedo
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vinicius N. Brito
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Monica M. França
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luciana R. Montenegro
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marina Cunha-Silva
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Leticia G. Silveira
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Tiago Hummel
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ignacio Bergadá
- Centro de Investigaciones Endocrinológicas ‘Dr. César Bergadá’, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Debora Braslavsky
- Centro de Investigaciones Endocrinológicas ‘Dr. César Bergadá’, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ana Paula Abreu
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass
| | - Andrew Dauber
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Berenice B. Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ursula B. Kaiser
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass
| | - Ana Claudia Latronico
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Latronico AC, Brito VN, Carel JC. Causes, diagnosis, and treatment of central precocious puberty. Lancet Diabetes Endocrinol 2016; 4:265-274. [PMID: 26852255 DOI: 10.1016/s2213-8587(15)00380-0] [Citation(s) in RCA: 252] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 09/28/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023]
Abstract
Central precocious puberty results from the premature activation of the hypothalamic-pituitary-gonadal axis. It mimics physiological pubertal development, although at an inappropriate chronological age (before 8 years in girls and 9 years in boys). It can be attributable to cerebral congenital malformations or acquired insults, but the cause in most cases in girls remains unknown. MKRN3 gene defects have been identified in familial disease, with important basic and clinical results. Indeed, genetic analysis of this gene should be included in the routine clinical investigation of familial and idiopathic cases of central precocious puberty. Gonadotropin-releasing hormone agonists are the gold-standard treatment. The assessment and management of this disease remain challenging for paediatric endocrinologists. In this Series paper, we describe current challenges involving the precise diagnosis and adequate treatment of this disorder.
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Affiliation(s)
- Ana Claudia Latronico
- Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - Vinicius Nahime Brito
- Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jean-Claude Carel
- Univ Paris Diderot, Sorbonne Paris Cité, Paris, France; Department of Pediatric Endocrinology and Diabetology, Hôpital Robert Debré, and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Paris, France; Institut National de la Santé et de la Recherche Médicale U1141, Paris, France
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Macedo DB, Cukier P, Mendonca BB, Latronico AC, Brito VN. [Advances in the etiology, diagnosis and treatment of central precocious puberty]. ACTA ACUST UNITED AC 2015; 58:108-17. [PMID: 24830587 DOI: 10.1590/0004-2730000002931] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 11/26/2013] [Indexed: 11/21/2022]
Abstract
The onset of puberty is first detected as an increase in the amplitude and frequency of pulses of gonadotropin-releasing hormone (GnRH) after a quiescent period during childhood. The reemergence of pulsatile GnRH secretion leads to increases in the secretion of the gonadotropins, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) by the pituitary gland, and the consequent activation of gonadal function. Early activation of the hypothalamic-pituitary-gonadal axis results in gonadotropin-dependent precocious puberty, also known as central precocious puberty (CPP), which is clinically defined by the development of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys. Pubertal timing is influenced by complex interactions among genetic, nutritional, environmental, and socioeconomic factors. CPP is diagnosed on the basis of clinical signs of progressive pubertal development before the age of 8 years in girls and 9 years in boys, pubertal basal and/or GnRH-stimulated LH levels, and advanced bone age. Magnetic resonance imaging of the central nervous system is essential for establishing the CPP form as organic or idiopathic. Depot GnRH-analogues represent the first-line of therapy in CPP. Very recently, the genetic component of CPP was demonstrated by the evidence that the deficiency of the MKRN3 gene, located on long arm of chromosome 15, causes familial CPP in humans. In this current review, clinical and therapeutic aspects of the CPP will be discussed, contributing to adequate diagnosis and criterious approach of this relevant condition of pediatric endocrinology.
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Affiliation(s)
- Delanie B Macedo
- Laboratório de Hormônios e Genética Molecular LIM/42, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Priscilla Cukier
- Laboratório de Hormônios e Genética Molecular LIM/42, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Berenice B Mendonca
- Laboratório de Hormônios e Genética Molecular LIM/42, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Ana Claudia Latronico
- Laboratório de Hormônios e Genética Molecular LIM/42, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Vinicius Nahime Brito
- Laboratório de Hormônios e Genética Molecular LIM/42, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Abstract
The hypothalamic hormone GnRH has traditionally been viewed as a central driver of the hypothalamic-pituitary-gonadal axis. Pulsatile GnRH release is required for pulsatile gonadotropin secretion, which then modulates gonadal steroid feedback and brings about full fertility in the adult. Pathways governing GnRH ontogeny and physiology have been discovered by studying humans with disorders of GnRH secretion. In this chapter, the human genetics of the kisspeptin signaling pathway in patients with diverse reproductive phenotypes will be explored. The discovery of defects in the kisspeptin system in several reproductive disorders has shed light on the mechanisms involved in regulating GnRH secretion, revealing the critical role played by the kisspeptin signaling pathway in pubertal initiation and reproductive function.
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Cukier P, Castro LHM, Banaskiwitz N, Teles LR, Ferreira LRK, Adda CC, da Costa Leite C, Arnhold IJ, Mendonca BB, Latronico AC, Brito VN. The benign spectrum of hypothalamic hamartomas: Infrequent epilepsy and normal cognition in patients presenting with central precocious puberty. Seizure 2013; 22:28-32. [DOI: 10.1016/j.seizure.2012.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 09/20/2012] [Accepted: 09/22/2012] [Indexed: 10/27/2022] Open
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14
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Imaging of recurrent intramuscular granulomatous masses induced by depot injection of leuprorelin. Skeletal Radiol 2012; 41:347-52. [PMID: 21861209 DOI: 10.1007/s00256-011-1254-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 08/01/2011] [Accepted: 08/05/2011] [Indexed: 02/02/2023]
Abstract
Leuprorelin is a luteinizing hormone-releasing hormone (LH-RH) agonist that is used as an agent of androgen deprivation in some patients with prostate cancer. When administered in depot form, local granulomatous reactions may occur at the injection site, which may mimic masses and which are associated with treatment failure. We present a patient who, over a period of 5 years, developed multiple intramuscular gluteal masses while receiving leuprorelin therapy via intramuscular depot injections; biopsy of one of the masses showed the specific histologic features of leuprorelin granuloma. To our knowledge, this entity has not been described in the radiology literature. Awareness of this entity is necessary to suggest the correct diagnosis in patients with a history of leuprorelin depot injections.
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15
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Pan R, Liu YZ, Deng HW, Dvornyk V. Association analyses suggest the effects of RANK and RANKL on age at menarche in Chinese women. Climacteric 2011; 15:75-81. [PMID: 22023082 DOI: 10.3109/13697137.2011.587556] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Age at menarche (AAM), the time of the first menstrual bleeding, is an important developmental milestone in the female life. It marks the beginning of the reproductive period. AAM is implicated in the risk of many health complications in later life. In this study, we conducted an analysis for association of single nucleotide polymorphisms (SNPs) and common haplotypes of two candidate genes, RANK (receptor activator of the NF-κB) and RANKL (receptor activator of the NF-κB ligand), with AAM in 825 unrelated Chinese women. METHODS In total, 73 SNPs of RANKL and 23 SNPs of RANK were genotyped. The SNPs and common haplotypes were then analyzed for their association with AAM. Age and age( 2 ) were used as covariates. RESULTS We found five individual SNPs (rs7239261, rs8094884, rs3826620, rs8089829, and rs9956850) of RANK significantly associated with AAM (p < 0.05). Although no significant association was identified for the RANKL gene, three polymorphisms showed nearly significant (0.05 < p < 0.08) association with AAM. Seven haplotypes of RANK were significantly associated with AAM (p < 0.05); the most significant association of the AT haplotype composed by rs1805034 and rs4524034 (p = 9.4 × 10(-4)) remained significant (p = 0.0235) after the Bonferroni correction for multiple testing. Three haplotypes of RANKL were significantly associated with AAM (p < 0.05). Importantly, the association of rs3826620 replicated our previous findings for Caucasian females. CONCLUSIONS The results of the present study suggest that the RANK and RANKL are two candidate genes for AAM in Chinese women.
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Affiliation(s)
- R Pan
- Laboratory of Molecular and Statistical Genetics, College of Life Sciences, Hunan Normal University, Changsha, Hunan, PR China
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16
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Teles MG, Silveira LFG, Tusset C, Latronico AC. New genetic factors implicated in human GnRH-dependent precocious puberty: the role of kisspeptin system. Mol Cell Endocrinol 2011; 346:84-90. [PMID: 21664234 DOI: 10.1016/j.mce.2011.05.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 05/11/2011] [Indexed: 12/21/2022]
Abstract
Human puberty is triggered by the reemergence of GnRH pulsatile secretion with progressive activation of the gonadal function. A number of genes have been identified in the complex regulatory neuroendocrine network that controls puberty initiation. KISS1 and KISS1R genes, which encode kisspeptin and its cognate receptor, respectively, are considered crucial factors for acquisition of normal reproductive function. Recently, rare missense mutations and single nucleotide polymorphisms (SNPs) of the kisspeptin system were associated with puberty onset. Two gain-of-function mutations of the KISS1 and KISS1R genes were implicated in the pathogenesis of GnRH-dependent precocious puberty, previously considered idiopathic. These discoveries have yielded significant insights into the physiology and pathophysiology of this important life transition time. Here, we review the current molecular defects that are implicated in human GnRH-dependent precocious puberty.
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Affiliation(s)
- Milena Gurgel Teles
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42 da Disciplina de Endocrinologia e Metabologia do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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17
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Silveira LFG, Trarbach EB, Latronico AC. Genetics basis for GnRH-dependent pubertal disorders in humans. Mol Cell Endocrinol 2010; 324:30-8. [PMID: 20188792 DOI: 10.1016/j.mce.2010.02.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 02/12/2010] [Accepted: 02/17/2010] [Indexed: 12/20/2022]
Abstract
Human puberty is triggered by the reemergence of GnRH pulsatile secretion, with progressive activation of gonadal function. Several mutations have been identified in an increasing number of genes that influence the onset of puberty. Mutations in GNRH1, KISS1R and GNRHR genes cause normosmic IHH, interfering with the normal synthesis, secretion or action of GnRH. More recently, mutations in TAC3 and TACR3 genes, which encode neurokinin B and its receptor, have been implicated in normosmic IHH, although their precise functions in reproduction remain unclear. Mutations in KAL1, FGFR1, FGF8, PROK2 and PROKR2 are related to disruption of the development and migration of GnRH neurons, thereby resulting in Kallmann syndrome, a complex genetic condition characterized by isolated hypogonadotropic hypogonadism (IHH) and olfactory abnormalities. Furthermore, mutations in CHD7 gene, a major gene involved in the etiology of CHARGE syndrome, were also described in some patients with Kallmann syndrome and normosmic IHH. Notably, the evidence of association of some of the genes implicated with GnRH neurons development and migration with both Kallmann syndrome and normosmic IHH, blurring the simplest clinical distinction between ontogenic and purely functional defects in the axis. Digenic or oligogenic inheritance of IHH has also been described, illustrating the extraordinary genetic heterogeneity of IHH. Interestingly, rare gain-of-function mutations of the genes encoding the kisspeptin and its receptor were recently associated with central precocious puberty phenotype, indicating that the premature activation of the reproductive axis may be also caused by genetic mutations. These discoveries have yielded significant insights into the current knowledge of this important life transition.
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Affiliation(s)
- Leticia Ferreira Gontijo Silveira
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42 da Disciplina de Endocrinologia do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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18
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Nagaki S, Otsuka E, Miwa K, Funatsuka M, Kubo O, Hori T, Shibata N, Sawada T, Osawa M. Two cases of precocious puberty associated with hypothalamic hamartoma. Clin Pediatr Endocrinol 2010; 19:31-7. [PMID: 23926376 PMCID: PMC3687620 DOI: 10.1297/cpe.19.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 11/20/2009] [Indexed: 11/29/2022] Open
Abstract
Hypothalamic hamartoma (HH) is a congenital malformation diagnosed based on magnetic resonance imaging (MRI)
and histological findings; it is often associated with central precocious puberty (CPP), gelastic seizures,
abnormal behavior and mental retardation. In the present paper, we report our retrospective hypothesis that
there is a relationship between symptoms and therapy, as well as the treatment for HH, and describe two cases
of HH associated with CPP. Both cases had sessile masses located in the interpeduncular cistern, with
extension to the hypothalamus on MRI (1.2 × 1.5 cm and 2.0 × 2.5 cm, respectively). The first case had
intractable seizures, while the second had no seizures with paroxysmal discharge. In both patients, the
hamartomas were partially removed, by γ-knife and surgical operation in the first case and surgically in the
second, and a gonadotropin releasing hormone (GnRH) analogue was prescribed. One case showed improvement of
both intelligence quotient (IQ) score and seizures, and the other showed improvements in IQ and abnormal
behavior. It was difficult to determine any topology/symptom relationships. Surgery and GnRH analogue
treatment can alleviate seizures, abnormal behavior and mental retardation associated with HH.
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Affiliation(s)
- Shigeru Nagaki
- Department of Pediatrics, Tokyo Women's Medical University, Tokyo, Japan
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19
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Krstevska-Konstantinova M, Jancevska A, Gucev Z. Autoimmune thyroiditis and diabetes mellitus type 1 after long-term gonadotropin-releasing hormone agonist treatment for central precocious puberty: evolution or coincidence? J Pediatr Endocrinol Metab 2010; 23:403-6. [PMID: 20583547 DOI: 10.1515/jpem.2010.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Very few abnormalities in endocrine function have been reported during long term gonadotropin-releasing hormone agonist (GnRHa) treatment in girls. Most authors agree that this therapy is safe and effective. We present an unusual outcome of long term GnRHa therapy in two girls with central precocious puberty(CPP) of idiopathic or organic origin. They have received monthly depot injections of triptorelin acetate for a time period of 8 years. Thyroid function was examined by measuring serum levels of thyrotropin (TSH), thyroxine (T4), thyroid antibodies, and ultrasound of the thyroid gland. One of the girls was at the age of 8.5 years, having elevated thyroid antibodies, mild goitier and an abnormal ultrasound of the thyroid gland, suggesting autoimmune thyroiditis. Another girl with a hypothalamic hamartoma developed diabetes mellitus at the age of 9 years. Both of these girls were early diagnosed for CPP, at 6 months and 8 months respectively, and given GnRHa treatment. So far, it is not known whether these autoimmune diseases are related to the GnRHa treatment or are simply a coincidence. However, we suggest a closer monitoring of girls with CPP who have had a long period of treatment.
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20
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Brito VN, Latronico AC, Arnhold IJP, Mendonça BB. Update on the etiology, diagnosis and therapeutic management of sexual precocity. ACTA ACUST UNITED AC 2009; 52:18-31. [PMID: 18345393 DOI: 10.1590/s0004-27302008000100005] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 10/10/2007] [Indexed: 11/22/2022]
Abstract
Precocious puberty is defined as the development of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys. Gonadotropin-dependent precocious puberty (GDPP) results from the premature activation of the hypothalamic-pituitary-gonadal axis and mimics the physiological pubertal development, although at an inadequate chronological age. Hormonal evaluation, mainly through basal and GnRH-stimulated LH levels shows activation of the gonadotropic axis. Gonadotropin-independent precocious puberty (GIPP) is the result of the secretion of sex steroids, independently from the activation of the gonadotropic axis. Several genetic causes, including constitutive activating mutations in the human LH-receptor gene and activating mutations in the Gs protein a-subunit gene are described as the etiology of testotoxicosis and McCune-Albright syndrome, respectively. The differential diagnosis between GDPP and GIPP has direct implications on the therapeutic option. Long-acting gonadotropin-releasing hormone (GnRH) analogs are the treatment of choice in GDPP. The treatment monitoring is carried out by clinical examination, hormonal evaluation measurements and image studies. For treatment of GIPP, drugs that act by blocking the action of sex steroids on their specific receptors (cyproterone, tamoxifen) or through their synthesis (ketoconazole, medroxyprogesterone, aromatase inhibitors) are used. In addition, variants of the normal pubertal development include isolated forms of precocious thelarche, precocious pubarche and precocious menarche. Here, we provide an update on the etiology, diagnosis and management of sexual precocity.
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Affiliation(s)
- Vinicius Nahime Brito
- Unidade de Endocrinologia do Desenvolvimento, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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21
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Moreno-Pérez O, Carles Genovés C, Moreno Macián F, Rius Peris J, Albiach Mesado V. Pubertad precoz completa isosexual: hallazgos clínicos, de laboratorio y ecografía pélvica. An Pediatr (Barc) 2008; 69:413-9. [DOI: 10.1157/13127995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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22
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Bertelloni S, Mul D. Treatment of central precocious puberty by GnRH analogs: long-term outcome in men. Asian J Androl 2008; 10:525-34. [PMID: 18478155 DOI: 10.1111/j.1745-7262.2008.00409.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In boys, central precocious puberty (CPP) is the appearance of secondary sex characteristics driven by pituitary gonadotropin secretion before the age of 9 years. In the last years, relevant improvements in the treatment of CPP have been achieved. Because CPP is rare in boys, the majority of papers on this issue focus on girls and do not address specific features of male patients regarding end results and safety. In the present paper, recent advances of CPP management with GnRH analogs in men are summarized. End results in untreated and treated patients are also reviewed by an analysis of the recently published literature on treatment of CPP in men. The available data indicate that therapy with GnRH analogs can improve final height into the range of target height without significant adverse short-term and long-term effects, but longer follow-up of larger series of patients is still required to draw definitive conclusions.
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Affiliation(s)
- Silvano Bertelloni
- Adolescent Medicine, Department of Obstetrics, Gynecology and Pediatrics, Santa Chiara University Hospital, Pisa, Italy.
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23
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Kashyap AS, Anand KP, Kashyap S, Arora S. One-year-old male with accelerated growth and development. Postgrad Med J 2007; 83:e4. [PMID: 17916866 DOI: 10.1136/pgmj.2007.062307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A 1-year-old male child with isosexual central (gonadotropin-dependent) precocious puberty caused by hypothalamic hamartoma is reported. Details of the diagnosis based solely on neuromaging characteristics, and satisfactory results of medical treatment with gonadotropin releasing hormone agonist analogues, are highlighted.
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Affiliation(s)
- Ajit Singh Kashyap
- Department of Endocrinology, Command Hospital (Central Command), Lucknow Cantt, India.
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24
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Daskivich TJ, Oh WK. Failure of gonadotropin-releasing hormone agonists with and without sterile abscess formation at depot sites: Insight into mechanisms? Urology 2006; 67:1084.e15-7. [PMID: 16698377 DOI: 10.1016/j.urology.2005.11.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2005] [Revised: 10/17/2005] [Accepted: 11/04/2005] [Indexed: 11/17/2022]
Abstract
We describe a patient with advanced prostate cancer who failed to achieve testosterone suppression with depot leuprolide after developing sterile abscesses at the injection sites. When the patient was switched to depot goserelin, he did not have any evidence of inflammation at the injection sites, but testosterone suppression again failed. This case suggests variable mechanisms for failure of gonadotropin-releasing hormone agonist therapy and highlights the necessity of prospective testosterone monitoring in patients who have developed sterile abscesses, even if switched to another gonadotropin-releasing hormone agonist.
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Affiliation(s)
- Timothy J Daskivich
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA
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25
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Abstract
Central precocious puberty (CPP) is characterized by early pubertal changes, acceleration of growth velocity, and rapid bone maturation that often result in reduced adult height. An onset of pubertal signs before the age of 8 years in girls and 9 years in boys should always be evaluated. A combination of clinical signs, bone age, pelvic echography in girls, and hormonal data are required to diagnose CPP and make a judgment concerning progression and prognosis. Not all children with apparently true CPP require medical intervention. The main reasons for treatment are to prevent compromised adult height and to avoid psychosocial or behavioral problems. The need for treatment for auxologic reasons is based on estimation of predicted adult height, with the finding of a reduced height potential, which may require a follow-up. Indication for treatment on the basis of psychologic and behavioral anomalies has to be determined on an individual basis. The main short-term aims of therapy are to stop the progression of secondary sex characteristics and menses (in girls) and to treat the underlying cause, when known. Long-term goals are to increase final adult height and to promote psychosocial well-being. Once it has been decided that treatment is appropriate, it should be initiated immediately with depot gonadotropin-releasing hormone (GnRH) agonists. The effective suppression of pituitary gonadal function is achieved with these compounds in practically all CPP patients. Long-term data are now available from 2 decades of GnRH agonist treatment for patients with CPP. Treatment preserves height potential in the majority of patients (especially in younger patients) and improves the final adult height of children with rapidly progressing CPP, with a complete recovery of the hypothalamic-pituitary-gonadal axis after treatment. GnRH agonist treatment using depot preparations is useful and has a good safety profile, with minimal adverse effects and no severe long-term consequences. Although further data are need, there may be a role in the future for combining somatropin (growth hormone) and GnRH agonist treatment for some patients with significantly impaired growth velocity. The introduction of GnRH antagonists is likely to improve the treatment options for CPP.
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26
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Kizilkilic O, Yalcin O, Yildirim T, Sener L, Parmaksiz G, Erdogan B. Hypothalamic hamartoma associated with a craniopharyngeal canal. AJNR Am J Neuroradiol 2005; 26:65-7. [PMID: 15661703 PMCID: PMC7975046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Hypothalamic hamartoma is a rare congenital lesion. We present the case of a 7-year-old girl who suffered from precocious puberty, the cause of which was diagnosed by using MR imaging and CT as pedunculated hypothalamic hamartoma associated with a large craniopharyngeal canal and sellar spine mimicking pituitary duplication.
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Affiliation(s)
- Osman Kizilkilic
- Department of Radiology, Adana Teaching and Medical Research Center, Baskent University, Adana, Turkey
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27
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Gulati S, Gera S, Menon PSN, Kabra M, Kalra V. Hypothalamic hamartoma, gelastic epilepsy, precocious puberty--a diffuse cerebral dysgenesis. Brain Dev 2002; 24:784-6. [PMID: 12453604 DOI: 10.1016/s0387-7604(02)00096-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Childhood epileptic syndrome characterized by early onset gelastic seizures, hypothalamic hamartoma and precocious puberty is well recognized though rare. We report association of agenesis of corpus callosum, Dandy-Walker complex and heterotopic gray matter with this childhood epileptic syndrome which is hitherto an unreported association. The child showed a satisfactory response to gonadotropin releasing hormone agonist.
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Affiliation(s)
- Sheffali Gulati
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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28
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Bajpai A, Sharma J, Kabra M, Kumar Gupta A, Menon PSN. Precocious puberty: clinical and endocrine profile and factors indicating neurogenic precocity in Indian children. J Pediatr Endocrinol Metab 2002; 15:1173-81. [PMID: 12387516 DOI: 10.1515/jpem.2002.15.8.1173] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to evaluate the clinical and endocrine profile of patients with precocious puberty followed up in a tertiary care hospital. Records of 140 patients (114 girls, 26 boys) with precocious puberty were reviewed. Clinical features including age of onset, stage of pubertal development, presenting symptoms, features suggestive of CNS involvement and family history were analyzed. Endocrine investigations included basal and GnRH-stimulated levels of LH and FSH as well as 17OHP, DHEA, hCG and thyroid profile. Abdominal and pelvic ultrasonography and CNS imaging were correlated with clinical features. Girls outnumbered boys in this series (4.4:1). Neurogenic central isosexual precocious puberty (CIPP) was more common in boys (10 out of 18, 55.6%) than girls (16 out of 77, 20.8%). The most common cause of neurogenic CIPP was hypothalamic hamartoma present in five girls and four boys. Other causes of neurogenic CIPP included neurotuberculosis, pituitary adenoma, hydrocephalus, post radiotherapy, CNS tumors and malformations. Peripheral precocious puberty (PPP) was secondary to adrenal causes in boys and ovarian cysts in girls. Benign variants of precocious puberty, such as premature thelarche and premature adrenarche, were present in 23 and six girls, respectively. Hypothyroidism was present in four girls and McCune-Albright syndrome in one girl. Girls with neurogenic CIPP had a lower age of onset as compared to idiopathic CIPP (3.6 +/- 2.7 years vs 5.4 +/- 2.5 years, p = 0.014). The lowest age of onset was seen in girls with hypothalamic hamartoma (1.6 +/- 0.9 years). Forty-seven girls with CIPP (seven neurogenic and 40 idiopathic) presented after the age of 6 years. Features of CNS involvement, in the form of seizures, mental retardation, raised intracranial tension or focal neurological deficits, were present in seven girls (43.8%) and four boys (40%), and gelastic seizures were present in three children. Girls with CIPP had greater bone age advancement (3.4 +/- 1.5 years) and negative height standard deviation for bone age (-2.7 +/- 1.5) than those with PPP (1.9 +/- 1.6 years and -1.3 +/- 1.3) and premature thelarche (0.4 +/- 0.4 years and -0.8 +/- 0.8). Patients with neurogenic CIPP had significantly higher levels of baseline and GnRH-stimulated levels of LH and FSH and LH:FSH ratio than those with idiopathic CIPP. Occurrence of neurogenic CIPP in seven girls with an age of onset after 6 years emphasizes the need for CNS imaging in these girls contrary to the current recommendations. The fact that 65.6% cases of idiopathic CIPP presented after the age of 6 years raises the possibility that these patients may be physiological variants of normal puberty. Pointers to neurogenic CIPP included early age of onset in girls, clinical features of CNS involvement, and elevated basal and stimulated LH levels and LH:FSH ratio.
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Affiliation(s)
- Anurag Bajpai
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
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29
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Abstract
This chapter describes several aspects of the management of treatment in girls and boys with central precocious puberty. Although there is some controversy about the indication for gonadotrophin releasing hormone (GnRH) agonist treatment in the literature, a list of clear indications is presented and monitoring requirements for treatment are discussed with reference to the pertinent literature. The development of clinical, psychological, hormonal, sonographical and auxological parameters that can be expected during GnRH agonist treatment is described in detail. In view of the scant evidence-based knowledge, we review the final outcome of patients treated with GnRH agonists with respect to reversibility of hormonal suppression, reproductive function, final height and side effects. The data published so far show that GnRH agonist treatment using the modern depot preparations is not only convenient but also safe, with relatively minor side effects. The outcome in terms of final height is favourable in the majority of patients.
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Affiliation(s)
- Carl-Joachim Partsch
- Division of Paediatric Endocrinology, Department of Paediatrics, Kinderklink, Christian Albrechts-Universität zu Kiel, Schwanenweg 20, D-24105 Kiel, Germany
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30
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Affiliation(s)
- Carl-Joachim Partsch
- Division of Paediatric Endocrinology, Department of Paediatrics, Christian-Albrechts University, Kiel, Germany
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31
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Partsch CJ, Sippell W. Pathogenesis and epidemiology of precocious puberty. Effects of exogenous oestrogens. APMIS 2001. [DOI: 10.1111/j.1600-0463.2001.tb05760.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Arisaka O, Negishi M, Numata M, Hoshi M, Kanazawa S, Oyama M, Nitta A, Suzumuara H, Kuribayashi T, Nakayama Y. Precocious puberty resulting from congenital hypothalamic hamartoma: persistent darkened areolae after birth as the hallmark of estrogen excess. Clin Pediatr (Phila) 2001; 40:163-7. [PMID: 11307963 DOI: 10.1177/000992280104000307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- O Arisaka
- Department of Pediatrics, Dokkyo University School of Medicine, Mibu, Tochigi, Japan
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33
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De Sanctis V, Corrias A, Rizzo V, Bertelloni S, Urso L, Galluzzi F, Pasquino AM, Pozzan G, Guarneri MP, Cisternino M, De Luca F, Gargantini L, Pilotta A, Sposito M, Tonini G. Etiology of central precocious puberty in males: the results of the Italian Study Group for Physiopathology of Puberty. J Pediatr Endocrinol Metab 2000; 13 Suppl 1:687-93. [PMID: 10969910 DOI: 10.1515/jpem.2000.13.s1.687] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We reviewed the hospital records of 45 boys, followed in 13 pediatric departments throughout Italy, who had undergone computed tomography and/or magnetic resonance imaging for central precocious puberty (CPP). Twenty-seven patients (60%) had idiopathic CPP and 18 (40%) neurogenic CPP. A hamartoma of the tuber cinereum was found in six patients (33%). All patients with hypothalamic hamartoma had earlier onset of symptoms than patients with idiopathic CPP. Five patients (27%) were affected by type 1 neurofibromatosis, two had ependymoma and five patients had an intracranial anomaly. Basal LH and basal and peak LH/FSH ratio were greater, but not significantly, in boys with neurogenic CPP than in boys with idiopathic CPP. The highest LH peak levels were observed in patients with hamartoma; however, no correlation was observed between LH peak and the size of the hamartomas. In addition, bone age at diagnosis was more advanced in patients with hamartoma than in patients with other conditions. In conclusion, gonadotrophin-dependent precocious puberty may be of idiopathic origin or may occur in association with any CNS disorder. Further studies are needed in order to evaluate the effects of nutritional, environmental and psychosocial factors on the timing of sexual maturation, to explain the high incidence of idiopathic CPP in our male patients.
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Affiliation(s)
- V De Sanctis
- Division of Pediatric and Adolescent Medicine, Azienda Ospedaliera Arcispedale S. Anna, Ferrara, Italy
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