Distinct Reproductive Phenotypes Segregate With Differences in Body Weight in Adolescent Polycystic Ovary Syndrome

Introduction

Polycystic ovary syndrome (PCOS) is a heterogenous clinical syndrome defined by hyperandrogenism and irregular menses. In adult women with PCOS, discrete metabolic and reproductive subgroups have been identified. We hypothesize that distinct phenotypes can be distinguished between adolescent girls who are lean (LN-G) and girls with obesity (OB-G) at the time of PCOS diagnosis.

Methods

Data were extracted from the CALICO multisite PCOS database. Clinical data collected at the time of diagnosis were available in 354 patients (81% with obesity) from 7 academic centers. Patients with body mass index (BMI) < 85th percentile for age and sex were characterized as lean (LN-G) and those with BMI percentile ≥ 95th percentile as obese (OB-G). We compared metabolic and reproductive phenotypes in LN-G and OB-G.

Results

Reproductive phenotypes differed between the groups, with LN-G having higher total testosterone, androstenedione, and LH levels, while OB-G had lower sex hormone binding globulin (SHBG) and higher free testosterone. Metabolic profiles differed as expected, with OB-G having higher hemoglobin A1c, alanine aminotransferase, and serum triglycerides and more severe acanthosis nigricans.

Conclusion

LN-G with PCOS had a distinct reproductive phenotype characterized by increased LH, total testosterone, and androstenedione levels, suggesting neuroendocrine-mediated ovarian androgen production. In contrast, phenotypes in OB-G suggest hyperandrogenemia is primarily driven by insulin resistance with low SHBG levels. These observations support the existence of distinct metabolic and reproductive subtypes in adolescent PCOS characterized by unique mechanisms for hyperandrogenemia.

Hyperinsulinemic Hypoglycemia and Growth Hormone Deficiency Secondary to 20p11 Deletion

Hypoglycemia is concerning for neurological complications in infants and children. Determining the cause of hypoglycemia is essential in providing appropriate treatment. Hyperinsulinism and growth hormone deficiency are known causes of hypoglycemia but are not commonly found together. We report a 4-month-old boy who presented with severe hypoglycemia and was found to have both hyperinsulinism and growth hormone deficiency. Treatment with both recombinant human growth hormone and diazoxide led to blood glucose normalization. Subsequently, he was found to have a genetic diagnosis of 20p11.22p11.21 deletion. 20p11 deletions have been associated with hypopituitarism, most commonly seen in growth hormone deficiency causing hypoglycemia. This case is one of a few to report hyperinsulinism as a manifestation of this deletion.

Selective Venous Sampling Prompting Unilateral Oophorectomy in an Adolescent With PCOS and Markedly Elevated Testosterone

BACKGROUND

For adolescents with suspected polycystic ovary syndrome (PCOS) and severely elevated testosterone concentrations, imaging is recommended to assess for neoplasm. Selective venous sampling (SVS) can be considered when imaging is nondiagnostic.

CASE

An adolescent female treated for PCOS had a peak testosterone of 344 ng/dL (11.9 nmol/L). Imaging did not localize a mass. SVS implicated the right ovary as the source of hyperandrogenism. Following laparoscopic right oophorectomy, pathology excluded a neoplasm and confirmed PCOS. She subsequently had rapid and persistent improvement in her hyperandrogenism.

SUMMARY AND CONCLUSION

Striking testosterone elevation can occur with adolescent PCOS. SVS is a tool for localizing the source of severe hyperandrogenism, yet unilaterality is not always diagnostic of a neoplasm. Unilateral oophorectomy could nonetheless be therapeutic for severe PCOS.

Persistence of β-Cell Responsiveness for Over Two Years in Autoantibody-Positive Children With Marked Metabolic Impairment at Screening

OBJECTIVE

We studied longitudinal differences between progressors and nonprogressors to type 1 diabetes with similar and substantial baseline risk.

RESEARCH DESIGN AND METHODS

Changes in 2-h oral glucose tolerance test indices were used to examine variability in diabetes progression in the Diabetes Prevention Trial-Type 1 (DPT-1) study (n = 246) and Type 1 Diabetes TrialNet Pathway to Prevention study (TNPTP) (n = 503) among autoantibody (Ab)+ children (aged <18.0 years) with similar baseline metabolic impairment (DPT-1 Risk Score [DPTRS] of 6.5-7.5), as well as in TNPTP Ab- children (n = 94).

RESULTS

Longitudinal analyses revealed annualized area under the curve (AUC) of C-peptide increases in nonprogressors versus decreases in progressors (P ≤ 0.026 for DPT-1 and TNPTP). Vector indices for AUC glucose and AUC C-peptide changes (on a two-dimensional grid) also differed significantly (P < 0.001). Despite marked baseline metabolic impairment of nonprogressors, changes in AUC C-peptide, AUC glucose, AUC C-peptide-to-AUC glucose ratio (AUC ratio), and Index60 did not differ from Ab- relatives during follow-up. Divergence between nonprogressors and progressors occurred by 6 months from baseline in both cohorts (AUC glucose, P ≤ 0.007; AUC ratio, P ≤ 0.034; Index60, P < 0.001; vector indices of change, P < 0.001). Differences in 6-month change were positively associated with greater diabetes risk (respectively, P < 0.001, P ≤ 0.019, P < 0.001, and P < 0.001) in DPT-1 and TNPTP, except AUC ratio, which was inversely associated with risk (P < 0.001).

CONCLUSIONS

Novel findings show that even with similarly abnormal baseline risk, progressors had appreciably more metabolic impairment than nonprogressors within 6 months and that the measures showing impairment were predictive of type 1 diabetes. Longitudinal metabolic patterns did not differ between nonprogressors and Ab- relatives, suggesting persistent β-cell responsiveness in nonprogressors.

Gender diversity in adolescents with polycystic ovary syndrome

OBJECTIVES

The objective of our study was to describe the prevalence of gender diverse (GD) youth  among adolescents with polycystic ovary syndrome (PCOS).

METHODS

We conducted a retrospective chart review on patients who met NIH criteria for PCOS in our Multidisciplinary Adolescent PCOS Program (MAPP). We compared those with PCOS to MAPP patients who did not meet PCOS criteria as well as to non-PCOS patients from the Adolescent Specialty Clinic (ASC). Variables analyzed included gender identity, androgen levels, hirsutism scores, and mood disorders. We used chi-square, Fisher's exact, t-tests, and Wilcoxon rank sum tests to compare groups.  Gender identities self-reported as male, fluid/both or nonbinary  were pooled into the GD category.

RESULTS

Within the MAPP, 7.6% (n=12) of PCOS youth self-identified as GD compared to 1.8% (n=3) of non PCOS youth (p=0.01, chi-square). When compared to non-PCOS GD adolescents from ASC (4.4%; n=3), the difference to PCOS youth was no longer significant (p=0.56). Among MAPP patients, gender diversity was associated with higher hirsutism scores (p<0.01), but not higher androgen levels. In PCOS, depression/anxiety was higher in GD vs cisgender youth (100% vs. 37.6%, p<0.01 and 77.8% vs. 35.8%, p=0.03 respectively).

CONCLUSIONS

Gender diversity was observed more commonly in those meeting PCOS criteria. PCOS GD youth were more hirsute and reported more depression/anxiety. Routine screening for differences in gender identity in comprehensive adolescent PCOS programs could benefit these patients, as alternate treatment approaches may be desired to support a transmasculine identity.

Urea as safe treatment for hyponatremia due to syndrome of inappropriate antidiuretic hormone in infant with solitary central incisor and neurofibromatosis-1

OBJECTIVES

Classic treatment for syndrome of inappropriate antidiuretic hormone (SIADH) is fluid restriction. However, this is not ideal for infants who need large fluid volumes to ensure adequate caloric intake for growth. The use of urea has not been thoroughly studied in children.

CASE PRESENTATION

This infant had SIADH complicated by poor growth, solitary central incisor, and NF1. Following failed attempts to correct hyponatremia with fluid restriction and other therapeutics, urea normalized sodium levels and allowed liberalization of formula volumes, which resulted in improved weight gain.

CONCLUSIONS

Urea is a safe, cost-effective, long-term treatment for SIADH in infants who are unable to fluid restrict due to caloric goals.

LBODP083 Pharmacokinetics Of Metformin In Obese Non-diabetic Youth: Drug Clearance Increases With Severity Of Obesity

Background

Severe obesity and obesity-related conditions, such as prediabetes, are increasing in prevalence among pediatric populations. Metformin is an oral biguanide that is often used off label to treat obesity and prediabetes in youth. Despite increased prescribing in youth, there is limited knowledge about pharmacokinetics (PK) of metformin in pediatric populations, and no published data describing the effect of obesity severity on metformin PK.

Research Questions What is the variability of pharmacokinetic properties of immediate release metformin in obese, non-diabetic adolescents? Does severity of obesity impact these properties?

Methodology

Youth 12-17 years of age were included if they were obese with laboratory evidence of insulin resistance (HOMA-IR &gt; 3) or met ADA criteria for prediabetes and had a normal renal function (GFR &gt; 60 mL/min/1.73m2). Obesity classes were defined as class I (BMI &gt; 95th to &lt; 120% of the 95th percentile), class II (&gt; 120% to &lt; 140% of the 95th percentile), and class III (&gt; 140% of the 95th percentile). Youth were treated with immediate release metformin dosed twice daily for at least 6 weeks. Pill diaries and pill counts were conducted to assess adherence. Youth arrived fasting and received their AM dose of metformin with a standardized meal. Blood was drawn pre-dose and at 0.5, 1, 1.5, 2, 2.5, 3, 4, 6, 8 and 12 hours post-dose and urine collected throughout the visit. Primary outcomes included the mean, standard deviation, and range for steady state area under the plasma drug concentration-time curve adjusted for dose (AUCss_D) and apparent oral clearance at steady state (CLss/F). These outcomes were compared between obesity classes. MAJOR RESULTS There were 11 subjects (10 females), mean (SD) age was 14.3 (1.8) years. Metformin doses included: 1000mg BID (N=8), 500mg qAM 1000mg qPM (N=2), 500mg BID (N=1). Mean (SD) weight was 102.8 (19.2) kg, and mean BMI 37.5 (3.3) kg/m2. Among participants, there were N=4 with class III obesity, N=4 with class II obesity, and N=3 with class I obesity. Across all study participants, mean AUCss _D was 12.5 (SD 2.46; range 8.48-16.9) h*ng/mL/mg and mean CLss/F was 85.7 (SD 16.6; range 59. 0-118) L/h. Mean CLss/F was 76.8, 83.6, and 86.2 L/h in class I, II, and III obesity, respectively. Mean AUCss _D was 13.5, 12.17, 12.14 h*ng/mL/mg in class I, II, and III obesity, respectively. No differences were statistically significant.

Conclusions

Our pilot data suggest a 2-fold variability in apparent clearance among study participants, with apparent clearance increasing in relation to obesity severity class. Greater clearance, and thus reduced systemic exposure (AUC), may indicate a need for a larger dose of metformin in severely obese youth. Additional data is needed to further evaluate the impact of the severity of obesity on metformin clearance.

Presentation: No date and time listed

PMON313 Hyperinsulinemic Hypoglycemia and Growth Hormone Deficiency Secondary to 20p11 Deletion

Introduction

Hyperinsulinism (HI) and growth hormone deficiency (GHD) are known causes of hypoglycemia but not commonly found together. We present a 4-month-old boy with hypoglycemia found to have both HI and GHD with subsequent genetic diagnosis of 20p11 deletion. This deletion has been associated with panhypopituitarism. This case represents a few to report HI as a manifestation of this deletion. Treatment with both recombinant human growth hormone (rhGH) and Diazoxide led to blood glucose (BG) normalization.

Clinical Case

A 4-month-old, full-term, large for gestational age (96th percentile), born to a nondiabetic mother presented with hypoglycemic seizures. He had transient hypoglycemia at birth, normal newborn screen, and exclusively breastfeeding with normal growth and development. He had a negative 60-hour video EEG. Further work-up was significant for serum glucose of 54 mg/dL despite blood draw being 20 minutes after a breastfeed, prompting endocrinology evaluation. Physical exam showed no dysmorphism and normal genitalia. He had a serum glucose of 39 mg/dL while asymptomatic. Critical sample revealed detectable insulin (3.2 mcIU/mL), low beta hydroxybutyrate (145.6 mcmol/L) and low growth hormone (GH) (4.2 ng/dL). He had normal cortisol, lactic acid and ammonia. A glucagon challenge showed an increase in BG of 26 mg/dL (35--&gt;61 mg/dL). He had a GH stimulation test with arginine (peak GH 3.8 ng/dL) and glucagon (peak GH 6.6 ng/dL). He had mildly elevated liver enzymes that resolved on repeat testing. Plasma amino acid, plasma acylcarnitine profile, urine organic acids, and brain MRI were normal. He was initially started on rhGH with continued hypoglycemia, hence, Diazoxide, and chlorothiazide were added. His BG was monitored until dextrose infusion was successfully weaned, while maintaining normoglycemia. Genetic testing with next-generation sequencing revealed 20p11.22-p11.21 deletion. He was discharged on Diazoxide (12 mg/kg/day), chlorothiazide, and rhGH (0.27 mg/kg/week).

Conclusion

It is important to determine the cause of hypoglycemia so specific treatment can be provided. HI is a common cause of hypoglycemia in infants due to abnormal insulin secretion in the pancreatic beta cells. GHD can also cause hypoglycemia and be associated with other pituitary hormone deficiencies. Evaluation of our patient's hypoglycemia revealed HI, GHD and 20p11 deletion. This deletion has been associated with hypoglycemia due to GHD and few reports with HI. This patient will need to be regularly screened for other pituitary hormone abnormalities. Other features of 20p11 deletion include cognitive delay, craniofacial dysmorphisms, gastrointestinal and genitourinary anomalies. While hypoglycemia is often the result of a single cause, this case shows that there are pathological conditions that can present with both GHD and HI, so the differential diagnosis for hypoglycemia should remain broad.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

OR15-4 Heterogeneity of Clinical Presentation of Adolescent PCOS Is Attributable to Distinct Subtypes

Objective

Adolescent polycystic ovary syndrome (PCOS) is a heterogenous clinical syndrome characterized by hyperandrogenism and irregular menses. Heterogeneous features of the syndrome include the presence/absence of obesity, degree of insulin resistance, and clinical and/or biochemical hyperandrogenism. In adult women with PCOS, discrete metabolic and reproductive subgroups can be identified. A recent study described distinct phenotypes using unsupervised hierarchical cluster analysis: a metabolic subgroup characterized by higher BMI, glucose, and insulin levels, and a reproductive subgroup demonstrating higher LH and SHBG levels. We hypothesized that non-obese and obese adolescent girls with PCOS would exhibit similar distinct phenotypes at the time of diagnosis.

Methods

Data were extracted from a multi-site PCOS registry including seven academic centers in the US with the following inclusion criteria: PCOS confirmed per 2018 international guidelines, diagnosis before age 18 years, and at least one follow-up visit. Data collected included demographics, medical and family history, physical characteristics including hirsutism, acanthosis nigricans, and laboratory measures such as HbA1c, ALT, lipid profiles and reproductive hormones (androgens, LH, FSH, SHBG). Hormone levels were normalized to the upper limit provided by the measuring laboratory. Patients were divided by obesity status, defined as obese (OB) with BMI ≥ 95th percentile for age and sex and non-obese (NO) < 85th percentile for age and sex. Differences in continuous variables were assessed with unpaired t-tests using GraphPad Prism.

Results

Complete diagnostic data from 390 patients from 7 different sites were included for analysis, with 284 OB (Age 15.3±1.5 years, BMI 36.1±5.6 kg/m²) and 68 NO (Age 15.8±1.3 years, BMI 22.6±3.4 kg/m²). OB presented with more severe acanthosis (p<0.0001) and higher HbA1c (OB 5.5±0.5, NO 5.2±0.3; %, p<0.0001), ALT (OB 35±30, NO 22±17; IU/L, p=0.0006), and triglycerides (OB 145±90, NO 110,±88; mg/dL, p=0.002). OB also presented with higher free testosterone (OB 219±188% vs NO 158±125% above upper limit of normal; p=0.003), while NO presented with higher total testosterone (OB 121±68%, NO 152±88% above upper limit of normal; p=0.003), androstenedione (OB 87±37%, NO 125±62 above upper limit of normal; p=0.002), and LH (OB 9.7±4.9, NO 15.2±10.4; mIU/mL, p=0.0001). No differences in Ferriman Gallwey score or number of menses in the 6 months prior to diagnosis were detected.

Conclusions

Metabolic and reproductive phenotypes differed in OB and NO adolescent girls at the time of PCOS diagnosis. The reproductive phenotype in NO was characterized by increased LH, total testosterone and androstenedione levels. In contrast, OB girls had a phenotype characterized by insulin resistance-driven hyperandrogenemia established by lower SHBG and higher free testosterone levels. Our data are consistent with findings reported for adult women with two divergent phenotypes: an insulin resistance-driven metabolic subtype and a primarily reproductive subtype, potentially driven by neuroendocrine mechanisms.

Presentation: Sunday, June 12, 2022 11:45 a.m. - 12:00 p.m.

ODP383 Clinical Presentation and Management of Diabetes Mellitus in Youth with Prader-Willi Syndrome

Background

Diabetes mellitus (DM) is reported in 7–24% of adults with PWS. It is thought that abnormal glucose metabolism develops as a consequence of severe obesity and/or insulin resistance. Given obesity and insulin resistance often develop in childhood in children with PWS, DM occurs in youth as well. There are limited data detailing the clinical presentation of DM, diabetes complications, and therapies used in pediatric patients with PWS.

Methods

A retrospective chart review of patients less than 21 years of age with genetically confirmed PWS seen July 2014 through July 2021 was performed. Patients were included if they also had a diagnosis of DM based on a single value meeting American Diabetes Association criteria: fasting blood glucose of ≥ 126 mg/dL, HbA1c ≥ 6.5%, 2-hour blood glucose of ≥ 200 mg/dL on oral glucose tolerance test, or random blood glucose of ≥ 200 mg/dL with symptoms of hyperglycemia.

Results

Of the 88 patients identified with PWS, nine (10%) were found to have DM. Means and range sat diabetes diagnosis were age 11.4 years (7–16), HbA1c8.2% (6.6– 12.4), BMI 38.7 kg/m2 (23.1–73.6),and BMI z-score2.4 (1.3–3.1). Five patients were female. Six patients were non-Hispanic white, two non-Hispanic black, and one Hispanic. Of these nine patients with DM, six had at least three diabetes autoantibodies assessed. All antibodies were negative in three patients, two patients had a weakly positive islet cell antibody only, and one patient had all four autoantibodies positive. Most patients were identified incidentally on screening laboratory evaluation in clinic, two patients had polyuria, and one patient was admitted with vomiting and mixed diabetic ketoacidosis/hyperosmolar hyperglycemic syndrome (DKA/HHS). Diabetes treatment methods included one patient on metformin only; four on metformin and insulin; three on metformin, insulin, and GLP1 receptor agonist; and one patient on insulin only. Of the six patients on insulin, only two were using short acting insulin with meals. No patients were treated using insulin pumps or continuous glucose monitors. No patients underwent bariatric surgery. Only one patient had hypertension requiring treatment with medication. No patients had nephropathy, dyslipidemia, neuropathy, or retinopathy.

Conclusions

DM is seen in children with PWS and often diagnosed incidentally. Regular screening is important as development of DKA/HHS is possible if diabetes goes unrecognized. While type 2 diabetes is more common than type 1 diabetes, diabetes antibodies should be measured. Standards of care for treatment are lacking resulting in variability in therapeutic regimens. Fortunately, despite markedly elevated BMI at DM diagnosis, diabetes comorbidities are not commonly seen.

Presentation: No date and time listed

ODP420 Ovarian Venous Sampling and the Diagnostic Challenges Associated with Identifying the Source of Severe Hyperandrogenism in an Adolescent Female

Background

Polycystic ovarian syndrome (PCOS) accounts for most cases of hyperandrogenism in adolescent females. Rarely, evaluation reveals testosterone concentrations (&gt; 200 ng/dL). In those instances, imaging is recommended to evaluate for an ovarian or adrenal neoplasm. Recommendations are lacking for when imaging is nondiagnostic, yet testosterone levels continue to rise on standard treatment. Ovarian venous sampling may be considered as a diagnostic tool to locate the source of hyperandrogenism. A 12-year-old female was referred for evaluation of secondary amenorrhea, weight gain, and possible PCOS. Thelarche was at age 10 years and menarche at age 11 years. Eighteen months post-menarche she developed amenorrhea, acne, and hirsutism. She had no clitoromegaly. Her height was 50th percentile, weight &gt;99 th percentile, and BMI 130th of the 95th percentile. She had no family history of PCOS. Initial lab evaluation showed mild hyperandrogenism: total testosterone of 52ng/dL (17-75), free testosterone of 1.3ng/dL (&lt;0. 04-0.84), and DHEA of 423ng/dL (&lt;202). OGTT done with only glucoses was normal. HbA1c was 5.6%. DHEAS, androstenedione, 17-OH progesterone, prolactin and TSH were normal. LH was 3.5mIU/mL, FSH 4.8mIU/mL, and estradiol 45pg/mL. Pelvic ultrasound showed enlarged right (25mL) and left ovaries (15.6mL). The follicular distribution was normal and bilateral simple cysts were noted. PCOS was suspected and she started on metformin and oral contraceptive pills. Her testosterone levels increased during subsequent visits with a peak total and free testosterone of 344ng/dL and 7.83ng/dL. HbA1c rose to 5.9%. She had fasting and postprandial insulin levels of 74.3 and 260mcIU/mL, respectively. Further evaluation revealed a normal AMH level of 6.4ng/mL (0.49-6.9), SHBG of 22.9nmol/L (7.7-108), a negative screen for anabolic steroid use, and 46,XX karyotype. Imaging over 8 months (multiple transabdominal ultrasounds, MRI of abdomen/pelvis and brain) was negative for neoplasm. The potential next steps discussed with the patient were continued serial imaging, GnRH agonist, or ovarian venous sampling with possible oophorectomy. Due to concern for neoplasm, the patient opted for venous sampling which showed a 10-fold gradient in total testosterone between right and left gonadal veins (2300ng/dL vs. 203ng/dL). She underwent right oophorectomy and switched from OCP to transdermal hormone therapy. Three months later, her total testosterone was normal (26ng/dL), she had lost 5kg and menstrual cycles returned. Pathology resulted as PCOS, with no evidence of neoplasm.

Conclusions

Localization of the source of severe hyperandrogenism can be a challenge. In our case, ovarian venous sampling results prompted unilateral oophorectomy, yet pathology showed no ovarian neoplasm. While ovarian venous sampling is a potential diagnostic tool, there is no data guiding when it should be used and interpretation of results, specifically if/when oophorectomy should be pursued. This is particularly relevant in the management of young, premenopausal females.

Presentation: No date and time listed

Can analysis of serum androgens aid in the diagnosis of polycystic ovary syndrome (PCOS) in adolescents?

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a female metabolic disorder that is characterized by ovulatory dysfunction, elevated serum androgen concentrations, and polycystic ovarian morphology (PCOM). However, diagnosis of PCOS in adolescents is challenging.

AREAS COVERED

The mechanisms of PCOS pathophysiology are discussed that include: i) dysregulation of the levels of steroidal enzymes ii) abnormalities in the secretion of gonadotropin releasing hormone, luteinizing hormone, and follicle stimulating hormone , and iii) abnormalities in ovarian Thecal and Granulosa cell function. Current clinical diagnosis protocols for PCOS in women are covered. The challenges in diagnosis of PCOS particularly in adolescents are highlightedWe highlighted an important unmet need for an accurate serum test for the early diagnosis of adolescent girls with PCOS.

EXPERT OPINION

Steroid metabolite profiling that captures hyperandrogenism has shown some early promise to serve as a biomarker for early diagnosis of PCOS in women, something that would be especially useful in adolescents.

Sleep Disorders in Children with Prader Willi Syndrome: Current Perspectives

Children with Prader-Willi syndrome (PWS) face a multitude of potential health challenges including life-threatening obesity, endocrinopathies, behavioral and emotional dysregulation, developmental delays, and sleep disorders. In the current perspective piece, we provide a focused review of the condition's etiology and clinical findings, as well as a more in-depth discussion of sleep disorders frequently associated with PWS. In particular, we highlight and discuss difficult clinical scenarios frequently encountered by the pediatric sleep physician caring for this patient population, including diagnosis and treatment of complex sleep-related breathing disorders, considerations for sleep apnea surgery, the interplay between growth hormone and sleep apnea, diagnostic challenges in hypersomnia/narcolepsy, and current and emerging therapies for hypersomnia/narcolepsy. Overall, although there are many areas that need further research, sleep disorders remain a fruitful target for improving quality of life of children with PWS and their families.

A Case Series of Hyperglycemic Hyperosmolar State During the Global COVID-19 Pandemic

Hyperglycemic hyperosmolar state (HHS) is rare in pediatrics, particularly in patients with antibody positive diabetes mellitus (DM). Recent literature has implicated COVID-19 in the reported increase in new-onset DM cases, as well as mixed diabetic ketoacidosis (DKA) and HHS cases, however a rise in HHS cases alone has not been well reported [1,2]. We noted an anecdotal increase in the frequency of HHS cases in our pediatric tertiary care center following the onset of the global COVID-19 pandemic. To investigate further, a retrospective chart review evaluating all patients with DM admitted in the first 6 months of 2019 and the first 6 months of 2020 was conducted. A diagnosis of HHS was defined as a blood glucose over 600 mg/dL with a serum osmolality (calculated or measured) greater than 320 mOsm/kg on initial laboratory evaluation. Patients with DKA, defined as a serum bicarbonate level less than 16 mmol/L with evidence of significant ketosis (serum ketones greater than 3 mmol/L), were excluded from the study. During the first 6 months of 2019, 1 patient met inclusion criteria. However, the diagnosis of HHS was complicated by a concurrent diagnosis of diabetes insipidus, which may have contributed to the hyperosmolar state, and a nonketotic lactic acidosis. Five HHS cases were noted in the first 6 months of 2020, 4 of which occurred in May and June. For the 2020 HHS cohort, the average patient age ± SD was 12 ± 3.34 years. The mean ± SD laboratory values included bicarbonate 18.2 ± 1.64 mmol/L, serum blood glucose 776.8 ± 30.75 mg/dL, calculated serum osmolality 328 ± 4.18 mOsm/kg, and HgA1C 12.72 ± 1.16%. All 5 patients in the 2020 cohort had new-onset DM, with 4 of the 5 patients having at least 1 positive DM antibody (GAD antibodies were positive in 3, ICA/IA-2 antibodies in 2, and Zinc Transporter 8 antibodies in 1). No patients displayed COVID-19 symptoms, and only 1 patient was tested for COVID-19 by PCR, which returned negative. However, SARS-CoV2 antibody testing was not available, and it is unknown if these patients had prior COVID-19 illness. In conclusion, we noted an increased incidence of HHS at our hospital, particularly among new-onset, antibody positive DM patients during the initial months of the COVID-19 pandemic. Further study and investigation are needed to determine the cause of this increased local incidence, and if infectious, social, or economic influences related to the COVID-19 pandemic contributed. References: [1] Chan, K.H., et al., Clinical characteristics and outcome in patients with combined diabetic ketoacidosis and hyperosmolar hyperglycemic state associated with COVID-19: A retrospective, hospital-based observational case series. Diabetes Res Clin Pract, 2020. 166: p. 108279. [2] Unsworth, R., et al., New-Onset Type 1 Diabetes in Children During COVID-19: Multicenter Regional Findings in the U.K. Diabetes Care, 2020.

Metreleptin and Metformin Use in an Infant With Congenital Generalized Lipodystrophy Secondary to AGPAT2 Mutation

Background: Congenital generalized lipodystrophy (CGL) is a rare inherited disease characterized by widespread loss of subcutaneous fat and severe metabolic abnormalities. Metreleptin, a synthetic analog of leptin, is a treatment modality that has been shown to decrease fasting triglycerides, fasting glucose, and HbA1c. Metformin use in infants has only been described in a few case reports of CGL and Donohue syndrome (insulin receptor mutation), and there is no established dosing for this age group. We report metreleptin, insulin, and metformin use in an infant with type 1 CGL who presented with marked hypertriglyceridemia, hypoleptinemia, hyperglycemia, and transaminitis.

Clinical Case: A 2-month-old African American female born SGA at term presented to her primary care physician for a well child check where she was noted to have poor weight gain, hyperphagia, and abdominal distension. She was subsequently admitted for failure to thrive with weight z-score of -2.17 and length z-score of -0.15. Initial labs were notable for triglycerides of 5,167 mg/dL, HDL 10 mg/dL, blood glucose 324 mg/dL, ALT 212 units/L, AST 215 units/L, and bicarbonate of 17 mmol/L. A random insulin level was elevated at 257 mcIU/mL. Adiponectin was undetectable and leptin was low at 0.3 ng/mL. Hemoglobin A1c was in diabetes mellitus range at 8.9%. She was started on detemir 1.0 units/kg/day on day 1 (titrated to a maximum dose of 4.4 units/kg/day) and metformin 50 mg/kg/day on day 3 of hospitalization. By day 4, triglycerides decreased to 758 mg/dL, AST to 119 units/L and ALT to 124 units/L. Pre-prandial glucoses improved ranging from 113 to 138 mg/dL. As her insurance denied coverage for detemir, she was discharged home on glargine 0.7 units/kg/day and metformin suspension. One month later, she was started on subcutaneous metreleptin, and glargine was discontinued. At 5 months of age, she had triglycerides 229 mg/dl, normal liver enzymes, and normal blood glucoses while on 0.056 mg/kg/day of subcutaneous metreleptin and metformin. Medications were well tolerated without side effects. She had improved growth and met all developmental milestones. Genetic evaluation revealed that she was homozygous for a pathogenic variant, c.589-2A&gt;G; p.Gln196fs*228 (rs116807569), in the AGPAT2 gene.

Conclusion: Leptin is important in regulation of lipid and glucose metabolism, and patients with CGL are deficient due to lack of adipose tissue. Metabolic abnormalities, including stabilization of glucoses and improved hypertriglyceridemia, in our patient markedly improved with initiation of metreleptin, metformin, and insulin. We present successful dosing of these treatment modalities without adverse reactions in an infant with CGL.

Trends in HbA1c Change Among Youth Referred to a Pediatric Type 2 Diabetes Prevention Clinic

Background: Pediatric type 2 diabetes (T2D) has increased in prevalence as childhood obesity rates climb. More youth are being referred to pediatric endocrinology due to the concern for developing T2D, yet prediction of which children will progress to overt T2D is challenging. We describe a single center experience with pediatric prediabetes referrals and trends in HbA1c change.

Methods: Retrospective review of new patients seen at a Type 2 Diabetes Prevention (T2DP) Clinic July 2015 - December 2019. All children referred to T2DP Clinic have an elevated BMI and findings of insulin resistance/prediabetes/early T2D. They are evaluated by pediatric endocrinology providers and dieticians at each visit.

The outcome of interest was categorical HbA1c change between patients’ initial and most recent T2DP Clinic visit. Only HbA1c measurements conducted at the study site were included to address inconsistencies in lab assays. HbA1c at the initial visit was categorized into 3 groups: 1) < 5.7%; 2) 5.7 to <6.5%; 3) 6.5% to <8.5%. Final HbA1c was categorized similarly with the option to progress to a 4^th HbA1c group of ≥8.5%. Patients were categorized as progressors, regressors, or stable depending on change in group (e.g., group 1 --> group 2) between initial and most recent HbA1c. Comparisons between groups were made using ANOVA and Fisher’s exact tests.

Results: Among 297 patients seen for an initial visit, mean BMI z-score was 2.3 and body fat percentage was 44%. High blood pressure occurred in 47%, high ALT in 24%, low HDL in 14%. Prevalence of initial HbA1c < 5.7%, 5.7 to < 6.5%, and 6.5% to < 8.5% was 46%, 42%, and 12%, respectively. One-third (31%) were prescribed metformin at their initial visit.

Only 63 patients (21%) had 2 or more visits in the T2DP Clinic with study site HbA1c data available. Of those 63 patients, mean age at initial visit was 12.5 years, BMI z-score 2.0, and body fat 46%. Most patients were female (68%) with public insurance (70%). Race/ethnicity was 35% black, 29% white, 30% Hispanic. Mean time between initial and most recent HbA1c was 11.9 months. Assessment of categorical HbA1c change showed 14% of patients with progression (n=9), 65% stable (n=41), and 21% with regression (n=13). Female sex, ALT elevation, HbA1c, fasting glucose were found to be statistically different between the groups at baseline (p < 0.05). Age, race/ethnicity, BMI, body fat percentage, elevated blood pressure, lipid profile, 120-minute glucose on OGTT, and metformin use were not different between the groups.

Conclusions. Only 14% of children who presented for follow up in our T2DP clinic demonstrated progression in HbA1c. Risk factors for those who progress include female sex and ALT elevation. Further development of predictive models to identify this high-risk population who will progress is necessary. Retaining consistent follow up in pediatric prediabetes clinics presents a challenge.

GnRH Agonist Improves Hyperandrogenism in an Adolescent Girl With an Insulin Receptor Gene Mutation

Type A insulin resistance (IR) is caused by heterozygous mutations in the insulin receptor gene. It presents with mild acanthosis nigricans, severe IR, and hyperandrogenism in the absence of obesity or lipodystrophy. Treatment aims to improve insulin sensitivity and decrease androgens. An adolescent girl was evaluated for secondary amenorrhea and prominent hirsutism. She had a normal body mass index, and laboratory testing revealed an elevated LH to FSH ratio (LH 11.6 mIU/mL, FSH 4.2 mIU/mL), testosterone 96 ng/dL (reference range <50 ng/dL), free testosterone 2.21 ng/dL (reference range <1.09 ng/dL), normal glucose, and HbA1c of 5.6%. She received a diagnosis of polycystic ovary syndrome (PCOS) and was referred to our Multi-Specialty Adolescent PCOS Program. There, oral glucose tolerance test showed fasting glucose and insulin of 80 mg/dL and 63.1 mIU/mL, respectively. The 2-hour glucose and insulin were 199 mg/dL and 1480 μIU/mL, respectively. Because of hyperandrogenism with severe IR, dysglycemia, and normal lipids, type A IR was considered. Genetic testing revealed a heterozygous mutation in the insulin receptor gene [c.3095G>A(pGly1032Asp)]. After standard treatment of hirsutism and hyperinsulinism failed, a trial of GnRH agonist therapy improved hyperandrogenism and reduced ovarian size while severe IR persisted. We describe an adolescent with type A IR who experienced resolution of clinical and biochemical hyperandrogenism during GnRH agonist treatment. Given the patient's marked reduction in testosterone and hirsutism despite persistent hyperinsulinism, this case challenges the idea that insulin increases steroidogenesis independently of gonadotropin effect. GnRH agonist therapy should be considered in the treatment of hyperandrogenism in severe cases of IR.