Naoto Shimura

Effect of Testosterone on Radial Bone Mineral Density in Adolescent Male Hypogonadism

Gonadal function is considered to be important in both men and women for the maintenance of normal bone mineral content; failure of gonadal function causes osteopenia in adults (1). Furthermore, it is known that bone mineral density increases during puberty (2, 3 ) . In order to assess the effect of gonadal steroid on bone mineral density in adolescent males with osteopenia due to hypogonadism, we compared the changes in bone density in patients given testosterone replacement with those in patients without this replacement therapy. This study was approved by the ethics committee of our hospital.

Central diabetes insipidus in hypoxic brain damage

We describe two children who after cardiopulmonary arrest developed hypernatremia at the terminal stage. Urinary antidiuretic hormone concentration was very low, indicating central diabetes insipidus. These cases illustrate the necessity of alertness to the development of central diabetes insipidus in patients with severe hypoxic brain damage.

Water intoxication in asthma assessed by urinary arginine vasopressin.

A 3-year-old girl with status asthmaticus developed a grand mal seizure in association with hyponatraemia after 16 h of fluid therapy. Urinary arginine vasopressin (AVP) was elevated during the attack and rose strikingly before the onset of the convulsion. In 13 of 17 other patients with moderately severe asthmatic attacks, increases in urinary AVP levels occurred before the initiation of treatment. Dilutional hyponatraemia (water intoxication) must be prevented in patients with severe asthmatic attacks in whom diuretic capacity is impaired.

Cystic adult granulosa cell tumor causing precocious pseudopuberty in a six‐year‐old girl

A very rare occurrence of adult granulosa cell tumor of the ovary (not of the juvenile type) causing precocious pseudopuberty in a six‐year‐old girl is described. An additional feature of interest was that the tumor appeared entirely cystic. To our knowledge, this condition in such a young premenarchal patient has not been reported previously.

Ovarian Cysts in Precocious Puberty

We describe a 7-year-old girl with precocious puberty in whom a single large cyst (5 cm) and several small cysts (8-10 mm) in the single remaining ovary were detected by the ultrasound examination. Endocrinological examinations confirmed the diagnosis of central precocious puberty. Pathologic findings after the removal of the cystic lesions revealed that the large cyst was derived from degenerated follicular cysts and the small cysts were identical to follicular cysts: all were considered to have been formed by gonadotropin stimulation. In general, surgical removal of an ovarian follicular cyst in central precocious puberty is inappropriate. However, in this unusual patient who had a degenerated large cyst, surgery seemed to be appropriate because of a previously removed teratoma in the contralateral ovary.

Urinary arginine vasopressin (AVP) measurement in children: water deprivation test incorporating urinary AVP.

The value of a water deprivation test incorporating urinary arginine vasopressin (AVP) measurement was investigated in 13 patients with polydipsia and/or polyuria (complete central diabetes insipidus [CCDI] in four; incomplete central diabetes insipidus [ICDI] in five; secondary nephrogenic diabetes insipidus [NDI] in three; compulsive water drinking [CWD] in one) and a group of 25 control subjects (C). Urine samples were collected after water deprivation during sleep and the urinary osmolalities and AVP concentrations were measured.

Aortocoronary bypass surgery for Kawasaki disease

SummaryA case of Kawasaki disease with precordial pain in a 6-year-old boy is described. Coronary arteriography revealed large aneurysms with subtotal obstruction of the left anterior descending artery and long-segment narrowings of the right coronary artery. The left ventriculogram revealed an old myocardial infarction of the inferoposterior wall of the left ventricle. The patient was given aortocoronary bypasses using both a left internal mammary artery and a fresh saphenous vein graft to the left anterior descending artery. Serial angiographic study, performed 6 weeks after the operation, revealed these grafts were both patent. Using the two techniques together may have the potential benefit of the saphenous vein bypass graft functioning as a temporary measure to ensure survival with the hope that the internal mammary artery supply will continue to grow.

Osteoporosis in a boy with hypogonadotropic hypogonadism

SummaryWe describe a 16-year-old boy with idiopathic hypogonadotropic hypogonadism associated with osteoporosis. Osteoporotic lesions of the hands, skull and spine were shown by routine radiography. Single-photon absorptiometry at the distal radius confirmed a significant reduction of bone mineral density. The parathyroid hormone-vitamin D axis and calcitonin secretion showed no derangement. Reduced bone mineral density in association with relatively elevated levels of serum osteocalcin and alkaline phosphatase suggested an increased bone turnover (so-called high-turnover osteoporosis). Tetosterone therapy for 3 months significantly increased the radial bone mineral density.This case illustrates that testosterone deficiency during puberty seems to alter the bone mineral status, impairing bone mineralization and bone remodeling.

Increase in bone density during testosterone therapy in adolescent hypogonadism

Sir: Abundant evidence links decreased bone density with oestrogen-deficient status in women, and increases in bone density have been noted after oestrogen therapy [7]. Osteopenia in male hypogonadism, especially in adolescent boys, and concomitant androgen therapy has been only rarely reported [3, 5]. Recently, we investigated the effect of testosterone therapy on bone density in a boy with hypogonadotropic hypogonadism. A 17-year-old boy with Tanner stage I external genitalia was diagnosed as having an idiopathic isolated gonadotropin deficiency based upon the results of both a luteinizing hormone-releasing hormone test and a human chorionic gonadotropin (HCG) loading test. There was no anosmia. Plasma testosterone response to HCG stimulation (HCG 3000 units/m 2 for 3 days) rose from 10 ng/dl (basal level) to 90 ng/dl (peak level). Plasma somatomedin C concentration was 1.5U/ml (normal = 1.35-3.0). The patient s skeletal age was 13 years. Serum calcium, phosphorus, carboxyterminal parathyroid hormone, calcitonin, and vitamin D metabolites (25-hydroxy vitamin D and 1,25-dihydroxy vitamin D) were all within normal limits. Bone mineral density evaluated by single-photon absorptiometry at the non-dominant distal radius was decreased: 0.50g/cm 2 (normal 0.59 +_ 0.05). Testosterone enanthate 125 mg every 3 weeks (total four times) led to a significant increase in bone density to 0.57 g/cm 2. During puberty, a marked increase in bone density occurs and this is thought to be due to increased sex steroid secretion [1, 2, 4, 6]. Androgen deficiency during puberty seems to be a risk factor for osteopenia in adolescent boys and young male adults [1, 4, 5]. As shown by our patient, testosterone replacement at the appropriate age stimulates the pubertal increase in bone density and increases the skeletal resistance to mechanical forces. References

Atrial natriuretic peptide and fludrocortisone therapy in congenital adrenal hyperplasia

In treating patients with congenital adrenal hyperplasia (CAH), sufficient mineralocorticoid (9a-fludrocortisone acetate) in addition to glucocorticoid therapy should be prescribed, but care should be taken to avoid overdose which could cause sodium and fluid retention (1 -3). This condition can be detected by regular blood pressure monitoring or measurement of serum sodium concentration, but these indices do not appear to be sufficiently sensitive. Recent studies of atrial natriuretic peptide (ANP) in man have demonstrated that plasma ANP increases in parallel with sodium and water load, and that elevated ANP plays an important hormonal role in overcoming the sodium retention induced by mineralocorticoids (4-6). The present study was carried out to clarify whether the plasma ANP level could be used to indicate the effect of fludrocortisone therapy on sodium and water balance in patients with CAH.