I have the pleasure of moderating this very interesting session, entitled Pituitary Dysfunction Beyond Pituitary Tumors. And I have four excellent speakers that are going to give their talks. And so I'd like to introduce them. So the first speaker is Dr. Jose Garcia, a friend of mine from Seattle VA. And he's gonna talk about mild traumatic brain injury. Dr. Garcia. Thank you. Thank you, Kevin, for that introduction. I want to thank also the Endocrine Society for this invitation, all of you to be here, especially on the last day. If you can scan the code, because I do have a couple of cases that I would like your input on. And here are my disclosures. So we're actually gonna go ahead and start with a case. So this is a 41-year-old male who did two tours in Iraq. So that means that he spent probably about two years in Iraq. He was exposed to multiple blasts. Two of them led to mild traumatic brain injury episodes where he had loss of consciousness for approximately less than five minutes. This happened a while ago now, it's in 2012. And he also reports having had multiple subconcussive episodes. This is actually quite common, where they're exposed to explosions, for instance, or even when firing their own weapons, but they don't quite meet the definition of concussion or mild traumatic brain injury. He complains of severe fatigue, insomnia, memory problems, cognitive problems, headaches, and tinnitus that started after these events and have been progressively getting worse. His BMI is 31. He also has post-traumatic stress disorder and depression. His only medication has been the vaccine. And his general labs show AST and ALT that were elevated about one and a half times the upper limit of normal. He has normal electrolytes, renal function, and there's no brain imaging available. Before the patient is referred to you, he undergoes baseline early morning hormonal evaluations, and you can see the results there. He had normal testosterone and bioavailable testosterone, LH, FSH, prolactin, TSH, and free T4. His cortisol is 8.6. His IGF-1 is 102, so both are in, you know, they're not flagged, they're marked as normal. HDL and LDL results are there. So I want you to look at these labs. And so the question is, what other tests would you recommend, if any? None. Repeat laboratory evaluations 12 months later. Perform an MRI. Recommend an insulin tolerance test. Or recommend a maxillary stimulation test. If you can go ahead and vote. So quite a spread. Yeah. All right, thank you for your input. Oh, it keeps coming up, all right. So I actually would recommend an insulin tolerance test, and the reason is that he is symptomatic. He has a risk factor for having pituitary hormone deficiencies, and even though his baseline evaluation may seem unremarkable, his cortisol is intermediate, and so he will need a provocative test to rule out a general insufficiency. His IGF-1, even though it's also in the normal range, but we know the sensitivity is quite low, especially if you have partial growth hormone deficiency, so he would also need a provocative test for growth hormone deficiency. The mass immoralin, it would be an option to investigate his growth hormone access, but it's contraindicated in somebody taking venlafaxine. I usually don't stop psychotropic agents unless I discuss it with the mental health providers. And it would not be useful to diagnose adrenal insufficiency. The vast majority of these patients do not have any anatomical abnormalities, so I wouldn't recommend an MRI unless I have a biochemical evidence of pituitary hormone deficiency. No further evaluation wouldn't be appropriate because he is symptomatic, and we haven't ruled out old hormone deficiencies. Repeat laboratory tests might be appropriate in somebody who's had a recent event, maybe less than 12 months before, but in somebody who's had this event in 2012, for now in 2022, I would not recommend simply just repeating the labs 12 months later. So what is traumatic brain injury? It's a traumatically induced structural injury in a physiological disruption of brain function due to an external force with new onset or worsening of at least one of the following. So loss or decreased consciousness, loss of memory, alteration in mental state, neurological deficits, or intracranial lesions. So the one that usually comes up more often is the loss of consciousness, but it doesn't necessarily have to be there if you have alterations in some of the other axis. Traumatic brain injury is actually a major cause of death and disability in the US and worldwide, and contributes to about 30% of all injury deaths. There's more than 50,000 deaths every year due to TBI, and it's estimated that 1.7 million of TBIs occur in the US every year. It's more common in men than in women, and you can see there the age distribution. So it affects kids, young adults, and then the elderly. So it really affects a wide distribution of individuals. Today we're focusing on mild TBI, which, as you can see there, is for those individuals that had a loss of consciousness of less than 30 minutes, with an initial Glasgow score of at least 13. Normal structural imaging, length of alteration of consciousness up to 24 hours, and post-traumatic amnesia of less than a day. If you have more than that, then that's considered moderate or severe, you can see there. Approximately 80% of all TBIs are mild. Sometimes you hear them referred as concussion as well. When you look at the symptoms that these patients report, you can see there on the left column the symptoms that they're most commonly reported. Poor concentration, irritability, fatigue, being tired a lot, depression, memory problems, headaches. On the center column you can see the frequency of the symptoms in the general population. It's on the far right. You can see how much more these symptoms are present in patients with concussions compared to individuals that have not had a concussion. And a lot of these symptoms will sound familiar to you if you ask these questions about this type of symptoms to patients, because there is a considerable overlap between the symptoms of post-concussion syndrome and neuroendocrine dysfunction. The one that is most common in my practice is fatigue. So that is the one that they report, and it seems to be out of proportion to those individuals. This population right now, the patients that I see are mostly young, but it would also present differently if you're talking to a much younger individual or a much older individual. Briefly about TBI in the military. And so I work at a military hospital. And traumatic brain injury occurs in approximately 10% of the personnel that was deployed to Iraq and Afghanistan. And 80% of them, as I mentioned before, is mild in severity. It's estimated that 200,000 of these veterans would have suffered at least one mild TBI. These individuals here in the US are seen in a military hospital for the most part, but they're also being seen in civilian hospitals. And that is the case also, I think, elsewhere. So TBI is really considered a signature injury from these conflicts. Of course, TBI and mild TBI is not limited to military populations. And there's, as I mentioned before, falls is a common cause, as it is sports. So really, everybody, or motor vehicle accidents. So everybody's at risk of having had these events. What is the pathophysiology behind this association of TBI when you're undergoing dysfunction? It's unclear, but it's likely to be multifactorial. And immediate trauma-induced tissue damage, hypoxia, and subsequent edema is commonly reported. Other proposed mechanisms include genetic predisposition as well as inflammatory and autoimmune processes. So there's a group in Turkey that has done quite extensive work looking at the presence of antibodies in these individuals. So what do we know about the prevalence of pituitary hormone dysfunction in TBI? And this is all TBI at three months after the event. And you can see there that about 40 to 50% of individuals will have an abnormality upon testing. And you can see there that there's a small fraction that will have multiple pituitary hormone deficiencies. Most of them will have loss of one axis. When you look at the individual deficiencies, this is a study that was published a couple of years ago, and it includes cross-hormone deficiency being the most common. Secondary hypogonadism is reported there as the second most common, then hypoadrenalism, and last, hypothyroidism. This is a nice summary of a JAMA article where they actually looked and did a meta-analysis of prospective studies that had looked at this at different time points. And so this is an important point. And so a number of studies looked at patients acutely. Then some looked at patients at three months, some at six, and then eventually some at 12 months after the events. And you can see there how acutely LH and FSH deficiency, so hypogonadism, tends to be more common. But then as time progresses, then the prevalence of other hormone deficiencies change. And you can see that at 12 months, there's about, and this is about a total of 240 individuals, 18% of them had growth hormone deficiency, 10% had hypogonadism, 12% had adrenal insufficiency, and 4% had hypothyroidism. So about 28% of individuals had at least one hormone deficiencies, and 6% have multiple deficiencies. What is interesting also is that at 12 months, when you compare the data with acute in three months, 50 new deficits and 113 new recoveries were found. And for this reason, it's generally recommended that you test, if you do test early, and at least I would say that adrenal insufficiency probably should be tested early, but test is repeated at 12 months, just because these deficiencies may be transient. So who should be tested? In general, we recommend testing for hypopituitarism for individuals that have a lesion or a disease known to cause pituitary hormone deficiencies, they have signs and symptoms that are consistent with that, and or lab abnormalities that are consistent with possible pituitary hormone deficiencies. And it is well known that head injury is a cause for pituitary hormone deficiency. But I think that even though we may think about it, but in general, the general medical population, rehab doctors don't necessarily think about TBI as a cause for pituitary hormone deficiency. So the vast majority of these patients are actually not even diagnosed and not being referred to an endocrinologist. The American Association of Clinical Endocrinologists and the American College of Endocrinology did a disease state clinical review where they summarized what should be the neuroendocrine approach to patients with TBI. Kevin was actually part of this group. And you can see there the test that they recommend. A few of the things that have changed, I think, since this was issued, is the cortisol levels that they recommend is probably using the old polyclonal antibodies that were not as sensitive as the newer assays. I come back to this issue in a minute. And they recommend also stimulation tests for those individuals that test intermediate. Also for growth hormone deficiency, it's listed there, the insulin tolerance test, the glucagon stimulation test, or the GHRH and R-gene test. That test is no longer available here in the U.S. Mass immorality is now available in the U.S. and the EU, and I don't know if in other countries as well. And then posterior pituitary function, even though it's rare, but it can happen. So serum sodium, uranosomalarity may also be recommended. As I mentioned before, with regards to the growth hormone axis, which is the most commonly affected, IGF-1 is not a sensitive test. Sensitivity, I think, is probably somewhat around 50%. And so a provocative test is indicated. With regards to the military population, there are a few studies. One, actually, probably the most comprehensive in mild TBI was done here in Atlanta, at the Atlanta VA. And looked at 20 individuals with mild TBI, and five of them had a peak growth hormone in the glucagon stimulation test below three. The relationship with BMI was not specified. This was done, I think, before we used different cutoffs for different BMIs, and one of them had a low IGF-1, driving the point that IGF-1 may not be necessarily the most sensitive test. Briefly, my experience at the Seattle Veterans of Earth Hospital, and this is a retrospective analysis of some of the patients that we see in the clinic. And we evaluated approximately 60 individuals. This is before the pandemic. And 58 of the 60 patients had a complete hormone panel done. We found two patients with hypogonadism that was secondary. Two others had primary hypogonadism. There was no central hypothyroidism. There were six patients that had primary hypothyroidism. And then a number of individuals were evaluated for adrenal insufficiency with provocative testing, and also for adult growth hormone deficiency. This was not a prospective study, so this is just simply what the provider was recommending in terms of the testing. So that's why the different tests are there. And if we used the cutoff of 18 on the ACTH stimulation test at peak cortisol levels, 13 out of the patients evaluated actually had a subnormal response. As I was alluding to before, now with newer assays, they use more monoclonal antibodies that are more sensitive. Probably the cutoff is gonna be lower, somewhere between 14 and 15, depending on the test. And so these individuals, some of them actually will stimulate to that level. For growth hormone deficiency, as you can see there, there also was a mix of different tests done, but about 12 individuals had a subnormal response. Coming to that is that for, when massymoronin became available and we started using it clinically, the, even though the recommended cut point is 2.8 because that was the design of the study that was performed, the sub-analysis of this test suggests that the cut point of 5.1 is actually more equivalent to an ITT peak, growth hormone level of 5.1 as well. And so for the purpose of this study, that's what we used. Prevalence of the symptoms, you can see there fatigue is extremely common in the patients that are referred for this. More common than in the general TBI population, just that's the reason why they're being referred to the clinic. Other things that are common, cognitive problems, memory problems, insomnia, erectile dysfunction, low libido, and mood problems. You can see there the glucose, growth hormone, and cortisol levels in those individuals that underwent an ITT. And I'd like to point out that the growth hormone levels was above three, which is considered a cutoff for severe growth hormone deficiency. So the patients that tested positive with the ITT had all partial growth hormone deficiency. And you can see also with the cortisol, and I'm not aware of any data of actually looking at the performance of these cortisol assays with an ITT, but we have to assume that it would be similar to what I was referring to before on the ACTH stimulation test. So they also had sort of a partial deficiency if you use a cut point of 18, or no deficiency if you use a cut point of 15. So the true prevalence remains to be determined. So to finalize, I would like to come back to the case. So this patient underwent an ITT, and you can see he successfully had hypoglycemia with a glucose of about 38. And his peak cortisol is 15. And a peak growth hormone was 2.8. So now I would like to ask you, what would you do with that patient? So peak growth hormone 2.8 on the ITT, peak cortisol of 15. Go ahead and answer. All right, so this is a tricky question. Again, it comes down to whether you think that somebody with a cortisol of 15 is enough or not. So the question of which assay was used was very important. So if it's a second generation ELIXIS assay, which I think is what was used here, then a cutoff of 15 would be equivalent to a cutoff of 18 on the older assays. And in that case, you would wanna do hydrocortisone and replace the individual for three months before you move on to doing growth hormone. It's important to also keep in mind that if you start growth hormone, sometimes you can precipitate during insufficiency. So even if you choose to do growth hormone alone, you probably wanna keep an eye on the patient and maybe you risk TMM later. So my last slide is, this is the Center of Excellence for Defense. What they recommend is that patients that are symptomatic for, that have symptoms that are consistent when you're endocrine dysfunction and have a history of TBI, they're evaluated. And this may avoid a delay in diagnosis and improve prognosis in these patients. Potentially we can have a therapeutic alternative for some of these patients if they test deficient for some of these hormones. The true effect of hormone replacement in this particular setting hasn't been really tested. So I think more research is needed for this. I thank you for your attention. Thank you. if you would like to come to the mic to ask your questions and introduce yourself. Frederick Spino, I've been following these patients since the late 90s and 2000, and in some very interesting cases, what I see is the baseline cortisol is elevated, suppresses with dexamethasone, and I presume that's because of low IJF1 leading to a regulation of the 11-HSD1. Have you seen this high cortisol levels baseline that suppress and then correct when you administer growth hormone? No, in general, the initial cortisol, the baseline cortisol we see in the morning, it tends to be intermediate. Yeah, I've seen around 30, and then they would suppress with dex, and then when treated with growth hormone, they would normalize. Some interesting cases. Thank you. Thank you. Good morning. Thank you for your talk. My name is Sarah Neswitz. I'm a pediatric endocrinology fellow at Walter Reed, so I'm also doing my research in TBI. My question is, coming from the active duty standpoint, also happy Army birthday, everybody. Coming from the active duty standpoint, is there any discussion about adding in this kind of screening when you're doing your VA rating as you're going off of active duty and kind of trying to figure out what your VA rating's gonna be? Yes, so no, I think that this is something that is needed, and I hope that this is where we move in the future. We're actually about to start a multicenter study where all these patients with mild TBI and symptoms will actually be screened for all pituitary hormone deficiencies, and so I think that, and then those that are deficient for growth hormone will be replaced. So I think that, in addition to testing the effect of growth hormone in those patients that are deficient, we're also gonna know a lot about the true prevalence of all hormone deficiencies and that patients will become more aware, and providers will become more aware of this, but we have a long way to go. Thank you. Thank you. Mark Muller from Chicago and Florida. I'm concerned about the ones with more severe TBI who we see in the hospital, not long after their TBI or even over the first three months, and find hormone deficiencies, especially growth hormone and testosterone in those individuals, and I've not seen any studies that have looked at replacement of those hormones in a prospective randomized study to see if they would actually help the rehabilitation of those individuals, so if they have profound loss of growth hormone and testosterone for several months, that might actually cause some delay in recovery, and I wonder if they should be treated. That is an excellent point. Thank you for bringing it up, and yes, you're correct. More studies are needed to see if patients with moderate to severe TBI would also benefit from these replacements. It's interesting that the prevalence of hormone deficiencies do not necessarily relate to the severity of the injury, so when you look at studies in subset of patients with moderate to severe and mild, the prevalence seems to be about the same. Anton Luger from Vienna, Australia. Three short questions concerning the patient, assuming that it was a real patient. The first is what dose did you decide to start this patient with? I mean, he had normal IGF-1. He had maybe normal cortisol peak, and what IGF levels would you target with the substitution that you are recommending, and what was the outcome of the patient? Yes, thank you for those questions. Those are obviously important points. So the dose that I usually start patients on when they have normal IGF-1 is 0.2 milligrams daily, and the target is to reach an IGF-1 level between plus one and plus two standard deviation scores, and so those individuals, the real challenge, in this case, he was a little lower than that. The real challenge is for those individuals that have baseline IGF-1 that is already on target, and those individuals are usually less likely to recommend testing for that particular reason because even if you start it with a small dose, then they're likely to go above target, which I don't think there's enough data to practice that way. With regards to this particular group of patients that I follow, those that I'm replacing with growth hormone, they tend to tolerate the treatment well. They're young, the mean age is somewhere around 35 to 40, and they do report improvement on symptoms. Of course, it's anecdotal, so the study still needs to be conducted. I usually sit down with them six to 12 months afterwards and have a conversation to see if they really wanna continue with this treatment, and the vast majority of them choose to continue because they think that it helps with their fatigue, at least. And hydrocortisone? So for hydrocortisone, this is a moving target, I'll say, and some patients that are highly functional, they have really no symptoms, and I trust them. I usually just give them sort of a dose for them to take in case of a crisis, but I don't replace them. Some others, I do, especially if they're very symptomatic, I do replace them with 15 milligrams of hydrocortisone 10 in the morning and five in the afternoon, and at least do a trial and see how they respond. Thank you. Hi, Sajitha Nanchala from Northern Virginia. Thank you for that excellent review, and I appreciate you taking care of all those veterans. So my question is, if you do happen to start someone on replacement therapy, how often are you checking them to see if they have recovered? Because you mentioned by 12 months, some of them do recover. And do you do an ITT, or you just would do, follow the axis that was affected? So on the same note, do some patients who do not have adrenal and thyroid deficiency initially, do they develop these later on? Yes, so I usually do not start growth hormone before 12 months. In fact, I don't evaluate people before 12 months from their injury. And so, it's an interesting question as to whether you wanna continue to evaluate them even after two or three years after, and I don't think there's enough data to say that whatever you see at 12 months is what's gonna be seen at 24 or 36 months. So that's an unanswered question. I do repeat testing for the other hormones later on, for thyroid and for adrenal insufficiency, they test it normal initially. I'm not aware of any guidelines that tell you exactly how often you should do it, but I do repeat them, I would say at least the first year after I see them, and then maybe another year after that. And you do an ITT each time? No, usually I do an ACTH stimulation test. It's interesting, what I've seen is that the ACTH stimulation test is a more powerful stimuli for cortisol than ITT. So in some cases, I've done both. And the hypoglycemia doesn't raise cortisol as high as ACTH. The low-dose ACTH? Even, well, when you do the 250, yeah, the high-dose. Thank you. Thank you. Thank you, Jose. All very interesting questions. We have to move on to our next speaker. And our next speaker is... Dr. Liza Das, who unfortunately is not going to be able to be here, but she is going to be presenting this on a pre-recorded session. She's from the Postgraduate Institute in Medical Education and Research in Chandigarh, India, and she's going to be talking about long-term consequences of Sheehan syndrome, a condition that I must admit I don't see much these days, as much as before, but it'll be interesting to hear what she says from her part of mind. Good morning, one and all. Respected Chair, esteemed co-speakers, august audience. Today, I am humbled, honored, and thrilled to be a part of Endo 2022. And I wish to thank the organizers for this immense opportunity. And I shall be talking today about the long-term consequences of Sheehan syndrome. These are my disclosures. So Sheehan's is an eponymous disorder, which is in fact named after this pathologist, Professor Harold Sheehan, who characterized the ischemic changes occurring in the pituitary, ischemia, and necrosis that ensues as a result of massive postpartum hemorrhage. And it is characterized by a varying degree of anterior pituitary dysfunction, and rarely there can be involvement of the posterior pituitary as well. Now, if you look at the epidemiology of the condition, so the prevalence depends on the population being studied. Like in this study from Iceland, the prevalence was found to be nearly five per 100,000 individuals. Whereas from other parts of the country, like in this study from Northern India, in which they took Paris women more than 20 years of age, the prevalence was found to be 3.1%. So depending on the population, like if we look at the prevalence in adult onset growth hormone deficiency, it can vary from 3.1 to nearly 11%. And interestingly, not all patients with Sheehan's, not all patients with postpartum hemorrhage actually go on to develop Sheehan's, as has been found in various studies. So overall, if we look at 100 hypopituitary patients, there will be at least five to six patients with Sheehan's. Now, regarding the pituitary enlargement during pregnancy, so pituitary undergoes an enlargement of up to 100 to 135% throughout the course of gestation. And this is predominantly contributed by an increase in the size and the number of the lactotropes, whereas the other cell lines either decrease or remain the same. So how do we diagnose Sheehan's in a female patient of hypopituitarism? So typically, there is a history of massive postpartum hemorrhage. Now, massive is important here because up to a blood loss of around 500 to 1,000 ml, the pituitary is able to maintain its autoregulation. And after this, a varying degree of pituitary dysfunction can be present, and the neuroimaging usually reveals a completely empty cell or in some cases, a partially empty cell. So these are the essential criteria. And if we talk about the additional criteria, there's usually a necessity for blood product replacement or fluid transfusion, and the female has a failure to lactate and failure to resume regular menses after her delivery. So that brings us to the question, is Sheehan's different from other forms of hypopituitarism? Well, Sheehan's is a model or a prototype of anterior lobe insufficiency. But if we look carefully at some data that is available, like for example, in the KIMS database, women with Sheehan's were not only found to have more severe and more, I mean, greater degree of the hormone deficiencies, but also earlier onset. Now, earlier onset is arguable because one can be tempted to think that Sheehan's is a disease of pregnancy and postpartum, and hence it will be present in younger females. But what is striking is the very long lag period, which can vary from up to a decade to nearly two decades. So by the time a patient is diagnosed, it is actually much later than when the insult had actually occurred. So I shall be presenting about our cohort of Sheehan's syndrome. So we had 60 females with the condition, and the median diagnostic delay was six years. Nearly one third had presented to the emergency room, most commonly with hyponatremic encephalopathy or with adrenal crisis. So we observed, in terms of the clinical features, a usual pattern such as loss of axillary and pubic hair, and the areola depigmentation that is reported. But we had some unusual features as well, that is prevalent myxidematous features in a patient of secondary hypothyroidism due to Sheehan's. And in this patient who presented with cardiac failure, I'll be coming to her case in a while. And this woman here, we can appreciate the forehead vitiligo despite diagnosis of Sheehan's. So the median follow-up of our cohort was eight years. Now, if you look at the pituitary hormone deficiency patterns, it is actually partial hypopituitarism, which is more prevalent. And in terms of the individual hormone access, it is a growth hormone deficiency, which is the most common. And gonadotropins are actually the most commonly preserved in cases of partial Sheehan's. And deficiency of the ADH or the posterior pituitary is very less. It is less than 5% in various large series, including ours. But what is equally important is that the pituitary function in a given patient and setting may be partial to begin with. It may progress with time. And that is most commonly due to the secondary autoimmunity that is reported in them. And rarely there may be some instances of recovery of the hormones. So I shall be talking about the long-term consequences that ail these patients in terms of their hepatic health, in terms of skeletal outcomes, the cardiometabolic consequences and attributes of sexual dysfunction and quality of life. So first to the hepatic health. Now, non-alcoholic fatty liver disease is one extremely common entity affecting every fourth person in the world globally, as per recent estimates. But it is neither possible to obtain a liver biopsy in all, nor is it prudent to use liver enzymes. So how can we address this gap is by using this FibroScan, which is a non-invasive measure to simultaneously estimate the presence of steatosis in the liver, which is measured by the controlled attenuation parameter and the fibrosis, which is measured by the liver stiffness measurement parameter. So there is some evidence in hypopituitary patients about a higher prevalence of NAFLD, which is almost five to six times higher. And in these studies, the liver enzymes have been used, I mean, studied at diagnosis, as well as following a replacement with growth hormone, showing some reduction. And also there has been improvement in a smaller subset of patients who underwent biopsy in terms of steatosis and fibrosis. But however, there have been very few to almost no cases of Sheehan's syndrome with NAFLD in these studies. So we did perform the NAFLD assessment using the FibroScan, and we found a significantly higher prevalence of steatosis. So these yellow bars actually represent the severe steatosis, which was significantly higher in Sheehan's as opposed to the controls, despite being age and BMI matched. And interestingly, nearly one third of our patients with NAFLD were lean or non-obese. Now, if you looked at the predictors of steatosis, so growth hormone deficiency was an important determinant because those who were deficient were found to have significantly higher levels of fatty content or the cap values. And expectedly, those with steatosis had higher BMI, but they also had a significantly lower IGF-1 as opposed to those who did not have steatosis. So BMI was in fact found to confer a 50% higher risk of steatosis in our patient cohort of Sheehan's. Now, this was a challenging case of a 47-year-old lady. She was diagnosed which she hence almost 15 years back. This is her MRI showing the completely empty cellar. She was doing well, but four years post her diagnosis, she presented with steatohepatitis and this is her MRI showing the gross hepatomegaly. So, the secondary causes of NAFLD were ruled out and following which she underwent a biopsy. So, biopsy did reveal features consistent with steatohepatitis in the form of macrovascular steatosis, perilobular inflammation that's going on here and here this arrow depicting the ballooning degeneration of the hepatocytes and the special mason trichrome stain showing the perilobular fibrosis. So, even as we followed her up for nearly 10 to 12 years, her liver enzymes were always higher than normal, almost twice to thrice the upper limit of normal, sometimes reaching even higher values and these were actually patterns persistent despite multiple courses of ursodeoxycholic acid, alpha-tocopherol and other conservative measures. So, we did step in and institute adult growth hormone replacement therapy for her and at a dose of 0.2 mg per day and she had a remarkable reduction of her liver enzymes as early as six weeks and the decline continued to over a period of four months such that at 16 weeks her liver enzymes for a very very long time of follow were actually normalized for the first time and simultaneously we performed the fibroscan and found that the fatty content of the liver or the cap measure also reduced from a very high value of 336 to nearly 260. So, this remarkable reduction was achieved with no simultaneous increase in fibrosis. So, establishing a cause and effect of GH deficiency for NAFLD in patients with Sheehan's. Then moving on to the skeletal aspects of health in patients with Sheehan's and analyzing the skeletal outcomes as a long-term consequence. So, a higher prevalence of osteopenia osteoporosis at both the lumbar spine and the femoral neck. So, almost double the prevalence at both these sites have been reported and there has been some association for BMD at the femoral neck with the daily hydrocortisone dose and at the lumbar spine with the daily levothyroxine replacement dose. But what is the data about the bone turnover in these patients? So, we performed the bone formation and resorption marker analysis and found that there was a persistently high bone resorption that was occurring in the patients of Sheehan's. The DEXA scan did reveal very high prevalence of osteopenia osteoporosis at both the femoral neck and the lumbar spine up to the tune of nearly 85 to 90 percent as opposed to age and BMI matched controls in both situations. And what we found was that those who had osteoporosis at femoral neck were older but they also had a lower BMI and similarly at the lumbar spine they had a lower body weight and were older. There were very few patients who sustained fractures but this was at the other end of the spectrum. This was a case of Sheehan's who was on replacement therapy and on routine surveillance found to have osteoporosis given annual injections of zoledronic acid which she received four in number then she was lost to follow-up. Almost three years after her last injection she presented with this fragility fracture which is in fact consistent with an atypical femoral fracture considering her location and the thickened cortices. So this is a rare complication but nevertheless reported in patients with Sheehan's. But we know how and where DEXA fails to comprehensively assess bone health in patients with Sheehan's because there may be a higher fracture risk even at a similar BMD and the bone quality as in any other case of secondary osteoporosis may be compromised more than the quantity and the volumetric BMD may actually provide more insights into the bone health. So for the first time we use the high resolution peripheral QCT using the extreme CT2 to perform volumetric BMD analysis of patients with Sheehan's. So here we have the representative images of how the non-dominant tibia sorry the non-dominant radius and the tibia of patients were analyzed with the scanner. So these were the beautiful images that were obtained to depict the volumetric BMD. So this upper panel shows the images of the radius and the bottom shows the images of the tibia. So at the radius we can very well appreciate the almost absent trabeculum in the central part that is in the trabecular part so very low trabecular number and very low volumetric BMD and thinner cortices as opposed to the age BMI and parity matched control and similar findings of lower volumetric BMD and lower trabecular number could be appreciable at the tibia of the patients was visibly the controls. Then moving on to the third dimension of long-term consequences that is the cardiometabolic outcomes. Now hormones of the anterior pituitary actually have a very important role to play in the cardiac structure and function such that deficiency of these hormones result in lower cardiac masses, lower ejection fraction, impaired relaxation of the heart and diastolic dysfunction. So it is no surprise that she hence can present with cardiomyopathy and there have been only a couple of case reports and which have documented cardiomyopathy at baseline and improved ejection fraction with thyroxin and glucocorticoids. But what happens to the long-term outcomes whether the cardiac dysfunction persists or worsens or improves that is actually the evidence on that is actually very limited. So there are a few studies showing a higher prevalence of coronary calcium deposits. Here we can appreciate the calcium deposit in the left anterior descending territory and simple 2D echo measures to show lower LV mass, lower ejection fraction and lower end diastolic diameter in these patients. But the echo does little more I mean provides little more than the ejection fraction. So important information is actually missed by the echo in terms of the strain pattern. Now the importance of the myocardial strain is that that can be increased even with a misleadingly normal ejection fraction and if we go only by the ejection fraction we will fail to diagnose a subclinical ventricular dysfunction. So for the first time we did perform the LV strain patterns in our patients which she hence and very simply a myocardial strain refers to the degree of deformation that the individual fibers undergo. So this is a relaxed state of a longitudinal myocardial fiber and this is the same fiber in the contracted state. So the degree of deformation is actually the myocardial strain which in fact is a measure of the systolic function of the heart. It is important because this flow diagram clearly demonstrates that even when the ejection fraction is normal the global longitudinal strain can be impaired which indicates a subclinical LV dysfunction that is going on and such that there have been studies proving the superiority of impaired longitudinal strain over ejection fraction in predicting cardiovascular events. So the speckle tracking echo to analyze the strain patterns actually revealed significantly higher borderline global longitudinal strain in our patients of Sheehan's as opposed to age and BMI matched controls. So this suggests that as a long-term consequence there can be a mildly impaired systolic function in patients with Sheehan's. But what happens to the diastolic function? So it is actually the other phenotype of heart failure with preserved ejection fraction that is the diastolic dysfunction. So this longitudinal study in much older adults in a community-based setting actually showed that even mild diastolic dysfunction conferred a very high mortality risk as compared to the absence of diastolic dysfunction. So there is no prior data available on diastolic dysfunction in Sheehan's. So when we analyzed our cohort using the parameters of deceleration time and the isobarometric relaxation time, the deceleration time is actually the time taken for the equalizing of pressures between the left atrium and the left ventricle and the isobarometric relaxation time is the time taken from the end of the systole to the start of the diastole. So based on the pre-specified cut-offs we found significantly prolonged deceleration time as well as the IVRT in our cases as opposed to the controls. But these indicate a degree of mild diastolic dysfunction which is nevertheless present in patients of Sheehan's. Now having said that systolic function is not very severely affected especially in terms of ejection fraction in Sheehan's syndrome patients, we have this slightly unusual presentation of this 45-year-old female who came straight to the ER with congestive cardiac failure. So the x-ray very clearly demonstrates a cardiomegaly and the echo showed similar findings of a very compromised ejection fraction of only 20 to 25 percent with a global hypokinesia and this is a bull's-eye view showing an impaired longitudinal strain in various areas of the myocardium. So this was her cardiac MRI at baseline and on retrospective questioning she did have a history of postpartum hemorrhage. She was found to have multiple pituitary hormone deficiencies which and the MRI also confirmed an empty cellar on the I mean an empty cellar. So she was instituted on multiple hormone replacements and we can very well appreciate how well the heart has become more compact, how it has changed from a globular and dilated shape to a more synchronized shape which was manifested after four months of therapy with improved ejection fraction, cardiac output, stroke volume and various other parameters. Now if we discuss about the metabolic health, so there's higher prevalence of metabolic syndrome as well as impaired glucose tolerance in these patients and there has been reports of significant improvement in the waist circumference with growth hormone replacement therapy. Now the fourth dimension of long-term consequence of Sheehan actually is the attribute of sexual dysfunction of quality of life. So sexual dysfunction in Sheehan's is highly prevalent up to as high as up to 80 to 90 percent and there are various factors which can contribute and can co-exist in a given patient of Sheehan's. So in this recent evidence intervention trial was performed using a DHEA at a dose of 25 microgram twice daily and that was even a short course therapy was found to improve the sexual function index scores. But one must not forget the other aspect of life of Sheehan's that is the quality of life and we use the SF-36 to assess the quality of life in our patients of Sheehan's as compared to controls and we did find significantly impaired general health as well as impaired other domains such as the energy levels and the physical functioning in the patient. Now if we look at the management of Sheehan's, so prevention is certainly better than cure. Improvement in obstetrics care should be encouraged even in resource-limited settings. A low threshold for suspicion and early diagnosis especially attracting the females who have had a failure to lactate is important. Adequate replacement of the patient is also important. Adequate replacement of the deficient hormones not only at the time of diagnosis but also later during follow-up. Continued surveillance for these hormone deficiencies is imperative and overall global health assessment is certainly key in improving. It can help in ameliorating the morbidity in these patients. Now what I believe the future holds for these patients is that Sheehan's is an important cause of hypopitreousism in developing countries and a non-negligible entity in developed countries. I hope I have apprised you of the fact that there are multiple metabolic consequences which can persist in these patients even on long-term treatment. So recognizing them and optimally managing them and going a step beyond a simple assessment of only diabetes, dyslipidemia and hypertension to more comprehensive assessments of adverse outcomes of the liver, of the bone and of the heart is recommended and in the wake of newer evidence affirming the safety of growth hormone replacement. It should certainly be encouraged more often and it may be really the key therapy in certain individuals who have altered metabolic consequences. So at this point I wish to thank my teachers Professor Dutta, Professor Korbonitz, Professor Bhadada, senior members of my team Dr. Sunil Taneja, Dr. Neelam, Dr. JP, Dr. Bashir, Dr. Bhatt to all my patients and their caregivers and this is the institute that I work. So I apologize once again for not being able to be present in person but nevertheless thank you for the opportunity and thank you for a very patient listening. Thank you. Thank you. We won't as you know have any questions so we'll move swiftly on to the next speaker which is Dr. Mehul Duttani who's a pediatrician and endocrinologist at UCL at the Great Ormond Street Institute of Child Health and he's going to talk to you a little bit about the novel genetic mechanisms associated with congenital hypopitreorism. Mehul. Thank you very much Dr. Yoon, ladies and gentlemen. So now we shift the focus a little bit to pediatric endocrinology but I'd just like to remind everyone that our patients will grow up and come to all the adult endocrinologists at some point. So these are my disclosures and this is the QR code. Okay so I'm going to talk about congenital hypopitreorism and I'm going to focus mainly on some recent work that we and others have done looking at novel mechanisms. So first of all about the condition. It occurs in one in four thousand to ten thousand live births. The presentation may be early in the neonatal period with hypoglycemia or later with growth failure. And these children may have a single hormone deficiency such as growth hormone deficiency or multiple pituitary hormone deficiencies. The important thing to realize is that this condition evolves and often you can find new hormone deficiencies as young adults. On the other hand they can also reverse. So these children often have associated abnormalities and the classical organs affected are the eyes, ears, other parts of the forebrain and the palate. And this is all related to the embryology of the gland itself. What we now know is the pituitary gland forms from Rathke's pouch which in turn derives from the anterior neural ectoderm, the part of the embryo that's going to give rise to the forebrain. So forebrain and pituitary and hypothalamic development are closely related. And if an insult affects one it's likely to affect the others. And what we now know is that the number of molecules, signaling molecules, which may never be expressed in the pituitary itself but are expressed in the developing hypothalamus. And these are members of the FGF, bone morphogenetic protein, wind signaling pathway, not signaling pathway in sonic hedgehog, very widely expressed throughout the body. But they may not be expressed in the pituitary yet dictate its development. And some of you will have spotted that some of these genes are also implicated in cancer, for instance, and that's a link that is very exciting at the moment. Transcription factors within the pituitary itself dictates its development and they're the best known. They may be homeobox genes, the HMG family, which is related to SRY or the TBX family. And they regulate gene expression, activators switch it on, repressors switch it off. And you can see from this cartoon here that what happens is that you start with the progenitor cell and then work down to the individual cell types producing all the hormones that we know in the pituitary. So where are we now? So the strategies for gene identification in the past have been candidate gene approaches using mouse models, naturally occurring or transgenic, chromosomal abnormalities, and genome mapping strategies. But it's all being rapidly replaced in a new world with whole exome and now whole genome sequencing. And this is what I'm going to focus on a little bit. And these are some of the genes that we know about. So I grouped them into early genes, which give you more, which give you wider phenotypes, genes implicated in cellular differentiation, which are well known, and then genes leading to isolated GHD. And I'm going to focus on a very few of these today. So these are the disorders we deal with. Isolated hypopituitarism, and you can see many genes involved in that. Septo-optic dysplasia is something we've got a big interest in, and I look after about 180 of these children. And they have eye abnormalities, pituitary abnormalities, and midline abnormalities of the brain. Relatively small number of genes and small percentage of children have been identified with mutations. Holoprosencephaly is a failure of the brain to divide properly. over 30 to 40 genes implicated in this already, and not all cases completely characterized. And then all the isolated hormone deficiencies, which all of you will know well, and I'm not gonna go into in huge detail. So, only one word about transcription factors, which we know, this is a young man from the Philippines who came to me at the age of eight years and with the size of a two-year-old at 70 centimeters or so. And he had a mutation in PIT1, which is important for determination, proliferation, and survival of thyrotrophs, lactotrophs, and somatotrophs and their genes. And he had GH, prolactin, and TSH deficiency thanks to the kindness of various companies who gave compassionate growth hormone. He got a height of 160 centimeters. And these can be recessive or dominant mutations. Okay, so moving on to the new genes. So this is next-generation sequencing. I'll start off with the first pedigree, which is an X-linked hypopituitarism family with glucose dysregulation, a very unusual combination. And here what you can see in this pedigree is that these are twins born to this set of parents, and the mother's sister had a child, also twins but non-identical, with a very similar condition. And these children had central hypothyroidism, a growth hormone deficiency, and an unusual pancreatic phenotype. So they swung, really, from hyperinsulinemic hyperglycemia to hyperglycemia. They had a small anterior pituitary and MRI, and they all had a micropenis. And this is the characteristics of the phenotype. You can see they were all pretty short at the start. They were completely growth hormone deficient on testing. And they've done reasonably well in terms of their height. And this is in response to growth hormone. This is the cortisol, which has been relatively spared. The T4 has been low in these individual. The older two boys have now gone through puberty. And so in spite of a micropenis, they have gone through puberty quite successfully. Okay, so this is the glucose dysregulation. And what you can see is that at the time of hyperglycemia, the insulin fails to switch off. That's hyperinsulinism, treated with dioxide for a number of years to stabilize them. And then these two started becoming diabetic. They put on a bit of weight and they became diabetic. Now we've controlled their weight and the glucose is much better. And interestingly, they still have a tendency to develop fasting hyperglycemia, although they have diabetes if they put on weight. So how can we approach that? And I think you can see from the pedigree that it was very likely that this was actually an X-linked disorder. So we went for the X chromosome and did exome sequencing, and we found a mutation in this gene called EIF2S3. So what does this gene do? Well, it's a new pathway now. So this is a gene that encodes a gamma subunit of a eukaryotic translation initiation factor two. And this is the largest subunit of a heterotrimeric GTP binding protein and contains GTP binding domains. It localizes to the nucleus and it's important for protein synthesis by forming a complex of GTP and transfer RNA. And it binds to the RNA to form a pre-initiation complex which scans the RNA to find the AUG code, basically, and to start off protein synthesis, so a completely new pathway. And in looking back at the literature, mutations in this gene have been associated with a very rare syndrome called MIMO syndrome, mental retardation, epilepsy, hypergonadism, microcephaly, and obesity. And if you look in detail at these papers, the clues were there. So some of these children had GHD and short stature. Some of them had diabetes. Some of them had neonatal hyperglycemia. Ours have a generally milder phenotype. And they all have forebrain abnormalities as well, which I haven't got time to show today. So this is the expression pattern which is done by Louise Gregory who's in the audience today, my post-doc. And what you can see is this is human embryonic tissue and you can see the expression in the hypothalamus and Rathke's pouch there. In the retina there and in the nasal ectoderm there. So nasal epithelium. And the last one is the pancreas there. It's in the islets of Langerhans and what's going to be the precursors of the islets of Langerhans basically. So expressed in the right places for the phenotype. And then we did a knockdown and we used a hybrid cell line formed by electrofusion of primary culture of human pancreatic islets with PANK1, which is pancreatic ductal carcinoma cell line. And we were lucky that we got transfection in one clone only. And that was enough for us to work with. And what we did here is look at apoptosis. And what you can see is there's caspase activity of the cell populations which is elevated both basally and in response to stimulation in these cells compared to the control cells. So it affects apoptosis. Okay, moving on to the next story. This is a collaboration with the Finnish collaborators Daneli Raivio. And this is looking at a gene called TBC1D3E2 mutations. And basically the Finnish group had two children. The first one tragically died at the age of three years there. And the second one is alive and doing reasonably well. And the first child had multiple pituitary hormone deficiencies and absent anterior pituitary and an ectopic posterior pituitary with hydrocephalus and developmental delay. His sister has a prominent forehead with some interesting facial features and also had multiple pituitary hormone deficiency with an ectopic posterior pituitary. She developed retinal dystrophy and she's got multiple other abnormalities. In the UK we had this family which is a consanguineous pedigree there. And the girl and then this child was actually aborted because the parents found out that this child had also been affected with the condition. And the girl had multiple abnormalities which gave rise to a condition called orofacial digital syndrome. But interestingly she had a very small anterior pituitary with corpus callosum hyperplasia, polyductally, and a Joubert-like MRI finding. So Joubert's is a ciliopathy. And that's now quite important to remember. And she's done well with growth hormone treatment but has developmental delay. The aborted fetus very clearly was very abnormal as can be seen from there. And so this is the Finnish boy who unfortunately died. His sister who's doing well and our patient at different ages. And what you can see is that they all had a small anterior pituitary. I'm sorry it's difficult to project there with an ectopic posterior pituitary, so structural abnormality of the pituitary gland. And our collaborators, Sir Taneli and his group looked at potential interactors of TBC1D32 using a MATTAG approach. And what they found is two particularly interesting families, the hedgehog family, which we now know is very important for pituitary development, and ciliopathy genes basically. Genes that are important for the formation of cilia. And so now what we know is that this is a ciliary protein playing a role in cell polarity determination and mediating vital signaling cascades such as the sonic hedgehog pathway. And deletion of the gene in the mouse leads to severe neurological phenotype. There's very little on the pituitary and we intend to look at that in the future. And that these neurons are affected with deficient sonic hedgehog signaling and impaired localization of a gene called GLII-2 which is known to be implicated in pituitary development. So these studies now link ciliary morphology, correct localization of GLII-2 in the cilia, and suggest that this hyperpituitary phenotype is probably due to the GLII-2 mislocalization. My third story is from collaborations with Turkey and Leila Akin who came to our lab and worked with Louise on this. And she had five pedigrees from Turkey, all consanguineous and probably all related to each other in the past. And we then did exome sequencing and we found a mutation in this gene called RNPC3. And this is a homozygous gene mutation as we would predict. And now we're into spliceosome territory. So genes need to be spliced. You have exomes and you have introns. The introns are spliced out. Now two types of spliceosomes catalyze splicing of pre-messenger RNAs. The major U2 type spliceosome removes U2 type introns and that's nearly 99% of pre-messenger RNA introns. The minor spliceosome U12 type removes U12 type introns which is 0.35% of all human introns are rare and reported to be present in 700 to 800 genes. And this consists of several small nuclear RNAs and associated proteins. And RNPC3 is one of these proteins and has been associated previously with isolated GHD. So we found in this pedigree, in these pedigrees that not only did they have growth hormone deficiency but they also had primary ovarian insufficiency with amenorrhea and elevated gonadotropins in the girls and elevated LHNFSH. They had hyperprolactinemia, mild TSH deficiency and anterior pituitary hyperplasia on the MRI as you can see just there. So the growth hormone response to growth hormone therapy was excellent in all of them but interestingly three boys' growth continued without growth hormone so they didn't have growth hormone for various reasons during the pubertal years and to everyone's surprise they continued growing. The males all have normal pubertal development and gonadal function including fertility so it's very much a female phenotype as far as reproduction's concerned. So we collaborated with Robin Lovell-Badge and Corinne Rizzotti at the Crick Institute in London and they inserted an analogous mutation into the mouse and they looked at the mutants compared to the wild type. And as you can see here in the females there was a reduction in growth hormone which was significant in one of these mice. They had two separate mice using CRISPR and the decrease in GNA was, GH was observed in both but was only significant in one of them. So we found further pedigrees and this is from a variety of collaborators, Italy, Russia and Macedonia and Spain and these were compound heterozygous but you can see that there's one hotspot mutation there, the P474T. And then the final story is this family that I looked after in an outreach clinic in Malta where two children had cerebellar hypoplasia, learning difficulties and hypogonadotrophic hypogonadism and it was a consanguinous pedigree. And then another child from Malta pitched up in the clinic and he had a completely identical phenotype but the parents were non-consanguinous. And what we found was a homozygous 13 base per deletion in a gene called PRDM13. So yet another new pathway here and I'll talk about that in a minute. And these patients had intellectual disability, ataxia, scoliosis and delayed puberty with congenital hypogonadotrophic hypogonadism and here you can see that they had cerebellar hypoplasia there and there compared with the normal and the vermis was very abnormal as well. Okay, so what we looked at was the expression studies again in mouse and human and found that the gene is expressed in the developing hypothalamus as you can see there. And so that was in the mouse and same in the human. In fact, Anna Caraboni who's a collaborator was struck by the very striking similarity really in these patients, in these sort of human samples. And what we saw was that KIS1 expression was absent. So kispeptin was absent in the mutants. So here is an interesting pathway really where there's absence of kispeptin in these or reduced kispeptin in these mice who had a knockout of the PRDM13. So we looked at the gonads in this mice and to our surprise the testes were not different in the human, sorry in the mutant mice compared to the wild type. But the ovaries were smaller but did not achieve statistical significance as you can see there. So what does this gene do? Well, it's also expressed in the cerebellum as you can see there. And it also leads to cerebellar hypoplasia. So you can see here in the mutants the cerebellum is much smaller than the controls. And how does it achieve its function? So what we found and this is collaborations with both Anna Caraboni and Albert Bassam who works on the cerebellum is that this changes sulfate from GABAergic to glutamatergic neurons in the mouse. So we used immunohistochemistry through the cerebellum and we had antibodies to PAX2 which is GABAergic interneurons and TLX3 which is glutamatergic. And what you can see here is that in the pink, so in the controls there's a lot of GABAergic neurons there but this has changed in the mutants where you get glutamatergic neurons mainly. So we think that that is the mechanism but we are doing more work on this. Okay, so to summarize now with my final slides. So these are all the genes that we know are implicated in congenital hypopituitism and this is from a review that we did a couple of years ago and published in JCM, I'll refer you to that and you can see the list is huge. Very pleiotropic phenotypes and modes of inheritance. But it's a difficult condition because now we're aware that there may be more than one gene affected in any one family that gives you the phenotype and so there's oligogenic and diagenic inheritance as well. And I think we'll hear more about this as we go along because many children have variable penitence so they are affected with the mutation. They carry the mutation from a parent and the parent isn't affected. So lots more to understand. And we've now got a big cohort of nearly 2,000 patients with a variety of phenotypes as you can see. It's skewed in the direction of septoptic dysplasia which is a rare condition but we've got a major interest and we've also got 81 with very unique phenotypes that have not been published to date. Now in the past we did Sanger sequencing and these are all the frequencies of the mutations and you'll see that most of them are very rare apart from SOX2 and severe eye defects, GH1 and GHRHR which are commonly found in children with IGHD or severe IGHD I should say. And this is just represented in the cartoon and you'll see that most of them are less than 10% except the severe eye defects which are explained in over 20% and the IGHD in about 14% so far. And when you look at the 81 patients from 52 pedigrees with familial or unique phenotypes we've done whole exome sequencing and 33 novel variants have been identified so far. Some of them I've described today but a lot we're working on at the moment and this Louise presented a poster on fatty acid synthase for instance implicated in hypothalamic pituitary development. So how are we gonna move forward? So I think microarrays and next generation sequence are now the way to identify the other 90% that are unexplained. And finally I'll conclude. So you've seen from what I've shown you that these children have very pleiotropic phenotypes. We're interested in how many of them have hypothalamic as compared to pituitary defects. Mutations and variations are generally rare but they show variable inheritance, variable penetrance suggesting the role of other genes and possibly environmental factors. Evolution of the phenotypes is important not only with something like PROP1 but even GH1, type 2 GH deficiency can lead to other human deficiencies with the mutation of the growth hormone gene. Careful interpretations are required of any changes and novel causative pathways are emerging. In the UK we've got the 100,000 Genome Project and we're finding some very interesting findings from that cohort as well which I can't obviously go into today. And care with genetic counseling is needed because we're in the early stages of understanding these conditions. None of this would have been possible without all of these people and I'll just mention a couple. Ian Robinson and Robin Lovell-Badge at the Crick. All my collaborators, it's lovely to see Sally here after several years in the audience. All the people who do the hard work, particularly Louise who's in the audience and all the other postdocs, et cetera. And Carlos and Juan Pedro Martinez-Barbera who have been instrumental in a lot of this work. All the funders, but most importantly, the patients and their families without whom I wouldn't be here. Thank you. We just have time for one question. Yeah, go ahead. I must say, friends, thanks for this beautiful talk and thanks for all the important discoveries. You've underlined that about 90% of multiple hormone deficiencies still remain unexplained. And so you've shown in many examples of syndromic cases where you found new genes. So are you also looking at this situation of pure endocrine phenotypes? And did you have new avenues for research? That's a great question. And the answer is we're looking. We've just started. So we're adopting a panel approach, putting in all these genes. So hopefully we'll be able to update you in due course. But yes, I mean, whether they're milder phenotypes or not, we don't know. We're particularly interested in the sidiopathies theory because that I think is, we found in mutations in a number of other sidiary genes as well. Thank you. Moving on swiftly to our final talk today is Dr. Pinaki Dutta. Also, he's from the Postgraduate Institute of Medical Education and Research in Chandigarh, India. And he's got a very catchy title for his talk, Lesser Known Rare Causes of Hypopituitarism when the hoofbeats belong to zebras. Dr. Dutta. So, very good morning to all of you. So I'm thankful to the endocrine society for giving me this opportunity. So I don't have any conflict of interest or declaration or any financial disclosure. This is the QR code. And I'm going to discuss lesser known causes of hypopitretism. These may be lesser in the western part of the world, however, they are relatively not uncommon in our part of the country or our part of the world. So coming to hypopitretism because of central nervous system tuberculosis. So as you know that tuberculosis affects almost 7 to 37% per 1000 per year, and it causes almost 1.5% of mortality in the globally, it is more than HIV related deaths even. And most rated form of tuberculosis is extra pulmonary tuberculosis, and endocrine dysfunction predicts poor outcome. And only three large studies are available with more than 50 patients. And the first two are cross-sectional studies and the last one is the prospective study that we found that almost most of these three studies, middle-aged persons are affected and hormonal abnormalities present in 50 to 80% at baseline. And the most prevalent hormonal deficiencies were hypocortisolism, hypogonadism, and elevated prolactin. And in one of the studies, it was found that basal exudates correlate with endocrine apathy at presentation. So we prospectively studied drug-naïve tubercular meningitis patients and did their clinical radiological hormonal evaluation at baseline and six months of follow-up and found that almost 84.2% had hormonal abnormalities at presentation and 42% had prostitution abnormality at six months of follow-up. And out of these 42%, almost 40% had multiple pituitary hormone deficiencies. And the disease severity correlated with hypocortisolism. So coming to the mechanisms and manifestations of pituitary involvement in central nervous system tuberculosis, it is because of the hematogenous spread of the organism, there is a local extension of the disease process in the subpile focus, there is compression because of adhesive arachnoiditis and hydrocephalus, or obliterative end-arteritis. The anatomical counterpart could be tuberculomas, apoplexy, basal exudates, hydrocephalus, or tubercular abscess. I will unfold one by one. So this is a patient who presented with multiple supracellular and cellular conglomerate tuberculoma and other parts of the brain were also affected. In another patient, the higher up also you can find out the tuberculoma. This is a patient who had a tuberculoma and it masqueraded as a pituitary apoplexy. He had recurrent episodes of apoplexy-like events. And you can find out there is a hypodense center and hyperdense periphery mimicking apoplexy. And to our utter surprise, there was a histopathology revealed fibrotic areas with ill-formed epithelial granuloma consistent with diagnosis of tuberculosis and he responded well to antidevacular therapy. This is showing hydrocephalus and basal exudate. Basal exudates are thick areas of contrast enhancement in the basal, prefrontal, and perimaging cephalic system and supracellular system, you can find out here. This is due to increased vascular permeability. It is composed of inflammatory cells, fibrin, and dead cells. So this is another patient you can find out there is an infarct because of the vasculitic process and in the perinfarct area, you can find out there is hemorrhage also. This particular patient is from a Portuguese literature. The patient had pure tubercular hypophysitis and following antidevacular therapy, there is complete improvement. And this is one of our patients you can find out. The antemortem diagnosis was that of a craniopharyngema, however, because of the lack of calcification and there is diffuse edema in the border zone, which is marked here by yellow arrows, you can find out we suspected that this patient must be having something else and autopsy revealed that it was teamed with acid-fast bacilli and this was a tubercular abscess of the pituitary gland. The second one is a child who presented with fever and central diabetes insipidus. The post-contrast MRI show there is enhancing peripheral solid part and non-enhancing central liquefied area and because of the fever, we thought of something else and we went ahead for a stereotactic biopsy which revealed that it was teamed with the acid-fast bacilli. And does pituitary dysfunction happen in children with tubercular meningitis? The answer is yes. It is a study from Hong Kong has shown that the pituitary dysfunction in survivors of TB meningitis can happen to the tune of 20% after they are evaluated after a period of almost two decades. So next is tubercular abscess, which is extremely rare actually. We had encountered only 10 patients in the last 20 years with 4,500 pituitary surgeries and this is a patient who presented with recurrent episodes of pyogenic meningitis and found to have a central necrotic area and peripheral enhancing area with thickened stock and histopathology revealed that there is a pituitary necrosis with neutrophilic infiltration. Another patient which was diagnosed post-mortem, he presented with a pneumonic onset of fever. Pseudomonas was grown from the blood culture and he was treated with that. The pneumonic phase disappeared but the patient's condition worsened and he presented with unconsciousness which revealed, MRI revealed that there was a large cellar, supracellar area showing abscess-like presentation and because of his condition, he could not be subjected to surgery and he died and autopsy revealed that pus is coming out, oozing out from the pituitary stock area. And coming to pituitary because of the parasitic disorders, this is a patient who is from Indochina border. She's a girl who presented with raised intracranial pressure and found to have, there is a high density membrane and low density cyst in the cellar-supracellar area. The MRI is showing typical endocyst membrane which is undulating, a typical feature known as water lily sign and on histopathology, we found that though two acellular layer and the cellular layer of the hydrated. So neurocystic sarcosis because of the tapworm disease is causing hypopituitarism extremely uncommon. There are only 23 case reports in the world literature. This is a case from California, this is a Mexican subject who presented with features of raised intracranial tension and you can find out here, there are multiple cysts here and the large fourth ventricular cyst and the histopathology revealed there is a cuticular layer, subcuticular layer, cells and smooth muscle fiber cells of the parasite. Thereby confirming the diagnosis. Many a times, they do not require surgery, only glucoparticulate therapy and alvendazole therapy may be curative in them. In our part of the world, we see mostly parenchymal form of neurocystic sarcosis and less often the pituitary involvement. So hypopituitarism because of snake bite. Snake bite involves almost 5.4 million subjects yearly and out of them, half are bitten by poisonous snakes and another half by viper bite which is the commonest cause of hypopituitarism in them. And out of them, almost 100,000 die every year and you will be surprised to know that in US itself also, snake bite because of the poisonous snakes, especially the viper subspecies happens in 7,000 to 8,000 with 5 to 10 deaths per year. So this is the distribution of species of both species of the Russell viper which exclusively cause hypopituitarism. One is Davoia russellii and Siamensis. Russell is usually present in the Indian subcontinent and the other one is in the Far East countries. This is a panel of photographs showing some of our patients. You can find out here there is cellulitis following the bite and here the envenomation at the tip of the finger, here the ankle. The mostly hypopituitarism found in nearly 15% of the survivors. Exclusively associated with concurrent renal injury, usually requiring hemodialysis. Acute kidney injury and capillary leak syndrome predicts hypopituitarism in most of the cases. Coming to the mechanism, it is because of disseminated intravascular coagulation because of the snake venom. The vascular toxicity leads to capillary leak, hypotension, and hemorrhagic impact of the pituitary gland. Rarely you can have a delayed presentation because of the autoimmunity like Sihan syndrome. And here is an autopsy finding of pituitary gland. You can see here the stalk is also hemorrhagic as well the pituitary gland is enlarged and hemorrhagic. And the histopathology also revealed there are evidences of macrophage-laden, hemocytin-laden macrophages suggestive of a recent hemorrhage in the past. And here you can find out more fresh hemorrhages. So the spectrum of MRI of the pituitary could be empty cell with hormone deficiency, it could be a partial empty cell or it could be completely normal pituitary with only isolated growth hormone deficiency. And we encountered patients with acquired ectopic posterior pituitary blight spot with thinned out cell also suggestive of acquired defect. And this patient's height was normal and acquired hypogonadism was there, thereby meaning excluding congenital causes. So in summary, the growth hormone, glucocorticoid, prolactin deficiency, and gonadotropin deficiency occur in that order following snake bite. Acute cases present radiologically with apoplexy and clinically with hypoglycemia, refractory hypertension, and rarely with hyperkalemia. Acute hypopituitarism usually presents within five hours to two days. Chronic hypopituitarism can present within days to years. Variable degree of empty cell is found on MRI. And evaluate all patients with acute kidney injury who require dialysis at least at third month or six months of follow-up. And posterior pituitary involvement is extremely rare. So coming to thalassemia endocrinopathy. So the orange colored area reflects the area of the world which are affected by thalassemia and beta thalassemia major. Almost 1.6% of the world population is affected by this. And the barometer of complication depends on the iron overload. Hypogonadism is related to cardiac sclerosis and short stature is related to hepatic sclerosis in one of the studies. And there is a study available with a large number of subjects in 2005, and it was incomplete in the sense that all the pituitary hormone vaccines were not done properly. And in our ongoing study we did complete pituitary hormone profile along with bone mineral density as well as high resolution peripheral quantitative CT and MRI of the heart, hepatic, and brain and pituitary MRI and found that the pituitary gland iron deposition is found in almost 57% subjects after 10 years of disease. And the small pituitary gland is found following iron overload in 26% of subjects. Here is a patient you can find out from the literature that the pituitary gland is shrunken at the age of 10 years, and on the other side you can find out the normal pituitary with the posterior pituitary gland. This happened as early as 10 years of age. And I must say that you should always do the T2 sequences to look for iron overload. Here you can find out a normal healthy individual with a pituitary, and you can find out hypo-intense pituitary gland. Other than the pituitary gland, dentate nucleus and the choroid plexus are also common areas of the brain which are affected by iron overload because of the high metabolic rate. Here you can find out that one subject is having a normal dentate nucleus and very hypo-intense dentate nucleus and T2-weighted MRI on the lower panel. So this is a patient with basal ganglia involvement. Somebody can suspect that this is because of calcium overload in a patient with hypoparathyretism because of the acquired cause in a patient with thalassemia, which is not uncommon. However, on susceptibility-weighted image you can find out that the hypo-intense areas on the brain, especially in the basal ganglia area, and in phase MRI you can find out these areas are hyper-intense, which is comparable to that of the blood vessels in the middle cerebral artery as well as the cerebral veins. It is much better appreciated here. You can find out both of them are showing hypo-intense signal on MRI. However, the calcification is still hypo-intense, the choroid plexus calcification is still hypo-intense as compared to the cerebral veins. However, iron overload will show hyper-intensity. Causes of hypogonadism in iron overload state could be functional, because of reduced body fat, because of their chronic illness, or low leptin level, and structurally it could be gonadotroph involvement directly. So there is a paper by Professor Kalman Kovak in which he did an autopsy in a patient with hereditary hemochromatosis and found that the iron overload is predominantly found in the areas of the pituitary, the gonadotroph cells. The LH and FSH immunostaining is positive, along with co-localization of the prussian blue. The basis of prussian blue stain is that ferric iron in presence of hydrochloric acid and potassium ferrocyanide produces potassium ferric ferrocyanide, which imparts blue color, which is the basis of pearl staining. And on MRI, sorry, electron microscope, you can find out cytoplasmic accumulation of lysosomes like structure at low density, confirming to the iron. Coming to organophosphate poisoning, it is very common in our part of the world, as well as in Turkey and some other Eastern European countries. Almost 3 million persons are affected by poisoning per year, mostly in developing countries, and it is because of the suicidal intent, because it is very widely available. And you will be knowing the surprise that 36 types of organophosphate compounds are still available in the USA, so it must be happening, we do not know, because of lack of screening. And acutely, they cause acute stress response and cytokine-mediated or acetylcholinesterase inhibition leading to increased ACTS, cortisol, prolactin, and growth hormone, but the delayed effect is because of the oxidative injury of the various neurons or pituitary gland. And in one of our studies, almost 50% of them had hormonal abnormalities at third month, and similar thing has been also corroborated by another Turkish study. So one of the interesting cases I will show you, as you know that hypothalamitis is one of the fourth dimension which has been added to the autoimmune disorders of hypothalamus pituitary area, and anatomically, the primary hypophysitis could be involvement of the anterior lobe, it could be tuberal infundibulitis, involving the stalk and the hypothalamus, and posterior pituitary, and really kind of a combination of them. We found isolated hypothalamic involvement, and this patient was proven by doing an anti-pituitary antibody, which was negative, and anti-hypothalamic antibody, which was positive, and this was directed against the vasopressin-secreting neurons, could see professor Anna Maria Devalis. And similar type of case was also found with the programmed cell death ligand antibody treatment in a patient with bladder cancer with metastatic disease in the lung, and the patient presented with hypothalamic dysfunction, as well as pan-hypopituitarism. So in summary, I will say that whoop-beats may not always signal horses, we may have to be prepared occasionally for zebras, knowledge on rare causes of hypoteriorism is important so that one is not caught off-guard. Some causes of hypoteriorism are unique to certain geographic region, like tuberculosis and snakebite. However, if somebody is a migrant and had lived for a long period of time in these countries, I had already told, you should suspect if there is a hypoteriorism in them, even if they are in UK or USA. So prompt suspicion and early identification are important for optimum care and good clinical outcome. So at last, I will acknowledge my mentors and my juniors. Thank you very much for your patient hearing. I'll be happy to invite you for questions. Thank you. Any final questions? Please come to the microphone if you have a question. With regard to the Shih-Han Syndrome presentation, the sequence of events of hormone deficiency doesn't involve SHH as the second one, as in your case. The second point is the resistant hypotension in patients with snakebite, I doubt very much that's related to hormone per se, rather than venom effect, either in the sympathetic nervous system or generalized circulatory failure. Can you explain why SHH is the second growth hormone and not like the other pattern of others? Yes. So the growth hormone secreting cells are the most abundant actually in the pituitary gland. Almost 50 to 60% of them are constituted by growth hormone secreting cells. However, they are situated with a precarious blood supply. Whenever there is hypotension or necrosis, they are the most one to be affected. Therefore, growth hormone deficiency may be the commonest one in either snakebite or traumatic brain injury or Shih-Han Syndrome. Thank you very much.

pituitary dysfunction

traumatic brain injuries

hypopituitarism

mild traumatic brain injury

fatigue

insomnia

memory problems

headaches

tinnitus

Sheehan syndrome

hepatic health issues

lesser-known causes

diagnostic approaches