Case Report

A case of an infant with congenital combined pituitary hormone deficiency and normalized liver histology of infantile cholestasis after hormone replacement therapy

Keisuke Wada1, Hironori Kobayashi1, Aisa Moriyama1, Yasuhiro Haneda1, Yuichi Mushimoto1, Yuki Hasegawa1, Kazumichi Onigata1, Koji Kumori2, Noriyoshi Ishikawa3, Riruke Maruyama3, Tsuyoshi Sogo4, Lynne Murphy5, and Takeshi Taketani11Department of Pediatrics, School of Medicine, Shimane University, Shimane, Japan2Department of Digestive and General Surgery, School of Medicine, Shimane University, Shimane, Japan3Department of Pathology, Shimane University Hospital, Shimane, Japan4Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Kanagawa, Japan5Department of Medical English Education, School of Medicine, Shimane University, Shimane, Japan

Abstract.Congenitalcombinedpituitaryhormonedeficiency(CPHD)maypresentwithcholestasisintheneonateorduringearlyinfancy.However,itsprecisemechanismisunknown.A3-mo-oldboypresentedwithcryptorchidismandhypoplasticscrotumafterbirth.Neonataljaundicewasnotedbuttemporarilyimprovedwithphototherapy.Jaundicerecurredat2moofage.Elevateddirectbilirubin(D-Bil)andliverdysfunctionwerefoundbutcholangiographyshowednosignsofbiliaryatresia(BA).Liverbiopsyfindingsshowedgiantcellformationofhepatocyteswithhypoplasticbileducts.Subsequentmagneticresonanceimaging(MRI)oftheheadrevealedahypoplasticpituitaryglandwithanectopicposteriorlobe,andthepatientwasdiagnosedwithcongenitalCPHDbasedondecreasedsecretionofcortisolandGHbythepituitaryanteriorlobeloadtest.D-Billevelspromptlyimprovedafterhydrocortisone(HDC)replacement.Wesubsequentlybeganreplacementwithlevothyroxine(L-T4)andGH,andliverhistologyshowednormalinterlobularbileductsat8moold.Thisisthefirstcasereportofprovenhistologicalimprovementafterhormonereplacementtherapy.Thissuggestedthatpituitary-mediatedhormones,especiallycortisol,mightbeinvolvedinthedevelopmentofthebileducts.

Key words:congenitalcombinedpituitaryhormonedeficiency,neonatalcholestasis,giantcellhepatitis,biliaryatresia,hydrocortisone

Introduction

Combined pituitary hormone deficiency (CPHD)ischaracterizedbydeficiencyofGH,PRL, thyroid-stimulating hormone (TSH),ACTH,LH,orFSH,kindsandseverityofwhichvaryaccordingtoeachcase(1).TherearebothcongenitalandacquiredCPHD;thelattermay

Received:March14,2017Accepted:May19,2017Correspondingauthor:KeisukeWada,MD,DepartmentofPediatrics,SchoolofMedicine,ShimaneUniversity,89-1Enya,Izumo,Shimane693-8501,JapanE-mailkeiwada@med.shimane-u.ac.jpThisisanopen-accessarticledistributedunderthetermsoftheCreativeCommonsAttributionNon-CommercialNoDerivatives(by-nc-nd)License<http://creativecommons.org/licenses/by-nc-nd/4.0/>.

ClinPediatrEndocrinol2017;26(4),251–257Copyright©2017byTheJapaneseSocietyforPediatricEndocrinology

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consist ofbrain tumorandhead injury.TheoriginofcongenitalCPHDismainlyunknown,butitmaybepartlyinfluencedbypelvicpositionduringdelivery,newbornasphyxia,orageneticabnormality related to transcription factorsinvolvedinthedevelopmentanddifferentiationofthepituitaryandhypothalamus.TheincidenceofcongenitalCPHDis1inapproximately50,000births,ofwhichabout10to35%presentwithcomorbidcholestasisduringtheneonatalperiodand infancy (2). Distinguishing cholestasisrelatedtocongenitalCPHDfrombiliaryatresia(BA) isakey issue,ascholestasisrelatedtocongenitalCPHDoftendevelopsafteraboutonemonthofbirth.OneormoredefectsofACTH,GH, and TSH have been reported as beingresponsible for cholestasis (2), but therearealsoreportsthatonlycortisolisresponsibleforcholestasis,andnoconsensushasbeenachievedonthematter(3,4).Itissuspectedthatpituitaryhormonedeficiencycausesadecreaseinbileacidsynthesis,adelayinthedevelopmentofthebileacidtransportpathway,andstructuralandfunctionalaberrationsofthecholangioles(5).LiverhistologyimagesofCPHDarecharacterizedbysignsofgiantcellformationofhepatocyteswithhypoplasticbileducts (6).Therearenoreportscomparinglivertissuefindingsbeforeandafterhormonereplacementtherapy.Here,wereportaninfantboywithcongenitalCPHDandcomorbidcholestasiscausedbyintrahepaticbile duct hypogenesis, and confirm that hisbileductsnormalizedreversiblybyhormonereplacementincludinghydrocortisone(HDC).

Case Report

Aboywasbornvianormalvaginaldeliveryatthegestationalageof38wkand5d.Hisbodyweightwas3,154gandhisheightwas49.5cm.HisApgarscoreafter1minand5minwas9points,respectively.Familyhistorydidnotinvolvehepatobiliarydiseaseorendocrinedisorder.Hewasafullybreastfedchild.Hepatosplenomegalywasnotfoundonphysicalexamination.External

malformation,cryptorchidism,scrotumcollapse,andswellingof thesacrumwere recognized.Neonataljaundicewasfound(day7:totalbilirubin[T-Bil]21.6mg/dL,directbilirubin[D-Bil]0.6mg/dL)anditrecoveredwithphototherapywithin2wkafterbirth.Healwaysproducedcream-coloredstoolfrombirth,butelevationofD-Bilandliverenzymeswasnotseen(day21:T-Bil18.6mg/dL,D-Bil0.2mg/dL,aspartatetransaminase[AST]49IU/L,alaninetransaminase[ALT]19IU/L).Gammaglutamyltranspeptidase(γGTP),whichshowedhighlevels(1,084IU/L)atbirth,graduallydecreased.Newbornmassscreeningwasnormal.

At one month old, a slight increase inD-Bil (1.1 mg/dL) was noted when the boysufferedfromaurinarytract infection(UTI)withaccompanyingvesicoureteralrefluxandhiscream-coloredfecespersisted.Slowbiliaryexcretion to the duodenum was found byhepatobiliaryscintigraphy,suggestingthatBAwasnotthediagnosis.Subsequently,thecolorofhisfecesbecamewhiteandjaundiceworsenedafterhewasinfectedwithrespiratorysyncytialvirus(RSV)at2moold.ElevatedD-Bil(10.6mg/dL)andliverdysfunction(AST1,903IU/L,ALT907IU/L)werefound,andBAwassuspected.Thepatientwasreferredtoourhospitalat3moold.

Atthetimeofhospitalization,hisheightwas60.8cm(–0.25standarddeviation[SD]),weightwas4,845g(–1.89SD),andhepresentedwithconjunctival icterusandjaundiceoftheskin. There was no hepatosplenomegaly onphysical examination. Laboratory findings(Table1)revealedmarkedelevationofserumliver enzymes (AST 2,367 IU/L, ALT 1,175IU/L)andD-Bil(9.9mg/dL).Theserumlevelofalkalinephosphatase(ALP)washigh(2,983IU/L), while that of γGTP was within thenormalrange(54IU/L).Plasmabloodglucoselevelwaslow(46mg/dL).Thyroidfunctiontestsshowedfreetriiodothyronine(freeT3)1.9pg/mL,freethyroxin(freeT4)0.5ng/dL,andTSH2.69μU/mL.Aminoacidandbileacidanalysesshowednoabnormalities.Testsscreeningfor

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hepatitisviruseswereallnegative,butserumanti-cytomegalovirus(CMV)immunoglobulinM(IgM)waspositive.ByimmunostainingoftheCMVpp65antigeninwhitebloodcells(CMVantigenemiaassay),5outof50,000cellswerepositive.Abdominalultrasonographyshowednohepatosplenomegalyandanormalgallbladder.Therewasnotriangularcordsign.

Transcystic cholangiography performedunder general anesthesia showed normalextrahepaticbileducts,rulingoutthepossibilityofBA.Intraoperativeliverbiopsyshowedbileducthypogenesiswithgiantcellformation,featherydegenerationofhepatocytes,andhemosiderindeposition,butneithersteatosisnorinflammatorycellinfiltrationwasobserved.(Figs.1aandb).Inlivertissues,CMV-positivecellsdidnotpresentusing immunohistochemistrywithanti-CMVantibodyandowl’seyeinclusionbodieswerenotobserved.Inaddition,theexpressionlevelofbiletransporterssuchasthebilesaltexportpump(BSEP),multidrugresistanceprotein3(MDR3),andmultidrugresistance-associatedprotein2(MRP2)variedinlivertissues,suggestingthatthediagnosisofprogressivefamilialintrahepaticcholestasiswas denied.We suspectedCMV-

inducedcholestasis,thereforeganciclovirwasadministeredfor22duntilCMV-antigenemia-positivecellsdisappeared.Jaundiceandliverdysfunctionimprovedtemporarily,butserumtransaminase levels reascended and D-Bildidnotnormalize,althoughaslightdeclineofD-BilbeforetheadministrationofHDCmighthavereflected improvementofCMV-inducedcholestasis. At this point, we performed astimulating test with L-arginine, CRH, andthyrotropin-releasinghormonetodifferentiatefromcongenitalhypopituitarism.GHandcortisolshowedanunder-response,whileACTHandTSH showed an over-response as well as adelayedresponse(Table2).AnMRIoftheheadrevealedahypoplasticpituitarywithformationofanectopicposteriorlobe(Fig.2).TheseresultsclarifiedthediagnosisofcongenitalCPHD.WeimmediatelyadministeredHDC(12.5mg/m2/d)atfivemonthsoldandhisD-Billevelsrapidlydecreased.Subsequently,levothyroxine(L-T4)(2.6µg/kg/d)andGH(0.175mg/kg/wk)werestartedat6and7moold,respectively.PriortoGHreplacement,D-Bilandhepaticenzymelevelswereconsiderablyimproved.Thesecondliver biopsy, performedat 8mo old, showed

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Table 1 Laboratorydataattheageof3mo

WBC 10,700 /µL Alb 4.3 g/dL CMVIgM (+)RBC 357×104 /µL T-Bil 15.1 mg/dL CMVIgG (+)Hb 9.8 g/dL D-Bil 9.9 mg/dL EBVVCAIgM <10Plt 42.3×104 /µL AST 2,367 IU/L EBVVCAIgG <20PT-INR 1.05 ALT 1,175 IU/L EBVEBNA <10APTT 39.3 sec LDH 974 IU/L HBs-Ag (–)HPT 71.6 % ALP 2,983 IU/L HCV-Ab (–)

γGTP 54 IU/LCK 105 IU/LT-Chol 174 mg/dLBUN 18.5 mg/dLCr 0.27 mg/dLNa 135 mEq/LK 5.5 mEq/LCl 107 mEq/LCa 10.0 mg/dLNH3 59 µg/dLCRP 0.26 mg/dLGlucose 46 mg/dL

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Fig. 1. Liverhistologybyhematoxylin-eosin(HE)stainingandcytokeratin19(CK19)immunohistochemistry.a:beforetreatment(HE):giantcellformationandfeatherydegenerationofhepatocyteswithextramedullaryhematopoiesis.b:beforetreatment(CK19):smallimmaturebileductwithoutlumenformation.c:aftertreatment(HE):improvementoftheenlargedhepatocytes.d:aftertreatment(CK19):neogenesisofthebileductswithlumenformation.

Table 2 Endocrinologicalexamination

0min 30min 60min 90min 120min

GH(ng/mL) 2.2 1.2 1.6 2.1 2.6Cortisol(µg/dL) 3 6 7 7 8ACTH(pg/mL) 18.9 100.8 83.3 77.3 91.3PRL(ng/mL) 21.6 37.4 37.3 36.5 32.1TSH(µU/mL) 5.38 31.18 35.71 40.90 45.37freeT3(pg/mL) 2.1freeT4(ng/dL) 0.7LH(mIU/mL) 0.2FSH(mIU/mL) <1.0

Congenital CPHD with cholestasis by HRT 255

improvementofhepatocyticdegenerationandrevival of normal interlobular bile ducts inportaltracts,suggestingthatsevereintrahepaticcholestasishadremarkablyrecovered(Figs.1candd).Thepatientmaintainednormalphysicalandmentaldevelopmentat1yrand9mooldandshowednosignsofjaundiceorliverdysfunctionatthetimeofhislastevaluation(Fig.3).Nogeneticmutationinvolvedintheformationofbileductsthatcausescholestasiswasnoted.

Discussion

LiverhistologyafterhormonereplacementwithHDC,L-T4,andGHshowedimprovementof the damagedhepatocytes and recovery ofthe intrahepatic bile ducts.Torbenson et al. reportedthathypopituitarismaccountedfor10(16%)of63casesofneonatalgiantcellhepatitis,placingitsecondtoidiopathic31(49%)cases(6).Interestingly,portalandlobularinflammationwasmildtoabsentin95%ofpatientswithneonatalgiantcellhepatitis(6).Thehistologicalfeatures

ofgiantcellhepatitisinhypopituitarismshowedasignificantdifferenceinhypoplasiaofthebileducts(6).LiverhistologicalfindingsinourcasewerethesameasthosereportedbyTorbensonet al.(6).Theseindicatedthatgiantcellformationofhepatocyteswithhypoplasticbileductsandno/few inflammatory cells isa characteristicof cholestasis causedbyhypopituitarism.Tothebestofourknowledge,ourcaseisalsothefirst case report that showed liver histologyimagesafterhormonereplacement.Hormonereplacementpromotedformationofbileductsandnormalizationofhepatocytes,suggestingthat giant cell formation of hepatocytes inhypopituitarismisreversible.

Congenital CPHD may present withcholestasis during the neonatal period andinfancy.However,itisunclearwhichpituitaryhormone deficiency causes cholestasis. InfourcasesofneonatalcholestasisreportedbyHussaini(twocaseswithfamilialglucocorticoiddeficiency and two with isolated ACTHdeficiency), thyroid hormone and GH levelswerenormalandcholestasisimprovedwithHDCreplacementalone(3).In16casesofneonatalpituitarystalkinterruptionsyndromewithorwithoutcholestasis,theplasmacortisollevelwassignificantlylowerinthecholestasisgroup,whiletherewasnosignificantdifferencewithrespecttoGHandthyroidhormone(4).OurcasefoundimprovementinD-BillevelsafterHDCreplacement, suggesting that cortisol mightplay an important role in the amelioration of cholestasis.Inanimalexperiments,Shiojiriet al.reportedthatimmaturehepatocytesfailedtodifferentiateintointrahepaticbileductcellswithout dexamethasone (7). Glucocorticoidexhibits choleretic effects by activating Cl–/HCO3

–exchangersviaglucocorticoidreceptors(8).Sincecortisolisnecessaryfordifferentiationintobileductsandforfunctionalcholeresis,weconsiderthatcortisolisoneofthemostimportanthormones involved in cholestasis caused bycongenitalCPHD.However, cholestasiswasimprovedwithadministrationofHDCinaddition

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Fig. 2. MRIimageofthebrain(T1weightedimage).Arrow indicates ectopic posterior lobe.Pituitaryhypoplasiaisobserved.Pituitarystalkisnotinterrupted.

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toL-T4andGH.Inratstudies,thyroidhormonehasaneffectonbileflow(9)andIGFIhasaprotectiveeffectonexperimentallivercirrhosis(10,11).ThesestudiesdemonstratedthatthyroidhormoneandGHmightalsobeimportantforimprovementofcholestasis.Furtherresearchisneededforpathologicalelucidationofcholestasisassociatedwithhypopituitarism.

Wemighthavebeenabletodiagnoseourcase as CPHD at an earlier stage becausecryptorchidism and hypoplastic scrotum inadditiontohypoglycemiaandhypothyroidismwere present. Examinations should beperformed,keepingthepossibilityofCPHDinmind,whenthepatientpresentswithneonatalcholestasis and hypopituitarism featuresincludingprolongedhypoglycemia,electrolyteabnormality,cryptorchidism,ormicrophallus.

NotallcongenitalCPHDpatientspresentwith cholestasis. Inour case,CMV infectionwas serologically and cytologically provedalthoughhistologically, itwasnot. Jaundicewas temporarily improved with ganciclovir.PreviousreportsshowedthatCMVisassociatedwithhepatitisandBA(12,13).ThesesuggestedthatnotonlyCPHDbutalsoCMVmighthavecontributedtocholestasisinourcase.Inaddition,urinarytractandRSVinfectionsmighthavepartlyledtoaggravationofliverdysfunction.Althoughthese infectionsmayhaveaffectedcholestasis,thiscaseisavaluablecaseinwhichimprovementcouldbeconfirmedclinicallyandhistologicallyafterhormonereplacement.

Wepresentedanabstractofthismanuscriptat the 50th annualmeeting of the JapaneseSocietyforPediatricEndocrinology.

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Fig. 3. Clinicalcourse.HDCsupplementationwasstartedat5moold.Directbilirubinbegantodeclinesoonaftertreatmentandnormalizedattheageof12mo.

Congenital CPHD with cholestasis by HRT 257

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