13F Central obesity with hypopituitarism WB PaJR

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

Our patient who is studying in 8th standard (age-13 years) is having central obesity. Her weight is around 50kg and height 4' 8". Recently according to doctor advised have done some blood test related to growth hormone and hand X-Ray. Some growth hormone deficiency was found inte report.

The PHR, patient journey record PaJR transcripts below reflect the therapeutic uncertainties around the patient and their resolution through team based learning :

Here's the rest of the discussions not yet updated in the case report 👇

[8/30, 10:04 PM] PAJR MEMBER : Please send images of her hands front and back, images of making a fist from forwards and also images of her neck front and side

[8/31, 7:55 AM] PaJR PHR Moderator: Share the hand x-ray and report of growth hormone after removing the patient identifiers

[8/31, 12:28 PM] patient advocate: Please find Blood Report and X-Ray Report

[8/31, 12:30 PM] patient advocate: Sending photos by EOD

[8/31, 1:22 PM] PaJR PHR Moderator: Did they order a pituitary MRI after seeing this report?

[8/31, 3:55 PM] patient advocate:Yes

[8/31, 4:02 PM] PaJR PHR Moderator: Was it done?

When was she first shown to the doctor and for what complaint at that time?

[8/31, 4:04 PM] patient advocate:No

[8/31, 4:06 PM] +patient advocate:Her paediatric doctor advised to visit an endocrinologist for central obesity and growth. It was 11th June 2024.

[8/31, 4:23 PM] patient advocate: Sir anything to worry about.

[8/31, 6:16 PM] pajr_member: Very well sent images. Thank you.

[8/31, 6:17 PM] pajr_member: Please take an image of the fist this way. From the front. Both hands please.

[8/31, 6:19 PM] pajr_member: Did she attain menarche? Has her monthly bleeding started?

[8/31, 6:30 PM] pajr_member: @⁨PaJR PHR Moderator⁩ there are clear features of insulin resistance (acanthosis + central adiposity) with IGF and GH deficiency.

What do you make of this?

[8/31, 6:32 PM] pajr_member: I think All Pituitary Endocrine hormones are best tested with Insulin stimulation test rather than one off serum values.

Common things common - a diagnosis of Turner syndrome appears likeliest from whatever data I'm getting. Although this does not agree with the low FSH and LH.

[8/31, 6:57 PM] patient advocate: No not yet.

Patient advocate: 

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[8/31, 9:56 PM] patient advocate:Hope this snap is ok

[8/31, 9:56 PM] pajr_member:Can do both hands together if possible.

[8/31, 9:57 PM] patient advocate:Surely sending both the snap again

[8/31, 9:59 PM] pajr_member: Please give us an entire history of how she was during her childhood. From milestones and any data from prenatal ultrasound scans if available would be very helpful.

[8/31, 10:03 PM] PaJR PHR Moderator: Her biochemical findings of low GH, igf and LH, FSH can all be explained by insulin resistance alone

[8/31, 10:04 PM] pajr member:  Agree with the GH but I'd expect LH and FSH to be high in Primary Ovarian / Insulin Resistance syndromes

[8/31, 10:05 PM] pajr member:  From whatever I can gather from this, the dimple of the 5th metacarpal does appear to be lost in this one. A clearer image would clinch it.

[9/1, 6:52 AM] PaJR PHR Moderator: Can you share the measurements of her midparental height?

[9/1, 10:40 AM] patient advocate: May I know the meaning of midparental height

[9/1, 5:41 PM] PaJR PHR Moderator: "To calculate the mid-parental height, we take the average of the mother’s height and the father’s height.

From there, we can use a growth chart to predict the child’s final adult height. This method is not perfect, but it gives us a general idea of how tall a child is likely to be as an adult."

If you enter her father and mother's height in the calculator here, you can get her expected height 👇

https://myendoconsult.com/learn/mid-parental-height-formula/

[9/1, 8:04 PM] patient advocate: Using this calculator I got the height of daughter as 153.25 cms. Considering father's height - 166 cms & Mother's height - 153.5 cms.

[9/1, 8:04 PM] patient advocate: Sharing shortly

[9/1, 8:06 PM] pajr member : Okay. Thanks. That means she is well below the midparental height

[9/2, 3:33 AM] PaJR Coordinator: @⁨pajr_member⁩ please kindly little elaborate what is means

[9/2, 3:49 AM] +pajr member : Yes. Basically her expected height should be at least 153 cm but her current height at that age is 142.2 cm which is 11 cm lesser.

This diagnoses a condition called Short Stature. A condition called Turner syndrome is very commonly associated with short stature.

[9/2, 3:52 AM] pajr member: Ideally this is how the little finger on both sides should look like. The little finger dimples as pointed above should be prominent. The hand xray image can help if possible please share.

[9/2, 3:59 AM] PaJR Coordinator: Great

[9/2, 4:00 AM] PaJR Coordinator: What does it mean about her health can you elaborate it more is it a serious condition or it can be handled

[9/2, 4:00 AM] pajr member: : A pituitary MRI would help and then perhaps we can take it from there. But yes the MRI is the next best step.

[9/2, 4:02 AM] pajr member : She's 13 so there is still a little window for intervention. First step would be make the correct diagnosis. For that MRI Pituitary would help and then testing for Turner syndrome can be pursued.

There are injection therapies which can improve her height and also treatment for her to have menstrual cycles.

[9/2, 4:04 AM] PaJR Coordinator: Ok

[9/2, 4:06 AM] PaJR Coordinator: Is it a very serious condition or common condition can be treated

[9/2, 4:06 AM] PaJR Coordinator: Can she come back to good health back

[9/2, 4:07 AM] pajr member : It is not life threatening. It can be treated but most importantly the diagnosis has to be made first. I don't want to worry the parents before any diagnosis is made.

If the problem is in the pituitary (brain) then the course and treatment options change completely.

[9/2, 4:10 AM] PaJR Coordinator: Great

[9/2, 4:10 AM] pajr member : Possibly. What are her goals at the moment?

[9/2, 4:11 AM] PaJR Coordinator: Get back to normal weight get physically active

[9/2, 4:11 AM] PaJR Coordinator: My little patient is good at studies

[9/2, 4:11 AM] pajr member : Very much possible.

[9/2, 4:12 AM] pajr member : I think we should be seeing her diet plates everyday then.

[9/2, 4:12 AM] PaJR Coordinator: Sure

[9/2, 4:12 AM] pajr member: And her daily normal routine in accordance to PaJR guidelines.

[9/2, 4:13 AM] PaJR Coordinator: Ok let's kick start it as well

[9/2, 8:29 AM] PaJR PHR Moderator: Asked meta AI to do it and here's the conversation with meta AI:

[01/09, 22:25] PaJR moderator: Calculate the midparental height of a girl with father's height 166 cms & mother's height 153.5 cms.

[01/09, 22:25] Meta AI: I can help you with that!

The midparental height (MPH) is a calculation used to estimate a child's expected adult height. For girls, the formula is:

MPH = (Father's height - 13) + Mother's height / 2

Plugging in the values, we get:

MPH = (166 - 13) + 153.5 / 2

MPH = 153 + 153.5 / 2

MPH = 153 + 76.75

MPH = 159.75

So, the midparental height for the girl is approximately 159.75 cm.

Note: This is an estimate, and actual height can vary depending on various factors, including genetics, nutrition, and overall health.

[01/09, 22:27] PaJR moderator: In a 13 year old girl with the above midparental height what should be her current height at her current age of 13?

[01/09, 22:27] Meta AI: To calculate the expected height of a 13-year-old girl, we need to consider her midparental height, which is 159.75 cm in this case ¹.

Girls typically grow 3-4 cm per year during puberty, and at 13, they usually reach 95-96% of their adult height ¹.

Assuming our girl is at the 50th percentile, we can estimate her current height as follows:

159.75 cm (midparental height) x 0.95 (95% of adult height) = 151.84 cm ¹

So, at 13 years old, she can be expected to be around 151-152 cm tall.

[9/2, 10:29 AM] patient advocate : Hand X-Ray Report

[9/2, 12:04 PM] patient advocate: During 2020 when she was in Grade 3 she had meningitis. She was admitted to the hospital for 14 days.

[9/2, 12:10 PM] patient advocate: During that time her age was 9. When she was 2 years age she had an urine infection. We done a routine sonography as advised by our Doctor and there we came to know about a benign tumor located just above the adrenal gland. She had to go through a surgery in the year 2013 November.

[9/2, 12:13 PM] PaJR PHR Moderator: Please share the report of the biopsy of that supra adrenal tumor

[9/2, 12:20 PM] +patient advocate: Ok. Will be sending it by evening.

[9/2, 12:20 PM] PaJR PHR Moderator: Did you mean the knuckle dimple sign?👇

https://academic.oup.com/qjmed/article/106/1/83/1531761

[9/2, 5:01 PM] pajr member : Do you have images of the hand xray please?

[9/2, 5:02 PM] pajr member : Something like this yes, although TS is known to affect either 4th or 5th digits.

[9/2, 6:36 PM] PaJR PHR Moderator: If we are strong on TS then a karyotyping will be the easiest to get done first? @⁨PaJR Coordinator⁩ can we inquire the nearest diagnostic laboratories closest to the patient that can provide this service preferably even collecting the sample from their home?

[9/2, 6:38 PM] PaJR Coordinator: Ok sir I will enquire and arrange for it

Patient advocate: 

[9/2, 7:22 PM] PaJR PHR Moderator: Thanks all the above was very useful. Will process this and get back with further inputs

[9/2, 7:36 PM] PaJR PHR Moderator: Thanks

Please delete this one and share again after removing the patient's name from the top right hand corner

[9/2, 7:58 PM] +patient advocate: I am not able to delete from everyone. Can you please delete from the group as well. This is doctor's name, not patient. Any ways I am sending again removing the name.

[9/2, 8:02 PM] patient advocate: Hand X-Ray image

[9/2, 8:05 PM]pajr member : Reference image in TS

[9/2, 8:08 PM] patient Advocate: Is it not ok? Since we have this image only

[9/2, 8:11 PM] pajr member: Normal xray for reference.

[9/2, 8:14 PM] patient advocate: This does look convincing to me.

[9/2, 8:16 PM] PaJR PHR Moderator: So if we draw a line along the heads of the 4th and 5th metacarpals, it will intersect the head of the 3rd metacarpal in this patient's x-ray too? Yes it very much looks like she has the metacarpal sign.

https://radiopaedia.org/cases/turner-syndrome-hand-3

[9/2, 8:18 PM] PaJR PHR Moderator: Let's go ahead with the karyotyping then as the next step before we move to the cranial MRI

Let's look for associations between Turner and adrenal neuro ganglioma. @⁨pajr member⁩ can you review the literature around this and share?

[9/2, 8:40 PM] PaJR PHR Moderator: Thanks

Please share the link to the study as well

[9/2, 8:42 PM] pajr member : https://pubmed.ncbi.nlm.nih.gov/20227019/

[9/2, 8:50 PM] PaJR PHR Moderator: Two similar patients

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5177693/#:~:text=Turner%20syndrome%20(TS)%20is%20a,hormone%20from%20the%20pituitary%20gland.

[9/2, 9:11 PM] pajr member: The paper does suggest that such tumors can occur in the brain and meninges as well. Perhaps a pituitary MRI would be in order, along with the karyotyping"

[9/7, 6:49 PM] PAJR MEMBER : Good evening. Any progress on this front?

[9/7, 6:50 PM] PaJR PHR Moderator: @⁨PA1⁩ @PA2⁩ please update current plans

[9/7, 7:19 PM]PA2 : Need your suggestion to proceed further. Shall we go for MRI or any other tests?

[9/7, 7:31 PM] PaJR PHR Moderator: As discussed above by our team, she needs the following two tests after you discuss with your local doctor.

1) A karyotyping test to look for Turner's syndromes.

I looked for labs where it's done and found this link https://www.lalpathlabs.com/blog/karyotype-test/

2) A cranial MRI with special focus on the pituitary

[9/7, 7:37 PM]PA: Ok.

[9/7, 7:39 PM] PA2:  If we say Karyotyping test in a path lab, will that enough or to be more specific

[9/7, 7:52 PM] +PA: Just now I have enquired about Karyotyping test to Dr. Roy & Trivedi path lab (one of the renowned lab in Kolkata), but they are asking for Prescription to give us more information. We need to have prescription for both Karyotyping and MRI test. How to get that?

[9/7, 7:59 PM] PaJR PHR Moderator: From your local doctor

[9/7, 8:00 PM] PaJR PHR Moderator: Share our conversation with them if necessary all of which is archived here 👇

https://24fpatientblog.blogspot.com/2024/09/13f-central-obesity-with.html?m=1

[9/7, 8:42 PM]PAJR MEMBER : Please mention Karyotyping for Turner Syndrome.

[9/8, 2:08 AM] PAJR MEMBER: Like “kindness” was the theme of the Teachers’ Day presentations, “love” seems to be the theme that makes the other four Ls meaningful!

Beautifully explained…..

https://www.facebook.com/reel/471793735807481?fs=e&mibextid=z9DgKg&fs=e&s=7MtrtK

[9/14, 6:29 PM] PAJR MEMBER: Any progress made? Please update if any.

[9/19, 10:33 AM] PA: MRI report

[9/19, 10:35 AM] PaJR PHR Moderator: 👆 Were you able to get this?

[9/19, 11:17 AM] PA: No

[9/19, 11:33 AM] PaJR PHR Moderator: This is needed