Role of the thyrotropin-releasing hormone stimulation test in diagnosis of congenital central hypothyroidism in infants

CONTEXT: A shortage of thyroid hormone during prenatal life and the first years after birth results in a spectrum of neuropsychological disorders, depending on the duration and severity of the deficiency. In the case of congenital hypothyroidism of central origin (CH-C), the majority of patients have multiple pituitary hormone deficiencies (MPHD). This condition poses an additional threat to postnatal central nervous system development, primarily on account of neuroglycopenia due to ACTH/cortisol deficiency with or without additional GH deficiency. Therefore, in CH-C, rapid diagnosis is even more urgent than in congenital hypothyroidism of thyroidal origin. OBJECTIVE: In the assessment of hypothalamic-pituitary-thyroid function, we considered the pituitary response to iv administration of TRH (TRH test) pivotal. We evaluated the usefulness of the TRH test in a cohort of infants with neonatal congenital hypothyroidism screening results indicative of CH-C by analyzing the results within the framework of investigations of the anatomical and functional integrity of the hypothalamo-hypophyseal system. DESIGN AND SETTING: The study was a Dutch nationwide prospective study (1994-1996). Patients were included if neonatal congenital hypothyroidism screening results were indicative of CH-C and patients could be tested within 3 months of birth. PATIENTS: Ten male and five female infants with CH-C, detected by neonatal screening, and six infants with false-positive screening results, nonthyroidal illness, or transient hypothyroidism, were included in the study. MAIN OUTCOME MEASURES: Results of TRH tests, within the framework of extensive endocrinological examinations and cerebral magnetic resonance imaging, were measured. RESULTS: All patients with type 3 TSH responses to TRH had MPHD, and the majority (67%) of patients with type 2 responses had isolated TSH deficiency. CONCLUSIONS: The TRH test has a pivotal role in the diagnosis of TSH deficiency in young infants. Abnormal TRH test results, especially a type 3 response, urge immediate assessment of integral hypothalamic-pituitary function because the majority of patients have MPHD.     

Role of thyrotropin-releasing hormone test in re-evaluation of congenital hypothyroidism

The thyrotropin-releasing hormone (TRH) test is useful for differentiating central and primary hypothyroidism, and is also valuable for diagnosing hypothyroidism. The threshold of the TRH test is usually set at 10–40 mIU/L. However, some experts are of the opinion that the TRH test has a limited role in evaluating hypothyroidism because of the clinical application of the new-generation thyroid-stimulating hormone (TSH) assay. We reviewed a case series to analyze the clinical use of the TRH test in the re-evaluation of congenital hypothyroidism. In total, data on 228 children with eutopic thyroid glands and neonatal hyperthyrotropinemia under levothyroxine replacement were collected. Basal TSH levels were measured and the TRH test was performed at the age of 3 years for re-evaluation of congenital hypothyroidism, and statistical analysis was performed. All of the patients were followed up to avoid over- or under-treatment. At the age of 3 years, 31.6% of the patients still had hypothyroidism. There was no significant difference between basal TSH level and TRH test in the diagnosis of hypothyroidism (p = 0.23). The negative predictive value of the basal TSH level was 100%, however, the positive predictive value was only 43.6%. When the TSH level was near the upper limit of the normal range (4.5–8.5 mIU/L), the TRH test result had a better correlation with hypothyroidism than the basal TSH level (p = 0.03). The threshold of the TRH test set at 60 mIU/L had the greatest area under the curve, with a negative predictive value of 95.2% and a positive predictive value of 80.2%. Neonatal hyperthyrotropinemia was a risk factor for hypothyroidism. We suggest that the TRH test should be administered in children with a basal TSH value near the upper limit of the normal range, and the threshold of the TRH test should be set at 60 mIU/L.     

Grades of subclinical hypothyroidism in asymptomatic autoimmune thyroiditis revealed by the thyrotropin-releasing hormone test

Serum levels of T4 T3, and TSH and peak TSH after TRH administration were determined in 60 female subjects affected with asymptomatic autoimmune thyroiditis (AAT), in 27 normal subjects, and in 8 myxoedematous patients used as controls. The AAT subjects were divided into 3 groups on the basis of their basal and peak TSH values. In the first group (grade I AAT), these parameters were similar to those of the normal controls; in the second (grade II AAT), basal TSH remained normal but peak TSH was significantly increased; and in the third (grade III AAT), both parameters were significantly increased. Serum T4 levels decreased progressively from group 1 to group 3, but all T4 values were within the normal range. T3 levels were similar in all groups. Peak and basal TSH values were highly correlated, except in grade II AAT. There seems to exist a graded process of subclinical hypothyroidism in AAT; a progressive pituitary TSH reserve is modulated by a progressive decrease in T4 levels still within the normal range.     

Increase in plasma growth hormone levels following thyrotropin-releasing hormone injection in children with primary hypothyroidism.

Thyrotropin-releasing hormone (TRH) induced a significant increase in plasma growth hormone (GH) levels in 4 of 8 children with primary hypothyroidism, while a slight decrease was observed in 8 control children. Base-line plasma prolactin (PRL) levels and peak responses to TRH were higher in hypothyroid children than in controls. These data may indicate the existence of dysfunction of central nervous system mechanisms of control of GH and PRL secretion in subjects with primary hypothyroidism.     

Is thyrotropin-releasing hormone immunoreactivity in peripheral blood an estimate for hypothalamic thyrotropin-releasing hormone release?

The significance of TRH for pituitary function is still unresolved mainly due to limitations in determining in vivo hypothalamic TRH release. We therefore examined whether TRH immunoreactivity (TRH-IR) in peripheral blood is an index for hypothalamic TRH release. Peripheral TRH-IR varied between 10 and 55 pmol/l and was similar in euthyroid and hypothyroid rats, but lower in hyperthyroid rats. Destruction of the hypothalamic paraventricular area reduced peripheral TRH-IR, while stimulation of this area increased it. Clearance of TRH during continuous TRH infusion was 1.9 +/- 0.2, 3.5 +/- 0.3 and 5.9 +/- 0.8 ml/min in hypothyroid, euthyroid and hyperthyroid rats, respectively. These and previous data on TRH in hypophysial portal blood indicate that 5-25 pmol TRH/l peripheral blood is of hypothalamic origin. Chromatography revealed that TRH-IR from hypothalamus and portal blood co-eluted with TRH, but in peripheral blood two peaks were found, one of which was authentic TRH. Thus, peripheral TRH-IR alters in experimental conditions and part of it seems to be of hypothalamic origin. However, the presence of TRH-like material in peripheral blood not identical to TRH and the fact that experimental conditions alter TRH clearance indicate that peripheral TRH-IR is not an index for hypothalamic TRH release.     

Is it necessary to adjust the replacement dose of thyroid hormone to the season in patients with hypothyroidism?

Hypothalamo-pituitary-thyroid activity varies with the temperature of the environment; we therefore measured variables involved with thyroid function in summer and winter in normal controls and in patients with primary hypothyroidism. All seven patients had impalpable thyroid glands and had received a set replacement dose of thyroxine for over a year. In the patients, serum T3 and FT4 levels were slightly but significantly lower in winter, and TSH levels and delta TSH at 30 minutes in the TRH tests were significantly higher. In the controls, there were no significant differences between summer and winter in these values. These findings suggest that the dose required for replacement of thyroid hormone in patients with hypothyroidism may be higher in winter than in summer.     

Effects of hypothyroidism on hypothalamic release of thyrotropin-releasing hormone in rats.

The aim of this study was to investigate whether the severity and duration of primary hypothyroidism influence hypothalamic TRH release. Hypothyroidism was induced in male Wistar rats by treatment with different thyrostatic drugs or by thyroidectomy. Serum TSH in rats treated for up to 3 weeks with methimazole (MMI; 0.05% in drinking water) increased 20-fold, but TRH release into hypophyseal portal blood (HPB) did not change. Treatment with propylthiouracil (PTU; 0.1% in drinking water), which inhibits thyroidal T4 production and peripheral conversion of T4 to T3, resulted in a more rapid reduction in serum T3 levels and increase in serum TSH than those in rats treated with 0.1% MMI. Although these differences were no longer observed after 3 weeks of treatment, TRH release into HPB of rats treated with PTU was 34-49% higher than that in MMI-treated rats. Combined treatment with MMI (0.05-0.1% in drinking water) and iopanoic acid (IOP; 4 mg/100 g BW.day, ip), an inhibitor of both peripheral and central T4 to T3 conversion, also tended to produce a more rapid decrease in serum T3 and increase in serum TSH. After 3 weeks of treatment, serum T4, T3, and TSH were not different in the two groups, but TRH release into HPB was 48-65% increased by MMI plus IOP vs. MMI alone. Three to 10 weeks after thyroidectomy, TRH release into HPB was 58-72% higher than that in untreated controls. In vitro incubation of hypothalami isolated from rats treated for 3 weeks with MMI, MMI plus IOP, or PTU, as described above, showed that basal and 56 mM K(+)-induced TRH release were not influenced by the different drugs. Also, the total hypothalamic TRH content was not changed by any of these treatments. However, in rats treated for 1 or 2 weeks with MMI or PTU, the TRH content of the median eminence was decreased by 17-25%. These findings indicate that, depending on severity and duration, experimental hypothyroidism may cause a significant increase in hypothalamic TRH release in rats. The magnitude of these changes compared with the much larger increases in serum TSH suggests that the feedback of thyroid hormone on TSH secretion is mainly exerted at the pituitary level.     

Is gluten challenge necessary for the diagnosis of coeliac disease in young children?

Sixty-seven children under 2 years of age presenting with a classic clinical picture of coeliac disease with a severe small-intestinal mucosal lesion were investigated. All improved clinically and histologically on a gluten-free diet. During gluten challenge the mucosal damage recurred in 64 (95.5%) children, thus fulfilling the criteria for coeliac disease formulated by the European Society for Paediatric Gastroenterology and Nutrition. Three (4.5%) children had no mucosal relapse 2 years or more after return to a gluten-containing diet. These children were classified as having transient gluten intolerance. The low frequency of non-relapsers in the present study calls into question the practice of performing gluten challenge.     

Hypothalamic hypothyroidism due to isolated thyrotropin-releasing hormone (TRH) deficiency

Cold intolerance and secondary amenorrhea developed in a patient who had meningoencephalitis 4 yr prior to study. A clinical diagnosis of hypothalamic hypothyroidism was made on the basis of low serum thyroxine and triiodothyronine levels, and low plasma thyrotropin concentrations, which were responsive to thyrotropin-releasing hormone (TRH). The secretion of the remaining pituitary hormones (growth hormone, prolactin, adrenocorticotropin and gonadotropins) was intact. Not only was thyroid function normalized by oral administration of TRH, but also menses resumed after adequate replacement therapy with thyroid hormone. These results imply that hypothyroidism in this patient was due to isolated dysfunction of hypothalamic TRH release.     

Immunolocalization of the thyrotropin-releasing hormone prohormone in the rat central nervous system

The distribution of immunoreactive TRH prohormone in the rat central nervous system was studied by immunocytochemistry using an antiserum raised against a synthetic decapeptide hypothesized to represent a portion of the mammalian TRH precursor protein. Reaction product was identified in several regions of the brain in a distribution typical of that previously described for the tripeptide. In contrast to TRH, however, immunoreactive pro-TRH was largely confined to neuronal perikarya and only rarely seen in axons or axon terminals. In addition, immunoreactive pro-TRH was present in portions of the telencephalon and brainstem where TRH has not previously been described in neurons by immunocytochemistry. These studies indicate that in most regions of the brain the TRH prohormone is rapidly processed within the cell soma and not during axonal transport, and raise the possibility that in certain regions of the brain processing of the prohormone may be to non-TRH peptides, which may be of biological importance.     

Characterization of thyrotropin-releasing hormone in the central nervous system of African lungfish

Central administration of thyrotropin-releasing hormone (TRH) produces potent effects on various physiological parameters, such as arousal, respiration, and cardiovascular function, in several species. As part of an investigation into the evolution of this tripeptide as a central modulator of these parameters, we examined its distribution in the central nervous system of the African lungfish (Protopterus). Lungfish brains were dissected into three regions: telencephalon, diencephalon, and medulla. Each region was assayed for TRH by radioimmunoassay and for norepinephrine, dopamine, and serotonin by HPLC/electrochemical methods. TRH immunoreactivity (IR-TRH) was present in all regions of lungfish brain examined. The telencephalon contained the highest concentrations of TRH, the diencephalon also contained a high concentration of TRH, and the medulla contained a markedly lower concentration. Similar concentration gradients (telencephalon greater than diencephalon greater than medulla) were observed for norepinephrine, dopamine, and serotonin. The identity of IR-TRH as authentic TRH was confirmed by elution profiles on HPLC. The results of this investigation demonstrated that TRH and the monoamine neurotransmitters are present in high concentrations in various regions of lungfish brain. The lungfish may represent a promising model for further studies of the interactions of TRH with these neurotransmitter systems.     

Is thyrotropin-releasing hormone receptor involved in thyrotrope adaptation to starvation?

The aim of the present study was to delineate the involvement of TRH receptors in the thyrotrope adaptation to starvation (i.e. plasma TSH and thyroid hormone decrease, increased sensitivity to T3) by measuring [3H]TRH binding in euthyroid, hypothyroid and T3-substituted rats (175 ng/100 g body weight). Our results show that in euthyroid rats, starvation does not significantly modify either the affinity or the number of pituitary binding sites. In hypothyroid and T3-substituted rats, starvation does not alter the negative control exerted by T3 on the number of TRH binding sites. Our data indicate that the adaptation of thyrotrope to starvation does not primarily result from alterations of TRH binding sites.     

继发性甲状腺功能减退患儿垂体-甲状腺激素改变及治疗探讨

探讨继发于伞垂体功能减退的甲状腺功能减退(继发性甲减)患儿的激素改变及治疗.测定1999年9月至2006年3月以生长迟缓就诊于山东省市医院儿科的57例继发性甲减患儿垂体-靶腺激素,同时观察激素替代治疗的合适剂量.57例继发性甲减患儿FT_4均降低,初诊时19例(33.3%)TSH低于正常,38例(66.7%)TSH正常或略高,但L-T_4有效治疗后55例(96.5%)TSH低于正常.57例患儿均伴有生长激素缺乏及垂体MRI影像异常.继发性甲减常伴有全垂体功能减退和MRI异常,其治疗目标应使FT_4尽快达到并维持在正常上限.     

Lafutidine increases hepatic blood flow via potentiating the action of central thyrotropin-releasing hormone in rats

BACKGROUND: Lafutidine, (+/-)-2-(furfurylsulfinyl)-N-[4-[4-(piperidinomethyl)-2-pyridyl]oxy-(Z)-2 butenyl]acetamide, is a newly synthesized histamine H2 receptor antagonist and possesses a cytoprotective efficacy, which comprises mucin biosynthesis and stimulation of gastric blood flow mediated through capsaicin-sensitive sensory neurons and endogenous calcitonin gene-related peptide (CGRP). In the present study, an effect of lafutidine on hepatic blood flow was investigated in rats that received an intracisternal injection of a subthreshold dose of thyrotropin-releasing hormone (TRH) analog, RX 77368. METHODS: Change in hepatic blood flow was determined by laser Doppler flowmetry. Male Wistar rats were anesthetized with urethane (1.5 g/kg, i.p.), and positioned on a stereotaxic apparatus. An abdominal incision was made, and a probe of laser Doppler flowmeter was placed on the surface of the liver. After a 60-min stabilization, basal hepatic blood flow was measured for 30 min, and lafutidine (0.5, 1, 3, 5 or 10 mg/kg) or vehicle was injected into the portal vein and a subthreshold dose (1.5 ng) of RX 77368 was injected intracisternally. Hepatic blood flow was monitored for 120 min postinjection. To investigate a role of capsaicin-sensitive sensory neurons and endogenous CGRP, systemic capsaicin treatment (125 mg/kg, s.c., 10-14 days before) and intravenous infusion of a CGRP receptor antagonist, human CGRP-(8-37) (15 micro g/kg as a bolus, followed by infusion at 3 micro g/kg/h) were performed, respectively. RESULTS: Intracisternal injection of RX 77368 (1.5 ng) or intraportal lafutidine (10 mg/kg) by itself did not affect hepatic blood flow, but co-injection of intracisternal RX 77368 (1.5 ng) and intraportal lafutidine (5 mg/kg) increased it with peak response at 30 min postinjection. The effect of lafutidine on hepatic blood flow in rats given RX 77368 was dose-related over the range 1-5 mg/kg. By contrast, intracisternal injection of RX 77368 (1.5 ng) did not change hepatic blood flow in rats injected with another histamine H2 receptor antagonist, famotidine (5 mg/kg), intraportally. The stimulatory effect of co-injection of TRH analog and lafutidine was abolished by systemic capsaicin-treatment and CGRP antagonist. CONCLUSION: These data suggest that lafutidine increases hepatic blood flow by sensitizing the liver to the action of central TRH via both capsaicin-sensitive sensory neurons and endogenous CGRP in urethane-anesthetized rats.     

Reduction of thyrotropin-releasing hormone concentrations in central nervous system of African lungfish during estivation

Thyrotropin-releasing hormone (TRH) has been implicated as an important modulator of arousal state in mammals. Changes in the content of TRH in several brain regions accompany hibernation in the ground squirrel. In the present study, the involvement of TRH in the regulation of arousal was further investigated in the African lungfish, Protopterus annectens, which contain high concentrations of TRH throughout its central nervous system and enter a hibernation-like state, estivation. Lungfish were divided into three groups. Group 1 was fed normally, group 2 was starved while aquatic, and group 3 was allowed to enter into a state of estivation. After 3 months, the lungfish were sacrificed and the concentrations of TRH, norepinephrine, dopamine, and serotonin were determined in the telencephalon, diencephalon, medulla, and spinal cord. In estivation, there was a significant decline in the concentration of TRH in the diencephalon, with no alteration in other regions. Starvation had no effect on regional TRH concentrations. The concentration of norepinephrine, dopamine, and serotonin did not change in estivation; however, a significant elevation of norepinephrine in the diencephalon and dopamine in the telencephalon was observed in starvation. Starvation and estivation were associated with significant declines in the protein content of the diencephalon and medulla. The estivation-linked decline in TRH in the diencephalon of the lungfish is similar to the decrease in TRH content in the hypothalamus in hibernating ground squirrels. These findings lend further support to the importance of TRH in the regulation of arousal state.