Laron syndrome (LS), also known as growth hormone insensitivity or growth hormone receptor deficiency (GHRD), is an autosomal recessive disorder characterized by a lack of insulin-like growth factor 1 (IGF-1; somatomedin-C) production in response to growth hormone (GH; hGH; somatotropin). It is usually caused by inherited growth hormone receptor (GHR) mutations. The syndrome is named after the scientist Zvi Laron who first discovered the syndrome in 1966. Affected individuals classically present with short stature between −4 and −10 standard deviations below median height, obesity, craniofacial abnormalities, micropenis, low blood sugar, and low serum IGF-1 despite elevated basal serum GH. LS is a very rare condition with a total of 250 known individuals worldwide. The genetic origins of these individuals have been traced back to Mediterranean, South Asian, and Semitic ancestors, with the latter group comprising the majority of cases. Molecular genetic testing for growth hormone receptor gene mutations confirms the diagnosis of LS, but clinical evaluation may include laboratory analysis of basal GH, IGF-1 and IGFBP levels, GH stimulation testing, and/or GH trial therapy. People with LS are unresponsive to growth hormone therapy; the disease is instead treated mainly with recombinant IGF-1, Mecasermin. Evidence has suggested that people with Laron syndrome have a reduced risk of developing cancer and diabetes mellitus type II, with a significantly reduced incidence and delayed age of onset of these diseases compared to their unaffected relatives. The molecular mechanisms of increased longevity and protection from age-related disease among people with LS is an area of active investigation.
Presentation
Physical features LS is recognized as being part of a spectrum of conditions that affect the Hypothalamic–pituitary–somatotropic axis and cause significant derangements in human growth, development, and metabolism. Along this spectrum of conditions, individuals with LS and growth hormone deficiency display short stature, while individuals with acromegaly and gigantism result in the opposite phenotype of tall stature. In addition to short stature, other characteristic physical symptoms of LS include: prominent forehead, depressed nasal bridge, underdevelopment of mandible, truncal obesity, and micropenis in males. Left untreated, the average height attained by individuals with LS are approximately 4–4.5 feet (1.2–1.4 m) in women/men respectively. Additional physical features include delayed bone age, hypogonadism, blue sclera, high-pitched voice, acrohypoplasia, sparse hair growth, and crowded teeth. The breasts of females reach normal size, and in some are large in relation to body size. It has been suggested that hyperprolactinemia may contribute to the enlarged breast size. Seizures are frequently seen secondary to hypoglycemia. Some genetic variations decrease intellectual capacity. Laron syndrome patients also do not develop acne, except temporarily during treatment with IGF-1 (if performed).
Pathophysiology
Under normal circumstances in humans, growth hormone (GH) is released in a pulsatile fashion from cells known as somatotrophs in the anterior pituitary gland. These pulses of GH are regulated by cells in the hypothalamus, via the release of growth hormone-releasing hormone (GHRH) into the hypothalamohypophysial system when stimulated by insulin, ghrelin, glucagon, arginine, deep sleep, exercise, fasting, sex hormone release during puberty, and a host of other factors. GH release is inhibited by somatostatin (GHIH), IGF-1, hyperglycemia, and glucocorticoids. Once released, the GH molecules travel through the bloodstream and eventually bind to GH receptors on the surface of cells composing bodily organs and tissues. One major site of action for GH is in the liver, where it stimulates gluconeogenesis and the release of IGF-1 through the JAK-STAT signaling pathway. IGF-1 promotes growth in a variety of tissues throughout the body, especially bone mineralization, and provides negative feedback on GH release. GH results in increased muscle mass, lipolysis, and protein synthesis. Obesity and increased adipose tissue, especially visceral fat, results in reduced GH secretion. There is a natural age-related decline in the GHRH-stimulated release of GH.
Growth hormone receptor mutations Molecular genetic investigations have shown that LS is mainly associated with autosomal recessive mutations in the gene for the growth hormone receptor (GHR). These can result in defective hormone binding to the ectodomain or reduced efficiency of dimerization of the receptor after hormone occupancy. LS is generally classified as "primary" GH insensitivity, which is distinguished from "secondary" GH insensitivity. Primary (congenital/hereditary) GH insensitivity may result from growth hormone receptor defects, as in the case of Laron syndrome, but can also be caused by defective post-receptor signal transduction (STAT5B), abnormalities of the IGF-1 gene or IGF-1 receptor. Secondary (acquired) GH insensitivity results from antibodies to growth hormone or the growth hormone receptor, as well as poor nutritional status, liver disease or diabetes mellitus. A GHR mutation that results in only partial insensitivity to GH can manifest as a form of idiopathic short stature.
STAT5B A related condition involving postreceptor insensitivity to growth hormone has been associated with STAT5B.
Diagnosis LS should be suspected in children or adults with distinctive physical features listed above, extremely elevated serum hGH concentrations despite low serum IGF-1 levels. A failure of IGF-1 to increase in response to exogenous hGH (IGF-1 stimulation test) is diagnostic for LS. The gold standard for confirming a diagnosis of LS is to perform a genetic analysis with PCR to identify the precise molecular defect in the GH receptor gene. Other laboratory abnormalities include GHBP (growth hormone binding protein) levels being low in cases with mutations in the extracellular domain of the GH receptor and normal in cases with mutations in the intracellular domain. Low serum levels of IGFBP are non-diagnostic for LS.
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