Profile of pubertal stage status in thalassemia children in Dr.

Soetomo Hospital

Muhammad Faizi1, Nur Rochmah2 , Maria Natalia Nababan3

Mia Ratwita Andarsini4
Pediatric Endocrinology Division, Department of Child Health 123
Pediatric Hemato-Oncology Division, Department of Child Health4,
Faculty of Medicine Airlangga University/Dr. Soetomo Hospital
Surabaya - Indonesia

Abstract
Background: Iron overload in thalassemia children caused due to multiple transfusion and
suboptimal chelating agents. The anterior pituitary is particularly sensitive to iron overload
which disrupts hormonal secretion, leading to gonadal dysfunction. The data about serum
ferritin, luteinizing hormone (LH), duration of illness, age of pubertal stage in thalassemia is still
controversy

Objective: To study the profile of pubertal stage in thalasemia children

Methods: Cross sectional study was done on May – September 2017, forty seven children were
enrolled in this study which females aged 8-18 years and male aged 9-18 years old. We
examined the pubertal stage according to Marshall and Tanner stage classification. We
conducted the profile of children based on age of pubertal stage, duration of illness, serum
ferritin, and luteinizing hormon serum.

Results: Median of the highest serum feritin was 3154.9 (519-6647.5) ug/L. Short stature was
found in 29 of 48 patients, 37 patients had moderate malnutrition. Twenty-six patients had
attained puberty, 2 of them still had low luteinizing hormone level. Median luteinizing hormone
was 0.3 (0.00-11.06) IU/L. None of the patient who had low LH level attained puberty clinically.

Conclusion:

Keywords : Serum ferritin, luteinizing hormone, beta thalassemia, tanner stage

INTRODUCTION

Hypogonadism is the most common endocrine complication in thalassemia. The

accumulation of iron in the anterior pituitary gonadotropic cells becomes the cause of secondary
hypogonadism and the accumulation of iron in the gonads will result in primary hypogonadism
that often coincides (Cunningham et al., 2004; Najafipour, 2008; Skordis, 2011). Iron overload is
represented by serum ferritin levels with hemosiderosis in the endocrine glands that affects
hypogonadism and delayed puberty in thalassemia patients. . Iron deposition on gonadotroph
cells of the pituitary leads to disruption of gonadotrophin production, proven by the poor
response of follicle-stimulating hormone and luteinizing hormone to gonadotropin-releasing
hormone (GnRH) stimulation. The damage to the hypothalamus and pituitary is progressive,
even if intensive chelating therapy is given and the hypogonadism in both sexes is often
unavoidable. Therefore, delayed sexual maturity and fertility disorder may occur and have an
impact on the quality of life of thalassemia patient who received recurrent transfusions.
According to the International Network on Endocrine Complication in Thalassemia (I-
CET), hypogonadism occurred in 35-50 percent thalassemia patients (De Sanctis et al., 2013). In
Jakarta, among 67 beta thalassemia children enrolled in the study, found that 14 children had
delayed puberty and 65 children had received iron-chelation therapy (Soesanti et al., 2012). In
Dr. Soetomo hospital, delayed puberty was found in 4 patients of 16 thalassemia patients who
underwent repeated transfusions and received iron chelation therapy (Kamaya et al., 2014).
However, research on the status of puberty and hormonal in transfusion dependent thalassemia
had never been done in Dr. Soetomo hospital so this research is needed to be used as
consideration in the management of thalassemia in order to improve the quality of life of
patients.

SUBJECTS AND METHODS

This was a cross-sectional study conducted during the period of May until September
2017. The samples were 48 thalassemia patients age 8 – 18 years old in hemato-oncology
outpatient clinic Dr. Soetomo Hospital, Surabaya, Indonesia. This study was approved by the
Research Ethics Committee, Dr. Soetomo Hospital..
Inclusion criteria was patient with serum ferritin level above 1000 µg/L (as a moderate
excessive of serum ferritin) (Kohgo et al., 2008). Serum feritin was examined by using the Cobas
machine with the Electrochemilluminescence Immunoassay (ECLIA). The stage of puberty was
examined by Marshall and Tanner stage (1999) and grouped as three groups, normal puberty was
identified by having the secondary sex features at 8 – 14 years in females, and 9 – 13 years in
males. Precocs puberty was happened by having the secondary sex features at under 8 years in
females, and under 9 years in males. Delayed puberty was identified by the absence of menarche
or telarche in age of above 13 years in females, and the diameter of testis was under 4 cm in age
of 14 years in males. Peco The luteinizing hormone serum was measured by using the ADVIA
Centaur immunoassay machine with imunoassay with direct chemiluminmetric technology,
which value of more than 0.83 IU/L as high LH (Houk CP, 2009).
Diagnosis of thalasemia based on clinical appearance like a pale-look, hepatomegaly,
splenomegaly, failure to thrive, icterus and deformity of long bones and craniofacial, and also
laboratory features such as hyphochromic microcytic anemia, and hemoglobin electrophoresis
that HbF was more than 5%, there was no HbA or decreasing in HbA in 10 – 30%. (Viprakasit
V, 2014; Origa R, 2014).
All of variables were analyzed by using SPSS with …..

RESULTS
There were 56 subjects, 9 subjects were excluded because of Tunner syndrome, severe
malnutrition and delayed puberty so that conditions were not yet possible impacted on hormonal
disturbances. Twenty two patients had already puberty and 25 patients were still in prepuberty
stage. Prepuberty patients were controlled to pediatric endocrinology clinic to further evaluation.

Baseline Characteristics
The baseline characteristics were differentiated by sex, age, nutritional status, stature,
history of familial puberty, type and duration of chelating agents, anthropometry status, and
tanner stage. The baseline characteristics are shown in table 1.
Table 1. Baseline characteristics
Variable n
Sex (n ; %)
Male 22 ; 45,8
Female 26 ; 54,2

Age (mean ; SD) month 147,1 ; 34,2

Nutritional status (%)

Normal (n,%) 11 ; 22,9
Moderate malnutrition (n,%) 37 ; 77,1

BB (mean ; SD) month 31,45 ; 9,9

TB (mean ; SD) cm 136,1 ; 13,9
LLA (mean, SD) cm 19,5 ; 2,6

Stature
Short Stature (n ; %) 29 ; 60,4
Normal (n ; %) 19 ; 39,6

Duration of chelating agent (mean ; SD) 75,8 ; 45

Testis
G1 (n ; %) 8 ; 16,7
G2 (n ; %) 6 ; 12,5
G3 (n ; %) 3 ; 6,3
G4 (n ; %) 1 ; 2,1
G5 (n ; %) 4 ; 8,3

Breast
B1 (n ; %) 17 ; 37,5
B2 (n ; %) 5 ; 10,4
B3 (n ; %) 3 ; 6,3

Chelating agent
Deferiprone (n ; %) 34 ; 70.8
Deferoxamine (n ; %) 1 ; 2.1
Defeasirox (n ; %) 13 ; 27.1

Duration of illness
Tabel 2. Serum ferritin dan luteinizing hormon in thalasemia patients
Median (minimum -
Tanner
N maximum)
Stage
Serum Ferritin
Gonad
1559.2
G1 8
(1115.9 – 5382.0)
3122.7
G2 6
(519 – 6647.5)
3412.3
G3 3
(1644.5– 4449.3)
G4 1 3108.7
3056.4
G5 4
(1242.4 – 6493.8)
Breast
2658
B1 17
(628.0 – 6472.1)
3555.3
B2 5
(1607.1 – 6646.1)
1838.7
B3 3
(1204.2 – 3094.9)
Median (mininum -
Tanner maximum)
N
Stage
LH serum
Gonad
G1 8 0.07 (0.07 – 0.3)
G2 6 1.3 (0.76 - 11.1)
G3 3 9.2 (3.8 - 9.5)
G4 1
4.5
G5 4 2.6 (1.97 – 5.1)
Breast
B1 17 0.07 (0 .0 – 0.65)
B2 5 2.8 (0.31 – 4.4)
B3 3 4.0 (1.8 – 9.2)
 In normal male children, pubertal stage G2, G3, G4 and G5 was achieved at 11.64, 12.85,
13.77 and 14.92 years old, respectively (Marshall and Tanner, 1970). In this study, G2, G3, G3,
G4 and G5 pubertal stage was achieved at 13.11, 15.56, 17.08 and 16.13 years old, respectively.
We concluded that pubertal periode was late in thalassemic patients at each stage.

Table 8 Age of pubertal stage in normal and beta thalassemic male patient
Pubertal stage Mean age Pubertal age Mean age
(year ± SD) (year ± SD)
G2 11,64 (1,07) G2 13,11 (1,15)
G3 12,85 (1,04) G3 15,56 (2,50)
G4 13,77 (1,02) G4 17,08
G5 14,92 (1,1) G5 16,13 (0,79)

In female normal children, B2, B3, B4 and B5 pubertal stage was achieved in 11.15,
12.15, 13.11 and 15.33 years old, respectively (Marshall and Tanner, 1969). In our study, B2 and
B3 pubertal stage was achieved at 13.25 and 16.68 years old, respectively.

Table 9. Age of pubertal stage in normal and beta thalassemic female patient
Pubertal Stage Mean age Pubertal Stage Mean Age
(Year ± SD) (Year ± SD)
B2 11,15 (1,10) B2 13,25 (1,39)
B3 12,15 (1,09) B3 16,58 (1,97)
B4 13,11 (1,15) B4 -
B5 15,33 (1,74) B5 -
DISCUSSION
Chronic anemia in thalasemic patients would also decrease the nutritional status that can
be one of the factors that cause delayed puberty (Batubara JRL, 2004). Luteinizing hormone
(LH) examination is as parameter to evaluate pubertal distubances in the central stage.
Researchers conducted this study because there has been no regular examination of puberty
disorder as one of the complications of endocrinopathy in beta thalassemic children in Dr.
Soetomo Surabaya, and there has been no agreement on when to begin screening for hormonal
screening examination in beta thalassemic children.
In this study, median serum ferritin was 3154.9 (519-6647.9) ug/L in pubertal group and
median serum ferritin was 2126.4 (62806472) ug/L in prepubertal group. Serum ferritin (SF)
generally correlates with body iron stores, and is relatively easy and inexpensive to determine
repeatedly. Serum ferritin is most useful in identifying trends (Mazza et al., 1998; Prabhu et al.,
2009). However, an increasing SF trend implies an increasing iron burden but may also be due to
inflammation or tissue damage (Vinchinsky, 2007). Pituitary biopsy is only done in autopsy.
Argyropoupou et al found that The T2 relaxation rate could be used as an index of pituitary iron
overload. A positive correlation was found between the 1/T2 and the serum ferritin level (r =
0.73, p < 0.001). The 1/T2 was higher in patients (mean, 0.020 m/sec; SD, 0.006) compared with
that of controls (mean,0.011m/sec;SD,0.001;p<0.001). In this study all the subject got chelator
agents. Negative net iron balance was observed in more patients receiving combination therapy
than in patients receiving monotherapy. Monotherapy chelator agents is able to maintain the
balance of iron, but it can not reduce the iron that have been accumulated over a long time.
Tranfussion dependent thalassemic patient require regular transfussion, a negative balance of
body iron is difficult to achieve (Beshlawy et al., 2008).
In normal male children, pubertal stage G2, G3, G4 and G5 was achieved at 11.64, 12.85,
13.77 and 14.92 years old, respectively (Marshall and Tanner, 1970). In this study, G2, G3, G3,
G4 and G5 pubertal stage was achieved at 13.11, 15.56, 17.08 and 16.13 years old, respectively.
We concluded that pubertal periode was late in thalassemic patients at each stage.

Table 8 Age of pubertal stage in normal and beta thalassemic male patient
Pubertal stage Mean age Pubertal age Mean age
(year ± SD) (year ± SD)
G2 11,64 (1,07) G2 13,11 (1,15)
G3 12,85 (1,04) G3 15,56 (2,50)
G4 13,77 (1,02) G4 17,08
G5 14,92 (1,1) G5 16,13 (0,79)

In female normal children, B2, B3, B4 and B5 pubertal stage was achieved in 11.15,
12.15, 13.11 and 15.33 years old, respectively (Marshall and Tanner, 1969). In our study, B2 and
B3 pubertal stage was achieved at 13.25 and 16.68 years old, respectively.

Table 9. Age of pubertal stage in normal and beta thalassemic female patient
Pubertal Stage Mean age Pubertal Stage Mean Age
(Year ± SD) (Year ± SD)
B2 11,15 (1,10) B2 13,25 (1,39)
B3 12,15 (1,09) B3 16,58 (1,97)
B4 13,11 (1,15) B4 -
B5 15,33 (1,74) B5 -

In our study, 2 patients had prepubertal LH level but both of the patients already have
attained puberty clinically. First patient was male, 12 years old, normal nutritional status and LH
serum was 0.76 IU/L. Testicular volume were 6 ml (left) and 6 ml (right). Second patient was
female, 11.5 years old with LH level was 0.31 IU/L. Tanner’s Sex Maturity Rating (SMR) was
B2 simetrically. LH examination was done at daytime. According to litherature, At the
beginning of puberty, a unique diurnal variation of pubertal hormones occurs, with little LH
secretion during the day and a significant increase in pulsatile secretion during sleep. In response
to nocturnal LH secretion, the pattern of gonadal sex steroid secretion differs between the sexes:
ovarian secretion of estradiol peaks in mid-day and testicular secretion of testosterone peaks
promptly during sleep. In addition, girls’ pubertal hormone secretion is subclinically cyclic from
early puberty. As puberty progresses, LH secretion persists further into the daytime. After
menarche, this diurnal variation no longer exists. Adult sex steroid concentrations, however,
have a mild diurnal variation, being highest on awakening (Rosenfield et al., 2011). Wennink et
al found that the LH consentration were 0.5 IU/L in G2 stage and 0.64 IU/L in G3 stage at
daytime. The night time LH level was higher than daytime level. LH level was 2.38 IU/L in G2
stage and 3.48 IU/L in G3 stage. The peak LH consentration was at 02.00 at midnight.
In conclusion, beta thalassemic patient attain late onset of pubertal development
eventhough it is still in range of normal age. There was correlation between LH level and
pubertal stage. Serum ferritin had a correlation with LH level. We suggested that transfusion
dependent beta thalassemic patient should have routine chelator agents. Pubertal stage evaluation
should be done periodically to assess patient’s compliance of iron chelation.