Treatment with Growth Hormone (GH)

16 Pages·2017·2.27 MB·English

International Journal o f
Molecular Sciences
CaseReport
Treatment with Growth Hormone (GH) Increased the
Metabolic Activity of the Brain in an Elder Patient,
Not GH-Deficient, Who Suffered Mild Cognitive
Alterations and Had an ApoE 4/3 Genotype
JesúsDevesa1,* ID,IriaNúñez2,CarlosAgra3,AlejandroBejarano2andPabloDevesa4
1 ScientificDirection,MedicalCenterFoltra,TravesíadeMontouto24,15886Teo,Spain
2 NuclearMedicine,HospitalHMModelo,VirreyOsorio30,15011Coruña,Spain;
[email protected](I.N.);[email protected](A.B.)
3 Neuropsychology,MedicalCenterFoltra,TravesíadeMontouto24,15886Teo,Spain;
[email protected]
4 ResearchandDevelopment,MedicalCenterFoltra,TravesíadeMontouto24,15886Teo,Spain;
[email protected]
* Correspondence:[email protected];Tel.:[phone]
(cid:1)(cid:2)(cid:3)(cid:1)(cid:4)(cid:5)(cid:6)(cid:7)(cid:8)(cid:1)
(cid:1)(cid:2)(cid:3)(cid:4)(cid:5)(cid:6)(cid:7)
Received:4June2018;Accepted:31July2018;Published:5August2018
Abstract: (1) Background: We analyzed, using PET-SCAN and cognitive tests, how growth
hormone (GH) could act in the brain of an older woman, not deficient in GH, who showed
mild cognitive alterations (MCI) and had a genotype of ApoE 4/3 and familial dyslipidemia.
(2) Methods: After performing a first psychometric study (TAVEC verbal learning test), the
metabolicactivityofbrainstructuresrelatedtoknowledge,memory,andbehaviorwasanalyzed
using 18-F fluorodeoxyglucose PET-SCAN. The patient was then treated with GH (0.4 mg/day,
subcutaneous) for three weeks and on the last day under this treatment, a new PET-SCAN was
performed. One month after beginning treatment with GH, a new TAVEC test was performed.
(3)Results: GHadministrationnormalizedthecognitivedeficitsobservedinthefirstpsychometric
testandsignificantly(p<0.025)increasedthemetabolicactivityinpracticallyallbraincorticalareas,
specificallyinthelefthippocampusandleftamygdala,althoughnotintheleftparahippocampus.
(4)Conclusions: ThisstudydemonstratesforthefirsttimethepositiveeffectsofGHoncerebral
metabolisminapatientwithoutGHdeficiency,recoveringthefunctionofaffectedareasrelatedto
knowledge,memory,andbehaviorinanelderlypatientwithMCI.
Keywords: Growth hormone; cognition; recent memory; PET-SCAN; hippocampus; amygdala;
parahippocampus;ApoEgenotype
1. Introduction
In1993,itwasdiscoveredthatthegrowthhormone(GH)receptorgenewasexpressedinmany
differentareasofthecentralnervoussystem(CNS)ofratsandrabbits[1],afindingconfirmedthree
yearslaterwhenitwasdescribedthatnotonlytheGHreceptor(GHR),butalsothehormoneitself
waspresentintheCNS[2]. ThesefindingsledtotheassumptionthatGHshouldperformimportant
functionsatthecentrallevel,beyondtheclassicalconceptthatGHisonlyapituitaryhormonewhose
actionstakeplaceatthemetaboliclevelandonthelongitudinalgrowthoftheorganismbeforepuberty
isfinished. Infact, thecurrentconceptisthatGHisapleiotropichormone, whichisexpressedin
virtuallyalltissuesandorgansinwhich,inadditiontoendocrineeffects,itexertsanumberofauto-
andparacrineactions[3,4].
Int.J.Mol.Sci.2018,19,2294;doi:10.3390/ijms19082294 www.mdpi.com/journal/ijms
Int.J.Mol.Sci.2018,19,2294 2of16
GHplaysakeyroleintheorganizationofthebrainduringthedevelopmentoftheCNS[5–7],
andalsoinitsnormalfunctioningafterbirth,bothinanimalsandhumans. Ithasbeenfoundthat
thehormoneisproducedinthepostnatalhippocampusinrats[8,9],probablytoinduceproliferation
andsurvivalofneuronalprecursorsatthislevel,asoccursaftertheadministrationofGHinnormal
adultrats[10];thisalsooccurs,inrats,whenthehormoneisgivenafterabraininjuryproducedbythe
administrationofkainicacidadministration,perhapscooperatingwiththeendogenouslyexpressed
GH,asitsreceptor,inprogenitorcellsofthehippocampus[11]. Inaddition,memorytasksinduce
the synthesis of GH in the hippocampus of mice, which leads to the appearance of newly formed
neurons[12].AllthissuggeststhatGHplaysanimportantroleinthehippocampus,astructuredirectly
relatedtotheacquisitionofrecentmemory. ItiswellknownthathumanadultswithGHdeficiency
(GHD) show clear psychological improvements when treated with the hormone [2], particularly
in aspects related to memory and cognition [13]. On the contrary, adults with GHD who do not
receivereplacementtherapyusuallyshowsignificantpsychologicalalterations,suchaslackofenergy,
impairedmemory, andcognitivealterations[14,15]. TheseeffectsofGHoncognitivefunctionsin
humanshavebeenwidelyreviewedrecently[4,16]. However,itisnotknowniftheyoccurasadirect
actionofthehormoneatthecentrallevel,oriftheydependonahigherproductionofhepaticIGF-I
inducedbyGH(ordirectlyinducedbythehormoneintheCNS),orifthoseactionsareaconsequence
oftheeffectsofbothhormones[4,17,18].Infact,ithasbeenshownthatGHinducesthelocalexpression
ofIGF-Iinthehumanfetalcortex[19],althoughthishasnotyetbeendemonstratedinthehumanadult
brain. ThepituitarysecretionofGHreachesveryhighlevelsatpuberty,butonceitends,agradual
decreaseinthesecretionofthehormonebegins,startingfrom18to30years,untiltheplasmalevelsof
GHarevirtuallyundetectableaswegetolder[4,17]. Therefore,itseemslogicalthatagingisassociated
withacognitivedeterioration,produced,amongotherfactors,byadeficitoftheGH/IGF-Iaxis[17,18].
Inthisstudy,wewilldescribetheeffectsofshort-termGHtreatment(0.4mg/day,3weeks)on
thecognitivedeficitsofanelderlywoman. GiventhatshehadafamilyhistoryofAlzheimer’sdisease,
inadditiontoacognitivetest(TAVECverballearningtest),wevisualizedthroughPET-SCANthe
metabolicactivityofherbrain,beforeandaftertheadministrationofGH.Thedataobtainedinthis
studyindicatethatinitiallytherewasacleardecreaseinthemetabolicactivityofthelefthippocampus,
leftamygdala,andleftparahippocampus,butthesehypometabolismsimprovedsignificantly,withthe
exception of the left parahippocampus, after treatment with GH. In addition, a clear increase in
metabolicactivitywasobservedinvirtuallyallcerebralcorticalareas. Thesebrainmetabolicchanges
were accompanied by positive changes in a new cognitive TAVEC test, and also reported by the
patientherself.
2. Results
2.1. CognitiveTest: TAVECTest
Mostofthevaluesrecordedasdeficientinthefirsttestchangedtoameanvalueforanormal
population during the second test performed. This indicates a positive learning curve, as well as
increased attention. Likewise, the discrimination index also indicated learning on the part of the
patient,becauseinthesecondtestshewasalreadyabletostoretheinformationinadiscriminatory
way. Also,duringthesecondtestperformed,therewasnolossofinformation(fading)overtime.
ThesedataindicatethatthetreatmentwithGHinducedanimprovementinlearning,attention,
andmemory,althoughduetotheshorttimeelapsedbetweenthetwotests,nostatisticalanalysisof
theresultsobtainedwasperformed.
ThescoresofthistestareshowninTable1.
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Table1. ResultsobtainedintheTAVECtestperformedinbasalconditions(Pre)and1monthlater
(sevendaysafterfinishingthetreatmentwithGH).Thevaluesinthefirstandsecondtestscorrespond
toZ-scores(theaveragevalueforanormalpopulationis0).Thescoresinthefirsttestwere,ingeneral,
lower(highlightedinbluecolor)thantheaverageofthenormalsubjects,indicatingamildcognitive
deficit. However,thesecondtestindicatesthatmostoftheresultsobtainedarenowintheaverage
rangefornormalsubjectsorevenhigherthantheaverage.
ASSAY ASSAY Pre 1Month
1.RI-A1 Immediaterecallofthefirstlearningassay −1 0
2.RI-A5 Immediaterecallofthefifthlearningassay −2 0
3.RI-AT Totalwordsrememberedinthewholeofthe5assays −2 0
4.RI-B Immediaterecallofthelistofinterference −1 1
Percentageofwordsintheregionofprimacy,overthetotalnumberofwords
5.RG-Pr −2 0
rememberedinthetotalofthe5tests
Percentageofwordsfromthemiddleregion,aboutthetotalnumberofwords
6.Rg-Rc 0 0
rememberedinthe5essays
Percentageofwordsfromtheregionofrecency,onthetotalnumberofwords
7.Rg-Rc −1 0
rememberedinthe5assays
8.RL-CP Short-termfreememory −1 1
9.RC-CP Long-termfreememory −1 0
10.RL-LP Memorywithshort-termkeys −1 0
11.RC-LP Memorywithlong-termkeys −2 0
12.Esem-RI-A UseoftheserialstrategyintheimmediaterecalloflistA −1 −1
13.Esem-RI-S UseoftheserialstrategyintheimmediaterecalloflistB −1 −1
14.Esem-RL-CP Useofserialstrategyinshort-termfreerecall −1 0
15.Esem-RL-LP Useofserialstrategyinlong-termfreerecall −1 −1
16.Eser-RI-A UseofthesemanticstrategyintheimmediaterecalloflistA −1 −1
17.Eser-RI-B UseofthesemanticstrategyintheimmediaterecalloflistB −1 0
18.Eser-RL-CP Useofthesemanticstrategyinshort-termfreerecall 0 0
19.Eser-RL-LP Useofthesemanticstrategyinlong-termfreerecall 1 0
20.P Totalnumberofperseverations 1 1
21.I-RL Numberofintrusionsinthewholeoffreerecalltests 0 1
22.I-RL Numberofintrusionsinthewholeofmemorytestswithkeys −1 0
23.Recon-Ac Numberofsuccessintherecognitiontest −2 1
24.FP Numberoffalsepositivesintherecognitiontest 1 0
25.Discriminability Discriminationindex −2 0
26.Bias Responsebiasindex 0 0
ComparisonbetweenthememoryoflistBandthememoryofthefirstlearning
27.RI-SversusR1-A1 0 1
testinlistA
Comparisonbetweenshort-termfreerecallandtheimmediaterecallofthefifth
28.RL-CPversusRI-A5 −1 0
learningtestinlistA
Comparisonbetweenrememberingwithshort-termkeysandremembering
29.RC-CPversusRO-LP 1 0
withlong-termkeys
30.RL-LPversusRL-CP Comparisonbetweenlong-termfreememoryandshort-termfreememory 1 0
31.RC-LPversusRL-LP Comparisonbetweenmemorywithlong-termkeysandlong-termfreerecall 0 1
32.Recon-AcversusRL-Lp Comparisonbetweenrecognitionandlong-termfreerecall −1 0
33.Recon-AcversusRcl-LP Comparisonbetweenrecognitionandrecallwithlong-termkeys −1 0
2.2. PET-SCANStudies
TreatmentwithGHledtoanoverallqualitativeandquantitativeincreaseinthemetabolicactivity
observedinmostcorticalbrainregionsinbothhemispheres.
WhenevaluatedusingthesoftwaredescribedinMethods,thefirstPET-SCANshowedsignificant
hypometabolism(Table2)inthefollowingregionsofinterest(ROI):thelefthippocampus(Z-score=
−2.79)andtheleftamygdala(Z-score=−2.23),theleftparahippocampus(Z-score=−2.12),theleft
cuneus(Z-score=−2.06),andthesubgenualareaoftheanteriorcingulatecortex(Z-score=−2.17)of
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therighthemisphere. Thesedeficits,exceptfortheleftcuneus,were1.5standarddeviations(SD)lower
thanthemeanvalueregisteredinthedatabaseofthenormalpopulation,andclearlyasymmetricwith
Int. J. Mol. Sci. 2018, 19, x FOR PEER REVIEW 4 of 15
respecttothemetabolicactivitydetectedintheotherhemisphere. Thesefindingswerecorroborated
by th(eSDst) altoiwsteicr atlhapna rtahme meteraicn mvaalupep irneggis(tSePreMd )ina nthael ydsaitsab(saesee oMf eththe ondosr)m,awl hpoicphulcaotinofin,r manedd cltehaartlyt hese
hypoamsyemtamboeltirsicm wsiwthe rreespsteactti tsoti cthaell ymseitgabnoifilicc aancttiv(pity< d0e.0te2c5t)e.d in the other hemisphere. These findings
were corroborated by the statistical parametric mapping (SPM) analysis (see Methods), which
Tcaobnlfeir2m.eQdu tahnatti ttahteivsee hanyaploymsisetoafbtohleismmest wabeorleis smta(tNisteiucarollcyl osuigdnPifEicTa)nitn (pth <e 0re.0g2i5o)n. sofinterestexpressed
asapercentageofdeviationwithrespecttothenormalpopulationofthedatabase,inthefirstand
seconTdabPlEe T2-.S CQAuaNntiptaetrivfoer maneadly.siTs hoef vthaelu mesethaibgohlilsimgh (tNedeuirnocbloluued iPnEdTic) aitne athset arnegdiaonrds dofe viniatetiroesnt <1.5
witherxepspreescstedto ast hae pmereceanntaogfe tohfe dnevoiramtioanl pwoitphu rleastpioecnt .toL t:hLee nfotrsmidael ;pRop:uRliagtihotn soifd teh;eA dsaytamba:sAe, siynm thme etry;
first and second PET-SCAN performed. The values highlighted in blue indicate a standard deviation
Hypom:Hypometabolism;Bilat:Bilateral;AC/SGA:Subgenualareaoftheanteriorcingulatecortex.p:
<1.5 with respect to the mean of the normal population. L: Left side; R: Right side; Asym: Asymmetry;
Statisticalsignificanceofeachhypometabolismwithrespecttothenormalpopulation.
Hypom: Hypometabolism; Bilat: Bilateral; AC/SGA: Subgenual area of the anterior cingulate cortex.
p: Statistical significance of each hypometabolism with respect to the normal population.
FirstPET-SCAN SecondPET-SCAN
ROI p<
L RFirst PAEsTy-mSCANH ypom L SecondR PET-SCAsAyNm Hypom
ROI p <
L R Asym Hypom L R Asym Hypom
Hippocampus −12.49 −6.55 −5.94 Left 0.025 −6.49 −2.84 −3.65
AmyHgidpaplaocampu−s 13.38−12.4−97 .20−6.55 −6.1−85.94 LefLteft 0.00.20525 −−69.4.497 −2−.814. 52−3.65− 7.96
ParahippoAcammypgudsala −11.93−13.3−87 .24−7.20 −4.6−96.18 LefLteft 0.00.20525 −−91.04.78 6 −1−.582. 19−7.96− 2.67 Bilat
CPuarnaehuisppocamp−u5s. 42−11.934 .06−7.24 −9.4−84.69 LefLteft 0.00.20525 −−100..8960 −8.169.4 1 −2.67− 7.31Bilat Left
AC/SGCAuneus −2.43 −5.4−2 11.164.06 8.7−39.48 RigLhteft 0.00.20525 −03..0980 6.401. 91 −7.31− 2.17Left
AC/SGA −2.43 −11.16 8.73 Right 0.025 3.08 0.91 −2.17
ThesehypometabolismswerenormalizedaftertreatmentwithGH,asindicatedinTable2,with
These hypometabolisms were normalized after treatment with GH, as indicated in Table 2, with
thesoleexceptionoftheparahippocampus,whichintheanalysisbasedonROIstillshowedadecrease
the sole exception of the parahippocampus, which in the analysis based on ROI still showed a
intheacquisitionoffluorodeoxyglucose(FDG)(Z-score=−2.04).
decrease in the acquisition of fluorodeoxyglucose (FDG) (Z-score = −2.04).
Thequalitativechangesinthemetabolismobservedintheseregionsareshowninthefollowing
The qualitative changes in the metabolism observed in these regions are shown in the following
Figures1–3:
Figures 1–3:

Figure 1. Cross section of the brain showing the metabolic activity in the left amygdala and left
Figure 1. Cross section of the brain showing the metabolic activity in the left amygdala and left
hippocampus (1a) and the left parahippocampus (1b), in the first (1) and the second (2) PET-SCAN
hippocampus(1a)andtheleftparahippocampus(1b), inthefirst(1)andthesecond(2)PET-SCAN
studies. Note that the low metabolic activity in the structures observed in the first PET-SCAN was
studies. Note that the low metabolic activity in the structures observed in the first PET-SCAN was
normalized in the left amygdala and the left hippocampus (p < 0.025) after treatment with GH (2a),
normbaulitz ietd wians tnhoet lsetfattaismticyaglldya sliagnanifdicathnte ilne ftthhe ilpefpto pcaarmahpipupso(cpa<m0p.u0s2 5(2)ba)f.t eAr: tArenattemrioern. tRw: RitihghGt.H L:( 2Lae)f,t.b utit
wasnPo:t Psotasttiesrtiiocra.l lysignificantintheleftparahippocampus(2b).A:Anterior.R:Right.L:Left.P:Posterior.
Int.J.Mol.Sci.2018,19,2294 5of16
Int. J. Mol. Sci. 2018, 19, x FOR PEER REVIEW 5 of 15
Int. J. Mol. Sci. 2018, 19, x FOR PEER REVIEW 5 of 15

Figure 2. Cross section of the brain showing, in two consecutive sections, the metabolic activity in the
Figure2.Crosssectionofthebrainshowing,intwoconsecutivesections,themetabolicactivityinthe
left cuneus in the first (1) and the second (2) PET-SCAN studies. Note that the low metabolic activity
Figure 2. Cross section of the brain showing, in two consecutive sections, the metabolic activity in the
leftcuobnseeurvseidn itnh ethfie rlsetft( c1u)naenuds tinh ethsee fciorsntd PE(2T)-SPCEATN-S C(1Aa,N1b)s twuadsi enso.rmNaoltiezetdh a(pt <th 0e.0l2o5w) amfteert atrbeoatlmiceanctt ivity
left cuneus in the first (1) and the second (2) PET-SCAN studies. Note that the low metabolic activity
obserwvietdh GinHt h(2ea,l2ebft).c Au:n Aenutseriniort.h Re: fiRrigsthPt. ELT: L-SeCft.A PN: P(o1sate,1ribo)r.w asnormalized(p<0.025)aftertreatment
observed in the left cuneus in the first PET-SCAN (1a,1b) was normalized (p < 0.025) after treatment
withGH(2a,2b).A:Anterior.R:Right.L:Left.P:Posterior.
with GH (2a,2b). A: Anterior. R: Right. L: Left. P: Posterior.

Figure 3. Cross section of the brain showing the metabolic activity in the subgenual area of the anterior
cingulate cortex (A C/SGA) in the first (1) and the second (2) PET-SCAN studies. Note that the low
Figure 3. Cross section of the brain showing the metabolic activity in the subgenual area of the anterior
Figurmee3t.abCorloics sascteicvtiitoyn oobfsetrhveebdr ainin As hCo/wSGinAg itnh ethme eftirasbt oPliEcTa-cStCivAiNty winatsh neosrumbagleizneuda (lpa r<e a0.0o2f5t)h eafatenrt erior
cingulate cortex (A C/SGA) in the first (1) and the second (2) PET-SCAN studies. Note that the low
cingutrlaeatetmceonrtt ewxit(hA GCH/. SAG: AAn)tienritohr.e Rfi: rRsitg(h1t.) La:n Ldeftth. Pe:s Peocsotnerdio(r2. )PET-SCANstudies.Notethatthelow
metabolic activity observed in A C/SGA in the first PET-SCAN was normalized (p < 0.025) after
m etabolic activity observed in A C/SGA in the first PET-SCAN was normalized (p < 0.025) after
treatment with GH. A: Anterior. R: Right. L: Left. P: Posterior.
treatmentwithGH.A:Anterior.R:Right.L:Left.P:Posterior.
Int.J.Mol.Sci.2018,19,2294 6of16
2.3. BloodAnalysis
Thebloodtestpriortothetreatmentshowedthatthepatienthaddyslipidemia(totalcholesterol
plasma values: 275 mg/dL (normal: 110–200 mg/dL), plasma triglycerides: 195 mg/dL
(normal:50–150mg/dL).Theerythrocytes(4.95 × 106/µL)andhemoglobin(Hb)(14.2g/dL)and
leukocytes were in normal values, as were the values of plasma glucose (94.8 mg/dL), proteins
(totalproteins: 7.1g/dL;albumin: 4.3g/dL),livertransaminases,urea,creatinine,andtumormarkers
(CA-125,CA15-3,CA19-9,alpha-fetoprotein,andCEA).Plasmathyroidstimulatinghormone(TSH)
was normal (2.18 µUI/mL), as was free thyroxine (fT4, 1.1 ng/dL); plasma cortisol at 08.00 h was
alsonormal(24µg/dL;normalvalues: 8–25µg/dL).PlasmaIGF-Ivalues(125ng/mL)andplasma
insulin-likegrowthfactor-bindingprotein3(IGFBP3: 2.8µg/mL)werealsonormalforthesexandage
ofthepatient. AtestofintravenousargininehydrochlorideshowedthatthepatientdidnothaveGHD
(maximumGHpeak: 4.6ng/mL).
Interestingly,theapolipoproteinE(ApoE)genotypeofthepatientwasE4/3,presentinganApoE4
allele(ε4)thatisrelatedtofamilialhypercholesterolemia,butalsowithanincreasedriskofAlzheimer’s
disease(AD)ormildcognitiveimpairment(MCI)[20].
ThebloodtestperformedafterthesecondPET-SCANindicatedthattherewerenosignificant
changesinthepreviouslyanalyzedparameters,exceptthattheplasmavaluesofIGF-IandIGFBP3
hadincreasedto185ng/mLand3.2µg/mL,respectively(bothwithintherangeofnormalvalues).
Therefore,themolarratioofIGF-ItoIGFBP3increasedfrom0.04(initialvalue)to0.057aftertreatment
withGH.Bloodglucoseremainedatnormalvalues(97.3mg/dL).
ThetreatmentwithGHdidnotproduceanysideeffects,asobservedthroughclinicalexaminations
andbloodtests.
3. Discussion
Inthisstudy,wedemonstrated,withPET-SCANbrainimages,thepositiveeffectthatGHexerts
onthehumanbraininanelderlypatientwithcognitivedeficitsandwithoutGHD,particularlyinareas
relatedtolearning,recentmemory,behavior,andvisuospatialperception;although,astheimages
indicate,themetaboliceffectsofthehormoneoccurredinpracticallyallcorticalareas. Inaddition,
asthepatientherselfreported,herqualityoflifeandtheperformanceofdailyactivitiesimproved
aftertreatmentwithGH,eventhoughtheadministrationofthehormonelastedonlythreeweeks.
TheeffectsofGHonthebrainhavebeenpreviouslyvisualizedinastudycarriedoutinpatients
withGHD,inwhomGHwasadministeredforsixmonths[21]. AfterthistimeofGHreplacement
therapy,theneuropsychologicaltestsshowedaclearimprovementinworkingmemoryandcognition,
but,perhapsevenmoreimportantly,thefunctionalmagneticresonanceimaging(fMRI)carriedout
duringtheworkingmemorytaskshowedgreateractivityinseveralcorticalareasandintheright
thalamusandtheanteriorcingulatecortex[21]. Alaterstudy,carriedoutinanolderGHDpatient
withcognitiveimpairmentsduetochronicopioidtreatmentforneuropathicpain,indicatedthatGH
treatmentproducedclearimprovementsinvisuospatialcognitivefunctionsandahighermetabolism
andfunctioningofthehippocampus,accordingtowhatwasshowedbyaprotonmagneticresonance
spectroscopystudy[22]. Ourstudycorroboratestheseeffects,seenwithimages,oftheGHatthebrain
level,althoughinourcasethepatientwaswithoutGHD,unliketheaforementionedstudies.
UnlikewhathappensinchildrenandadultswithGHD,fewstudiesshowthattheadministration
ofGHincreasescognitioninnon-GHDhumanpatientswithcognitivedeficitsproducedasaresultof
differentpathologies[23–28]. However,thesepositiveeffectsofGHhavebeenwidelydemonstratedin
differentexperimentalanimalmodels[29–33];eveninoldanimals,inwhichthecognitiveimpairment
ofhippocampal-dependentfunctions,suchaslearningandmemory,isassociatedwithadecreasein
thesecretionofGHandIGF-I,asinourspecies[4,17,18,32].
Inthecaseofthehippocampus,ithasbeenshowntobeanimportantneurogenicniche,where
adultneurogenesistakesplaceinhumans[34]. Functionally,thehippocampusisresponsibleforthe
acquisitionofmemory,learning,andrecentspatialorientationandnavigation(inneuronsknownas
Int.J.Mol.Sci.2018,19,2294 7of16
“placecells”). Thesefunctionsareaffectedinpersonalitydisorders,perhapsduetoacontinuousexcess
ofglucocorticoids[35],whichnegativelyregulatestheformationofnewneuronsinthesubgranular
zone(SGZ)ofthedentategyrusofthisstructure[36].
Recently, it was published that hippocampal neurogenesis begins to decrease abruptly from
adolescence to undetectable levels in adults [37]. This led to great controversy, and very recent
publicationsquestionorcontradictthesepostmortemfindings[38–40],althoughthereisapossibility
that neurogenesis in the adult hippocampus can be deregulated by neurological diseases, such as
epilepsyorbehavioraldisorders[41],whichwouldexplainthecurrentdivergentopinionsaboutthe
persistenceofadultneurogenesisinmanthroughoutlife.
Inourstudy,themetabolicactivityofthelefthippocampusincreasedsignificantlyaftertreatment
withGH.Thismayindicatethattreatmentwiththehormonehasinducedanincreaseinthenumber
ofneuronsinthisarea,asweandothershaveshowninrats[10,11]. AnotherpossibilityisthatGH
hasinducedtheoutbreakofdendriticspinesandchangesinthelengthanddensityofpre-existing
dendritesinthehippocampus,ashasbeenshowntooccurafterintracerebroventricularadministration
ofthehormoneinadultrats[42]. Ifwecouldhaveused3(cid:48)-deoxy-3(cid:48)-[18F]fluoro-L-thymidineinstead
ofFDG,wecouldhavedetectedwhetherthechangesobservedinPET-SCANweredueornottoadult
neurogenesis,asastudyhasshowninadultrats[43].
Interestingly,hippocampalatrophy(measuredbyMRI)isanearlymarkerofADthatcorrelates
withmemorydisturbances[44],andithasbeenfoundthatcerebralglucosemetabolismissignificantly
reducedinearlystagesofthisdisease[45].Inaddition,theApoEgenotypeofthepatientwasε4/3,and
ithasbeendescribedthatthepresenceofasinglecopyoftheε4alleleincreasestheriskofdeveloping
AD, MCI, or other cerebral pathologies with cognitive impairment [20], although the main risk of
developmentofADoccursinhomozygousindividualsshowingtwoε4copies(ε4/4)[20]. Thepatient
fulfilledtwoofthecoreclinicalcriteriaforthediagnosisofMCI,suchastheconcernforachange
incognitionanddeteriorationinoneormorecognitivedomains[46]. Althoughwedidnotanalyze
whethertherewasanaccumulationofβ-amyloidthataccompaniedthecognitivedeteriorationexisting
inthepatient,astypicalcharacteristicsofAD,itseemsunlikelythatwewerefacinganearlystageof
thisdisease,becausethedecreaseinmetabolisminthelefthippocampuscouldonlybedetectedafter
thequantitativeanalysisperformedwithNeurocloudandtherewasnodecreaseinthetemporoparietal
acquisitionofFDG.Thepatientwillbestudiedagaininthenextmonthstoanalyzeifthepositive
resultsobtainedwiththeGHtreatmentcontinue. Inanycase,ithasrecentlybeenpostulatedthata
treatmentwithGHcouldbeusefulinthisneurodegenerativedisease[47,48].
WecannotdiscardtheobservationthatGHhasinducedneurogenesisinthehippocampusofthe
patientdescribedinthisstudy,thusimprovingherrecentmemory;butitisveryunlikely,orpractically
impossible, that adult neurogenesis has been the cause of the increase in glucose metabolism in
virtuallyallcerebralcorticalareas,duetothelownumberofneurogenicnichesdescribedintheadult
humanbrainandtheirprogressivelyloweractivityaswegetolder.
OtherregionsofinterestinwhichhypometabolismwasobservedbeforetreatmentwithGHwere
theleftamygdala,theleftparahippocampus,theleftcuneus,andthesubgenualareaoftheanterior
cingulatecortex.
The amygdala is involved in emotional responses (pleasure, fear, anger, anxiety), but it also
determineshowemotionsadheretomemories,mainlyformingnewmemoriesrelatedtofear,although
arecentarticledescribesfearastheresultofaverycomplexmemorynetwork[49]. Amorerecent
studyreportsthatinthebasolateralamygdalaofadultmice,thereareneurogenicprecursorcellsthat
giverisetonewlyformedinterneurons[50]. However,adultneurogenesisinthehumanamygdala
hasnotyetbeendemonstrated;therefore,itisunlikelythattheincreasedmetabolismobservedinthis
structureafterthetreatmentwithGHcouldbeduetoadultneurogenesis.
Asfortheparahippocampus,recentlyithasbeendescribedthat,inhumans,itsposteriorsection
isinvolvedinvisuospatialperception,whiletheprevioussectionisrelatedtomnemonicprocesses,
suggestingthatthisstructureactsasafunctionalinterfacebetweenperceptionandmemories[51].
Int.J.Mol.Sci.2018,19,2294 8of16
ThetreatmentwithGHalsoimprovedthelowmetabolicactivitypreviouslyobservedinthisstructure,
butthechanges,inthiscase,didnotreachstatisticalsignificance.
Thecuneusreceivesinformationfromtheupperareaofthecontralateralretina,whichrepresents
thelowervisualfield. Itsfunctionisbasicvisualprocessing,relatedtoattentionandworkingmemory.
Inthiscase,theexistenceoflefthypometabolismbeforetreatmentwithGHwasdetectedafterthe
Neurocloud PET analysis, showing a clear asymmetry between the left and the right side of this
structure. TreatmentwithGHalsoledtoanincreaseintheacquisitionoftheleftsidethatwasnow
withintherangeofvaluesforthenormalpopulationofthedatabaseused,butalsoontherightside;
therefore,theasymmetrybetweenbothsidescontinuedtoexist,asshowninTable2.
Inthecaseofthesubgenualareaoftheanteriorcingulatecortex,therewasaclearasymmetry
between the left and right side before administration of GH, but this disappeared after treatment
withthehormone,withthemetabolismalreadynormalonbothsides. Thisareahasbeenrelatedto
depression[52]anditsaffectationisrelatedtomooddisorders[53],whichmayexplainsomeofthe
symptomsobservedinourpatient. Ontheotherhand,structuralandfunctionalanomaliesinthis
regionhavebeenassociatedwithmajordepressivedisorders, mainlywhentheyareaccompanied
byadecreasedvolumeofbothtemporallobesandthelefthippocampusandparahippocampus[54],
butthiswasnotthecaseinthepatientdescribedhere.
Thebrainusesmainlyglucosetoobtaintheenergyneededtofunctioncorrectly[55]. Arecent
studydescribesthatthereisasignificantcorrelationbetweenthecerebralmetabolicrateofglucose,
measuredbyFDGPET,andthelevelofconsciousnessinpatientsinavegetativeorminimallyconscious
state,withthemetabolicrateofglucosebeingcapableofdifferentiatingbetweenbothconditions[56].
An elegant study carried out in a model of dwarf rats specifically deficient in GH and IGF-I
showed that in these animals, there was a marked decrease in glucose metabolism in many areas
ofthebrain,particularlythoseinvolvedinlearningandmemory,dependentonthehippocampus,
indicatingthatthedecreaseinGH/IGF-Iproductionassociatedwithagingplaysanimportantrolein
theevolutiontowardsanelderlybrain[57]. Moreover,inthatstudy,itwasseenthattheproduction
ofATPinthehippocampuswasdecreasedby15%,whichcontributedtothestatementthatGHand
IGF-Iplayaclearroleintheregulationofglucoseuseandcerebralenergymetabolism[57]. Thesame
happensinman: agingleadstoaseriesofbraindeficits,suchaslearningandmemory,neurogenesis,
synapticdensity, andmodificationsindendritearchitecture(see[57]forreview). Inaddition, itis
logicalthatadecreaseintheproductionofGH/IGF-Ialterstherateofmetabolicrenewalofimportant
neurotransmitters,suchasacetylcholineandnoradrenaline,giventheimportantroletheyplayinthe
hypothalamicregulationofthesynthesisandreleaseofGH[58].
Theseage-relatedcerebraldeficitshavebeenshowntobereversedbychronicinfusionofIGF-I
intothelateralventricleofagedrats[59],orbyGHtreatmentinveryoldrodents[60],andmorerecent
studiesinmanindicatethathighplasmalevelsofGHandIGF-Imaintainthefunctionalqualityof
theworkingmemoryduringaging[61]. However,thepatientwetreatedwaswithoutGHD,andthe
plasmalevelsofIGF-IwerewithinnormalvaluesbeforetreatmentwithGH.Therefore,herMCIand
thehypometabolismsfoundinthefirstPET-SCANcannotbeexplainedbyanormalprocessofaging
associatedwithadeficientfunctioningofGH/IGF-I.
CerebralglucosehypometabolismhasbeenlinkedtotheearlystagesofAD[62];inaddition,the
genotypeofthepatientpresentsacopyoftheε4allele,whichimpliesanincreasedriskofdeveloping
AD [20], but also a decrease in the cerebral metabolism of glucose [63]. A recent study in mice,
geneticallymodifiedtocarryoneofthethreehumanApoEallelesinplaceoftheirnormalApoEgene,
demonstratedthattheApoE3andApoE4brainsoftheseanimalsshowedasignificantreductionin
theexpressionofmoleculesinvolvedinIGF-Isignaling,namelyIGF-Iitself,Irs1(insulinreceptor
substrates),andtheGlut4glucosetransporter[64];theresultisareductioninglucoseuptakebythe
brain. Inthesamestudy,itwasshownthatApoE4brainshadlowerlevelsofPparg,anuclearreceptor
thatregulatesneuronalsurvival[65]andmitochondrialbiogenesis[66]. Thesefindingsmayexplain
thereductionofglucoseuptakeanddeficientenergyproductioninthebrainofsubjectswithaε4
Int.J.Mol.Sci.2018,19,2294 9of16
allele, aswellasmayexplainthecognitiveandmetabolicdeficitsobservedinourpatientandthe
recoveries (cerebral metabolic activity and cognitive functions) observed after treatment with GH.
Asindicatedabove,GHinducesthelocalexpressionofIGF-Iinthehumanfetalcortex[19],andthereis
thepossibilitythatthiseffectalsotakesplaceintheadultbrain,buthasnotyetbeenseen.GHincreases
theproductionofIGF-Iintheliverand,consequently,theplasmalevelsofthispeptide,asithappened
inthisstudy. However,unlikewhathappenswithGH,onlyasmallfraction(approximately30%)of
circulatingIGF-I[freeIGF-I],crossestheblood–brainbarrier. Therefore,insteadofconsideringthe
totalIGF-I,wemustanalyzetheIGF-I/IGFBP3molarratio,whichinthisstudy,onlyincreasedfrom
0.04to0.057aftertreatmentwithGH,anamountthatdoesnotseemtobehighenoughastoattribute
thechangesobservedinthebraintothecirculatingIGF-I.Hence,iftheeffectsweobservedinthis
studywereproducedbyIGF-I,thismusthaveoccurredduetotheinductionexertedbyGHonthe
synthesisofthatpeptideinthebrain. IGF-IsignalingimpliestheactivationofPI3K/Aktpathways,
and phosphorylated Akt induces the translocation of Glut4 vesicles to the plasma membrane for
allowingtheentryofglucoseintothecells[67];buttheactivationofPI3K/Aktisalsoakeysignaling
pathwayforGHactions,asourgroupdemonstrated[68,69]. Therefore,adirecteffectofGHonbrain
metabolismseemstobethemostfeasibleexplanationfortheresultsobtainedinthisstudy. Inaddition,
GHmayhaveproducedanincreaseinbloodflowtothebrain,whichwouldallowincreaseduptake
of FDG. Recently, we described that GH induces a significant reparative effect on the endothelial
dysfunctionthatappearsafteratherogenicstimuli,suchashypercholesterolemia[70];moreover,GHis
amitochondrialprotector[26,71],andatherogenesisisrelatedtooxidativestress[70]. Giventhatthe
patientwetreatedhadhighlevelsofcholesterolandtriglyceridesinplasma,itisalsopossiblethat,
despitetheshorttimeoftreatment,GHmayhavecontributedtoimprovingbloodsupplytothebrain,
facilitatingtheuptakeandmetabolismofglucoseandproducingthechangesdescribedhere(bothin
termsofPET-SCANimagesandcognitivetests).
GHRH(growthhormone-releasinghormone)isamajorinducerofthesynthesisandsecretionof
GH in the pituitary gland [58] and perhaps in other territories [4]. A randomized, double-blind,
placebo-controlled trial analyzed the effects of a synthetic analogue of GHRH (Tesamorelin;
TheratechnologiesInc.,Montreal,QC,Canada)administeredsubcutaneously(1mg/day)for20weeks
in61adultswithMCIand76healthyadults.TheresultsobtainedshowedthatthisGHRHanaloguehad
positiveeffectsoncognitioninbothgroupsstudied[72]. Anadditionalclinicaltrialofthesamegroup
carriedouton30adults(age55–87years,17withMCI),usingthesameGHRHanalogatthesamedoses
andtime,showedthatthistreatmentsignificantlyincreasedgamma-aminobutyriclevelsacid(GABA)
inthreebrainregionsoftheleftside(frontaldorsolateral,posteriorcingulate,andposteriorparietal),
increasedN-acetylaspartylglutamateinthefrontalcortex,anddecreasedmyoinositol(anosmolyte
relatedtoAD)intheposteriorcingulate, inducingapositiveeffectoncognitioninbothgroupsof
participantswithoutaffectingtheregulationofplasmaglucose[73].However,inthatstudy,nochanges
werefoundinbrainglutamatelevels,unlikewhathasbeenreportedinpreparationsofhippocampal
cutsfromoldratstreatedwithGHorIGF-I[32],butconsistentwiththeeffectsofGHonthedensityand
functionalityofGABABreceptorsinmaleratsinareasofthebrainrelatedtocognition[74]. Thesedata
seemtosupportourfindingsusingGHinthisstudybecausealthoughitcannotbediscardedthat
GHRHexertsitsowneffectsatthebrainlevel,asitseemstodoinotherterritories,itisclearthatthe
administrationofGHRHoroneofitsanaloguesinducesthereleaseofGH[75].
Insummary,forthefirsttime,wedemonstratedwithFDGPET-SCANthepositiveeffectsthatGH
exertsonthemetabolicactivityofthebrainofanon-GHDolderwomanwithMCIanddyslipidemia.
Our data do not allow us to verify if the existing MCI was due to the presence of the ε4 allele or
dyslipidemia, or both, but it is clear that the GH treatment significantly improved the patient’s
cognitivedisabilities. Thisimprovementstillcontinues,threemonthsafterthetreatmenthasbeen
interrupted,andcorroboratesourpreviousdatainpatientsandanimalmodelswithcognitivedeficits
producedbyacquiredbraindamageafterbeingtreatedwithGH.
IInntt.. JJ.. MMooll.. SSccii.. 22001188,, 1199,, 2x2 F9O4R PEER REVIEW 1100 ooff 1165
4. Materials and Methods
4. MaterialsandMethods
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TThhee ssttuuddieiessa nanddt retraetamtmenetnwt ewreercea rcraierdrieodu toauctc oarcdcionrgdtiongth teop trhoeto pcorolstoocfothlse oFfo ltthrea MFoeldtriaca MlCeednitcearl
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FFiigguurree 44 sshhoowwss tthhee sseeqquueennccee ooff eexxaammiinnaattiioonnss aanndd ttrreeaattmmeenntt ccaarrrriieedd oouutt..

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hhoorrmmoonneess,, aanndd ppllaassmmaa ttuummoorraall mmaarrkkeerrss)) wwaass ppeerrffoorrmmeedd;; ddaayy 11.. IInn tthhee ssaammee ddaayy,, aa TTaavveecc tteesstt ((TTTT))
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abnludeb lliunee)l.i nTew).eTnwtye-notnye- odnaeyds alyastelra, tear ,naewne wFDFGD-GPE-PTE-STC-SACNA Nwawsa pseprefrofromrmede djujsuts t11 hh aafftteerr tthhee llaasstt
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doanye adfatyer atfhteisr, tahnise, wa nceliwni ccalilneixcaalm eixnaamtioinnawtioans pwearsf opremrfeodr.med.