Combined Pituitary Hormone Deficiency-4 (CPHD-4) via the LHX4 Gene

  • Summary and Pricing
  • Clinical Features and Genetics
  • Citations
  • Methods
  • Ordering/Specimens
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Test Code Test Copy GenesIndividual Gene PriceCPT Code Copy CPT Codes
629 LHX4$610.00 81479 Add to Order
Targeted Testing

For ordering targeted known variants, please proceed to our Targeted Variants landing page.

Turnaround Time

The great majority of tests are completed within 18 days.

Clinical Sensitivity
Sensitivity of this test is currently unknown.

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Deletion/Duplication Testing via aCGH

Test Code Test Copy GenesIndividual Gene PriceCPT Code Copy CPT Codes
600 LHX4$690.00 81479 Add to Order
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Turnaround Time

The great majority of tests are completed within 28 days.

Clinical Features
Short stature is a multifactorial developmental disorder. Combined pituitary hormone deficiency (OMIM 262700) is a genetic disorder due to at least one pituitary hormone deficiency combined with growth hormone deficiency (Machinis et al. Am J Hum Genet 69:961-968, 2001). Patients diagnosed with combined pituitary hormone deficiency usually have short stature along with growth hormone deficiency associated with thyroid-stimulating hormone (TSH), adrenocorticotropin hormone (ACTH), prolactin (PRL), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) deficiencies. Brain MRI often shows hypoplastic anterior pituitary, ectopic posterior lobe, and a poorly developed sella turcica (Machinis et al. 2001, Pfaeffle et al. J Clin Endocr Metab 93:1062-1071, 2008; Castinetti et al. J Clin Endocr Metab 93:2790-2799, 2008). In addition, Chiari malformation and corpus callosum hypoplasia have been reported in less than 8% of the patients (Machinis et al. 2001; Tajima et al. Endocr J 54:637-641, 2007; Castinetti et al. 2008).
Combined pituitary hormone deficiency is inherited as an autosomal dominant disorder (Machinis et al. 2001; Machinis et al. J Clin Endocr Metab 90:5456-5462, 2005). Mutations in the LHX4 gene cause combined pituitary hormone deficiency (Machinis et al. 2001). The LHX4 gene encodes a transcription factor known as LIM-homeodomain protein 4 (LHX4), which is predicted to have a role in the genesis and development of the Rathke’s pouch (Machinis et al. 2005). LHX4 proteins contain two LIM domains and one homeobox domain. It has been reported that LHX4 is involved in the activation of the POU1F1 transcription factor, the main regulator of the growth hormone secretion (Machinis et al. 2005). A mix of missense, splicing, frameshift and gross deletion mutations within the LHX4 gene have been reported (Machinis et al. 2001; Tajima et al. 2007; Pfaeffle et al. 2008; Castinetti et al. 2008; Tajima et al. Exp Clin Endocrinol Diabetes 118:405-409, 2010; Dateki et al. J Clin Endocr Metab 95:4043-4047, 2010).
Testing Strategy
This test involves bidirectional sequencing using genomic DNA of the 6 coding exons (exons 1-6) of the LHX4 gene. The full coding region of each exon plus ~10 bp of flanking non-coding DNA on each side are sequenced. We will also sequence any single exon (Test #100) in family members of patients with a known mutation or to confirm research results.
Indications for Test
Candidates for this test are patients with symptoms consistent with combined pituitary hormone deficiency and family members of patients who have known LHX4 mutations.


Official Gene Symbol OMIM ID
LHX4 602146
Inheritance Abbreviation
Autosomal Dominant AD
Autosomal Recessive AR
X-Linked XL
Mitochondrial MT


Name Inheritance OMIM ID
Pituitary Hormone Deficiency, Combined 4 262700


Genetic Counselors
  • Castinetti, F., (2008). "A novel dysfunctional LHX4 mutation with high phenotypical variability in patients with hypopituitarism." J Clin Endocrinol Metab 93(7): 2790-9. PubMed ID: 18445675
  • Dateki, S., (2010). "Mutation and gene copy number analyses of six pituitary transcription factor genes in 71 patients with combined pituitary hormone deficiency: identification of a single patient with LHX4 deletion." J Clin Endocrinol Metab 95(8): 4043-7. PubMed ID: 20534763
  • Machinis, K., Amselem, S. (2005). "Functional relationship between LHX4 and POU1F1 in light of the LHX4 mutation identified in patients with pituitary defects." J Clin Endocrinol Metab 90(9): 5456-62. PubMed ID: 15998782
  • Machinis, K., (2001). "Syndromic short stature in patients with a germline mutation in the LIM homeobox LHX4." Am J Hum Genet 69(5): 961-8. PubMed ID: 11567216
  • Pfaeffle, R. W., (2008). "Three novel missense mutations within the LHX4 gene are associated with variable pituitary hormone deficiencies." J Clin Endocrinol Metab 93(3): 1062-71. PubMed ID: 18073311
  • Tajima, T., (2007). "A novel missense mutation (P366T) of the LHX4 gene causes severe combined pituitary hormone deficiency with pituitary hypoplasia, ectopic posterior lobe and a poorly developed sella turcica." Endocr J 54(4): 637-41. PubMed ID: 17527005
  • Tajima, T., (2010). "A novel mutation (V101A) of the LHX4 gene in a Japanese patient with combined pituitary hormone deficiency." Exp Clin Endocrinol Diabetes 118(7): 405-9. PubMed ID: 19856252
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Bi-Directional Sanger Sequencing

Test Procedure

Nomenclature for sequence variants was from the Human Genome Variation Society (  As required, DNA is extracted from the patient specimen.  PCR is used to amplify the indicated exons plus additional flanking non-coding sequence.  After cleaning of the PCR products, cycle sequencing is carried out using the ABI Big Dye Terminator v.3.0 kit.  Products are resolved by electrophoresis on an ABI 3730xl capillary sequencer.  In most cases, sequencing is performed in both forward and reverse directions; in some cases, sequencing is performed twice in either the forward or reverse directions.  In nearly all cases, the full coding region of each exon as well as 10 bases of non-coding DNA flanking the exon are sequenced.

Analytical Validity

As of February 2018, we compared 26.8 Mb of Sanger DNA sequence generated at PreventionGenetics to NextGen sequence generated in other labs. We detected only 4 errors in our Sanger sequences, and these were all due to allele dropout during PCR. For Proficiency Testing, both external and internal, in the 14 years of our lab operation we have Sanger sequenced roughly 14,300 PCR amplicons. Only one error has been identified, and this was an error in analysis of sequence data.

Our Sanger sequencing is capable of detecting virtually all nucleotide substitutions within the PCR amplicons. Similarly, we detect essentially all heterozygous or homozygous deletions within the amplicons. Homozygous deletions which overlap one or more PCR primer annealing sites are detectable as PCR failure. Heterozygous deletions which overlap one or more PCR primer annealing sites are usually not detected (see Analytical Limitations). All heterozygous insertions within the amplicons up to about 100 nucleotides in length appear to be detectable. Larger heterozygous insertions may not be detected. All homozygous insertions within the amplicons up to about 300 nucleotides in length appear to be detectable. Larger homozygous insertions may masquerade as homozygous deletions (PCR failure).

Analytical Limitations

In exons where our sequencing did not reveal any variation between the two alleles, we cannot be certain that we were able to PCR amplify both of the patient’s alleles. Occasionally, a patient may carry an allele which does not amplify, due for example to a deletion or a large insertion. In these cases, the report contains no information about the second allele.

Similarly, our sequencing tests have almost no power to detect duplications, triplications, etc. of the gene sequences.

In most cases, only the indicated exons and roughly 10 bp of flanking non-coding sequence on each side are analyzed. Test reports contain little or no information about other portions of the gene, including many regulatory regions.

In nearly all cases, we are unable to determine the phase of sequence variants. In particular, when we find two likely causative mutations for recessive disorders, we cannot be certain that the mutations are on different alleles.

Our ability to detect minor sequence variants, due for example to somatic mosaicism is limited. Sequence variants that are present in less than 50% of the patient’s nucleated cells may not be detected.

Runs of mononucleotide repeats (eg (A)n or (T)n) with n >8 in the reference sequence are generally not analyzed because of strand slippage during PCR and cycle sequencing.

Unless otherwise indicated, the sequence data that we report are based on DNA isolated from a specific tissue (usually leukocytes). Test reports contain no information about gene sequences in other tissues.

Deletion/Duplication Testing via Array Comparative Genomic Hybridization

Test Procedure

Equal amounts of genomic DNA from the patient and a gender matched reference sample are amplified and labeled with Cy3 and Cy5 dyes, respectively. To prevent any sample cross contamination, a unique sample tracking control is added into each patient sample. Each labeled patient product is then purified, quantified, and combined with the same amount of reference product. The combined sample is loaded onto the designed array and hybridized for at least 22-42 hours at 65°C. Arrays are then washed and scanned immediately with 2.5 µM resolution. Only data for the gene(s) of interest for each patient are extracted and analyzed.

Analytical Validity

PreventionGenetics' high density gene-centric custom designed aCGH enables the detection of relatively small deletions and duplications within a single exon of a given gene or deletions and duplications encompassing the entire gene. PreventionGenetics has established and verified this test's accuracy and precision.

Analytical Limitations

Our dense probe coverage may allow detection of deletions/duplications down to 100 bp; however due to limitations and probe spacing this cannot be guaranteed across all exons of all genes. Therefore, some copy number changes smaller than 100-300 bp within a targeted large exon may not be detected by our array.

This array may not detect deletions and duplications present at low levels of mosaicism or those present in genes that have pseudogene copies or repeats elsewhere in the genome.

aCGH will not detect balanced translocations, inversions, or point mutations that may be responsible for the clinical phenotype.

Breakpoints, if occurring outside the targeted gene, may be hard to define.

The sensitivity of this assay may be reduced when DNA is extracted by an outside laboratory.

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Ordering Options

myPrevent - Online Ordering
  • The test can be added to your online orders in the Summary and Pricing section.
  • Once the test has been added log in to myPrevent to fill out an online requisition form.
  • A completed requisition form must accompany all specimens.
  • Billing information along with specimen and shipping instructions are within the requisition form.
  • All testing must be ordered by a qualified healthcare provider.


(Delivery accepted Monday - Saturday)

  • Collect 3 ml -5 ml (5 ml preferred) of whole blood in EDTA (purple top tube) or ACD (yellow top tube). For Test #500-DNA Banking only, collect 10 ml -20 ml of whole blood.
  • For small babies, we require a minimum of 1 ml of blood.
  • Only one blood tube is required for multiple tests.
  • Ship blood tubes at room temperature in an insulated container. Do not freeze blood.
  • During hot weather, include a frozen ice pack in the shipping container. Place a paper towel or other thin material between the ice pack and the blood tube.
  • In cold weather, include an unfrozen ice pack in the shipping container as insulation.
  • At room temperature, blood specimen is stable for up to 48 hours.
  • If refrigerated, blood specimen is stable for up to one week.
  • Label the tube with the patient name, date of birth and/or ID number.


(Delivery accepted Monday - Saturday)

  • Send in screw cap tube at least 5 µg -10 µg of purified DNA at a concentration of at least 20 µg/ml for NGS and Sanger tests and at least 5 µg of purified DNA at a concentration of at least 100 µg/ml for gene-centric aCGH, MLPA, and CMA tests, minimum 2 µg for limited specimens.
  • For requests requiring more than one test, send an additional 5 µg DNA per test ordered when possible.
  • DNA may be shipped at room temperature.
  • Label the tube with the composition of the solute, DNA concentration as well as the patient’s name, date of birth, and/or ID number.
  • We only accept genomic DNA for testing. We do NOT accept products of whole genome amplification reactions or other amplification reactions.


(Delivery preferred Monday - Thursday)

  • PreventionGenetics should be notified in advance of arrival of a cell culture.
  • Culture and send at least two T25 flasks of confluent cells.
  • Some panels may require additional flasks (dependent on size of genes, amount of Sanger sequencing required, etc.). Multiple test requests may also require additional flasks. Please contact us for details.
  • Send specimens in insulated, shatterproof container overnight.
  • Cell cultures may be shipped at room temperature or refrigerated.
  • Label the flasks with the patient name, date of birth, and/or ID number.
  • We strongly recommend maintaining a local back-up culture. We do not culture cells.
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