[Prenatal diagnosis and therapy of adrenogenital syndrome with 21-hydroxylase deficiency]

Genetic counselling of the parents is prerequisite before prenatal diagnosis and prenatal therapy of CAH. Today, chorionic villous biopsy with DNA probe is the method of choice to identify homozygous CAH-fetuses. The aim of prenatal therapy is to prevent intrauterine virilization of the external genitalia in affected female fetuses. Therefore, dexamethasone (3 x 0.5 mg/d p.o.) is given to the mother immediately when pregnancy is confirmed, before prenatal diagnosis and karyotyping is possible. After the result of prenatal diagnosis, treatment is continued until term only when the fetus is affected and female. Prenatal diagnosis and effective treatment of female CAH fetuses greatly reduces the need for corrective surgery and thus helps to alleviate anxieties of prospective parents and therefore encourages further pregnancies. However, prenatal treatment of CAH to date still is an experimental therapy [corrected].

Transsphenoidal microsurgery for craniopharyngioma

We report on our series of 32 craniopharyngiomas operated on by the transsphenoidal route since 1983. In 15 of 19 patients (79%) with primary transsphenoidal surgery and in 8 of 13 patients (62%) with a transsphenoidal approach following previous surgical procedures, the craniopharyngioma was totally removed. Primary transsphenoidal surgery is a safe and successful procedure for intrasellar and suprasellar infradiaphragmatic craniopharyngiomas. In secondary surgery and in the presence of tumor calcifications the indication for this approach must be considered more carefully. Postoperative posterior pituitary deficiency is a frequent occurrence. Anterior pituitary function usually remains unchanged after surgery except for normalization of hyperprolactinemia.

[Adrenal cortex carcinoma. A rare cause of a Conn syndrome in childhood]

A 2 1/3 year old girl presented classical Conn-Syndrome as diagnostic feature of an adrenocortical carcinoma. Sonographic diagnosis was confirmed by CT-scan, typical hormonal pattern and subsequent surgical procedure. Without further therapy there has been no relapse with a follow-up of 3 years.

[Life threatening menorrhagia in thrombasthenia. (Glanzmann-Naegeli) thrombasthenia]

Glanzmann's Thrombasthenia is a rare inherited disorder of platelet aggregation with normal platelet count and humoral coagulation. It is caused by the deficiency or functional disorder of platelet membrane glycoproteins IIb und IIIa. This complex is considered to be a receptor for fibrinogen. Menorrhagia often occurs as a clinical manifestation of affected females. We report a case of severe menorrhagia in a 13-year-old girl during her third menstrual cycle. She needed several red blood cell transfusions. The bleeding could only be stopped by administration of Lynestrenol.

[Single incisor syndrome and growth hormone deficiency]

The syndrome of single incisor belongs to the group of midline malformations and is characterized by a single incisor in the patient's maxilla. A growth hormone deficiency (GHD) can be associated. We report about two of our patients with this syndrome. A GHD was diagnosed at the age of 11.0 and 7.6 years, respectively, although a single incisor had already been present during their first dentition. The first patient was treated with HGH to a chronological age of 18.6 years (final height 168 cm), the second patient is still on therapy. The growth of children with craniofacial dysmorphic features must be controlled closely in order to diagnose a GHD in time.

[Experiences with specific screening for early detection of congenital adrenogenital syndrome with 21-hydroxylase defect]

In Southern Bavaria over 32 months a total of 575 newborn babies was selectively screened for CAH due to 21-hydroxylase deficiency. Whenever one of the 3 key symptoms "failure to thrive", "ambiguous or atypical genitalia" and/or "positive family history" were present, a small plasma sample was drawn for the rapid and centralized radioimmunologic determination of 17-hydroxyprogesterone (17-OHP) and cortisol. Pathologically elevated 17-OHP plasma levels were found in 9 babies with CAH in whom adequate replacement therapy with gluco- and mineralocorticoids could be initiated without delay. On the basis of a mean birth rate of 60 000 per year a relatively low prevalence of 1:20 000 was calculated. It is likely that this is due to the fact that such a selective newborn screening program fails to detect the clinically normal male infants with simple virilizing CAH.

[The effect of maternal dexamethasone treatment after the 12th week of pregnancy on fetal genital development in adrenogenital syndrome with 21-hydroxylase deficiency]

Prenatal treatment with dexamethasone starting with gestation week 5 has been proposed to prevent virilization of female fetuses with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. We report dexamethasone treatment in a mother during her third pregnancy; this treatment could not be started before the 12th week of gestation. The second child (index case) had a simple virilizing 21-hydroxylase deficiency CAH and Prader IV genitalia. Because after amniocentesis a normal female karyotype and HLA identity with the index case were found, the dexamethasone treatment (3 x 0.5 mg/die) was continued until delivery.-In contrast to patients with salt-wasting CAH, the 17-alpha-hydroxyprogesterone level in the amniotic fluid was within the normal range. Decreased maternal plasma and urine estriol concentrations, as well as the plasma cortisol values, demonstrated adequate suppression of the fetal and maternal adrenal gland. No side effects were found in the mother as a result of the dexamethasone treatment. The newborn had virilization of the external genitalia according to Prader III but without hypertrophy of the clitoris. The degree of rugated scrotum was less marked in relation to the index case and the sinus urogenitalis was more distally shifted. Thus, surgery on the clitoris could be avoided. The conditions for further surgery (vaginoplasty) could probably be improved. Therefore, dexamethasone treatment of a mother with a female CAH fetus due to 21-hydroxylase deficiency seems to be justified starting at the 12th week of gestation. However, the optimal beginning of therapy is in early pregnancy.

Longitudinal study of progestins, mineralocorticoids, and glucocorticoids throughout human pregnancy

The maternal adrenal cortex seems to be involved in the adaptation to pregnancy. To study in detail adrenocortical secretion during pregnancy, we measured plasma aldosterone, corticosterone, 11-deoxycorticosterone, progesterone, 17-hydroxyprogesterone, 11-deoxycortisol, cortisol, and cortisone simultaneously by RIA after extraction and automated Sephadex LH-20 chromatography of 10 normal pregnant women longitudinally throughout pregnancy at weeks 8-10, 14-17, 21-24, 28-32, and 38 as well as at the time of admission to the delivery room. The mean plasma progesterone and 17-hydroxy-progesterone concentrations increased from 37.2 +/- 6.5 (+/- SE) and 8.2 +/- 1.0 nmol/L, respectively, in early gestation to maximum levels of 138.0 +/- 25.7 and 22.8 +/- 2.2 nmol/L at week 38 (P less than 0.01). Plasma glucocorticoid levels rose 2- to 3-fold (P less than 0.01) from weeks 8-10 (corticosterone, 18.5 +/- 5.4; 11-deoxycortisol, 1.9 +/- 0.2; cortisone, 24.2 +/- 4.2; cortisol, 195.5 +/- 37.6 nmol/L) to week 38 (corticosterone, 42.9 +/- 11.2; 11-deoxycortisol, 4.6 +/- 0.5; cortisone, 71.5 +/- 13.6; cortisol, 420 +/- 63 nmol/L). Similarly, plasma mineralocorticoid levels increased 5- to 7-fold (P less than 0.01) from weeks 8-10 (11-deoxycorticosterone, 0.69 +/- 0.12; aldosterone, 0.41 +/- 0.08 nmol/L) to maximum levels at week 38 (5.3 +/- 0.9 and 2.1 +/- 0.3 nmol/L, respectively). At the time of admission to the delivery room, plasma 11-deoxycortisol, corticosterone, and cortisol concentrations were higher (P less than 0.02) than at 38 weeks, but plasma progestin and mineralocorticoid concentrations were not. We conclude that the source of the elevated maternal corticosteroid levels in pregnancy in addition to the estrogen-mediated rise in corticosteroid-binding globulin is the maternal adrenal cortex itself. The peak glucocorticoid levels at admission to the delivery room reflect increased maternal and fetal stress with the onset of labor.

Human corticotropin-releasing hormone during pregnancy

Elevated irCRH levels up to 14 ng/ml were measured in 176 females in the last trimester. The highest maternal CRH levels were found in those females in whom the period from the onset of labour to full dilatation of the cervix and the time span of delivery were shortest. irCRH in amniotic fluid (120 +/- 180 pg/ml; n = 14) was in the same range as in umbilical cord plasma (233 +/- 188 pg/ml; n = 66) and 20-fold lower than in prepartal maternal plasma (5.38 +/- 4.49 ng/ml; n = 66). irCRH in maternal plasma correlated highly to irCRH in umbilical cord plasma (p less than 0.001; n = 66). After delivery irCRH disappeared from maternal plasma with a half-life of 50 minutes (n = 14). One day postpartum irCRH levels (n = 22) were undetectable. The height of the irCRH levels in the various biological fluids did not correlate to the mode or the pathological events of delivery (n = 43). Maternal ACTH levels above the normal range were encountered only in women immediately prepartal and did not correlate to the CRH levels (253 +/- 229 pg/ml; n = 66). Cortisol levels were higher in maternal plasma than in umbilical cord plasma due to elevated CBG (n = 78). Free cortisol levels were higher in the 3rd trimester than in the 1st (2.18 +/- 0.16 vs 1.16 +/- 0.73 ng/ml; n = 42). irCRH in maternal and umbilical cord plasma correlated to the hPl and estriol levels (p less than 0.001 and p less than 0.05; n = 66). We conclude that irCRH is secreted by the placenta into both maternal and fetal circulation. Though placental CRH is undistinguishable from hypothalamic CRH, the biological significance of placental CRH remains open. Our data show that placental CRH might be responsible for the changed function of the adrenal gland during pregnancy, with higher free cortisol levels in the last trimester. The extremely elevated ACTH levels during labour and delivery indicate that CRH is not the only mediator of stress-induced ACTH secretion in the regulation of the maternal hypothalamo-pituitary-adrenal axis.

Postnatal course of plasma levels of adrenocortical steroids in premature infants with and without NaCl supplementation

To assess the adrenocortical response of premature infants to alterations in sodium balance, the postnatal course of plasma progesterone, 11-deoxycorticosterone, corticosteronoe, aldosterone, 17-hydroxyprogesterone, 11-deoxycortisol, cortisol and cortisone was compared in healthy premature infants kept on low (1-2 mEq/kg per day) or high (3-5 mEq/kg per day) sodium diet. The mean birthweight (1470 g, range: 1210-1670 g vs 1410 g, range: 1130-1750 g) and mean gestational age (30.5 weeks, range: 29-32 weeks vs 30.2 weeks, range: 28-32 weeks) in the low and high sodium groups, respectively, were similar. Simultaneous steroid hormone measurements were made weekly up to the 5th week of life using mechanized Sephadex LH-20 multicolumn chromatography and standardized radioimmunoassays. It was demonstrated that in response to renal salt wasting and negative sodium balance there was a significant rise in plasma aldosterone concentration. The plasma levels of other individual corticosteroids generally declined with advancing age, the initial fall, however, was followed by a transient and insignificant but simultaneous increase in 11-deoxycortisol, cortisol, cortisone and corticosterone in prematures on low a sodium diet. This effect could be prevented by giving NaCl supplement. The NaCl-suppressible increase in adrenocortical activity may be the result of the combined effect of stress or angiotensin 11-induced adrenocorticotropic hormone (ACTH) release and/or prolactin-mediated enhanced adrenal response to ACTH.

Estrone and estradiol concentrations in human ovaries, testes, and adrenals during the first two years of life

To determine the origin of estrogens in infant blood, we measured estrone (E1) and estradiol (E2) in the gonads of 50 girls and 64 boys who died suddenly between birth and 2 yr of age as well as in the adrenals of 18 of these infant girls and 16 of the boys. In the adrenals, E1 [median, 2.8 ng/g (10.4 pmol/g); range, 1.1-4.8 ng/g (4.1-17.8 pmol/g)] and E2 [median, 3.0 ng/g (10.9 pmol/g); range, 1.2-5.3 ng/g (4.4-19.5 pmol/g)] were found in similar concentrations and were independent of age and sex. In the gonads, E2 was the major estrogen, but the concentrations differed markedly between the sexes; E2 exceeded E1 almost 10-fold in the ovaries and 2-fold in the testes. On the average, the gonads of the infant girls had 5 times more E2 and 2 times more E1 than those of the boys. As in plasma, E2 concentrations were highest in the ovaries of 1- to 6-month-old girls [median, 10.5 ng/g (38.5 pmol/g); range, 1.1-55.1 ng/g (4.0-202.0 pmol/g)] and in testes of 1- to 3-month-old boys [median, 1.8 ng/g (6.6 pmol/g); range, 0.6-6.4 ng/g (2.3-23.5 pmol/g)]. Ovarian E2 concentrations declined to less than 3.0 ng/g (11.0 pmol/g) by the end of the first year of life, and testicular E2 declined to less than 1.0 ng/g (3.7 pmol/g) after only 6 months of age. Gonadal estrogen concentrations paralleled changes in gonadal morphology. Ovarian weights varied in a pattern of rise and fall similar to that of ovarian E2 concentrations; the biggest ovaries contained multiple macroscopic cysts. Testicular E2 closely correlated with Leydig cell development and testicular testosterone concentrations. We infer, therefore, that the surge of plasma E2 in infant girls originates from ovarian follicles and that of boys from testicular Leydig cells, and that these both occur as a result of the postnatal surge in gonadotropin secretion. The basal plasma E1 and E2 pool, however, is derived from the adrenals and remains at a comparatively constant level in both sexes.

Plasma aldosterone and 11-deoxycortisol in term neonates: a reevaluation

We reported previously reference values for seven corticosteroids in the plasma of term neonates and their mothers, including values for aldosterone (Aldo) that appeared high compared to the values in the literature. Plasma 11-deoxycortisol (S) was not measured in that longitudinal study. Using an improved technique of chromatographic separation of Aldo and S, the Aldo levels were measured again, and S levels were newly determined in stored plasma samples of the 12 newborn infants of our original report. The mean concentrations were: (Formula: see text). These plasma Aldo values should replace those of our original report. Thus, both plasma Aldo and S levels decline in the first week of life in normal infants.

Dexamethasone-suppressible hyperaldosteronism: pathophysiology, clinical aspects, and new insights into the pathogenesis

A profile of dexamethasone-suppressible hyperaldosteronism (DSH), a variant of primary aldosteronism, is drawn by reviewing its pathophysiological and clinical aspects. Genetic studies show no HLA linkage and point to an autosomal dominant mode of inheritance, suggesting that the prevalence of this disease has been underestimated in the past. Hypertension, hypokalemia, suppressed renin, and high aldosterone values characterize DSH in the basal state, similar to the other forms of primary aldosteronism, i.e., aldosterone-producing adenoma (APA) or bilateral idiopathic adrenal hyperplasia (IAH). Biochemically DSH and APA can be differentiated from IAH since in both aldosterone does not respond to upright posture, to angiotensin II infusion, and to angiotensin-converting enzyme (ACE) captopril. In contrast, morphologically DSH is similar to IAH, since neither macroscopic nor histologic examinations of the adrenals give evidence of any unilateral abnormality. However, DSH is differentiated from APA and IAH by the hyperresponsiveness of aldosterone to acute ACTH administration as well as by the failure of aldosterone to escape from prolonged ACTH stimulation. The final diagnosis of DSH rests upon the prompt reversal of the features of mineralocorticoid excess by glucocorticoid therapy. In some cases hypertension is unresponsive to dexamethasone and needs alternative treatment. The main pathogenetic hypotheses point to a pituitary and/or an adrenal abnormality, but the intrinsic nature of the disease remains to be elucidated.

[Pseudohypoaldosteronism--renal salt loss syndrome. Therapy and course exemplified by 2 siblings]

In 2 sibs pseudohypoaldosteronism was diagnosed by measurements of high serum aldosterone and elevated plasma renin activity. During their first week of life the first born girl, phenotypically normal, went through a severe salt-losing crisis with hyponatremia and hyperkalemia. Steroids given because of suspected congenital adrenal hyperplasia had no effect. High parenteral and later oral substitution of sodium normalized the serum electrolytes. The younger brother had milder symptoms. His salt-losing crisis developing during the first week of life was treated immediately with salt substitution. Both children developed normally with high oral sodium chloride supplementation, as regulated by the parents, using daily body weight measurements. Both children frequently suffer salt-losing crises, generally preceded by simple upper respiratory tract infections, which have to be treated in the hospital by infusion with a hyperosmolar sodium chloride solution.

Contribution of the adrenal gland to the production of androstenedione and testosterone during the first two years of life

Androstenedione and testosterone were measured in whole adrenal glands of 56 previously healthy boys who died suddenly between birth and 2 yr of age. In each adrenal gland, the concentration of androstenedione considerably exceeded that of testosterone. The highest concentrations were found during the first week of life (median, 295 ng/g; range, 98-320 ng/g). Thereafter, values decreased rapidly until the end of the first year of life (median, 10 ng/g; range, 4.4-22.7 ng/g). Adrenal testosterone concentrations averaged 15% of those of androstenedione in the same gland and similarly decreased until the end of the first year. The decrease of adrenal androgen concentrations paralleled the involution of the fetal adrenal zone. A close correlation existed between the concentration of androstenedione in adrenal tissue and plasma. However, no correlation existed between adrenal and plasma testosterone. When the adrenals and testes of the same infant were compared, there was 10 times more androstenedione in the adrenals than in the testes during the first 2 yr of life. The testes contained more testosterone than the adrenals only during the first 4 months. Thus, in infant boys the adrenals are the main source of androstenedione during the first 2 yr. After the sixth month of life, they also are the main source of testosterone.

Etomidate: a selective adrenocortical 11 beta-hydroxylase inhibitor

To investigate the adrenocortical suppression caused by the anesthetic etomidate, plasma levels of progesterone (P), 17-hydroxyprogesterone (17-OHP), 11-deoxycorticosterone (DOC), corticosterone (B), aldosterone (Aldo), 11-deoxycortisol (S), cortisol (F), and cortisone (E) were measured simultaneously before and after a short-term ACTH stimulation test in a 6.5-year-old boy whose convulsions could be kept under control only with constant etomidate infusions. During etomidate therapy, plasma levels of DOC and S were extremely elevated, the progestins P and 17-OHP were slightly elevated, whereas B and Aldo were in the lower normal range, and F and E were markedly decreased. A short-term ACTH stimulation test during etomidate infusion gave a blunted response of B, Aldo, F and E, whereas the level of DOC remained high and S even further increased. P and 17-OHP showed a positive response to ACTH. The ratios of B/DOC and F/S, which reflect adrenocortical 11 beta-hydroxylase activity, were extremely decreased during etomidate and did not change after ACTH stimulation. In contrast, the ratios of DOC/P and S/17-OHP, which reflect 21-hydroxylase activity, were elevated and remained elevated after ACTH stimulation. After discontinuation of etomidate therapy, all the baseline steroid levels were somewhat elevated, but responded normally to ACTH. These results demonstrate that etomidate causes a specific and reversible blockade of the 11 beta-hydroxylation of adrenal steroid synthesis.

Pseudohypoaldosteronism in a child with Down syndrome. Long-term management of salt loss by ion exchange resin administration

At 4 weeks of age, an infant with Down syndrome developed severe dehydration and salt loss with the typical features of pseudohypoaldosteronism (PHA). Plasma renin activity, 11-deoxycorticosterone, corticosterone and aldosterone levels were all increased several-fold over the normal range for age, thus excluding an adrenal biosynthetic defect. Clinical condition, hyponatraemia and hyperkalaemia could be rapidly normalised by the ion exchange resin Resonium A administered first as enema and later orally (3 g/day). At that time, no further salt supplementation was necessary. At 18 months of age, Resonium A could be completely withdrawn with neither clinical deterioration nor electrolyte abnormalities. However at 3 1/2 years of age, plasma renin activity and aldosterone were still markedly elevated while precursor steroids were normal and the clinical condition satisfactory. No side effects were observed with the Resonium A therapy. The combination of trisomy 21 and PHA is very unusual. Similarly, the successful treatment of severe renal salt loss during infancy by sodium supplementation and concomitant potassium withdrawal via an oral ion exchange resin has not yet been described and warrants further therapeutic trials.

Virilization without adrenal hyperplasia in 21-hydroxylase deficiency during fetal life

The characteristic excess production of androgens in the cortisol 21-hydroxylase defect is generally considered to be secondary to ACTH stimulation of alternate pathways. Whenever a morphological examination of the adrenals has been possible in this disorder, adrenocortical hyperplasia was a constant finding. The availability of methods for the prenatal diagnosis of the 21-hydroxylase defect has made it possible to examine some of the manifestations of this disorder during fetal life. We studied a severely virilized 20-week-old aborted female fetus with the 21-hydroxylase defect whose adrenals were neither grossly enlarged nor microscopically hyperplastic. In a pregnancy at risk for congenital adrenal hyperplasia due to a 21-hydroxylase deficiency, amniocentesis was performed in the 18th week of gestation. The 21-hydroxylase defect was established by HLA typing and highly elevated levels of 17-hydroxyprogesterone, testosterone, and androstendione in amniotic fluid. After counselling, the parents, who already had a girl with the salt-wasting form of 21-hydroxylase deficiency, wished termination of the pregnancy. The aborted 20-week-old fetus was within the normal range for gestational age in weight and height. The external genitalia were ambiguous and extremely virilized, with an enlarged clitoris and fused labioscrotal folds. A urogenital sinus opened at the base of the clitoris. The internal organs were female, with a normal uterus and ovaries. Both adrenals were normal in size and weight for their gestational age. Histological examination of the adrenals revealed no abnormalities, and no hyperplasia was detectable. Thus, the adrenals in the 21-hydroxylase defect during fetal life secrete excessive amounts of androgens and cause virilization in the absence of adrenocortical hyperplasia.

Testosterone and androstenedione concentrations in human testis and epididymis during the first two years of life

Testosterone and androstenedione were measured in testicular and epididymal tissue of 37 previously healthy infants between 1 and 24 months of age who died suddenly. In half of the patients elevated plasma levels of cortisol and androstenedione suggested preterminal stress. Plasma testosterone levels, however, did not differ from those in healthy infants. Testicular testosterone concentrations were maximal in boys from 1-3 months of age (median, 36.6 ng/g; range, 7-380 ng/g) with peak values similar to those found in pubertal or even adult testes. Thereafter testicular testosterone concentrations decreased and after the age of 6 months all values were below 12.5 ng/g, which corresponds to the low normal range of older prepubertal boys. Plasma testosterone and testicular testosterone correlated significantly (P less than 0.001). On average the testicular concentrations were 36.4 times higher than the corresponding plasma concentrations. Testicular androstenedione was low but correlated significantly with testicular testosterone (P less than 0.001). Epididymal testosterone concentrations were surprisingly high (1-3 months: median, 10.3 ng/g; range, 4-42.7 ng/g) and averaged 30% of the testicular testosterone concentration. Thus, epididymal testosterone concentrations were significantly higher than the circulating plasma testosterone levels, indicating the capacity of the infant epididymis to accumulate androgens. These findings suggest that high local testosterone concentrations during early infancy are important not only for the testis itself but particularly for the developing epididymis.

Corticotropin releasing factor (CRF)-stimulation test in normal controls and patients with disturbances of the hypothalamo-pituitary-adrenal axis

Intravenous application of 100 micrograms synthetic ovine corticotropin releasing factor (CRF) led to stimulation of ACTH-secretion in nine normal controls, with a maximum 30 min after CRF. Cortisol, corticosterone, cortisone and 11-deoxycortisol increased with a maximum at 60 min after CRF, whereas no rise was seen in aldosterone, 11-deoxycorticosterone, 17-alpha-hydroxyprogesterone, progesterone, DHEA-S and testosterone. The specificity of CRF-stimulation was also shown by unchanged TSH, LH, FSH, hGH, prolactin and thyroid hormone levels, als well as unchanged insulin and gastrin levels. No serious side-effects were observed during the test period and afterwards. CRF-tests were performed in ten patients with disturbances of the hypothalamo pituitary adrenal axis (HPAA). Preliminary findings show hyperresponsiveness of ACTH in all situations of ACTH-hypersecretion (two patients with Cushing's disease, one patient with Nelson's syndrome, and one with Addison's disease). In contrast, one patient with successful microadenomectomy showed no response of ACTH to CRF, whereas in another patient with a macroadenoma ACTH and cortisol-levels still increased postoperatively. Divergent patterns in ACTH-responsiveness to CRF were seen in four patients with secondary adrenal insufficiency, allowing the localization of the defect. These data point to the possible importance of the "CRF-test" as a differential diagnostic tool and prognostic factor in diseases of the HPAA.

The effect of ACTH stimulation on plasma steroids in two patients with congenital hypoaldosteronism and in their relatives

In two children with isolated congenital hyperreninaemic hypoaldosteronism, as well as in their relatives, plasma levels of aldosterone (Aldo), corticosterone (B), deoxycorticosterone (DOC), 18-OH-B and 18-OH-DOC were measured before and after an iv bolus of 0.25 mg Synacthen (Ciba). A corticosterone methyl oxidase deficiency type II was demonstrated in one child. Her normoreninaemic parents (no consanguinity) had plasma values consistent with heterozygosity. The results in the other child and one asymptomatic sib were compatible with a partial corticosterone methyl oxidase deficiency type I. His parents were consanguine but had normal Aldo levels. Overnight dexamethasone administration did not suppress any of the steroids measured except cortisol, suggesting synthesis of these steroids by the zona glomerulosa.

Blunted aldosterone response to dexamethasone in female patients with endogenous depression

(1) The dexamethasone suppression test (DST) was utilized to study the aldosterone (Aldo) response in patients with endogenous depression (ED). This adrenal steroid is believed to be regulated by CNS factors different from ACTH. (2) Six female patients (two pre- and four post-menopausal) and six female healthy controls (three pre-and three post-menopausal) were studied under equivalent conditions. Venous blood samples were taken at 0900 and 2300 hr before and at 0900, 1600 and 2300 hr after dexamethasone (2 mg p.o.) given at 2300 hr. In healthy controls, the median of plasma Aldo at 0900 hr before dexamethasone was lower than at 0900 hr after drug administration (p less than 0.01), while the opposite change occurred in the patients. The median of the controls at 0900 hr post-dexamethasone was 101 pg/ml, and that of the patients was 23 pg/ml (p less than 0.025). (3) According to these observations dexamethasone appears to have a stimulatory effect on 0900 hr plasma Aldo-levels, which are blunted in patients with ED. This finding possibly signifies disinhibited central dopaminergic function in ED. Whether dopamine acts directly on the adrenal gland or modulates Aldo secretion via Aldo-releasing factors different from ACTH remains unresolved. The neurotransmitter process which underlies Aldo regulation appears to be substantially altered in ED.

Concentrations of aldosterone, corticosterone, 11-deoxycorticosterone, progesterone, 17-hydroxyprogesterone, 11-deoxycortisol, cortisol, and cortisone determined simultaneously in human amniotic fluid throughout gestation

Corticosteroids (CS) are essential for fetal organ maturation; yet, knowledge of endogeneous CS and precursor levels throughout fetal life is limited. Therefore, unconjugated aldosterone (Aldo), corticosterone (B), 11-deoxycorticosterone (DOC), progesterone (P), 17 alpha-hydroxyprogesterone (17-OHP), 11-deoxycortisol (S), cortisol (F), and cortisone (E) were simultaneously determined by RIA after automated Sephadex LH-20 chromatography in 70 control samples of amniotic fluid (AF) obtained at all gestational ages between 14-42 weeks. Levels of the progestins P and 17-OHP slowly increased from means (+/- SE) of 14.7 +/- 2.8 and 1.63 +/- 0.21 ng/ml, respectively, in early gestation to maximum levels of 32.4 +/- 3.5 and 3.80 +/- 0.74 ng/ml at 36-38 weeks (P less than 0.005), then dropped significantly (P less than 0.01) to 19.2 +/- 2.2 and 1.58 +/- 0.22 ng/ml at term. All CS levels except E rose very markedly by 3- to 12-fold (P less than 0.0001) from the weeks 14-16 (DOC, 0.44 +/- 0.08; B, 1.49 +/- 0.23; Aldo, 0.043 +/- 0.012; S, 0.51 +/- 0.10; F, 5.96 +/- 0.93 ng/ml) until the 36-38th weeks (DOC, 3.50 +/- 0.66; B, 4.60 +/- 0.78; Aldo, 0.530 +/- 0.109; S, 6.00 +/- 0.75; F, 60.8 +/- 8.9 ng/ml). Term levels were significantly reduced (P less than 0.01) in the less active CS DOC (0.51 +/- 0.07 ng/ml), B (2.35 +/- 0.35 ng/ml), and S (1.14 +/- 0.14 ng/ml), whereas those of the biologically most potent CS Aldo and F declined less markedly (0.272 +/- 0.053 and 23.0 +/- 0.75 ng/ml, respectively, at 39-42 weeks). Levels of the inactive glucocorticoid E rose from 8.83 +/- 1.08 ng/ml at 14-16 weeks to 16.8 +/- 2.6 ng/ml at 31-35 weeks (P less than 0.01), then remained rather constant around 11.5 ng/ml until term. It is concluded that after the 25th week, large amounts of biologically active CS are available in AF which probably directly induce the final epithelial maturation of fetal lungs and intestinal tract.

Plasma levels of aldosterone, corticosterone, 11-deoxycorticosterone, progesterone, 17-hydroxyprogesterone, cortisol, and cortisone during infancy and childhood

Plasma aldosterone (A), corticosterone (B), deoxycorticosterone (DOC), progesterone (P), 17-hydroxyprogesterone (17-OHP), cortisol (F), and cortisone (E) were measured simultaneously by specific radioimmunoassays in small plasma samples obtained from 174 normal infants and children between 2 hr and 15 yr of age. The significantly elevated neonatal mean levels (ng/ml) of 2.5 (A), 4.1 (DOC), 53.0 (P), and 6.6 (17-OHP) dropped significantly during infancy reaching prepubertal levels between 3 months and 3 yr of age, with a transient, significant DOC increase between 1--7 yr. The glucocorticoids F andB declined significantly from means of 68 and 4.4 to 11.4 and 0.28 ng/ml, respectively, during the first weeks of life, then increased significantly reaching adult levels between 1--3 yr of age. Mean E fell progressively from 74 ng/ml after birth to 10 ng/ml during 1--5 yr (P less than 0.0001), then slightly increased to adult levels. After age 7 yr, P and 17-OHP, in contrast to the other steroids, rose significantly in both boys and girls relative to pubertal development. The observed changes are thought to be due to (1) adaptation of the adrenal neocortex to extrauterine life after disruption of the fetoplacental unit, (2) a physiologic lack of corticosteroid binding globulin (CBG) during infancy due to maturation of hepatic CBG biosynthesis, (3) the functional immaturity of the infant kidney compensated by an increased activity of the renin-angiotensin-aldosterone system, and (4) gradually increasing gonadal secretion of progestins during puberty.

Simultaneous determination of seven unconjugated steroids in maternal venous and umbilical arterial and venous serum in elective and emergency cesarean section at term

In order to assess specific gluco- and mineralocorticoid functions in both mother and fetoplacental unit in relation to the presence or absence of labor, serum levels of unconjugated aldosterone (A), corticosterone (B), deoxycorticosterone (DOC), progesterone (P), 17-hydroxyprogesterone (17-OHP), cortisol (F), and cortisone (E) were determined simultaneously. These levels were determined by specific radioimmunoassays in two groups of 24 paired maternal venous and umbilical arterial and venous samples obtained at term delivery by either elective (Group I, N = 8) or emergency (Group II, N = 8) cesarean section. In Group II, after spontaneous labor, mean maternal serum levels of all steroids investigated exceeded those found in Group I (not in labor). These increases were most pronounced (p less than 0.005) in F (74%) and DOC (106%) levels demonstrating stimulation of both the glucocorticoid (cortisol)--and the mineralocorticoid (aldosterone)--producing pathways of the maternal adrenals by spontaneous labor. Arteriovenous differences in umbilical steroid levels revealed in both groups the placental origin of P, 17-OHP, and E (p less than 0.05 to 0.005), with greater (more negative) mean AV differences after labor (Group II). The negative AV difference of DOC, B, A, and F found in Group I, however, decreased after labor and became even positive in the cases of B and F, reflecting the close relationship between spontaneous labor and the fetal adrenal's active production not only of the glucocorticoids B and F, but also, to a lesser extent, of the mineralocorticoids DOC and aldosterone.