Progressive virilization of a pubertal phenotypic female: 17 beta-hydroxysteroid dehydrogenase deficiency

17 beta-Hydroxysteroid dehydrogenase deficiency is an uncommon inherited disorder characterized by genital ambiguity and progressive pubertal virilization. We describe the clinical and biochemical features in a 13-year-old 46, XY individual who presented with progressive pubertal virilization.

Who is a carrier? Detection of unsuspected mutations in 21-hydroxylase deficiency

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is a common autosomal-recessive disorder. During our routine genotyping of affected individuals and their relatives using allele-specific oligonucleotide hybridization and single-strand conformational polymorphism analysis, we identified two families each segregating three mutations. In both families, a mutation known to be associated with 21-hydroxylase deficiency was identified in healthy individuals but was not detected in the propositus. The propositus in family 1 was shown to be a homozygous carrier for G at nucleotide 655, which alters the splice acceptor site at exon 3. The propositus in family 2 carried the same splicing mutation on the maternal allele and a gene deletion/conversion on the paternal allele. In both families, other clinically unaffected relatives carried the Q318X mutation in exon 8. If molecular diagnostic studies had been limited to the mutation carried by the propositi, relatives would have been misinformed regarding their status as carriers or mildly affected individuals. The findings in these two families emphasize the high frequency of alleles causing 21-hydroxylase deficiency in the population.

Ultradian rhythms in performance on tests of specialized cognitive function

Performance on cognitive tasks cycled at ultradian frequencies for 24 males over a test period of eight hours. The verbal task of written word production cycled at 80 minutes; the spatial task of locating points in space cycled at 96 minutes. Multiple cycles were seen for a perceptual speed task that factor loads on both the verbal and spatial task. Replication of the results for the first 12 and second 12 subjects demonstrated their robustness. The verbal and spatial tasks were chosen to reflect specialized functions of the left and right cerebral hemispheres, respectively. Accordingly, the results are interpreted as evidence that specialized task performances are associated with independent neurochemical systems. In addition, blood samples were taken at task performance to assess cyclicity of hormone levels. Luteinizing hormone had a period of 120 minutes, testosterone and cortisol were inconsistent and none seemed to be related to the cognitive tasks. However when subjects were divided according to a winter or summer testing schedule, the spatial periodicity was absent for the summer group and the verbal periodicity was absent for the winter peak.

Consequence of cryptorchidism: relationship to etiology and treatment

Increased risk of infertility and testicular tumors after cryptorchidism is the basis for treatment. Over the past few decades the recommended age of therapy has become younger and younger, so that currently therapy is recommended before 2 years of age and as early as 6 months. Evidence indicates that treatment before 10 years of age reduces the incidence of testicular tumors among men who formerly had unilateral cryptorchidism to that of men without a history of cryptorchidism. However, the effect of the age of treatment among the bilateral group is unknown. Infertility after bilateral cryptorchidism is about six times greater than that of the general population, affecting about half of patients; it appears to be only two times greater among the unilateral group, affecting about 10% of patients. To date no effect of age of therapy has been demonstrated, although current studies have not been able to consider the underlying cause of the cryptorchidism. Data are not yet available to determine whether pretreatment testicular location or size is related to subsequent fertility. The current recommendation for treatment within the first 2 years of life is based on the progressive degeneration of germ cells within the persistently cryptorchid testis after the first year of life. This recommendation should stand, even though some testes may be irretrievably damaged before such early therapy, and others may suffer minimal or no detrimental effect after delayed treatment. Future information may identify specific causes of cryptorchidism and, hence, determination of which patients will benefit from early therapy.

Normal ranges for immunochemiluminometric gonadotropin assays

OBJECTIVE

We sought to establish normative data for spontaneous and gonadotropin-releasing hormone (GnRH)-stimulated serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels measured by new immunochemiluminometric assays (ICMA) in children and adolescents.

METHODS

Random serum samples were obtained from 375 normal subjects (0.1 to 17.7 years, 230 female subjects). Intravenous GnRH stimulation tests were performed in 41 normal subjects (4.8 to 18 years, 20 female subjects). Normal ranges were calculated by age and Tanner stage. Immunochemiluminometric assays of LH and FSH concentrations were compared with levels obtained by a sensitive immunofluorometric assay and a less sensitive radioimmunoassay.

RESULTS

Random gonadotropin concentrations in normal children followed the pattern of transient elevation in infancy, low but measurable prepubertal levels, and markedly increased values at puberty. Spontaneous LH levels were higher in male infants but were not statistically different in boys and girls after infancy. Mean prepubertal LH was 0.04 +/- 0.04 IU/L (n = 66), rising 100-fold during puberty. Spontaneous FSH levels were much higher than LH values, were higher in female infants, and rose threefold at puberty. Peak GnRH-stimulated LH was identical in prepubertal boys and girls (1.8 +/- 1.3 IU/L, n = 17) and increased 20-fold at puberty. Mean peak GnRH-stimulated FSH was highest in prepubertal female subjects. Luteinizing hormone values measured by ICMA and immunofluorometric assay were highly correlated, but radioimmunoassay levels diverged markedly from ICMA levels at lower concentrations. Because absolute levels were higher, FSH values correlated adequately in the three assays throughout the normal physiologic range.

CONCLUSIONS

Measurement of LH by ICMA is much more sensitive than older assay methods. Spontaneous LH can be accurately measured by ICMA to the very low levels present in normal prepubertal children, providing a potentially important biochemical discriminator of pubertal status. An ICMA GnRH-stimulated LH level greater than 5 IU/L is suggestive of maturing gonadotropin secretion. The ICMA LH assays provide significant enhancement in sensitivity; these assays should be used when levels may be low, and by their accuracy may reduce the time and expense of testing procedures.

Spontaneous serum gonadotropin concentrations in the evaluation of precocious puberty

OBJECTIVE

We assessed the utility of spontaneous and gonadotropin-releasing hormone (GnRH)-stimulated serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels measured by new immunochemiluminometric assays in the evaluation and monitoring of precocious puberty.

METHODS

We evaluated serum gonadotropin values from intravenous GnRH stimulation tests in 49 girls with clinical signs suggesting central precocious puberty (CPP). Because GnRH-stimulated LH has been considered the standard for diagnosing CPP, we used it as the basis for comparison with GnRH-stimulated FSH levels and spontaneous LH and FSH measured by immunochemiluminometric assay.

RESULTS

Twenty-six patients had a peak serum LH value above the +2 SD threshold for normal prepubertal female subjects (LH > 5 IU/L). The GnRH-stimulated FSH values had a narrow range and did not discriminate patients with CPP. In contrast, elevations in spontaneous LH and FSH were found to be specific for CPP. Spontaneous LH levels correlated strongly with peak stimulated LH levels in subjects with precocious puberty (r = 0.79) or in control subjects (r = 0.93, both p (0.0001). Spontaneous LH levels in excess of 0.1 IU/L detected true puberty with 94% sensitivity and 88% specificity. Random LH levels in excess of 0.3 IU/L had 100% specificity for CPP.

CONCLUSIONS

The GnRH-stimulated FSH levels do not adequately differentiate children with and without CPP and have limited utility in the evaluation of precocious puberty. Spontaneous FSH levels are elevated in CPP with fair sensitivity and marked specificity. Elevated random LH, measured by third-generation assay such as immunochemiluminometric assay, is strongly correlated with and highly predictive of elevated peak GnRH-stimulated LH, and is a useful screening tool for CPP.

Paternity after cryptorchidism: lack of correlation with age at orchidopexy

OBJECTIVE

To determine whether paternity is decreased among men who were formerly unilaterally or bilaterally cryptorchid and to ascertain whether paternity is related to their age at orchidopexy.

SUBJECTS AND METHODS

Men who underwent orchidopexy between 1955 and 1969 at the Children's Hospital of Pittsburgh (363) and a group of age-matched control men (336) were surveyed by questionnaire and their medical records reviewed.

RESULTS

Of the married men, significantly more of the unilateral cryptorchid (75%) and control (76%) groups had fathered children than had the bilateral cryptorchid group (P < 0.005). Furthermore, when the groups were compared during the period of regular intercourse with no contraception until conception of their first child, the bilateral group had relatively fewer conceptions during the first year and more after the first year. When the unilateral and bilateral groups were analysed separately, there was no relationship between either age at orchidopexy and paternity or between the age at orchidopexy and the duration of regular unprotected intercourse before conception.

CONCLUSIONS

Compared with a control group, paternity was compromised after bilateral, but not unilateral, cryptorchidism. Age at orchidopexy was not correlated with paternity.

Meningioma In Congenital Adrenal Hyperplasia

A diversity of malignancies have been reported in patients with congenital adrenal hyperplasia. We report a case of multiple meningiomas, tumors which are more common in females and reported to have sex steroid receptors, in a 46,XX male (severe female hermaphrodite raised as a male) with 21-hydroxylase deficiency. The patient has been treated with glucocorticoids since 3 years of age and testosterone since puberty.

Detection of Y chromosome sequences in a 45,X/46,XXq--patient by Southern blot analysis of PCR-amplified DNA and fluorescent in situ hybridization (FISH)

In some cases of gonadal dysgenesis, cytogenetic analysis seems to be discordant with the phenotype of the patients. We have applied techniques such as Southern blot analysis and fluorescent in situ hybridization (FISH) to resolve the phenotype/genotype discrepancy in a patient with ambiguous genitalia in whom the peripheral blood karyotype was 45,X. Gonadectomy at age 7 months showed the gonadal tissue to be prepubertal testis on the left side and a streak gonad on the right. The karyotype obtained from the left gonad was 45,X/46,XXq- and that from the right gonad was 45,X. Three different techniques, PCR amplification, FISH, and chromosome painting for X and Y chromosomes, confirmed the presence of Y chromosome sequences. Five different tissues were evaluated. The highest percentage of Y chromosome positive cells were detected in the left gonad, followed by the peripheral blood lymphocytes, skin fibroblasts, and buccal mucosa. No Y chromosomal material could be identified in the right gonad. Since the Xq- chromosome is present in the left gonad (testis), it is likely that the Xq- contains Y chromosomal material. Sophisticated analysis in this patient showed that she has at least 2 cell lines, one of which contains Y chromosomal material. These techniques elucidated the molecular basis of the genital ambiguity for this patient. When Y chromosome sequences are present in patients with Ullrich-Turner syndrome or gonadal dysgenesis, the risk for gonadal malignancy is significantly increased. Hence, molecular diagnostic methods to ascertain for the presence of Y chromosome sequences may expedite the evaluation of patients with ambiguous genitalia.

Automated reticulocyte counting and measurement of reticulocyte cellular indices. Evaluation of the Miles H*3 blood analyzer

This study evaluated reticulocyte counting and measurement of reticulocyte cellular indices with the Miles H*3 blood analyzer, a new instrument that combines the Technicon/Miles technology for blood cells counting with a staining technique allowing counting of reticulocytes, quantification of staining intensity and measurement of reticulocyte cellular indices. Reticulocyte counts obtained with the Miles H*3 analyzer were compared with those obtained by manual counting, flow cytometry (thiazole orange method) and by the Sysmex R-3000 (Baxter Diagnostics) reticulocyte analyzer. Reticulocyte counting with the Miles H*3 showed excellent precision, and linearity in the range tested (1.1-49% and 1-72% reticulocytes, respectively, with two different protocols) with no significant carryover. Reticulocyte counts were stable after storing blood samples for 72 hours at 4 degrees C. Comparison of the four different methods, showed an acceptable intraclass correlation between Miles H*3 and Sysmex R-3000 (intraclass correlation coefficient, [ri] = .952), Miles H*3 and flow cytometry (ri = .922), and Sysmex R-3000 and flow cytometry (ri = .938). There was no satisfactory correlation between any of the three automated methods and the values obtained with manual counting of reticulocytes (ri = .538-.755), consistent with the well known imprecision of the manual technique. For a group of normal pediatric subjects, age 1-10, we obtained the following values (+/- SD) of reticulocyte indices: mean corpuscular volume 97.6 +/- 4.7 fL; cell hemoglobin concentration mean 28.2 +/- 1.4 g/dL; cell hemoglobin content 26.7 +/- 1.6 pg. We determined the direct cost, including depreciation, of the manual and instrumental methods. Cost/test varied from $1.61 for manual method to $6.03 for the Sysmex R-3000. Cost/test for flow cytometry and Miles H*3 were $3.34 and $3.49, respectively.

Laboratory monitoring of children with precocious puberty

It is necessary not only to perform laboratory tests for the correct diagnosis of children with precocious puberty, but also to monitor laboratory tests to ensure adequacy of therapy. Careful laboratory testing is a requisite in the differentiation of central from peripheral precocious puberty. It is also required to determine whether the patient who presents with early physical changes of pubertal development with peripheral precocious puberty has evidence of pubertal hormonal secretion. The most useful single test is gonadotropin-releasing hormone (gonadorelin) stimulation of luteinizing hormone release. The same stimulation test is also indicated to verify the adequacy of suppression of gonadotropin secretion among patients with central precocious puberty who are being treated with gonadotropin-releasing hormone analogue. It is necessary to know which gonadotropin assay is being used and the range of normal levels to correctly interpret the tests.