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.

Fertility in cryptorchidism. Does treatment make a difference?

The testis which remains nonscrotal beyond puberty will not produce sperm. While much of the data presented imply that therapy of cryptorchidism during childhood will decrease the likelihood of infertility, the available data do not substantiate this. There are also inadequate data to indicate whether treatment at very young ages in childhood decreases the risk of infertility. In fact, it is not clear that fertility rates among males who were unilaterally cryptorchid is different than that of the unaffected male population! Therefore, verification is needed to determine whether or not fertility is decreased in cryptorchidism. Paternity is a better index for verification than sperm counts since it is known that men with subnormal sperm counts may have normal paternity rates. Such verification using paternity may require more than fathering a child, such as the age of the father at the birth of the first child, length of marriage or partnership before birth of the first or subsequent children, or duration of intercourse without contraception to birth. Because of the multiple etiologies of the cryptorchid state, factors such as the relative size of the testis before treatment, and the position of the testis and the histology of the testis need to be considered since the small testis, the abdominal testis and the testis with the most histologic changes would appear to be at the greatest risk for defects in spermatogenesis. Until these data become available, most physicians are likely to recommend treatment of the undescended testis when detected if the child is older than six months. However, it must be remembered that there are no data to indicate benefit of early treatment. Before treatment is initiated, the physician must be careful to rule out a retractile testis. Also, the possibility of ascent of the testis which may occur during midchildhood, the age of physiologically normal hypogonadotropism, must be remembered. The testis which was previously normally descended but resides much of the time during midchildhood years within the inguinal canal may be a variant of normal and not require therapy. The approach to the patient with cryptorchidism must involve a careful history and repeated examinations looking for a cause and for accurate position of the testis. If the testis can be moved from the nonscrotal position into the scrotum, the potential function of the testis should not be harmed.(ABSTRACT TRUNCATED AT 400 WORDS)

Polycystic ovary syndrome

Polycystic ovary syndrome, characterized by hyperandrogenism and menstrual irregularities, is a heterogeneous group of disorders that can disrupt normal hypothalamic-pituitary-ovarian function. Ovarian physiology is reviewed with regard to possible etiologies for excessive androgen secretion. Similar features may be present in errors in steroidogenesis, hyperprolactinemia, androgen-secreting tumors, and Cushing's syndrome. Analysis of the interrelationships between the reproductive axis and carbohydrate metabolism suggests that the associated insulin resistance can induce hyperandrogenism. Improved understanding of the various etiologies may expand the therapeutic options for patients.

Altered CYP21 genes in HLA-haplotypes associated with congenital adrenal hyperplasia (CAH): a family study

Disorders of the CYP21 gene, which is located within the major histocompatibility complex on the short arm of chromosome 6, are the leading causes of congenital adrenal hyperplasia (CAH). The coding gene and a highly homologous pseudogene are tandemly arranged with the two genes for the fourth component of complement (C4A and C4B). To analyse the prevalence rates of mutations of the CYP21 genes and the segregation of the CYP21 genes with their corresponding human leucocyte antigen (HLA)-haplotypes, 21 families with one or two children with the severe form of 21-hydroxylase deficiency were studied. Mutations of the CYP21 gene on their corresponding HLA-haplotype were detected by hybridisation of polymerase chain reaction (PCR)-amplified genomic DNA with sequence-specific oligonucleotides and solid phase direct sequencing. Our study has shown the following. (1) A single basepair mutation (A-->G or C-->G) within the second intron is the most frequent mutation leading to impaired 21-hydroxylase activity. This mutation is only detected in HLA-haplotypes associated with the salt-wasting form of CAH. (2) A large deletion of part or all of the CYP21 gene is associated with the HLA-haplotype A3, BW47, C6, DR7, DR53, DQ2 but is also observed in other HLA-haplotypes and can be detected by a simple rapid PCR restriction fragment length polymorphism method. (3) Two alleles of the coding CYP21 gene differing in a leucine codon within the first exon, (formerly described as a mutation associated with 21-hydroxylase deficiency) have been found with an equal distribution in patients with 21-hydroxylase deficiency, non-disease HLA-haplotypes and the local healthy controls.

Detection of Y chromosome sequences in Turner's syndrome by Southern blot analysis of amplified DNA

Only about half of all patients with Turner's syndrome are monosomy 45,X on karyotyping and there are grounds for supposing that cryptic mosaicism for at least part of the Y chromosome may be present in some patients. If so this would be clinically important because of the risk to patients of gonadal neoplasms and virilisation. We have used a very sensitive method to detect Y chromosomal segments in eighteen patients with Turner's syndrome, none of whom had evidence of Y chromosomal material by cytogenetic analysis. In DNA from peripheral blood lymphocytes and/or fibroblasts we looked for specific nucleotide sequences from the sex-determining region of the Y chromosome (SRY gene) and repetitive sequences located at the centromeric region (DYZ3). By polymerase chain amplification (PCR) one patient had a definite positive signal and two patients had faintly positive signals for the SRY gene. Southern blot analysis of PCR material with a SRY-specific probe confirmed that these patients were positive for SRY and revealed another three. No patient was positive for DYZ3, suggesting that only a small portion of Y was present. These results suggest that "pure" 45,X monosomy is less frequent than previously supposed. Long-term follow-up of patients with Y sequences is needed to determine their risk for subsequent gonadal neoplasms and virilisation.

Continuous arteriovenous hemofiltration therapy for Staphylococcus aureus-induced septicemia in immature swine

OBJECTIVES

The goals of this study were: a) to evaluate the efficacy of controlled, continuous arteriovenous hemofiltration in improving morbidity and mortality rates in an immature swine model of Staphylococcus aureus-induced septicemia; b) to determine if ultrafiltrate from septic animals contained mediators that produce pathophysiologic changes observed in untreated S. aureus septic pigs.

DESIGN

Prospective, randomized, controlled study with age-matched controls.

SETTING

U.S. Department of Agriculture-licensed biomedical research facility.

SUBJECTS

Sixty-five weaned Poland-China swine (4 to 6 wks of age; 5 to 10 kg).

INTERVENTIONS

Part 1: Animals received a lethal dose of live S. aureus (8 x 10(9) colony-forming units/kg) over 1 hr. The three treatment groups included: hemofiltration group 1 (eight filtered, eight nonfiltered animals), plasma filtration fraction = 5.5%; hemofiltration group 2 (six filtered, six nonfiltered animals), filtration fraction = 16.6%; and hemofiltration group 3 (six filtered, six nonfiltered animals), filtration fraction = 33.4%. A control, nonseptic group of animals (n = 4) was filtered to obtain "clean" ultrafiltrate (hemofiltration group 4). Part 2: Sterile ultrafiltrate concentrate batches obtained from each group of filtered, septic animals were concentrated and infused into healthy, nonseptic pigs (reinfusion groups 1 through 3).

MEASUREMENTS AND MAIN RESULTS

Physiologic, biochemical, and hematologic variables were measured in all animals every 1 to 3 hrs. Overall length of survival was also recorded. In hemofiltration groups 1 through 3, filtered animals survived significantly longer than matched, nonfiltered (sham-filtered) animals. Increments in survival time increased directly with filtration fraction. Ultrafiltrate concentrate from septic pigs produced death (LD41) and disease similar to those rates observed in untreated S. aureus-septic pigs. Infusion of clean ultrafiltrate concentrate produced no response.

CONCLUSIONS

Continuous arteriovenous hemofiltration significantly improved survival rates in swine with S. aureus-induced sepsis. Resultant ultrafiltrate concentrate contained mediators responsible for some pathophysiologic responses observed in this animal model.