Familial male hermaphroditism with ambiguous external genitalia

Agonadism in two sisters with XY gonosomal constitution, mental retardation, short stature, severely retarded bone age, and multiple extragenital malformations: a new autosomal recessive syndrome

We report on 12- and 14-year old sisters with a 46, XY chromosome constitution, normal female external genitalia, and absence of gonadal tissue. Except for omphalocele, right renal agenesis and malrotation of the colon in the elder sister, the internal organs were normal. Both were mentally retarded, of short stature, and had extremely retarded bone age. In addition, they had an almost identical pattern of minor anomalies: peculiar face, hypodontia, short neck, inverted nipples, thoracolumbar scoliosis, "dysplastic" hips, partial clino-/syndactyly of toes. The occurrence of a basically similar set of malformations in two sisters and the first cousin consanguinity of the parents suggests autosomal recessive inheritance. The conserved region of the SRY gene ([high mobility group] HMG box) was sequenced in the elder sib and was normal. No consistent malformations are observed at present in agonadal patients. This supports the idea that several autosomal genes have the potential of influencing the sequence of events of sex determination.

Familial occurrence of agonadism and multiple internal malformations in phenotypically normal girls with 46,XY and 46,XX karyotypes, respectively: a new autosomal recessive syndrome

We report on 2 phenotypic sisters, one with 46,XY; the other with 46,XX. The 2 girls had similar related internal malformations, including agonadism, hypoplasia of the right pulmonary artery, hypoplasia of the right lung, isolated dextrocardia with complex vitium cordis, and diaphragmatic hernia (only sib 1) or omphalocele (only sib 2). This combination of malformations did not fit into any of the previously described syndromes. For this syndrome we suggest the acronym PAGOD ([hypoplasia of the] pulmo, and pulmonary artery, agonadism, omphalocele/diaphragmatic defect, dextrocardia). The occurrence of a basically similar set of malformations in 2 unlike sex is interpreted as evidence for autosomal recessive inheritance. The different gonosomal status excludes the Y chromosome as a responsible factor. The peculiar finding of a 46,XX sex chromosome constitution combined with agonadism and an intact urogenitral tract emphasizes the concept of secondary regression of Wolffian and Müllerian structures. The associated malformations of mesodermal structures can be interpreted as midline defects. We suggest that, from the developmental field perspective, secondary regression of midline structures including the gonadal anlage explains the pathogenesis reasonably well.

Steroid 17β-hydroxysteroid dehydrogenase deficiency in man: an inherited form of male pseudohermaphroditism

Sixty-eight males with testicular 17β-hydroxysteroid dehydrogenase deficiency (17β-HSD) were identified among a highly inbred Arab population in Israel, and 45 studied over the last 15 years. The founders of this defect originated in the mountainous region of present Lebanon and Syria, but most of the families now live in Jerusalem, Hebron, the Tel-Aviv area, and in particular Gaza, where the frequency of affected males is estimated at 1 in 100 to 150. Affected individuals (46,XY) are born with ambiguity of the genitalia and reared as females until puberty. Thereafter marked virilization occurs, leading in many cases to the spontaneous adoption of a male gender role. Adults develop a male habitus with abundant body hair and beard, and the phallus and testes enlarge to adult proportions. Gender reassignment was possible only when enough erectile tissue was present at birth and developed into a normal size penis with systemic testosterone. male genitoplasty was performed in 15 children and 8 post-pubertal patients, and female genitoplasty in 2 children and 4 post-pubertal patients. In adults the defect is characterized by markedly increased concentrations of 4-androstendione (4-A) with borderline low to normal testosterone (T) levels, and a high 4-A/T ratio. Dihydrotestosterone (DHT) concentrations were either moderately decreased, normal, or high, and dehydroepiandrosterone levels were high. The estrogen pathway was also impaired, even though both estrone and estradiol-17β levels were elevated. Children had low basal levels of all androgens, but the defect could be demonstrated after prolonged stimulation with human chorionic gonadotropin. LH and FSH levels were very high after puberty, and normal in childhood. However, an over-response to gonadotropin-releasing hormone was found at all ages. Studies in testicular tissue revealed various abnormalities in steroid metabolism. Tissue from pre-pubertal patients metabolized progesterone (P) only to 4-A, while tissue from post-pubertal patients metabolized P to 16α- and 16β-hydroxyprogesterone (5.4- to 10.3-fold greater production), 17α-hydroxyprogesterone (5.4- to 8-fold smaller production), 4-A and T. 4-A was also metabolized to T, indicating that 17β-HSD was no longer deficient. Flow studies with equimolar concentrations of [¹⁴C]P and [³H]pregnenolone showed that the 5-ene pathway was the preferential one for androgen biosynthesis. Both in vivo and in vitro studies indicate that the severity of testicular 17β-HSD deficiency changes with age. Whereas the enzyme activity is absent in childhood, there is a progressive restoration after puberty. Androgen production increases progressively to normal so that T and DHT concentrations are sufficiently high to gradually induce somatic and genital virilization, thus enabling an adequate male gender function.

True agonadism: report of a case analyzed with Y-specific DNA probes

We report on a 5-year-old girl with a male karyotype (46,XY), severe psychomotor and physical retardation, minor anomalies, and female external genitalia with a blindly ending vagina. She has normal adrenal function, prepubertal serum gonadotropin and testosterone levels, which did not rise after hCG stimulation. On abdominal exploration no gonads were found, and only mesonephric and Müllerian remnants. She was HY positive, and no deletion was detected in the Y chromosome using 5 different probes. Although a genetic defect is not excluded, pregnancy complications suggest an environmental insult to the developing testes.

Unilateral true hermaphrodite with 46,XX/46,XY dispermic chimerism

A 13 year old female presented with ambiguous external genitalia, right inguinal ovotestis, left ovary, apparently normal Mullerian system, and absent Wolffian system. Cultured lymphocytes showed a 46,XX/46,XY karyotype. Histopathology of the gonads confirmed true hermaphroditism. The presence of two genetically different erythrocyte populations was observed. The findings suggested that the patient is a true hermaphrodite dispermic chimera.

Abnormal sexual differentiation and neoplasia

The prevalence of neoplasia is increased in individuals with certain disorders of sexual differentiation. Etiology and frequency of neoplasia vary with the particular disorder. In uncomplicated cryptorchidism, the testis is at least 10 times more likely to undergo neoplastic transformation than a normal scrotal testis. Neoplasia probably is a function of both testicular location (intraabdominal) and underlying dysgenetic structure. If cryptorchidism is unilateral, and if orchiopexy has not been performed prior to age 6-10 years, orchiectomy should be encouraged. In those forms of gonadal dysgenesis not associated with a Y chromosome (e.g., 45,X; 45,X/46,XX; 46,XX) there is no definite increase in neoplasia, suggesting that elevated gonadotropin levels per se are not carcinogenic. Gonadal tumors are found in at least 30% of individuals with XY gonadal dysgenesis and are particularly frequent (55%) in H-Y antigen-positive patients. These tumors are almost always gonadoblastomas or dysgerminomas. Similar tumors are found in 15%-20% of 45,X/46,XY individuals. In either situation the neoplastic transformation could be a) secondary to the existence of XY gonadal tissue in an inhospitable environment, or b) integrally related to that process--genetic or cytogenetic--producing the dysgenetic gonads. The risk of neoplasia is sufficiently high that most of these patients should be offered early gonadal extirpation. The prevalence of gonadal tumors is not increased in Klinefelter's syndrome, further indicating that gonadotropins are not carcinogenic per se. However, Klinefelter patients are 20 times more likely to develop a carcinoma of the breast than are 46,XY males. Extragonadal germ cell tumors also are more common. In female pseudohermaphrodites there is probably no increased risk of neoplasia, whereas, in true hermaphrodites neoplasia is unusual but does occur. Neoplasia occurs in patients with complete testicular feminization (complete androgen insensitivity) but rarely in those with incomplete testicular feminization/Reifenstein's syndrome, 5 alpha-reductase deficiency, anorchia, agonadia, or testosterone biosynthetic defects. In complete testicular feminization the risk of malignant tumors is small prior to age 25. After age 25, it is about 2%-5%. Orchiectomy is recommended after pubertal feminization.

Embryonic testicular regression syndrome: variable phenotypic expression in siblings

Two 46,XY agonadal siblings with variable degrees of sexual ambiguity are described. The eldest child is a phenotypic male with micropenis. The younger patient, a phenotypic female with slight fusion of the genital folds and absent müllerian ducts, conforms to the criteria usually accepted for the diagnosis of true agonadism. Coexistence of anorchia and true agonadism in the same sibship supports the hypothesis, suggested by others, that both disorders are related and are due to the regression of the embryonic testes.

Diagnosis and management of the infant with genital ambiguity

Clinical management of a child with ambiguous external genitalia requires physicians to consider the immediate management of the condition, as well as parental reactions. They must also obtain the necessary data upon which to make a diagnosis. This review summarizes the most common disorders causing genital ambiguity and suggests approaches toward delineation.

An etiologic and pathogenetic classification of male hermaphroditism

Based on defects in the central nervous system, the gonads, the end organs and the chromosomes, an etiologic and pathogenetic classification of male hermaphroditism is presented. At least 16 categories of disorders can cause male hermaphroditism--all seem to be basically genetic in origin.