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Balagamage C, Arshad A, Elhassan YS, Ben Said W, Krone RE, Gleeson H, Idkowiak J. Management aspects of congenital adrenal hyperplasia during adolescence and transition to adult care. Clin Endocrinol (Oxf) 2023. [PMID: 37964596 DOI: 10.1111/cen.14992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/11/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023]
Abstract
The adolescent period is characterised by fundamental hormonal changes, which affect sex steroid production, cortisol metabolism and insulin sensitivity. These physiological changes have a significant impact on patients with congenital adrenal hyperplasia (CAH). An essential treatment aim across the lifespan in patients with CAH is to replace glucocorticoids sufficiently to avoid excess adrenal androgen production but equally to avoid cardiometabolic risks associated with excess glucocorticoid intake. The changes to the hormonal milieu at puberty, combined with poor adherence to medical therapy, often result in unsatisfactory control exacerbating androgen excess and increasing the risk of metabolic complications due to steroid over-replacement. With the physical and cognitive maturation of the adolescent with CAH, fertility issues and sexual function become a new focus of patient care in the paediatric clinic. This requires close surveillance for gonadal dysfunction, such as irregular periods/hirsutism or genital surgery-associated symptoms in girls and central hypogonadism or testicular adrenal rest tumours in boys. To ensure good health outcomes across the lifespan, the transition process from paediatric to adult care of patients with CAH must be planned carefully and early from the beginning of adolescence, spanning over many years into young adulthood. Its key aims are to empower the young person through education with full disclosure of their medical history, to ensure appropriate follow-up with experienced physicians and facilitate access to multispecialist teams addressing the complex needs of patients with CAH.
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Affiliation(s)
- Chamila Balagamage
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Amynta Arshad
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- The Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yasir S Elhassan
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Wogud Ben Said
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ruth E Krone
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Helena Gleeson
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jan Idkowiak
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Ferreux L, Boumerdassi Y, Dulioust E, Bertagna X, Roucher-Boulez F, Bourdon M, Thiounn N, Patrat C. Testicular impairment in Primary Adrenal Insufficiency caused by Nicotinamide Nucleotide Transhydrogenase (NNT) deficiency - a case report: implication of oxidative stress and importance of fertility preservation. Basic Clin Androl 2023; 33:17. [PMID: 36918776 PMCID: PMC10015661 DOI: 10.1186/s12610-022-00176-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 11/08/2022] [Indexed: 03/15/2023] Open
Abstract
INTRODUCTION Nicotinamide nucleotide transhydrogenase (NNT) gene deficiency has recently been shown to be involved in Primary Adrenal Insufficiency (PAI). NNT encodes an inner mitochondrial membrane protein that produces large amounts of NADPH. NADPH is used in several biosynthesis pathways and the oxidoreduction of free radicals by the glutathione and thioredoxin systems in mitochondria. Patients with PAI due to NNT deficiency may also exhibit extra-adrenal manifestations, usually including gonadal impairment. CASE REPORT We present the case of a 35-year-old patient referred to our center for primary infertility with non-obstructive azoospermia, in a context of PAI and obesity. PAI genetic exploration carried out at the age of thirty revealed NNT deficiency due to the presence of two deleterious mutations (one on each allele) in the NNT gene. Scrotal ultrasound revealed a right Testicular Adrenal Rest Tumor (TART). Intensification of glucocorticoid therapy over the course of 8 months failed to reduce the TART volume or improve sperm production and endocrine function. No spermatozoa were found after surgical exploration of both testes, and subsequent histopathological analysis revealed bilateral Sertoli cell-only syndrome. A retrospective review of the hypothalamic-pituitary-gonadic axis hormonal assessment over 20 years showed progressive impairment of testicular function, accelerated during adulthood, leading to hypergonadotropic hypogonadism and non-obstructive azoospermia when the patient reached his thirties, while the PAI remained controlled over the same period. CONCLUSION This case report provides, for the first time, direct evidence of complete germ line loss in an azoospermic man with NNT deficiency. Additional data further support the hypothesis of a determinant role of oxidative cellular damage due to reactive oxygen species (ROS) imbalance in the severe gonadal impairment observed in this NNT-deficient patient. Early and regular evaluation of gonadal function should be performed in patients with PAI, especially with NNT deficiency, as soon as the patients reach puberty. Fertility preservation options should then be provided in early adulthood for these patients.
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Affiliation(s)
- Lucile Ferreux
- Service de Biologie de La Reproduction-CECOS, CHU Cochin - Bâtiment Port Royal, Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris CitéHôpital Cochin, 123 Boulevard de Port-Royal, 75679, Paris 14, France.
| | - Yasmine Boumerdassi
- Service de Biologie de La Reproduction-CECOS, CHU Cochin - Bâtiment Port Royal, Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris CitéHôpital Cochin, 123 Boulevard de Port-Royal, 75679, Paris 14, France
| | - Emmanuel Dulioust
- Service de Biologie de La Reproduction-CECOS, CHU Cochin - Bâtiment Port Royal, Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris CitéHôpital Cochin, 123 Boulevard de Port-Royal, 75679, Paris 14, France.,Université de Paris Cité Institut Cochin, U1016, INSERM, CNRS, F-75014, Paris, France
| | - Xavier Bertagna
- Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris Cité, Hôpital Cochin, Service d'endocrinologie Et Maladies Métaboliques, Paris, France
| | - Florence Roucher-Boulez
- Hospices Civils de Lyon, HCL. Centre - Laboratoire de Biochimie Et Biologie Moléculaire, UM Endocrinologie- Centre de Référence du Développement Génital- Univ Lyon, Université Claude Bernard, Lyon 1, Lyon, France
| | - Mathilde Bourdon
- Université de Paris Cité Institut Cochin, U1016, INSERM, CNRS, F-75014, Paris, France.,Hôpitaux de Paris (AP-HP), AP-HP. Centre - Université de Paris Cité, Hôpital Cochin, Service de Gynécologie-Obstétrique II Et de Médecine de La Reproduction, Paris, France
| | - Nicolas Thiounn
- Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris Cité, Hôpital Européen Georges-Pompidou (HEGP), Service d'Urologie, Paris, France
| | - Catherine Patrat
- Service de Biologie de La Reproduction-CECOS, CHU Cochin - Bâtiment Port Royal, Hôpitaux de Paris (AP- HP), APHP. Centre - Université de Paris CitéHôpital Cochin, 123 Boulevard de Port-Royal, 75679, Paris 14, France.,Université de Paris Cité Institut Cochin, U1016, INSERM, CNRS, F-75014, Paris, France
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Onishi A, Okada K, Sato K, Kaku Y, Chiba K, Fujisawa M. Improvement in semen parameters by switching steroids in a male congenital adrenal hyperplasia patient with severe oligozoospermia. Urol Case Rep 2023; 47:102368. [PMID: 36915704 PMCID: PMC10006705 DOI: 10.1016/j.eucr.2023.102368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/25/2023] [Accepted: 03/01/2023] [Indexed: 03/05/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) causes hypogonadotropic hypogonadism due to the excessive production of adrenal androgens, which results in hypospermatogenesis in some male patients. We herein present a CAH case with hypogonadotropic hypogonadism and male infertility. A 26-year-old male receiving steroid therapy for 21 hydroxylase deficiency was diagnosed with low gonadotropin levels, an elevated ACTH level, and severe oligozoospermia. The switching from hydrocortisone to dexamethasone resulted in the normalization of gonadotropin levels and semen findings. The couple underwent ICSI-ET, resulting in a live birth. In cases of CAH with hypospermatogenesis, the continuous suppression of ACTH by dexamethasone may restore spermatogenesis.
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Affiliation(s)
- Atsushi Onishi
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Keisuke Okada
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Katsuya Sato
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Yasuhiro Kaku
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Koji Chiba
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
| | - Masato Fujisawa
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 6500017, Japan
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Yu SY, Freed KM. Testicular Adrenal Rest Tumors in a Patient With Congenital Adrenal Hyperplasia. Cureus 2022; 14:e28350. [PMID: 36168332 PMCID: PMC9506676 DOI: 10.7759/cureus.28350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Ultrasound is the imaging examination of choice for evaluation of suspected testicular pathology. The differential diagnosis of bilateral testicular lesions includes malignancy such as lymphoma and metastases, infection, and, uncommonly, adrenal rest tumors. We present a patient who developed bilateral testicular adrenal rest tumors after years of poorly controlled congenital adrenal hyperplasia, possibly due to chronically elevated adrenocorticotropic hormone stimulating the growth of testicular stem cells. Our patient also has a testicular ultrasound appearance that is hyperechogenic, rather than hypoechogenic as commonly described in the literature. Treatment adherence is important in the management of congenital adrenal hyperplasia, as testicular adrenal rest tumors may eventually lead to infertility.
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Huneif MA, Al Mutairi M, AlHazmy ZH, AlOsaimi FK, AlShoomi AM, AlGhofely MA, AlSaheel A. Screening for testicular adrenal rest tumors among children with congenital adrenal hyperplasia at King Fahad Medical City, Saudi Arabia. J Pediatr Endocrinol Metab 2022; 35:49-54. [PMID: 34757702 DOI: 10.1515/jpem-2021-0291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/04/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess the incidence of testicular adrenal rest tumors (TARTs) among male children with congenital adrenal hyperplasia (CAH) in tertiary care centers. METHODS All male children aged 1-14 years diagnosed with CAH due to 21-hydroxylase deficiency (21 HOD), 11β-hydroxylase deficiency, and 3β-hydroxysteroid dehydrogenase deficiency, confirmed by biochemical and/or genetic testing, underwent scrotal ultrasound examination to identify TARTs. After receiving the diagnosed patients' data, patients' electronic medical records were accessed to collect demographic data and scrotal ultrasound results, along with growth parameters and specific biochemical test results within 2 months of the ultrasound. RESULTS TARTs were observed in 5 (10.9%) of 46 male children with CAH. Four patients with positive findings had 21 HOD classical CAH with salt loss and one had 21 HOD simple virilizing classical CAH. All patients had poor compliance and stage 2 bilateral TARTs. Three TART-positive patients (60.0%) had high ACTH levels, 5 patients (100%) had elevated 17-OHP levels, and 5 patients (100%) had advanced bone age. The youngest patient with positive findings was 4 years old. CONCLUSIONS The prevalence of TARTs increases with age and can be present in young males with classical CAH with 21 HOD. It is associated with elevated 17-hydroxyprogesterone (17-OHP) and advanced bone age SDS. TARTs are less likely to be associated with nonclassical CAH with 21 HOD or other less common CAHs due to 11β-hydroxylase deficiencies and 3β-hydroxysteroid dehydrogenase deficiencies in children. Our study recommends early and routine screening of TARTs in children with CAH.
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Affiliation(s)
- Mohammed Ayed Huneif
- Pediatric Endocrinologist at at Department of Pediatrics, College of Medicine, Najran University Hospital, Najran University, Najran Saudi Arabia
| | - Majed Al Mutairi
- Pediatric Radiologist at the Pediatric Radiology Department, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Fatima Khalid AlOsaimi
- Senior Ultrasound Sonographer in the Pediatric Radiology Department, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Anas M AlShoomi
- Pediatric Endocrinologist in the Pediatric Endocrine Department, Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed A AlGhofely
- Pediatric Endocrinologist in the Pediatric Endocrine Department, Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulhameed AlSaheel
- Pediatric Endocrinologist in the Pediatric Endocrine Department, Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
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Akbarzadeh Pasha A, Shafi H, Teimorian M, Rostami G, Nasirimehr K, Moudi E. Congenital adrenal hyperplasia presented with bilateral testicular tumor: A case report. CASPIAN JOURNAL OF INTERNAL MEDICINE 2021; 12:S431-S434. [PMID: 34760099 PMCID: PMC8559653 DOI: 10.22088/cjim.12.0.431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 11/08/2022]
Abstract
Background: Congenital adrenal hyperplasia (CAH) refers to group of congenital diseases resulting from impaired adrenal steroidogenesis, and its most common cause is 21-hydroxylase deficiency. Testicular adrenal residual tumor (TART) is one of the major complications of CAH, possibly resulting from ectopic remnants of intra-testicular adrenal tissue which is stimulated by excessive secretion of adrenocorticotropic hormone (ACTH). This tumor can be misdiagnosed as Leydig cell tumor (LCT) in these people. Case Presentation: The patient we are presenting is a 20-year-old man with a history of precocious puberty and a height below 3% of the population who underwent radical left testicular orchiectomy with a complaint of bilateral testicular mass, which is reported LCT in the pathology report. In preoperative imaging examinations, bilateral adrenal hyperplasia is observed. In hormonal examinations, the patient is diagnosed with CAH and has been treated with corticosteroids for one year. Conclusion: In patients who present with bilateral testicular mass, it is the best image by abdominopelvic CT scan before surgery to detect CAH.
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Affiliation(s)
- Abazar Akbarzadeh Pasha
- Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Hamid Shafi
- Clinical Research Development Center, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, I.R.Iran
| | - Mohamad Teimorian
- Department of Urology, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, Iran
| | - Ghasem Rostami
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
| | - Khatereh Nasirimehr
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
| | - Emadoddin Moudi
- Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
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Kolli V, da Cunha IW, Kim S, Iben JR, Mallappa A, Li T, Gaynor A, Coon SL, Quezado MM, Merke DP. Morphologic and Molecular Characterization of Adrenals and Adrenal Rest Affected by Congenital Adrenal Hyperplasia. Front Endocrinol (Lausanne) 2021; 12:730947. [PMID: 34616364 PMCID: PMC8488225 DOI: 10.3389/fendo.2021.730947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/26/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction Adrenocortical hyperplasia and adrenal rest tumor (ART) formation are common in congenital adrenal hyperplasia (CAH). Although driven by excessive corticotropin, much is unknown regarding the morphology and transformation of these tissues. Our study objective was to characterize CAH-affected adrenals and ART and compare with control adrenal and gonadal tissues. Patients/Methods CAH adrenals, ART and control tissues were analyzed by histology, immunohistochemistry, and transcriptome sequencing. We investigated protein expression of the ACTH receptor (MC2R), steroidogenic (CYP11B2, CYP11B1, CYB5A) and immune (CD20, CD3, CD68) biomarkers, and delta-like 1 homolog (DLK1), a membrane bound protein broadly expressed in fetal and many endocrine cells. RNA was isolated and gene expression was analyzed by RNA sequencing (RNA-seq) followed by principle component, and unsupervised clustering analyses. Results Based on immunohistochemistry, CAH adrenals and ART demonstrated increased zona reticularis (ZR)-like CYB5A expression, compared to CYP11B1, and CYP11B2, markers of zona fasciculata and zona glomerulosa respectively. CYP11B2 was mostly absent in CAH adrenals and absent in ART. DLK1 was present in CAH adrenal, ART, and also control adrenal and testis, but was absent in control ovary. Increased expression of adrenocortical marker MC2R, was observed in CAH adrenals compared to control adrenal. Unlike control tissues, significant nodular lymphocytic infiltration was observed in CAH adrenals and ART, with CD20 (B-cell), CD3 (T-cell) and CD68 (macrophage/monocyte) markers of inflammation. RNA-seq data revealed co-expression of adrenal MC2R, and testis-specific INSL3, HSD17B3 in testicular ART indicating the presence of both gonadal and adrenal features, and high expression of DLK1 in ART, CAH adrenals and control adrenal. Principal component analysis indicated that the ART transcriptome was more similar to CAH adrenals and least similar to control testis tissue. Conclusions CAH-affected adrenal glands and ART have similar expression profiles and morphology, demonstrating increased CYB5A with ZR characteristics and lymphocytic infiltration, suggesting a common origin that is similarly affected by the abnormal hormonal milieu. Immune system modulators may play a role in tumor formation of CAH.
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Affiliation(s)
- Vipula Kolli
- National Institutes of Health Clinical Center, Bethesda, MD, United States
| | | | - SunA Kim
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, United States
| | - James R. Iben
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Tianwei Li
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Alison Gaynor
- National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Steven L. Coon
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Martha M. Quezado
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, United States
| | - Deborah P. Merke
- National Institutes of Health Clinical Center, Bethesda, MD, United States
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
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Ozer Kaya S, Erisir M, Gur S, Kandemir FM, Benzer F, Kaya E, Sonmez M, Turk G. The changes in semen quality, arginase activity and nitric oxide level in dexamethasone-treated rams. Andrologia 2019; 52:e13464. [PMID: 31721281 DOI: 10.1111/and.13464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/23/2019] [Accepted: 10/07/2019] [Indexed: 11/30/2022] Open
Abstract
This study was made to investigate the effects of intramuscular administrations of dexamethasone on seminal plasma nitric oxide levels and arginase activity, and some spermatological parameters in rams. Ten Akkaraman rams weighing 50-60 kg and 2 years old were used as material in this study. The study was performed during the breeding season (September-November) for rams. The semen was collected by artificial vagina at 1st, 4th, 24th, 48th, 72nd and 96th hours for control group before dexamethasone administration. For treatment group, 0.25 mg/kg dexamethasone was administered and semen was collected at the time points described for control group. Spermatological characteristics of semen samples (semen volume, pH, sperm motility, density and abnormal sperm rate), seminal plasma arginase enzyme activities and nitric oxide levels were determined. It was determined that the administration of dexamethasone was detected to decrease seminal plasma arginase activity (p < .05 and .01) and nitric oxide level (p < .05), semen volume (p < .05 and .01), mass activity (p < .05 and .01), sperm density (p < .05) and sperm motility (p < .05 and .01), and to increase abnormal sperm rate (p < .05 and .01). In conclusion, dexamethasone is not recommended to be used during the breeding season as it damages the sperm quality of the rams.
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Affiliation(s)
- Seyma Ozer Kaya
- Department of Reproduction and Artificial Insemination, Faculty of Veterinary Medicine, Firat University, Elazığ, Turkey
| | - Mine Erisir
- Department of Biochemistry, Faculty of Veterinary Medicine, Firat University, Elazığ, Turkey
| | - Seyfettin Gur
- Department of Reproduction and Artificial Insemination, Faculty of Veterinary Medicine, Firat University, Elazığ, Turkey
| | - Fatih Mehmet Kandemir
- Department of Biochemistry, Faculty of Veterinary Medicine, Ataturk University, Erzurum, Turkey
| | - Fulya Benzer
- Department of Food Engineering, Faculty of Engineering, Munzur University, Tunceli, Turkey
| | - Emre Kaya
- Department of Biochemistry, Faculty of Veterinary Medicine, Firat University, Elazığ, Turkey
| | - Mustafa Sonmez
- Department of Reproduction and Artificial Insemination, Faculty of Veterinary Medicine, Firat University, Elazığ, Turkey
| | - Gaffari Turk
- Department of Reproduction and Artificial Insemination, Faculty of Veterinary Medicine, Firat University, Elazığ, Turkey
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Jha S, El-Maouche D, Marko J, Mallappa A, Veeraraghavan P, Merke DP. Individualizing Management of Infertility in Classic Congenital Adrenal Hyperplasia and Testicular Adrenal Rest Tumors. J Endocr Soc 2019; 3:2290-2294. [PMID: 31745525 PMCID: PMC6853670 DOI: 10.1210/js.2019-00227] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 10/11/2019] [Indexed: 12/31/2022] Open
Abstract
Testicular adrenal rest tumors (TARTs) are a common cause of male infertility in patients with classic congenital adrenal hyperplasia (CAH). These tumors are located in the rete testis and can lead to impaired blood flow and functional impairment of seminiferous tubules. We describe restoration of fertility in a man with CAH and bilateral TARTs with use of lower-dose glucocorticoid therapy than previously described. A 28-year-old man with classic salt-wasting CAH presented with impaired fertility. Biochemical evaluation showed poor CAH control despite reported compliance with prednisone 5 mg every morning and fludrocortisone 50 μg twice daily. Semen analysis showed azoospermia. Testicular ultrasonography showed TARTs occupying 16% of total testicular volume. After 5 months of dexamethasone 250 μg at bedtime, total TART volume decreased 90%, biochemical control improved, and semen analysis showed a sperm count of 132 × 106 million per milliliter. The patient’s wife was confirmed to be pregnant 9 months after the initial visit and delivered a healthy full-term baby girl. The patient’s glucocorticoid therapy was changed to prednisone 3 mg twice daily, and 2 years later he continues to show adequate CAH control, stable TART volume, and normal semen analysis, and his wife is pregnant again. Management of CAH in men with TARTs needs to be individualized, and high-dose dexamethasone may not be indicated. The use of a long-acting glucocorticoid at typical recommended dosages can decrease TART size and reverse male infertility. Prednisone given once daily does not adequately control the ACTH-driven complications of CAH.
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Affiliation(s)
- Smita Jha
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland.,Clinical and Investigative Orthopedics Surgery Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Diala El-Maouche
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jamie Marko
- Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Maryland
| | - Ashwini Mallappa
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Padmasree Veeraraghavan
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Deborah P Merke
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Engels M, Span PN, van Herwaarden AE, Sweep FCGJ, Stikkelbroeck NMML, Claahsen-van der Grinten HL. Testicular Adrenal Rest Tumors: Current Insights on Prevalence, Characteristics, Origin, and Treatment. Endocr Rev 2019; 40:973-987. [PMID: 30882882 DOI: 10.1210/er.2018-00258] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/23/2019] [Indexed: 11/19/2022]
Abstract
This review provides the reader with current insights on testicular adrenal rest tumors (TARTs), a complication in male patients with congenital adrenal hyperplasia (CAH). In recent studies, an overall TART prevalence of 40% (range, 14% to 89%) in classic patients with CAH is found. Reported differences are mainly caused by the method of detection and the selected patient population. Biochemically, histologically, and molecularly, TARTs exhibit particular adrenal characteristics and were therefore thought to originate from aberrant adrenal cells. More recently, TARTs have been found to also exhibit testicular characteristics. This has led to the hypothesis of pluripotent cells as the origin of TARTs. High concentrations of ACTH could cause hyperplasia of these pluripotent cells, as TARTs appear to be associated with poor hormonal control with concomitant elevated ACTH. Unfortunately, as yet there are no methods to prevent the development of TARTs, nor are there guidelines to treat patients with TARTs. Intensified glucocorticoid treatment could improve fertility status in some cases, although studies report contradicting results. TARTs can also lead to irreversible testicular damage, and therefore semen cryopreservation could be offered to patients with TARTs. Further research should focus on the etiology and pharmacological treatment to prevent TART development or to treat TARTs and improve the fertility status of patients with TARTs.
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Affiliation(s)
- Manon Engels
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul N Span
- Department of Radiation Oncology, Radiotherapy and OncoImmunology Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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11
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Fouques C, Fatfouta I, Hieronimus S, Sadoul JL, Bongain A. Two cases of male patients followed for a classical form of congenital adrenal hyperplasia (CAH), presenting an azoospermia: analysis and review of the literature. Basic Clin Androl 2019; 29:10. [PMID: 31143447 PMCID: PMC6532123 DOI: 10.1186/s12610-019-0084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background Congenital hyperplasia of the adrenal glands is a rare pathology, which can have an impact on male fertility. We report 2 cases of azoospermia in patients followed for a classical form of congenital adrenal hyperplasia. Cases presentation 1st case: After 18 months of infertility of the couple, explorations showed a high level of ACTH on the hormonal biological analysis. A therapeutic strategy combining hydrocortisone with dexamethasone induced a normal semen analysis, and the female partner of the patient subsequently had three spontaneous pregnancies.2nd case: After two years of infertility of the couple, explorations showed adrenal testicular inclusions invading the 4/5th of the testis with a hypergonadotropic hypogonadism, the therapeutic reinforcement did not allow the improvement of semen analysis. Discussion Sertolian deficiency can be explained by: gonadotropic deficiency by excess of adrenal androgens and adrenal testicular lesions (risk of major spermatic alteration). Conclusion Congenital hyperplasia of the adrenal glands is a rare pathology in the context of male infertility. A semen analysis could be performed after puberty and a semen preservation may be proposed.
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Affiliation(s)
- Clélia Fouques
- 1Department of Gynecology-Obstetrics, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - Imène Fatfouta
- 1Department of Gynecology-Obstetrics, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - Sylvie Hieronimus
- 2Departments of Endocrinology, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - Jean-Louis Sadoul
- 2Departments of Endocrinology, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - André Bongain
- 1Department of Gynecology-Obstetrics, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
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12
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Lottspeich C, Müller-Lisse U, Seiler L, Schmitt-Graeff AH, Reincke M, Reisch N. Three Cases of Testicular Adrenal Rest Tumors in Congenital Adrenal Hyperplasia-A Diagnostic and Therapeutic Challenge. Urology 2019; 129:24-28. [PMID: 30898461 DOI: 10.1016/j.urology.2019.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/22/2019] [Accepted: 03/08/2019] [Indexed: 12/31/2022]
Affiliation(s)
| | | | | | | | - Martin Reincke
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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13
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Turcu AF, Nanba AT, Auchus RJ. The Rise, Fall, and Resurrection of 11-Oxygenated Androgens in Human Physiology and Disease. Horm Res Paediatr 2018; 89:284-291. [PMID: 29742491 PMCID: PMC6031471 DOI: 10.1159/000486036] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/05/2017] [Indexed: 12/19/2022] Open
Abstract
The 11-oxyandrogens, particularly 11-ketotestosterone, have been recognized as a biologically important gonadal androgen in teleost (bony) fishes for decades, and their presence in human beings has been known but poorly understood. Today, we recognize that 11-oxyandrogens derive from the human adrenal glands and are major bioactive androgens, particularly in women and children. This article will review their biosynthesis and metabolism, abundance in normal and pathologic states, and potential as biomarkers of adrenal developmental changes and disease. Specifically, 11-oxyandrogens are the dominant active androgens in many patients with 21-hydroxylase deficiency.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | - Aya T Nanba
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, USA
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14
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Turcu AF, Mallappa A, Elman MS, Avila NA, Marko J, Rao H, Tsodikov A, Auchus RJ, Merke DP. 11-Oxygenated Androgens Are Biomarkers of Adrenal Volume and Testicular Adrenal Rest Tumors in 21-Hydroxylase Deficiency. J Clin Endocrinol Metab 2017; 102:2701-2710. [PMID: 28472487 PMCID: PMC5546849 DOI: 10.1210/jc.2016-3989] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/24/2017] [Indexed: 01/13/2023]
Abstract
CONTEXT Patients with 21-hydroxylase deficiency (21OHD) have long-term complications, resulting from poor disease control and/or glucocorticoid overtreatment. Lack of optimal biomarkers has made it challenging to tailor therapy and predict long-term outcomes. OBJECTIVE To identify biomarkers of disease control and long-term complications in 21OHD. SETTING AND PARTICIPANTS Cross-sectional study of 114 patients (70 males), ages 2 to 67 years (median, 15 years), seen in a tertiary referral center. METHODS We correlated a mass-spectrometry panel of 23 steroids, obtained before first morning medication, with bone age advancement (children), adrenal volume (adults), testicular adrenal rest tumors (TART), hirsutism, menstrual disorders, and pituitary hormones. RESULTS Total adrenal volume correlated positively with 18 steroids, most prominently 21-deoxycortisol and four 11-oxygenated-C19 (11oxC19) steroids: 11β-hydroxyandrostenedione (11OHA4), 11-ketoandrostenedione (11ketoA4), 11β-hydroxytestosterone (11OHT), and 11-ketotestosterone (11ketoT) (r ≈ 0.7, P < 0.0001). Nine steroids were significantly higher (P ≤ 0.01) in males with TART compared with those without TART, including 11OHA4 (6.8-fold), 11OHT (4.9-fold), 11ketoT (3.6-fold), 11ketoA4 (3.3-fold), and pregnenolone sulfate (PregS; 4.8-fold). PregS (28.5-fold) and 17-hydroxypregnenolone sulfate (19-fold) levels were higher (P < 0.01) in postpubertal females with menstrual disorders. In males, testosterone levels correlated positively with all 11oxC19 steroids in Tanner stages 1 and 2 (r ≈ 0.7; P < 0.001) but negatively in Tanner stage 5 (r = -0.3 and P < 0.05 for 11ketoA4 and 11ketoT). In females, testosterone level correlated positively with all four 11oxC19 steroids across all Tanner stages (r ≈ 0.8; P < 0.0001). CONCLUSION 11oxC19 steroids and PregS might serve as clinically useful biomarkers of disease control and long-term complications in 21OHD.
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Affiliation(s)
- Adina F. Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan 48109
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland 20892
| | | | - Nilo A. Avila
- National Heart, Lung, and Blood Institute, Bethesda, Maryland 20892
- Washington DC Veterans Affairs Medical Center, Radiology Service, Washington, DC 20422
| | - Jamie Marko
- National Institutes of Health Clinical Center, Bethesda, Maryland 20892
| | - Hamsini Rao
- National Institutes of Health Clinical Center, Bethesda, Maryland 20892
| | - Alexander Tsodikov
- School of Public Health, University of Michigan, Ann Arbor, Michigan 48109
| | - Richard J. Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan 48109
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan 48109
| | - Deborah P. Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland 20892
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20892
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15
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Ozisik H, Yurekli BS, Simsir IY, Altun I, Soyaltin U, Guler E, Onay H, Sarsik B, Saygili F. Testicular Adrenal Rest Tumor (TART) in congenital adrenal hyperplasia. Eur J Med Genet 2017; 60:489-493. [PMID: 28676275 DOI: 10.1016/j.ejmg.2017.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia is one of the most common autosomal recessive genetic disorders. Testicular adrenal tumors are significant complications of congenital adrenal hyperplasia. We would like to present two patients of testicular adrenal rest tumors. Patient 1 24 year-old male, he was diagnosed with congenital adrenal hyperplasia at the age of 8 due to precocious puberty. He received hydro-cortisone treatment until the age of 18. Testicular mass had been detected and right radical orchiectomy had been applied 6 months ago and reported as testicular adrenal rest tumor. In scrotal ultrasound, a mixed type mass lesion (6 × 4x3 cm) covering a large part of left testis was observed. The imaging findings were consistent with adrenal rest tumor. The patient took adrenocorticotropic hormone supressive therapy with dexamethasone 0.75 mg once a day. Patient 2, 38 year-old male, he had been followed-up as adrenal insufficiency for 35 years. He underwent right orchiectomy operation due to the testicular mass in 2010 and the pathological examination revealed Leydig cell tumor. In scrotal ultrasound, small multifocal lesions were detected on the left testis and resection was done. It was reported as testicular adrenal rest tumor. He is being followed-up with glucocorticoid treatment according to androgen and adrenocorticotropic hormone levels. Early diagnosis of testicular adrenal rest tumor is significant in preventing irreversible testicular damage and infertility. In the differential diagnosis, we should keep in mind that testicular adrenal rest tumor can mimic other testicular tumors such as primary germ cell tumors.
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Affiliation(s)
- Hatice Ozisik
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey.
| | - Banu Sarer Yurekli
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Ilgin Yildirim Simsir
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Ilker Altun
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Utku Soyaltin
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Ezgi Guler
- Ege University, Faculty of Medicine, Department of Radiology, Turkey
| | - Huseyin Onay
- Ege University, Faculty of Medicine, Department of Medical Genetics, Turkey
| | - Banu Sarsik
- Ege University, Faculty of Medicine, Department of Pathology, Turkey
| | - Fusun Saygili
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
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16
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Güven A, Polat S. Testicular Adrenal Rest Tumor in Two Brothers with a Novel Mutation in the 3-Beta-Hydroxysteroid Dehydrogenase-2 Gene. J Clin Res Pediatr Endocrinol 2017; 9:85-90. [PMID: 27476613 PMCID: PMC5363172 DOI: 10.4274/jcrpe.3306] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Testicular adrenal rest tumors (TART) occur frequently in adolescents and adults with 21-hydroxylase deficiency. There have been no reports of TART in children with 3β-hydroxysteroid dehydrogenase deficiency (HSD3β). Biopsy proven TART was diagnosed in a 31/12-year-old male patient and also in his 22-month-old sibling. Hormonal and anthropometric measurements were performed during glucocorticoid and fludrocortisone treatment. The mutational analysis was performed by direct DNA sequencing of the complete coding region of the HSD3β2 gene. Initially, both siblings were treated with high doses of hydrocortisone and fludrocortisone. TART regressed with dexamethasone treatment in both patients. However, growth velocity decreased and weight gain increased in both patients. Dexamethasone was changed to high-dose hydrocortisone (>20 mg/m2/d). Sequencing analyses revealed a novel homozygous p.W355R (c.763 T>C) mutation at exon 4 of the HSD3β2 gene in both siblings. These two patients are, to our knowledge, the first known cases of TARTs with a novel mutation in the HSD3β2 gene detected during childhood. High-dose hydrocortisone treatment is more reliable for TART in children.
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Affiliation(s)
- Ayla Güven
- Göztepe Training and Research Hospital, Clinic of Pediatric Endocrinology, İstanbul, Turkey E-mail:
| | - Seher Polat
- Erciyes University Faculty of Medicine, Department of Medical Genetics, Kayseri, Turkey
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17
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Stangler Herodež Š, Fijavž L, Zagradišnik B, Kokalj Vokač N. Detection of mutations in the CYP21A2 gene: genotype-phenotype correlation in Slovenian couples with conceiving problems. Balkan J Med Genet 2016; 18:25-32. [PMID: 27785393 PMCID: PMC5026265 DOI: 10.1515/bjmg-2015-0082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The objective of this study was to compare the CYP 21A2 genetic profiles of couples with unexplained fertility problems (UFP) with genetic profiles of healthy controls (HCs). Furthermore, we analyzed associations between mutations in the CYP21A2 gene and various clinical and laboratory parameters. Allele-specific polymerase chain reaction (PCR) was used in 638 probands with UFP and 200 HCs. Statistic analysis with χ2 was used to study the association of mutations with infertility. The effect of mutations on particular clinical and laboratory parameters was assessed with the analysis of variance (ANOVA) test. With regard to the CYP21A2 gene, 0.6% of probands with UFP and 0.5% of HCs were positive for the c.290-13A/C>G mutation; 0.6% of probands with UFP and 1.5% of HCs were positive for the p.I172N mutation; there were no probands with UFP positive for the p.P30L mutation, whereas 0.5% of HCs were; and 0.2% of probands with UFP and 0.5% of HCs were found to have the p.V281L mutation. We found a significant association between c.290-13A/C>G mutation and the frequency of significant hormone deviations (χ2 = 6.997, p = 0.008). Similar association was also observed between the c.29013A/C>G mutation and the frequency of polycystic ovary syndrome (PCOS) (χ2 = 16.775, p = 0.000). Our findings indicate that no significant difference in the prevalence of CYP 21A2 mutations can be found in probands with UFP when compared with HCs without infertility history. The results also imply the significant association of the c.290-13A/ C>G mutation in the CYP21A2 gene, not only with the frequency of PCOS, but also with the frequency of significant hormone deviations.
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Affiliation(s)
- Š Stangler Herodež
- Laboratory of Medical Genetics, University Clinical Centre Maribor, Maribor, Slovenia
| | - L Fijavž
- Medical Faculty, University of Maribor, Maribor, Slovenia
| | - B Zagradišnik
- Laboratory of Medical Genetics, University Clinical Centre Maribor, Maribor, Slovenia
| | - N Kokalj Vokač
- Laboratory of Medical Genetics, University Clinical Centre Maribor, Maribor, Slovenia; Medical Faculty, University of Maribor, Maribor, Slovenia
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18
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King TFJ, Lee MC, Williamson EEJ, Conway GS. Experience in optimizing fertility outcomes in men with congenital adrenal hyperplasia due to 21 hydroxylase deficiency. Clin Endocrinol (Oxf) 2016; 84:830-6. [PMID: 26666213 DOI: 10.1111/cen.13001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 11/19/2015] [Accepted: 12/09/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Men with congenital adrenal hyperplasia (CAH) have impaired fertility. We aimed to assess fertility outcomes and the importance of hypogonadotropic hypogonadism, testicular failure and the presence of testicular adrenal rest tumours (TART). DESIGN Retrospective analysis of men attending an adult CAH clinic in a tertiary centre. PATIENTS Fifty men with CAH due to 21 hydroxylase deficiency were identified of whom 35 were salt wasting and 15 were non-salt-wasting. MEASUREMENTS Review of fertility history and parameters including luteinizing hormone (LH), follicle-stimulating hormone (FSH), androstenedione, 17-hydroxyprogesterone (17-OHP), semen analysis and the presence of testicular adrenal rest tissue (TART) on ultrasound. RESULTS TART were detected by ultrasound in 21 (47%), and their presence was associated with an elevated FSH (P = 0·01). Severe oligospermia was present in 11 of 23 (48%), and this was associated with an elevated FSH (P = 0·02), suppressed LH (P < 0·01) and TART (P = 0·03) when compared to those with a sperm count >5 × 10(6) per ml. Of those that desired fertility, 10 of 17 (59%) required treatment intensification and four underwent in vitro fertilization. Intensification resulted in a rise in median LH (0·6-4·3 IU/l; P = 0·01). Live birth rate was 15 of 17 (88%) with a median (range) time to conception of 8 (0-38) months. CONCLUSIONS Suppressed LH is a marker for subfertility and is often reversible. Testicular failure is closely associated with TART formation. If TART are detected, sperm cryopreservation should be offered given the risk of progression to irreversible testicular failure. Male fertility in CAH can be improved by intensified treatment and assisted reproductive technology.
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Affiliation(s)
- Thomas F J King
- Department of Endocrinology, University College London Hospitals, London, UK
- Institute for Women's Health, University College London Hospitals, London, UK
| | - Marilyn Cheng Lee
- Department of Endocrinology, University College London Hospitals, London, UK
- Institute for Women's Health, University College London Hospitals, London, UK
| | | | - Gerard S Conway
- Department of Endocrinology, University College London Hospitals, London, UK
- Institute for Women's Health, University College London Hospitals, London, UK
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19
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Lekarev O, Lin-Su K, Vogiatzi MG. Infertility and Reproductive Function in Patients with Congenital Adrenal Hyperplasia: Pathophysiology, Advances in Management, and Recent Outcomes. Endocrinol Metab Clin North Am 2015; 44:705-22. [PMID: 26568487 DOI: 10.1016/j.ecl.2015.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Individuals with congenital adrenal hyperplasia have reduced fertility. However, reproductive outcomes have improved over the years. This review provides an update on the multiple pathologic processes that contribute to reduced fertility in both sexes, from alterations of the hypothalamic-pituitary-gonadal axis to the direct effect on gonadal function by elevated circulating adrenal androgens. In addition, elevated serum progesterone concentrations may hinder ovulation and embryo implantation in women, whereas in men testicular adrenal rest tumors can be a major cause of infertility. Suppression of adrenal androgen secretion represents the first line of therapy toward spontaneous conception in both sexes.
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Affiliation(s)
- Oksana Lekarev
- Pediatric Endocrinology, Weill Cornell Medical College, New York, NY, USA
| | - Karen Lin-Su
- Pediatric Endocrinology, Weill Cornell Medical College, New York, NY, USA
| | - Maria G Vogiatzi
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA.
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20
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Yu MK, Jung MK, Kim KE, Kwon AR, Chae HW, Kim DH, Kim HS. Clinical manifestations of testicular adrenal rest tumor in males with congenital adrenal hyperplasia. Ann Pediatr Endocrinol Metab 2015; 20:155-61. [PMID: 26512352 PMCID: PMC4623344 DOI: 10.6065/apem.2015.20.3.155] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/19/2015] [Accepted: 09/21/2015] [Indexed: 11/20/2022] Open
Abstract
PURPOSE In male patients with congenital adrenal hyperplasia (CAH), the presence of testicular adrenal rest tumors (TARTs) have been reported, however their prevalence and clinical manifestations are not well known. Untreated TARTs may lead to testicular structural damage and infertility. This study was conducted to investigate the prevalence of TARTs in male patients with CAH, and characterize the manifestations to identify contributing factors to TART. METHODS Among 102 CAH patients aged 0-30 years, 24 male patients have been regularly followed up in our outpatient clinic at Severance Children's Hospital from January 2000 to December 2014. In order to reveiw the characteristics of TART patients, we calculated the mean levels of hormones during the 5 years before the time of investigation. Five patients underwent follow-up scrotal ultrasonography (US) after adjusting the dosage of glucocorticoids. RESULTS TARTs were detected in 8 of the 13 patients (61.5%). The median age of TARTs diagnosis was 20.2 years with the youngest case being 15.5 years old. The mean serum level of adrenocorticotropic hormone (ACTH) was higher in the TARTs patient group compared to the non-TARTs group (P<0.05). The tumor size decreased in 3 cases, slightly increased in 1 case, and had no change in another case. CONCLUSION The serum ACTH level might be associated with the growth promoting factor for TARTs, but the exact mechanism has not been clearly identified. Screening for TARTs using US is important in male patients with CAH for early-detection and prevention of ongoing complications, such as infertility.
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Affiliation(s)
- Min Kyung Yu
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Mo Kyung Jung
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Eun Kim
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ah Reum Kwon
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Wook Chae
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duk Hee Kim
- Department of Pediatrics, Sohwa Children's Hospital, Seoul, Korea
| | - Ho-Seong Kim
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
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21
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Claahsen-van der Grinten HL, Dehzad F, Kamphuis-van Ulzen K, de Korte CL. Increased prevalence of testicular adrenal rest tumours during adolescence in congenital adrenal hyperplasia. Horm Res Paediatr 2015; 82:238-44. [PMID: 25195868 DOI: 10.1159/000365570] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 06/18/2014] [Indexed: 12/20/2022] Open
Abstract
UNLABELLED Testicular adrenal rest tumours (TART) are one of the most important causes of infertility in adult male patients with congenital adrenal hyperplasia (CAH). These benign tumours are already detected in children, but screening of TART is not routinely performed. OBJECTIVE To define retrospectively the prevalence of TART in 41 paediatric male CAH patients aged 0-19 years regularly followed by high-frequency (Fcentral 12-MHz) ultrasound techniques. RESULTS Above the age of 10 years, there was a clear increase in the prevalence of TART: 10-12 years, 28% (2 of 7 patients), 13-14 years, 50% (4/8), and 15-16 years, 75% (3/4). Above the age of 16 years, TART were detected in 100% of the patients (7/7). The tumours were not detectable by palpation. CONCLUSION TART is already present in childhood with an increasing prevalence after onset of puberty. We recommend regular ultrasound from the onset of puberty in all boys with classic CAH.
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22
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Smeets EEJW, Span PN, van Herwaarden AE, Wevers RA, Hermus ARMM, Sweep FCGJ, Claahsen-van der Grinten HL. Molecular characterization of testicular adrenal rest tumors in congenital adrenal hyperplasia: lesions with both adrenocortical and Leydig cell features. J Clin Endocrinol Metab 2015; 100:E524-30. [PMID: 25485724 DOI: 10.1210/jc.2014-2036] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
CONTEXT Testicular adrenal rest tumors (TART) are one of the major long term complications in patients with congenital adrenal hyperplasia. Although several adrenal-like properties have been assigned to these benign lesions, the etiology has not been confirmed yet. OBJECTIVE The aim of this study was to describe TART in more detail by analyzing several (steroidogenic) characteristics that may be classified as adrenal cortex or Leydig cell specific. METHODS Gene expression analysis by qPCR was performed for 14 genes in TART tissue (n = 12) and compared with the expression in healthy control fibroblasts (nonsteroidogenic control). In addition, a comparison was made with the expression levels in testis tissue (n = 9) and adrenal tissue (n = 13). RESULTS Nearly all genes were highly expressed in TART tissue, including all genes that encode the key steroidogenic enzymes. TART expression levels are in the majority almost identical to those found in adrenal tissue. The expression of adrenal cortex specific genes (CYP11B1, CYP11B2, and MC2R) in both TART and adrenal tissue is approximately 1000-10 000 times higher compared to that in testes samples. In addition, the Leydig cell markers INSL3 and HSD17B3 were not only found in testes, but also in TART, both at significantly higher levels than in the adrenal (p < 0.01). CONCLUSION Our study shows for the first time that TART have multiple steroidogenic properties, which include not only the expression of adrenal cortex but also of Leydig cell markers. Therefore, the origin of these tumors might be a more totipotent embryonic cell type.
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Affiliation(s)
- Evelien E J W Smeets
- Departments of Pediatrics (E.E.J.W.S., H.L.C.-v.d.G.), Laboratory Medicine (E.E.J.W.S., A.E.v.H., R.A.W., F.C.G.J.S.,), Radiation Oncology (P.N.S.), and Internal Medicine (A.R.M.M.H.), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
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23
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Januś D, Wójcik M, Tyrawa K, Popławska K, Starzyk JB. Testicular adrenal rest tumors in congenital adrenal hyperplasia: a case report and literature overview. Endocr Pract 2014; 20:e219-24. [PMID: 25100387 DOI: 10.4158/ep14188.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In this paper, the etiology, differential diagnosis, and therapy of testicular adrenal rest tumors (TARTs) is presented based on a patient presentation and an overview of the most recent literature concerning this subject. METHODS Retrospective analysis of the clinical and biochemical data of an 18-year-old male patient diagnosed at the age of 2 weeks with the classic salt-wasting form of congenital adrenal hyperplasia that has been monitored in the pediatric and adolescent outpatient department since the age of 4 years. RESULTS The results of adrenal hormone tests (17-hydroxyprogesterone, 17-ketosteroids, and pregnanes) had been unsatisfactory, particularly over the previous 5 years. Scrotal ultrasound detected TARTs bilaterally. After increasing the dose of hydrocortisone and introducing dexamethasone, considerable regression of the tumors was noted. CONCLUSION Lack of complete regression of the lesions is caused by fibrosis and is probably due to decreased sensitivity of adrenocorticotropic hormone and angiotensin II receptors in this tissue.
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Affiliation(s)
- Dominika Januś
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Małgorzata Wójcik
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Katarzyna Tyrawa
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Karolina Popławska
- Department of Pediatrics, Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Jerzy B Starzyk
- Department of Pediatric and Adolescent Endocrinology, Chair of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
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Han TS, Walker BR, Arlt W, Ross RJ. Treatment and health outcomes in adults with congenital adrenal hyperplasia. Nat Rev Endocrinol 2014; 10:115-24. [PMID: 24342885 DOI: 10.1038/nrendo.2013.239] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a genetic disorder caused by defective steroidogenesis that results in glucocorticoid deficiency; the most common underlying mutation is in the gene that encodes 21-hydroxylase. Life-saving glucocorticoid treatment was introduced in the 1950s, and the number of adult patients is now growing; however, no consensus has been reached on the management of CAH beyond childhood. Adult patients are prescribed a variety of glucocorticoids, including hydrocortisone, prednisone, prednisolone, dexamethasone and combinations of these drugs taken in either a circadian or reverse circadian regimen. Despite these personalized treatments, biochemical control of CAH is only achieved in approximately one-third of patients. Some patients have a poor health status, with an increased incidence of obesity and osteoporosis, and impaired fertility and quality of life. The majority of poor health outcomes seem to relate to inadequate treatment rather than the genotype of the patient. Patients receiving high doses of glucocorticoids and the more potent synthetic long-acting glucocorticoids are at an increased risk of obesity, insulin resistance and a reduced quality of life. Further research is required to optimize the treatment of adult patients with CAH and improve health outcomes.
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Affiliation(s)
- Thang S Han
- Department of Diabetes and Endocrinology, St Peter's NHS Foundation Trust, Guildford Road, Chertsey, Surrey KT16 0PZ, UK
| | - Brian R Walker
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Wiebke Arlt
- Centre for Endocrinology, Diabetes and Metabolism, School of Clinical & Experimental Medicine, University of Birmingham, Birmingham B15 2TT, UK
| | - Richard J Ross
- Academic Unit of Diabetes, Endocrinology & Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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Dudzińska B, Leubner J, Ventz M, Quinkler M. Sexual well-being in adult male patients with congenital adrenal hyperplasia. Int J Endocrinol 2014; 2014:469289. [PMID: 24672547 PMCID: PMC3941169 DOI: 10.1155/2014/469289] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 12/17/2013] [Accepted: 12/21/2013] [Indexed: 01/07/2023] Open
Abstract
Introduction. Men with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency show impaired fecundity due to testicular adrenal rest tumors and/or suppression of the gonadal axis. Sexual well-being might be an additional factor; however, no data exists. Patients and Methods. Prospective longitudinal monocentric study included 20 male CAH patients (14 salt wasting, 6 simple virilizing; age 18-49 yr). Clinical assessment, testicular ultrasound, biochemical and hormonal parameters, three validated self-assessment questionnaires (SF-36, GBB-24, and HADS), and male Brief Sexual Function Inventory (BSFI) were analyzed at baseline and after two years. Results. Basal LH and testosterone levels suggested normal testicular function. LH and FSH responses to GnRH were more pronounced in patients with a good therapy control according to androstenedione/testosterone ratio < 0.2. This group had significant higher percentage of patients on dexamethasone medication. GBB-24, HADS, and SF-36 showed impaired z-scores and no changes at follow-up. BSFI revealed impairments in dimensions "sexual drive," "erections," and "ejaculations," whereas "problem assessment" and "overall satisfaction" revealed normal z-scores. Androstenedione levels correlated (P = 0.036) inversely with z-scores for "sexual drive" with higher levels associated with impaired "sexual drive." Conclusion. Male CAH patients showed a partly impaired sexual well-being which might be an additional factor for reduced fecundity.
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Affiliation(s)
- Bogna Dudzińska
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jonas Leubner
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Manfred Ventz
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Marcus Quinkler
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- *Marcus Quinkler:
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Abstract
The management of congenital adrenal hyperplasia involves suppression of adrenal androgen production, in addition to treatment of adrenal insufficiency. Management of adolescents with congenital adrenal hyperplasia is especially challenging because changes in the hormonal milieu during puberty can lead to inadequate suppression of adrenal androgens, psychosocial issues often affect adherence to medical therapy, and sexual function plays a major part in adolescence and young adulthood. For these reasons, treatment regimen reassessment is indicated during adolescence. Patients with non-classic congenital adrenal hyperplasia require reassessment regarding the need for glucocorticoid drug treatment. No clinical trials have compared various regimens for classic congenital adrenal hyperplasia in adults, thus therapy is individualised and based on the prevention of adverse outcomes. Extensive patient education is key during transition from paediatric care to adult care and should include education of females with classic congenital adrenal hyperplasia regarding their genital anatomy and surgical history. Common issues for these patients include urinary incontinence, vaginal stenosis, clitoral pain, and cosmetic concerns; for males with classic congenital adrenal hyperplasia, common issues include testicular adrenal rest tumours. Transition from paediatric to adult care is most successful when phased over many years. Education of health-care providers on how to successfully transition patients is greatly needed.
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Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
| | - Dix P Poppas
- the Institute for Pediatric Urology, Comprehensive Center for Congenital Adrenal Hyperplasia, Komansky Center for Children's Health, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
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Abstract
The most common form of congenital adrenal hyperplasia is steroid 21-hydroxylase deficiency (21OHD). When the nonclassical (mild) form is included, 21OHD is the most common genetic disease in human beings. With the advent of pharmaceutical preparation of glucocorticoids starting in the 1960s and newborn screening starting in the 1990s, the majority of children with 21OHD are reaching adulthood, which has yielded a cohort of patients with, in essence, a new disease. Only recently have some data emerged from cohorts of adults with 21OHD, and in some centers, experience with the management of these patients is growing. These patients suffer from poor health, infertility, characteristic tumors in the adrenal glands and gonads, and consequences of chronic glucocorticoid therapy. Their care is fragmented and inconsistent, and many stop taking their medications out of frustration. Internal medicine residents and endocrinology fellows receive little training in their care, which further discourages their seeking medical attention. Adults with 21OHD have a different physiology from patients with Addison's disease or other androgen excess states, and their needs are different than those of young children with 21OHD. Consequently, their care requires unorthodox treatment and monitoring strategies foreign to most endocrine practitioners. Our goal for this article is to review their physiology, complications, and needs in order to develop rational and effective treatment and monitoring strategies.
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Affiliation(s)
- Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine and the Program for Disorders of Sexual Development, University of Michigan, Room 5560A, MSRBII, 1150 West Medical Center Drive, Ann Arbor, Michigan 48109, USA.
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McLachlan RI. When is azoospermic infertility treatable without intracytoplasmic sperm injection? Clin Endocrinol (Oxf) 2013; 78:176-80. [PMID: 22998070 DOI: 10.1111/cen.12026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 06/30/2012] [Accepted: 08/21/2012] [Indexed: 11/30/2022]
Abstract
Infertility with azoospermia requires a diligent search for reversible factors and treatment to restore natural fertility, even though most cases are due to untreatable primary spermatogenic failure and are destined to require consideration of assisted reproductive treatment (ART) options. Complete clinical and diagnostic evaluation is essential for avoiding both unnecessary ART and overlooking important co-morbidities. Gonadotrophin deficiency is the most treatable cause, resulting from drug effects or congenital or acquired disease, and medical therapy is highly efficacious. A range of uncommon endocrinocrinopathies may also result in reversible azoospermia. Finally, obstructive azoospermia may be surgically remediable in selected cases.
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Affiliation(s)
- Robert I McLachlan
- Prince Henry's Institute of Medical Research, Monash Medical Centre, Monash University, Clayton, VIC 3168, Australia.
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Abstract
Non-obstructive azoospermia is diagnosed in approximately 10% of infertile men. It represents a failure of spermatogenesis within the testis and, from a management standpoint, is due to either a lack of appropriate stimulation by gonadotropins or an intrinsic testicular impairment. The former category of patients has hypogonadotropic hypogonadism and benefits from specific hormonal therapy. These men show a remarkable recovery of spermatogenic function with exogenously administered gonadotropins or gonadotropin-releasing hormone. This category of patients also includes some individuals whose spermatogenic potential has been suppressed by excess androgens or steroids, and they also benefit from medical management. The other, larger category of non-obstructive azoospermia consists of men with an intrinsic testicular impairment where empirical medical therapy yields little benefit. The primary role of medical management in these men is to improve the quantity and quality of sperm retrieved from their testis for in vitro fertilization. Gonadotropins and aromatase inhibitors show promise in achieving this end point.
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Affiliation(s)
- Rajeev Kumar
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India.
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30
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Nimkarn S, Lin-Su K, New MI. Steroid 21 hydroxylase deficiency congenital adrenal hyperplasia. Pediatr Clin North Am 2011; 58:1281-300, xii. [PMID: 21981961 DOI: 10.1016/j.pcl.2011.07.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Steroid 21 hydroxylase deficiency is the most common form of congenital adrenal hyperplasia (CAH). The severity of this disorder depends on the extent of impaired enzymatic activity, which is caused by various mutations of the 21 hydroxylase gene. This article reviews adrenal steroidogenesis and the pathophysiology of 21 hydroxylase deficiency. The three forms of CAH are then discussed in terms of clinical presentation, diagnosis and treatment, and genetic basis. Prenatal diagnosis and treatment are also reviewed. The goal of therapy is to correct the deficiency in cortisol secretion and suppress androgen overproduction. Glucocorticoid replacement has been the mainstay of treatment for CAH, but new treatment strategies continue to be developed and studied.
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Affiliation(s)
- Saroj Nimkarn
- Adrenal Steroid Disorders Program, Division of Pediatric Endocrinology, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1198, New York, NY 10029, USA
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Claahsen-van der Grinten HL, Stikkelbroeck NMML, Otten BJ, Hermus ARMM. Congenital adrenal hyperplasia--pharmacologic interventions from the prenatal phase to adulthood. Pharmacol Ther 2011; 132:1-14. [PMID: 21635919 DOI: 10.1016/j.pharmthera.2011.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 04/28/2011] [Indexed: 12/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is one of the most common inherited autosomal recessive disorders, caused by deficiency of one of the enzymes involved in steroid synthesis. The clinical picture of the most prevalent form, i.e. 21-hydroxylase deficiency, is characterized by cortisol and mostly aldosterone deficiency and androgen excess (leading to congenital virilization in girls). Treatment consists of glucocorticoids, aimed at substitution of cortisol deficiency and, decrease of androgen excess. Usually supraphysiological doses of glucocorticoids are required to effectively suppress adrenal androgens. Furthermore, with the currently available glucocorticoid preparations, it is not possible to simulate a normal circadian rhythm in CAH patients. Therefore, it is a difficult task for (pediatric) endocrinologists to find the best balance between under- and overtreatment thereby avoiding important long term complications. In this review we will discuss the current pharmacologic treatment options. We give age dependent dose recommendations and describe the limitations of current treatment strategies. We discuss effects on fertility, bone density and cardiovascular risks. Recommendations about the use of glucocorticoids in case of fever or stress situations are given. The principles of treatment of non classic (mild) CAH are discussed in a separate section. Also prenatal therapy, to prevent congenital virilization of a female CAH newborn, is discussed. Furthermore, an overview of alternative pharmacological treatment options in the future is given.
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Sonnet E, Roudaut N, Kerlan V. Results of the prolonged use of subcutaneous continuous infusion of hydrocortisone in a man with congenital adrenal hyperplasia. ISRN ENDOCRINOLOGY 2011; 2011:219494. [PMID: 22363868 PMCID: PMC3262628 DOI: 10.5402/2011/219494] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Accepted: 02/16/2011] [Indexed: 11/25/2022]
Abstract
This is a case report study of a young man with Congenital Adrenal Hyperplasia (CAH) who has been treated during 2 years by a subcutaneous continuous infusion hydrocortisone (SCIH) to optimize his treatment.
Hydrocortisone was delivered via an insulin infusion device. We also studied the evolution of testicular adrenal rest tumors (TARTs) and the quality of life through SF36 survey.
Four rates were determined, with a total of 47 mg per day. Biochemical parameters were normalized at 2 months. The SF36 questionnaire showed a progress of well-being. The weight decreased to 106 kg, that is, −5 kg (height: 1.71 m). Unfortunatly, there was no change of the TARTs. Two episodes of dermohypodermitis, with abscess at the infusion site, were observed.
This case demonstrates the feasibility of prolonged SCIH therapy in patients with CAH, reporting positive effects on quality of life and on BMI.
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Affiliation(s)
- Emmanuel Sonnet
- Service d'Endocrinologie, Hôpital de la Cavale Blanche CHU de Brest, Boulevard Tanguy Prigent, 29609 Brest Cedex, France
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33
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Jin HY, Choi JH, Kim GH, Lee CS, Yoo HW. Testicular adrenal rest tumors in a patient with untreated congenital adrenal hyperplasia. KOREAN JOURNAL OF PEDIATRICS 2011; 54:137-40. [PMID: 21738545 PMCID: PMC3121001 DOI: 10.3345/kjp.2011.54.3.137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 10/10/2010] [Accepted: 10/29/2010] [Indexed: 11/27/2022]
Abstract
Testicular adrenal rest tumors (TARTs) are considered to be formed from aberrant adrenal tissue that has become hyperplastic because of elevated adrenocorticotropic hormone (ACTH) in male patients with congenital adrenal hyperplasia (CAH). A 6-year-old boy presented with testicular enlargement and pubic hair. He was diagnosed with CAH complicated by precocious puberty. However, he was not followed-up. At the age of 17, he visited the outpatient clinic because of testicular enlargement and short stature. His right and left testicles were 10×6 cm and 7.5×4.5 cm, respectively. His height was 155.1 cm (standard deviation score [SDS], -2.90). The diagnosis of CAH due to 21 hydroxylase deficiency was confirmed by mutation analysis of CYP21A2. Histological examination of the testes showed large, polygonal, eosinophilic cells with round nuclei and prominent nucleoli, which were suggestive of TARTs. He was treated with dexamethasone for 3 weeks and tumors regressed. Subsequently, dexamethasone was replaced by prednisolone and 9α-fludrocortisone; thereafter, the reduced testis size has been maintained.
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Affiliation(s)
- Hye Young Jin
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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34
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Jin HY, Choi JH, Kim GH, Lee CS, Yoo HW. Testicular adrenal rest tumors in a patient with untreated congenital adrenal hyperplasia. KOREAN JOURNAL OF PEDIATRICS 2011. [DOI: 10.3345/kjp.2011.54.3.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hye Young Jin
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Ho Choi
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Gu Hwan Kim
- Department of Pediatrics, Medical Genetics Clinic and Laboratory, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Chung Sik Lee
- Department of Pathology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Han Wook Yoo
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
- Department of Pediatrics, Medical Genetics Clinic and Laboratory, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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35
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Congenital adrenal hyperplasia: do the benefits of prenatal treatment defeat the risks? Obstet Gynecol Surv 2010; 65:196-205. [PMID: 20214835 DOI: 10.1097/ogx.0b013e3181d61046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Congenital adrenal hyperplasia (CAH) is caused by a defect in any of the 5 enzymes necessary for the synthesis of cortisol. However, in more than 90% of cases, CAH results from a defect in the enzyme 21-hydroxylase. Antenatal dexamethasone for the treatment of fetuses with CAH was introduced in 1978, and has been shown to prevent virilizaton of affected girls. Some researchers have been concerned about the possible long-term side effects of this therapy. A variety of studies have evaluated cognition and behavioral traits as well as metabolic alterations in treated children and in animals, and some investigators have reported adverse effects of antenatal treatment, but no firm conclusions about the potential risks of dexamethasone have been reached. This review summarizes the outcomes of affected children with and without antenatal dexamethasone treatment, and evaluates the benefits of prenatal treatment as well as the potential risks. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader should be able to recall the pathophysiology, broad clinical presentation, differences in prognosis with and without antenatal treatment, and face the importance of the antenatal dexamethasone treatment in congenital adrenal hyperplasia despite the potential adverse effects.
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Abstract
PURPOSE OF REVIEW Patients born with congenital adrenal hyperplasia (CAH), the majority of which is 21-hydroxylase deficiency (21OHD), have been studied by pediatric endocrinologists for decades and treated successfully since the pioneering work of Lawson Wilkins. As is the case for other previously fatal diseases of childhood, such as type 1 diabetes mellitus and cystic fibrosis, these children are now surviving into adulthood. This success has created a new clinical entity, for which the natural history and optimal management strategies are not known. RECENT FINDINGS Longitudinal and cross-sectional studies of adults with CAH have begun to emerge from a few centers. The major challenges faced by these patients include infertility, neoplasia, and consequences of chronic glucocorticoid therapy. SUMMARY The treatment goals of the adult with CAH differ from those for children, and data from specialized centers have identified some of the major issues guiding management. More data and better therapies for these patients are sorely needed.
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Affiliation(s)
- Richard J Auchus
- Division of Endocrinology and Metabolism, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas 75390-8857, USA.
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37
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Management of the adult with congenital adrenal hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:614107. [PMID: 20613954 PMCID: PMC2896848 DOI: 10.1155/2010/614107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Accepted: 03/09/2010] [Indexed: 11/18/2022]
Abstract
Congenital adrenal hyperplasia (CAH), most commonly due to 21-hydroxylase deficiency (21OHD), has been studied by pediatric endocrinologists for decades. Advances in the care of these patients have enabled many of these children to reach adulthood. In contrast to the course and management of the disease in childhood, little is known about CAH in adults. In many patients, the proclivity to salt-wasting crises decreases. Linear growth ceases, and reproductive function becomes an issue. Most importantly, management must minimize the potential for long-term consequences of conventional therapies. Here we review the existing literature regarding comorbidities of adults with 21OHD, goals of treatment, and approaches to therapy, with an emphasis on need for improved management strategies.
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Growth and reproductive outcomes in congenital adrenal hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:298937. [PMID: 20148087 PMCID: PMC2817857 DOI: 10.1155/2010/298937] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 12/11/2009] [Indexed: 11/21/2022]
Abstract
The treatment of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is complex. In addition to disease control, important therapeutic goals are the maintenance of normal growth and the acquisition of normal reproductive function. Here, data regarding final adult height (FH) in patients with CAH will be reviewed. Additional difficulties associated with CAH, including risks of obesity and hypertension, will be discussed. Information about fertility and reproductive outcomes in men and women with CAH will also be summarized. Although the treatment of each child with CAH needs to be individualized, close medical followup and laboratory monitoring along with good compliance can often result in positive clinical outcomes.
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39
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Nebesio T, Eugster E. Growth and Reproductive Outcomes in Congenital Adrenal Hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-298937] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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40
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Nimkarn S, Lin-Su K, New MI. Steroid 21 hydroxylase deficiency congenital adrenal hyperplasia. Endocrinol Metab Clin North Am 2009; 38:699-718. [PMID: 19944288 DOI: 10.1016/j.ecl.2009.08.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Steroid 21 hydroxylase deficiency is the most common form of congenital adrenal hyperplasia (CAH). The severity of this disorder depends on the extent of impaired enzymatic activity, which is caused by various mutations of the 21 hydroxylase gene. This article reviews adrenal steroidogenesis and the pathophysiology of 21 hydroxylase deficiency. The three forms of CAH are then discussed in terms of clinical presentation, diagnosis and treatment, and genetic basis. Prenatal diagnosis and treatment are also reviewed. The goal of therapy is to correct the deficiency in cortisol secretion and suppress androgen overproduction. Glucocorticoid replacement has been the mainstay of treatment for CAH, but new treatment strategies continue to be developed and studied.
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Affiliation(s)
- Saroj Nimkarn
- Mount Sinai School of Medicine, New York, NY 10029, USA
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41
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Dörr HG, Schöfl C. [Congenital adrenal hyperplasia and growth hormone deficiency. Special care in transition to adulthood]. Internist (Berl) 2009; 50:1202, 1204, 1206 passim. [PMID: 19707731 DOI: 10.1007/s00108-009-2401-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Children with chronically endocrine diseases should be treated as young adults by adult endocrinologists. To optimize the transfer from the pediatric to adult endocrinologist, the model of a common transition clinic has been developed. Within this setting it should be possible to exchange experiences, extend the knowledge and understanding of the disease with the other side, and to provide for the patient an optimal outpatient care. This model, however, has only been sporadically realized to date. To set an example for the problems of the transition into adult endocrinology, we used two different endocrine diseases, the classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency, and the childhood-onset growth hormone deficiency. Specific problems for this transfer to adult care are the fixation of the patients to their pediatricians and the lack of comprehension in the need of a long term and continuous therapy. The consequence is a dramatic impairment in the quality of the therapy.
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Affiliation(s)
- H G Dörr
- Pädiatrische Endokrinologie, Kinder- und Jugendklinik, Universität Erlangen, Loschgestrasse 15, 91054, Erlangen.
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Reisch N, Flade L, Scherr M, Rottenkolber M, Pedrosa Gil F, Bidlingmaier M, Wolff H, Schwarz HP, Quinkler M, Beuschlein F, Reincke M. High prevalence of reduced fecundity in men with congenital adrenal hyperplasia. J Clin Endocrinol Metab 2009; 94:1665-70. [PMID: 19258407 DOI: 10.1210/jc.2008-1414] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Testicular adrenal rest tumors (TARTs) are regarded to contribute to the high prevalence of subfertility in males with congenital adrenal hyperplasia (CAH). OBJECTIVES Our objectives were to evaluate reduced fecundity and its possible causes in well-controlled adult males with CAH, and to investigate diagnostic tools for improved treatment monitoring with respect to fertility outcomes. DESIGN In a cross-sectional study at the Department of Endocrinology at the University Hospital München, Germany, 22 adult male CAH patients (15 salt wasting and seven simple virilizing, age 19-48 yr) were clinically assessed according to their hormonal control. We performed testicular ultrasound (22 of 22), magnetic resonance imaging (18 of 22), and a semen analysis (19 of 22) in the participants. RESULTS All patients had a pathological semen analysis. TART prevalence was 10 of 22 (eight salt wasting, two simple virilizing). Poor therapy control was present in five patients, and all five had TARTs. Of the other 17 well-controlled patients with normal or suppressed adrenal androgens and 17-hydroxyprogesterone levels, five presented with TARTs. There was a significant correlation between sperm concentration and functional testicular volume (r = 0.70; P = 0.002), TART volume (r = -0.70; P = 0.036), as well as inhibin B levels (r = 0.75; P < 0.0001), respectively. In several men, hormonal control parameters suggested hypogonadism, with glucocorticoid overtreatment as a relevant factor for poor semen quality. CONCLUSIONS Poor semen parameters are common in male CAH patients. TARTs, most likely reflecting undertreatment, as well as inhibin B are important indicators of fecundity. On the other hand, long-term glucocorticoid overtreatment also seems to contribute to low semen quality.
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Affiliation(s)
- Nicole Reisch
- Endocrinology and Metabolism, University Hospital München, D-80336 München, Germany.
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Claahsen-van der Grinten HL, Otten BJ, Stikkelbroeck MML, Sweep FCGJ, Hermus ARMM. Testicular adrenal rest tumours in congenital adrenal hyperplasia. Best Pract Res Clin Endocrinol Metab 2009; 23:209-20. [PMID: 19500764 DOI: 10.1016/j.beem.2008.09.007] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In adult patients with congenital adrenal hyperplasia (CAH) the presence of testicular adrenal rest tumours (TART) is an important cause of gonadal dysfunction and infertility. In the last decade several papers have focused on the origin and pathogenesis of these tumours. In this paper we review the embryological, histological, biochemical and clinical features of TART and discuss the treatment options. Furthermore, we propose a new five-stage classification of TART, based on sonographic, clinical and biochemical parameters, that may lead to a better follow up and treatment of patients with TART.
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Mouritsen A, Juul A, Jørgensen N. Improvement of semen quality in an infertile man with 21-hydroxylase deficiency, suppressed serum gonadotropins and testicular adrenal rest tumours. ACTA ACUST UNITED AC 2009; 33:518-20. [DOI: 10.1111/j.1365-2605.2009.00958.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Testicular adrenal rest tumours in congenital adrenal hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2009; 2009:624823. [PMID: 19956703 PMCID: PMC2777016 DOI: 10.1155/2009/624823] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 01/13/2009] [Indexed: 11/17/2022]
Abstract
In adult patients with congenital adrenal hyperplasia (CAH), the presence
of testicular adrenal rest tumours (TART) is an important complication leading to
gonadal dysfunction and infertility. These tumours can be already found in childhood and puberty. In this paper, we review the embryological, histological, biochemical,
and clinical features of TART and discuss treatment options.
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Merke DP. Approach to the adult with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Clin Endocrinol Metab 2008; 93:653-60. [PMID: 18326005 PMCID: PMC2266964 DOI: 10.1210/jc.2007-2417] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Congenital adrenal hyperplasia (CAH) describes a group of autosomal recessive disorders where there is impairment of cortisol biosynthesis. CAH due to 21-hydroxylase deficiency accounts for 95% of cases and shows a wide range of clinical severity. Treatment of the classic or severe form of CAH is targeted at replacing cortisol and aldosterone and effectively controlling excess androgen symptoms by using the lowest possible glucocorticoid dose. Treatment of the mild or nonclassic form is targeted at controlling excess androgen symptoms and may or may not involve glucocorticoid therapy. Hydrocortisone is the treatment of choice for children, but there is no consensus on how patients should be treated as adults. Current glucocorticoid therapy is suboptimal because it is often difficult to reduce excess androgen without giving excess glucocorticoid, and patients may experience hypercortisolism, androgen excess, or a combination of these states. Treatment of CAH, especially in the adult patient, remains controversial given the lack of prospective randomized controlled trials comparing treatment regimens. Nevertheless, patients benefit from careful individualized therapy with avoidance of Cushingoid side effects and optimization of reproductive, sexual, and bone health.
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Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center, Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-1932, USA.
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Hughes IA. Congenital adrenal hyperplasia: a lifelong disorder. HORMONE RESEARCH 2007; 68 Suppl 5:84-9. [PMID: 18174717 DOI: 10.1159/000110585] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH), the most common cause of ambiguous genitalia of the newborn, requires rapid assessment by a multidisciplinary team including a neonatologist, paediatric endocrinologist, paediatric urologist and geneticist. There is also a role for the clinical psychologist with psychosexual counselling experience as families cope with disorders of sex development. This brief review summarises the continuum of disorders that are manifested in patients with CAH according to age and sex, with emphasis on the lifetime nature of the issues that accompany this disorder and on the long-lasting ramifications of pediatric management decisions for both males and females. CONCLUSIONS There are many management aspects of caring for patients with CAH that clearly fall into the purview of paediatricians or adult-care physicians. There are also areas where responsibilities overlap and require several professionals providing coordinated care.
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Affiliation(s)
- Ieuan A Hughes
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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Riepe FG, Sippell WG. Recent advances in diagnosis, treatment, and outcome of congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Rev Endocr Metab Disord 2007; 8:349-63. [PMID: 17885806 DOI: 10.1007/s11154-007-9053-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21-OHD) is an autosomal-recessive disease causing cortisol deficiency, aldosterone deficiency and hyperandrogenism. Diagnosis of 21-OHD is confirmed by steroid analysis in newborn screening or later on. Standard medical treatment consists of oral glucocorticoid and mineralocorticoid administration in order to suppress adrenal androgens and to compensate for adrenal steroid deficiencies. However, available treatment is far from ideal, and not much is known about the long-term outcome in CAH as trials in patients in adulthood or old age are rare. Here we briefly describe the pathophysiology, clinical picture, genetics and epidemiology of 21-OHD. This is followed by a comprehensive review of the recent advances in diagnosis, treatment and outcome. Novel insights have been gained in the fields of newborn screening, specific steroid measurement utilizing mass spectrometry, genetics, glucocorticoid stress dosing, additive medical therapy, prenatal treatment, side-effects of medical treatment, adrenomedullary involvement, metabolic morbidity, fertility and gender identity. However, many issues are still unresolved, and novel questions, which will have to be answered in the future, arise with every new finding.
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Affiliation(s)
- Felix G Riepe
- Division of Pediatric Endocrinology, Department of Pediatrics, Christian-Albrechts-Universität Kiel, Schwanenweg 20, 24105, Kiel, Germany.
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