Androgen Insensitivity Syndrome: A rare genetic disorder

Complete Androgen Insensitivity Syndrome in a Young Girl with Primary Amenorrhea and Suspected Delayed Puberty: A Case-Based Review of Clinical Management, Surgical Follow-Up, and Oncological Risk

Background: Complete androgen insensitivity syndrome (CAIS) is a rare disorder of sex development characterized by 46,XY karyotype and testes, yet presenting with a complete female phenotype, which is related to mutations in the androgen receptor (AR) gene. Case presentation: We herein present the case of a 14-year-old adolescent with primary amenorrhea and suspected delayed puberty whose diagnostic journey led to the identification of CAIS through the demonstration of a novel AR variant (c.159_207del). Case-based review: Our report encompasses the complexity of CAIS management, focusing on the risk of malignancy, surveillance options, hormone replacement therapy, timing of an eventual gonadectomy, and the psychosocial impact of such a diagnosis. An algorithm has been formulated for the management of CAIS starting in adolescence, highlighting the conservative approach for those patients unwilling to undergo gonadectomy. Conclusions: Primary amenorrhea and delay in puberty development may provide clues, ultimately leading to a diagnosis of CAIS. This review emphasizes the cruciality of a multidisciplinary approach in managing patients with CAIS, needing for an individualized care to optimize the overall outcome.

Advances in the understanding of androgen receptor structure and function and in the development of next-generation AR-targeted therapeutics

Androgen receptor (AR) and its ligand androgens are important for development and physiology of various tissues. AR and its ligands also play critical role in the development of various diseases, making it a valuable therapeutic target. AR ligands, both agonists and antagonists, are being widely used to treat pathological conditions, including prostate cancer and hypogonadism. Despite AR being studied widely over the last five decades, the last decade has seen striking advances in the knowledge on AR and discoveries that have the potential to translate to the clinic. This review provides an overview of the advances in AR biology, AR molecular mechanisms of action, and next generation molecules that are currently in development. Several of the areas described in the review are just unraveling and the next decade will bring more clarity on these developments that will put AR at the forefront of both basic biology and drug development.

Histologic Analysis of 'Distraction Vaginogenesis' in a Rat Model

Vaginal agenesis (VA) is frequently associated with mullerian agenesis. VA treatments include mechanical dilation and surgical vaginoplasty. We created a vaginal expansion sleeve (VES) as a novel device to progressively lengthen the vaginal canal. This study evaluated the histologic effects of the VES on rat vaginal tissue. The VES is a spring-like device made of proprietary woven cylindrical material and flat resin caps. The VESs were constructed as 25-30 mm, pre-contracted springs, which were secured into the vaginas of six Sprague Dawley rats and allowed to re-expand post-surgically. After one week, the VESs were removed, and the vaginas were harvested and measured in length. Test (n = 6) and control (n = 4) formalin-fixed paraffin-embedded tissues were stained with hematoxylin and eosin (H&E), Masson's trichrome, and anti-Desmin antibodies. The VESs achieved significant vaginal lengthening. The mean vaginal canal length increased from 20.0 ± 2.4 mm to 23.8 ± 1.2 mm after removal of the VESs (n = 6, p < 0.001), a 19% increase. There was a positive correlation between the expander/tension generated in the vagina and the amount of acute and chronic inflammation. H&E staining revealed increased submucosal eosinophilia in five of the six test tissues. One VES sample that was lengthened to 30 mm long showed evidence of lymphocytic and neutrophilic inflammation. Desmin immunostaining and Masson's trichrome stain revealed a thinner muscularis with more infiltrative fibrous tissue between muscle fibers in the test tissue compared to the control tissue. Although effective, the VES may provoke at least a transient increase in eosinophils consistent with a localized immune reaction during muscularis remodeling.

Complete androgen insensitivity syndrome diagnosed after inguinal surgery in era of modern technology: a case report

Introduction

Androgen Insensitivity Syndrome (AIS) is a rare X-linked recessive disorder of sexual development. It results from mutations in the Androgen Receptor (AR) gene located on chromosome Xq11-12. Affected individuals have a male genotype but a female phenotype.

Case presentation

A 20-year-old female presented to the emergency room with a history of pain in the bilateral inguinal region. In ultrasonography (USG), bilateral inguinal hernia was suspected. While performing an emergency operation for hernia repair, hernia was revealed as bilateral abdominal testis. Then, after a gynecology consultation, a bilateral orchidectomy was done. Postoperative karyotyping showed a male genotype. Then the patient was discharged on hormone replacement therapy to maintain normal bone mineral density and secondary sexual characteristics.

Discussion

AIS presents with primary amenorrhea in pubertal females. The growth spurt and secondary sexual characteristics are normal except for absent axillary and pubic hair. There is a short-blind vagina, but the uterus is absent, and the abdominal testis presents as an inguinal hernia. Serum gonadotropin level, karyotyping, and imaging studies are done to reach a diagnosis. Management includes gonadectomy, genitoplasty, and hormone replacement therapy.

Conclusion

The objective of this report was to make clinicians aware that AIS can present as a bilateral inguinal hernia. In acute presentations, it can be misdiagnosed as a strangulated femoral hernia only later to be identified as an undescended abdominal testis during surgery. An absence of proper clinical judgment and reliance on USG for imaging can often lead to misdiagnosis in acute settings.

A 10-YEAR STUDY OF CHILDREN WITH GONADAL TUMORS AND DISORDERS OF SEX DIFFERENTIATION, IN ROMANIA

Context

Children having gonadal tumors and disorder of sex differentiation (DSD) are rare.

Objective

To investigate the presentation of DSD children with malignant gonadal tumors.

Methods

A retrospective study from 2010-2020, that evaluated 17 children with DSD, including 13 females, eight months to 16 years, with congenital adrenal hyperplasia, 5-alpha reductase deficiency, androgen insensitivity syndrome, Turner, Sywer, and Klinefelter syndromes.

Results

Ten children had malignant gonadal tumor; nine had germ cell tumors and one person granulosa cell tumors, while seven children with non-malignant tumor had gonadoblastoma, cystadenoma (five children), and cysts. Systemic malformations, obesity, elevated tumor markers, and psychosocial issues were observed in 90%, 90%, 70%, and 50% of children with malignancy unlike 28.6%, 42.9%, 14.35%, and 57.1% children without malignancy respectively. Most (9/10) children >12 years, had psychosocial issues, unlike 0/7 children ≤12 years. From 8/17 children presenting with symptoms suggestive of tumor, 75% had malignancy, while from 9/17 children with DSD presentation, 44% had malignant tumors. Malignancy was observed in 3/10 children between eight months to age six, while 7/10 children had stage 1-2 tumors. We reported a child, identified as female, aged 13 years, with partial androgen insensivity syndrome (PAIS) 46,XY, and testicular papillary serous cystadenoma with genomic variant AR NM_000044.4:c.2750del. p.(F917Sfs*27) chromosome Xq12, never published in people with PAIS nor population databases (GnomAD).

Conclusion

DSD diagnosis raises numerous challenges. People with DSD have increased risk of malignancy, especially when obesity and, systemic malformations are present; also, psychosocial issues in these children are associated with postpubertal age.

One-stage sex reassignment surgery at the delayed presentation in a patient with partial androgen insensitivity syndrome: A case report

Introduction and importance

The partial androgen insensitivity syndrome (PAIS) is a rare genetic disorder, which needs to be diagnosed early and provided suitable treatment. One-stage sex reassignment surgery can be considered as one of the treatment options for PAIS patients.

Case presentation

A 44-year-old patient with PAIS was admitted to our hospital. After getting a consultation, the patient decided to choose the one-stage sex reassignment surgery to be reassigned to be a female. The surgery consisted of breast augmentation and genital surgery. After 8 months of follow-up, the patient's breast had a desired shape and volume. The clitoris was in normal size with normal sensation, and the neovagina was 8 cm in depth with a smooth mucosal surface. We also observed that the minor labia were symmetric. The patient reported achieving orgasms with sex toys.

Clinical discussion

The one-stage sex reassignment surgery for the PAIS patient is safe and reduces treatment time for patients. It could also bring many benefits to the patients, such as reducing the incision, preventing gonadoblastoma and giving a sense of the patient's female gender which helps the patient feel confident and improve her quality of life. Thus, the one-stage surgery should be indicated for the patient at middle-aged who shouldn't be delayed anymore to have normal female breast and external genitalia.

Conclusion

The one-stage sex reassignment surgery was performed safely and successfully on the delayed presentation of the PAIS patient. This could be an effective and appropriate approach to treat late-diagnosed PAIS patients.

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One-stage sex reassignment surgery for a patient with partial androgen insensitivity syndrome

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A 44-year-old patient at the delayed presentation of the disorder

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We observed good treatment outcomes with a 8-moth follow-up

Animal Models and Alternatives in Vaginal Research: a Comparative Review

While developments in gynecologic health research continue advancing, relatively few groups specifically focus on vaginal tissue research for areas like wound healing, device development, and/or drug toxicity. Currently, there is no standardized animal or tissue model that mimics the full complexity of the human vagina. Certain practical factors such as appropriate size and anatomy, costs, and tissue environment vary across species and moreover fail to emulate all aspects of the human vagina. Thus, investigators are tasked with compromising specific properties of the vaginal environment as it relates to human physiology to suit their particular scientific question. Our review aims to facilitate the appropriate selection of a model aptly addressing a particular study by discussing pertinent vaginal characteristics of conventional animal and tissue models. In this review, we first cover common laboratory animals studied in vaginal research-mouse, rat, rabbit, minipig, and sheep-as well as human, with respect to the estrus cycle and related hormones, basic reproductive anatomy, the composition of vaginal layers, developmental epithelial origin, and microflora. In light of these relevant comparative metrics, we discuss potential selection criteria for choosing an appropriate animal vaginal model. Finally, we allude to the exciting prospects of increasing biomimicry for in vitro applications to provide a framework for investigators to model, interpret, and predict human vaginal health.