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Fraga NR, Minaeian N, Kim MS. Congenital Adrenal Hyperplasia. Pediatr Rev 2024; 45:74-84. [PMID: 38296783 DOI: 10.1542/pir.2022-005617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
We describe congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, which is the most common primary adrenal insufficiency in children and adolescents. In this comprehensive review of CAH, we describe presentations at different life stages depending on disease severity. CAH is characterized by androgen excess secondary to impaired steroidogenesis in the adrenal glands. Diagnosis of CAH is most common during infancy with elevated 17-hydroxyprogesterone levels on the newborn screen in the United States. However, CAH can also present in childhood, with late-onset symptoms such as premature adrenarche, growth acceleration, hirsutism, and irregular menses. The growing child with CAH is treated with hydrocortisone for glucocorticoid replacement, along with increased stress doses for acute illness, trauma, and procedures. Mineralocorticoid and salt replacement may also be necessary. Although 21-hydroxylase deficiency is the most common type of CAH, there are other rare types, such as 11β-hydroxylase and 3β-hydroxysteroid dehydrogenase deficiency. In addition, classic CAH is associated with long-term comorbidities, including cardiometabolic risk factors, impaired cognitive function, adrenal rest tumors, and bone health effects. Overall, early identification and treatment of CAH is important for the pediatric patient.
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Affiliation(s)
- Nicole R Fraga
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
| | - Nare Minaeian
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Mimi S Kim
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine of University of Southern California, Los Angeles, CA
- The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, CA
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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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Yildiz M, Bayram A, Bas F, Karaman V, Toksoy G, Poyrazoglu S, Soysal FG, Onder S, Uyguner ZO, Darendeliler F. Ovarian and paraovarian adrenal rest tumors are not uncommon in gonadectomy materials of historical congenital adrenal hyperplasia cases in childhood. Eur J Endocrinol 2022; 187:K13-K18. [PMID: 35550562 DOI: 10.1530/eje-21-0913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 05/12/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of this study was to assess the prevalence of ovarian and paraovarian adrenal rest tumors (ARTs) in gonadectomy materials of a subgroup of congenital adrenal hyperplasia (CAH) patients. METHODS A total of 20 historical cases with clinical/molecular diagnosis of classical CAH were included in the study. All patients had 46,XX karyotype and underwent gonadectomy because of being raised as male. RESULTS Median age at diagnosis of CAH was 5.7 years and was markedly delayed. All patients revealed severe virilization. Bone age was significantly advanced, and bone age/chronological age ratio was increased with a median ratio of 1.8. Median age at the time of gonadectomy was 9.2 years. Ovarian and paraovarian ARTs were detected during the pathological evaluation of gonadectomy materials in four patients (20%) (two with simple virilizing 21-hydroxylase and two with 11-beta-hydroxylase deficiency) with previously normal pelvic imaging. In three cases with ARTs, paraovarian area was composed of medium-sized polygonal cells, with round or oval monomorphic nuclei and abundant granular eosinophilic cytoplasm which is characteristic of adrenocortical tissue. The fourth case had bilateral ovarian 'steroid cell tumors, not otherwise specified', and the tumor was accepted as benign. Except for the ARTs, heterotopic prostate and bilateral paratubal epididymis tissue were detected in a patient. CONCLUSIONS Ovarian and paraovarian ARTs might be more common than previously described, especially among patients with excessive and prolonged adrenocorticotropic hormone exposure. These tumors could be detected histopathologically even if not detected by classical imaging methods.
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Affiliation(s)
- Melek Yildiz
- Department of Pediatric Endocrinology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Aysel Bayram
- Department of Pathology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Firdevs Bas
- Department of Pediatric Endocrinology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Volkan Karaman
- Department of Medical Genetics, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Guven Toksoy
- Department of Medical Genetics, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Sukran Poyrazoglu
- Department of Pediatric Endocrinology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Feryal Gun Soysal
- Department of Pediatric Surgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Semen Onder
- Department of Pathology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Zehra Oya Uyguner
- Department of Medical Genetics, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Feyza Darendeliler
- Department of Pediatric Endocrinology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
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Ladjouze A, Donaldson M, Plotton I, Djenane N, Mohammedi K, Tardy-Guidollet V, Mallet D, Boulesnane K, Bouzerar Z, Morel Y, Roucher-Boulez F. Genotype, Mortality, Morbidity, and Outcomes of 3β-Hydroxysteroid Dehydrogenase Deficiency in Algeria. Front Endocrinol (Lausanne) 2022; 13:867073. [PMID: 35757411 PMCID: PMC9229600 DOI: 10.3389/fendo.2022.867073] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND 3β-hydroxysteroid dehydrogenase 2 (3βHSD2) deficiency is a rare form of congenital adrenal hyperplasia (CAH), with fewer than 200 cases reported in the world literature and few data on outcomes. PATIENTS AND METHODS We report a mixed longitudinal and cross-sectional study from a single Algerian center between 2007 and 2021. Virilization and under-masculinization were assessed using Prader staging and the external masculinization score (EMS), pubertal development staged according to the system of Tanner. Adrenal steroids were measured using mass spectrophotometry (LC-MS/MS). A genetic analysis of HSD3B2 was performed using Sanger sequencing. RESULTS A 3βHSD2 defect was confirmed in 6 males and 8 females from 10 families (8 consanguineous), with p.Pro222Gln mutation in all but two siblings with a novel deletion: c.453_464del or p.(Thr152_Pro155del). Probable 3βHSD2 deficiency was diagnosed retrospectively in a further 6 siblings who died, and in two patients from two other centers. In the genetically confirmed patients, the median (range) age at presentation was 20 (0-390) days, with salt-wasting (n = 14) and genital anomaly (n = 10). The Prader stage for female patients was 2 (1-2) with no posterior fusion of the labia. The EMS for males was 6 (3-9). Median (range) values at diagnosis for 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEA-S), and 17-hydroxypregnenolone (17OHPreg) were elevated: 73.7 (0.37-164.3) nmol/L; 501.2(9.4-5441.3) nmol/L, and 139.7 (10.9-1500) nmol/l (NB >90 nmol/L diagnostic of 3βHSD2 defect). Premature pubarche was observed in four patients (3F:1M). Six patients (5F:1M) entered puberty spontaneously, aged 11 (5-13) years in 5 girls and 11.5 years in one boy. Testicular adrenal rest tumors were found in three boys. Four girls reached menarche at 14.3 (11-14.5) years, with three developing adrenal masses (surgically excised in two) and polycystic ovary syndrome (PCOS), with radiological evidence of ovarian adrenal rest tumor in one. The median IQ was 90 (43-105), >100 in only two patients and <70 in three. CONCLUSIONS The prevalence of 3βHSD2 deficiency in Algeria appears high, with p.Pro222Gln being the most frequent mutation. Mortality is also high, with significant morbidity from adrenal tumors and PCOS in adolescence and an increased risk of learning disability. The finding of adrenal tumors in older patients with 3βHSD2 indicates under-replacement, requiring effective hydrocortisone and fludrocortisone treatment rather than surgical removal.
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Affiliation(s)
- Asmahane Ladjouze
- Department of Paediatrics, Centre Hospitalo-Universitaire Bab El Oued, Algiers, Algeria
- *Correspondence: Asmahane Ladjouze,
| | - Malcolm Donaldson
- Section of Child Health, School of Medicine, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Ingrid Plotton
- Molecular Endocrinology and Rare Diseases, Hospices Civils de Lyon, Lyon University Hospital, Bron-Lyon, France
| | - Nacima Djenane
- Department of Pathological Anatomy, Centre Hospitalo-Universitaire Bab El Oued, Algiers, Algeria
| | - Kahina Mohammedi
- Department of Paediatrics, Centre Hospitalo-Universitaire Bab El Oued, Algiers, Algeria
| | - Véronique Tardy-Guidollet
- Molecular Endocrinology and Rare Diseases, Hospices Civils de Lyon, Lyon University Hospital, Bron-Lyon, France
| | - Delphine Mallet
- Molecular Endocrinology and Rare Diseases, Hospices Civils de Lyon, Lyon University Hospital, Bron-Lyon, France
| | - Kamélia Boulesnane
- Department of Paediatrics, Centre Hospitalo-Universitaire Bab El Oued, Algiers, Algeria
| | - Zair Bouzerar
- Department of Paediatrics, Centre Hospitalo-Universitaire Bab El Oued, Algiers, Algeria
| | - Yves Morel
- Molecular Endocrinology and Rare Diseases, Hospices Civils de Lyon, Lyon University Hospital, Bron-Lyon, France
| | - Florence Roucher-Boulez
- Molecular Endocrinology and Rare Diseases, Hospices Civils de Lyon, Lyon University Hospital, Bron-Lyon, France
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Koren R, Koren S, Khashper A, Benbassat C, Pekar-Zlotin M, Vaknin Z. Ovarian adrenal rest tumor in congenital adrenal hyperplasia: Is medical treatment the first line option? ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:841-845. [PMID: 34762785 PMCID: PMC10065401 DOI: 10.20945/2359-3997000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Ovarian adrenal rest tumors (OARTs) are very rare. We describe a case of a young woman with uncontrolled classical congenital adrenal hyperplasia (CCAH), presenting with bilateral OARTs, successfully treated with steroid replacement. A 20-year-old woman, known to have 21OH-CCAH, presented with severe abdominal pain, vomiting, diarrhea, and fever. As a result of poor compliance, 6 months before her admission hirsutism worsened and amenorrhea, hyperpigmentation, and weakness developed. ACTH levels were 278 < pmol/L and 17OHP 91.3 nmol/L. She was admitted for parenteral antibiotics and high-dose hydrocortisone treatment. CT revealed bilateral juxta-ovarian masses (6.2 × 3.6 × 7.4 cm left and 5 × 2.2 × 3.2 cm right) that on MRI were iso-intense in T1 and hypointense in T2, with early enhancement and rapid washout. One week of high-dose hydrocortisone resulted in significant clinical and laboratory improvement and the patient was discharged with 2 mg dexamethasone/day. One month later US revealed shrinkage of the masses and dexamethasone dose was decreased. At three months from discharge, she has resumed regular menses, and a repeated MRI revealed the para-ovarian masses have shrunk. One year after the diagnosis, the para-ovarian masses have shrunk more to 2.8 × 1.9 × 4.3 on the left and 2.1 × 0.9 × 1.2 on the right with less contrast enhancement in comparison to previous test possibly due to fibrotic changes of the tissue. OARTs are rare tumors with a poorly known natural history, and surgery has been the first option in the few reported cases. We demonstrate that medical treatment is a good alternative, leading to significant tumor shrinkage over a short period.
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Affiliation(s)
- Ronit Koren
- Department of Internal Medicine A, Shamir Medical Center, Zerifin, Israel, .,Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel
| | - Shlomit Koren
- Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel.,Endocrine Institute, Shamir Medical Center, Zerifin, Israel.,Diabetes Unit, Shamir Medical Center, Zerifin, Israel
| | - Alla Khashper
- Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel.,Department of Diagnostic Imaging, Shamir Medical Center, Zerifin, Israel
| | - Carlos Benbassat
- Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel.,Endocrine Institute, Shamir Medical Center, Zerifin, Israel
| | - Marina Pekar-Zlotin
- Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Shamir Medical Center, Zerifin, Israel
| | - Zvi Vaknin
- Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Shamir Medical Center, Zerifin, Israel
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6
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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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Driano JE, Creo AL, Kumar S, Chattha AJ, Lteif AN. Ovarian Steroid Cell Tumor Masquerading as Steroid-Unresponsive Congenital Adrenal Hyperplasia. AACE Clin Case Rep 2021; 7:261-263. [PMID: 34307849 PMCID: PMC8282522 DOI: 10.1016/j.aace.2021.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
Objective Ovarian neoplasms in children are rare. The objective of this report is to emphasize the importance of considering those neoplasms in the differential diagnosis of hyperandrogenism even with negative diagnostic imaging. Methods We report the case of a 12-year-old girl who presented with virilization and elevated 17 hydroxyprogesterone (17-OHP) and who was subsequently diagnosed with an ovarian neoplasm. Results The patient was initially seen for hirsutism and deepening of the voice. Elevated 17-OHP, androstenedione, and testosterone prompted the initial diagnosis of nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency, but those levels failed to suppress on corticosteroid therapy. Ultrasound, computed tomography scan, and magnetic resonance imaging of the abdomen and pelvis were normal. Genetic testing for congenital adrenal hyperplasia was negative. Bilateral selective adrenal and ovarian venous sampling confirmed the ovarian origin of her hyperandrogenism. A unilateral salpingo-oophorectomy revealed a steroid cell tumor. Postoperatively there was normalization of testosterone and 17-OHP. Conclusion This report highlights the utility of selective adrenal and ovarian sampling when suspecting a primary androgen-secreting neoplasm, even in the setting of elevated 17-OHP levels and negative imaging studies, as early diagnosis can prevent manifestation of irreversible symptoms of virilization
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Affiliation(s)
- Jane E Driano
- Creighton University School of Medicine, Omaha, Nebraska
| | - Ana L Creo
- Division of Pediatric Endocrinology and Metabolism
| | - Seema Kumar
- Division of Pediatric Endocrinology and Metabolism
| | - Asma J Chattha
- Division of Pediatric Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Aida N Lteif
- Division of Pediatric Endocrinology and Metabolism
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Matsukawa J, Takahashi T, Hada Y, Kameda W, Ota K, Fukase M, Takahashi K, Matsuo K, Mizunuma H, Nagase S. Successful laparoscopic resection of virilizing ovarian steroid cell tumor, not otherwise specified, in a 22-year-old woman: a case report and evaluation of the steroidogenic pathway. Fukushima J Med Sci 2019; 65:133-139. [PMID: 31827013 DOI: 10.5387/fms.2019-25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Ovarian steroid cell tumor (SCT) is a rare tumor with steroid-producing ability. We report a 22-year-old woman with secondary amenorrhea and hirsutism caused by an ovarian SCT-not otherwise specified (NOS), who underwent successfully laparoscopic resection of the tumor. CASE REPORT A 22-year-old null gravida woman presented to a hospital, having amenorrhea for 18 months and increasing facial hair. Physical examination revealed obesity (body mass index, 37.3 kg/m2) with evident facial and trunk hair. Total and free serum testosterone, and dehydroepiandrosterone sulfate levels were found to be elevated. Levels of serum adrenocorticotropic hormone, gonadotropins, cortisol, aldosterone, and ovarian steroids were observed to be within reference intervals. Although polycystic ovaries were not found, a hyperechogenic solid tumor (3 cm) was detected on transvaginal ultrasonography. Laparoscopic resection of the tumor was performed. One month post-surgery, total and free testosterone levels were observed to have decreased, and menstruation resumed two months thereafter. The patient was histologically diagnosed with ovarian SCT-NOS. Expression of ovarian steroidogenic enzymes, which are related to hyperandrogenism, was observed. No disease recurrence has been reported for more than 5 years post-surgery.
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Affiliation(s)
- Jun Matsukawa
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine
| | - Toshifumi Takahashi
- Fukushima Medical Center for Children and Women, Fukushima Medical University
| | - Yurika Hada
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine
| | - Wataru Kameda
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology, Yamagata University Faculty of Medicine
| | - Kuniaki Ota
- Fukushima Medical Center for Children and Women, Fukushima Medical University
| | - Mika Fukase
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine
| | - Kyoko Takahashi
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine
| | - Koki Matsuo
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine
| | - Hideki Mizunuma
- Fukushima Medical Center for Children and Women, Fukushima Medical University
| | - Satoru Nagase
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine
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9
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Hyperandrogenism, Elevated 17-Hydroxyprogesterone and Its Urinary Metabolites in a Young Woman with Ovarian Steroid Cell Tumor, Not Otherwise Specified: Case Report and Review of the Literature. Case Rep Endocrinol 2019; 2019:9237459. [PMID: 31772787 PMCID: PMC6854983 DOI: 10.1155/2019/9237459] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/03/2019] [Indexed: 01/11/2023] Open
Abstract
We describe a case of a 24-year-old overweight woman who presented with hirsutism, secondary amenorrhea, clitoromegaly, and symptoms of diabetes mellitus (DM). While a diagnosis of polycystic ovary syndrome (PCOS) with its associated metabolic disturbances was initially considered, serum total testosterone, androstenedione, and 17-hydroxyprogesterone (17-OHP) measured by liquid chromatography tandem mass spectrometry (LC-MS/MS) were significantly increased. As 17-OHP did not increase upon ACTH (Synacthen) stimulation and the urinary steroid profile (USP) was compatible with an ovarian source of 17-OHP excess rather than adrenal, non classical congenital adrenal hyperplasia (NCCAH) was unlikely and an androgen-secreting tumor was suspected. Transabdominal ultrasound revealed the presence of an enlarged right ovary with a polycystic ovary morphology and no discrete mass. Transvaginal ultrasound and [18F]− fluorodeoxyglucose positron emission tomography–computed tomography (FDG PET–CT) enabled the localization of a right ovarian tumor. Laparoscopic right salpingo-oophorectomy was performed and a histological diagnosis of steroid cell tumor, not otherwise specified (SCT–NOS) was made. Hyperandrogenism and menstrual disturbances resolved postoperatively. A literature review revealed that 17-OHP-secreting SCT–NOS may uncommonly show positive responses to ACTH stimulation similar to 21-hydroxylase deficiency. Alternatively, USP might be useful in localizing the source of 17-OHP to the ovaries. Its diagnostic performance should be evaluated in further studies.
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Abstract
Ectopia of nodular adrenocortical tissue is very frequently found in the periadrenal region. It corresponds to accessory adrenal tissue and is a normal variant. Ectopia in more distant regions are found in inner male or female genitalia. Strong long-lasting hyperstimultions induce hyperplasia and simulate true tumors ("adrenal rest tumors"). Real autonomic tumors from ectopic adrenal tissue with or without hyperfunction are rare. Ectopia of adrenomedullary tissue are nearly exclusively found in the surroundings of normal medulla. Ectopia in the adrenals corresponds almost exclusively with thyroid tissue. Ectopic secretion of hormones, mostly ACTH, can be found in pheochromocytomas and induces hyperfunction (Cushing's syndrome).
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Benavent Correro P, Sáenz Valls M, García Cano A, Jiménez Mendiguchia L, Moreno Moreno E, Luque-Ramírez M. An unusual circulating steroid profile in a virilized postmenopausal woman. ACTA ACUST UNITED AC 2018; 5:83-87. [PMID: 29752879 DOI: 10.1515/dx-2018-0007] [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: 03/19/2018] [Accepted: 04/09/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Virilism is a female disorder in which secondary male sexual characteristics develop, caused by an excessive adrenal or ovarian androgen secretion. CASE PRESENTATION Here, we report an unusual case of an ovarian steroid cell tumor, not otherwise specified (NOS), in a 68-year-old female who presented with androgenic alopecia, clitoromegaly and an increased muscle mass. Laboratory investigations revealed both ovarian and adrenal hyperandrogenism with an elevation of androgen precursors mimicking congenital adrenal hyperplasia. A left adnexal mass was confirmed by imaging techniques. A laparoscopic bilateral salpingo-oophorectomy was performed and histopathology confirmed the diagnosis of an ovarian steroid cell tumor NOS. After surgical intervention, circulating androgen levels and their precursors returned to normal values in the postmenopausal woman. CONCLUSIONS A detailed anamnesis and physical examination are key to the correct diagnosis in a woman with hyperandrogenism independent of her circulating androgen profile.
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Affiliation(s)
| | - Marta Sáenz Valls
- Department of Clinical Biochemistry, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Ana García Cano
- Department of Clinical Biochemistry, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Esther Moreno Moreno
- Department of Pathological Anatomy, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Manuel Luque-Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain.,Diabetes, Obesity and Human Reproduction Research Group, Hospital Universitario Ramón y Cajal and Universidad de Alcalá and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Centro de Investigación Biomédica en Red Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
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12
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Chen HD, Huang LE, Zhong ZH, Su Z, Jiang H, Zeng J, Liu JC. Ovarian Adrenal Rest Tumors Undetected by Imaging Studies and Identified at Surgery in Three Females with Congenital Adrenal Hyperplasia Unresponsive to Increased Hormone Therapy Dosage. Endocr Pathol 2017; 28:146-151. [PMID: 28032206 DOI: 10.1007/s12022-016-9461-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with congenital adrenal hyperplasia have a predisposition for developing adrenal rest tumors. In contrast to testicular adrenal rest tumors, ovarian adrenal rest tumors are less common, and only a few cases have been reported in the literature. This report presents three Chinese female congenital adrenal hyperplasia patients (9 to 15 years of age) with small ectopic adrenal cortical nodules that were not detected by imaging but were diagnosed at surgery. All three patients developed virilization with elevation of 17- hydroxyprogesterone, androstenedione, and androgen levels despite receiving maximum adrenal hormone replacement therapy. Ultrasound and magnetic resonance imaging of the abdomen and pelvis suggested bilateral expansion of the adrenal glands, but no lesions of the ovaries were observed. Laparoscopy and/or laparotomy revealed small nodular lesions surrounding the pelvic gonad in all three cases. Histopathological examination of the resected tissue in all cases revealed hyperplasic nodules of cells surrounded by fibrous tissue. The cells were arranged as nests with abundant cytoplasm, which were partially lightly stained with a small centered nucleus. Immunohistochemistry staining revealed the cells to be synaptophysin positive, melan-A positive, and chromogranin A negative, indicating the cells were adrenocortical tissue and not adrenal medullary cells. Thus, the findings of the histopathological examination were consistent with ovarian adrenal rest tumors. Female congenital adrenal hyperplasia patients with virilization who showed an inadequate response to hormone therapy and had negative imaging results may benefit from laparoscopic examination or laparotomy in order to confirm the diagnosis of ovarian adrenal rest tumors while receiving unilateral subtotal adrenalectomy or subtotal bilateral adrenalectomy.
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Affiliation(s)
- Hua-Dong Chen
- Pediatric Surgery Department of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li-E Huang
- Pediatric Surgery Department of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi-Hai Zhong
- Pediatric Surgery Department of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhe Su
- Pediatric Department of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hong Jiang
- Pediatric Surgery Department of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Zeng
- Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jun-Cheng Liu
- Pediatric Surgery Department of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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13
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Yokozawa T, Asano R, Nakamura T, Furuya M, Nagashima Y, Koyama-Sato M, Kanda Y, Hirahara F, Sakakibara H. Steroid cell tumour, not otherwise specified: Rare case with primary amenorrhoea in a 16-year-old. J OBSTET GYNAECOL 2015. [PMID: 26214349 DOI: 10.3109/01443615.2015.1022141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- T Yokozawa
- a Department of Obstetrics and Gynecology , Yokohama City University School of Medicine , Yokohama , Japan
| | - R Asano
- a Department of Obstetrics and Gynecology , Yokohama City University School of Medicine , Yokohama , Japan
| | - T Nakamura
- a Department of Obstetrics and Gynecology , Yokohama City University School of Medicine , Yokohama , Japan
| | - M Furuya
- b Department of Pathology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Y Nagashima
- b Department of Pathology , Yokohama City University School of Medicine , Yokohama , Japan.,c Department of Surgical Pathology , Tokyo Women's Medical University Hospital , Tokyo , Japan
| | - M Koyama-Sato
- a Department of Obstetrics and Gynecology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Y Kanda
- a Department of Obstetrics and Gynecology , Yokohama City University School of Medicine , Yokohama , Japan
| | - F Hirahara
- a Department of Obstetrics and Gynecology , Yokohama City University School of Medicine , Yokohama , Japan
| | - H Sakakibara
- a Department of Obstetrics and Gynecology , Yokohama City University School of Medicine , Yokohama , Japan
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