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Santos HC, Barros BA, El-Beck MS, Miranda ML, Guaragna MS, Fabbri-Scallet H, Mazzola TN, Vieira TP, Mello MP, Marques-de-Faria AP, Maciel-Guerra AT, Guerra-Junior G. Patients with genital ambiguity referred without a sex definition: the relationship between clinical picture and defined sex of rearing. J Pediatr (Rio J) 2024:S0021-7557(24)00069-X. [PMID: 38823786 DOI: 10.1016/j.jped.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 06/03/2024] Open
Abstract
OBJECTIVE It was to verify the association between the definition of sex of rearing and, clinical and cytogenetic features among patients with genital ambiguity referred without a sex assignment. METHODS The sample consisted of 133 patients with genital ambiguity seen at a single reference service. These patients did not have a defined social sex at the first consultation and their etiological diagnosis was obtained during follow-up. RESULTS A total of 133 cases were included, 74 of which were reared as males and 59 as females. No correlation was found between the year of birth and the year of the first consultation with the definition of sex of rearing. However, the definition of sex of rearing was associated with age at the first consultation, severity of genital ambiguity, presence of palpable gonad(s), presence of uterus on ultrasound, karyotype, and diagnosis. Palpable gonad(s), more virilized genitalia, absence of a uterus on ultrasound, 46, XY karyotype, or a karyotype with sex chromosome abnormalities emerged as strong predictors for defining male sex. All 77 (58 %) patients over 18 years old had a gender identity in accordance with the sex of rearing; though 9 of 77 (12 %) had homo or bisexual orientation, especially girls with Congenital Adrenal Hyperplasia. CONCLUSIONS Clinical and cytogenetic data were strongly associated with the definition of the sex of rearing of children with genital ambiguity referred to a DSD center without sex assignment. Management in a specialized center allows the establishment of a gender identity in accordance with the sex of rearing.
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Affiliation(s)
- Henrique C Santos
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Beatriz A Barros
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Mayra S El-Beck
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Marcio L Miranda
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Mara S Guaragna
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Helena Fabbri-Scallet
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Taís N Mazzola
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Tarsis P Vieira
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Maricilda P Mello
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Antonia P Marques-de-Faria
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Andrea T Maciel-Guerra
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil
| | - Gil Guerra-Junior
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas e Hospital das Clínicas Universitárias, Grupo Interdisciplinar para o Estudo da Determinação e Diferenciação do Sexo, Campinas, SP, Brazil.
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Palui R, Ravichandran L, Kamalanathan S, Chapla A, Sahoo J, Narayanan N, Naik D, Thomas N. Clinical, Hormonal, and Genetic Spectrum of 46 XY Disorders of Sexual Development (DSD) Patients. Indian J Pediatr 2024:10.1007/s12098-024-05144-8. [PMID: 38761274 DOI: 10.1007/s12098-024-05144-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/23/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVES To evaluate the clinical, hormonal and genetic characteristics of 46XY disorders of sexual development (DSD) patients from South India. METHODS 46XY DSD patients with a provisional diagnosis of 17β-hydroxysteroid dehydrogenase 3 (17BHSD3) deficiency, 5 alpha-reductase type 2 deficiency (5ARD2) or partial androgen insensitivity syndrome (PAIS) based on clinical and hormonal analysis were included in this study. All the patients underwent detailed clinical and hormonal evaluations. Targeted next-generation sequencing for all three genes (AR, HSD17B3, and SRD5A2) in parallel was carried out for all the included patients and their parents. RESULTS Based upon the clinical and hormonal analysis, among the 37 children with 46XY DSD in the present study, 21 children were diagnosed with 5ARD2, 10 with PAIS, and six with 17BHSD3 deficiency. However, genetic analysis revealed pathogenic mutations in nine patients - six in the AR gene, two in the SRD5A2 gene, and one in the HSD17B3 gene. The concordance rate between provisional hormonal and genetic diagnosis was only 22.2%. Two out of six subjects with AR gene variants were positive for somatic mosaicism. CONCLUSIONS In the present study, a positive genetic diagnosis was detected in nine patients (24%), including five novel variants. In this study, mutations in the AR gene was the most reported. The authors did not find the testosterone: dihydrotestosterone (T: DHT) ratio to be an accurate hormonal diagnostic tool.
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Affiliation(s)
- Rajan Palui
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Lavanya Ravichandran
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Sadishkumar Kamalanathan
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
| | - Aaron Chapla
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Jayaprakash Sahoo
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Niya Narayanan
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Dukhabandhu Naik
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
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LGBTQ+ Youth Health: An Unmet Need in Pediatrics. CHILDREN 2022; 9:children9071027. [PMID: 35884011 PMCID: PMC9325167 DOI: 10.3390/children9071027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 11/19/2022]
Abstract
At present, lesbian, gay, bisexual, transgender, queer and intersex people (LGBTQ+) are increasingly being empowered to freely express themselves, particularly young people and rising generations. Although data underline the trend of more open expression of different sexual orientations and gender identities, LGBTQ+ adolescents still suffer discrimination in the health care framework. Inclusive care by providers to look after the health of LGBTQ+ indiviuals is needed. Pediatricians are often the first health care providers for LGBTQ+ youth facing their sexual and gender identities. Unfortunately, pediatricians have limited knowledge about LGBTQ+ issues, which keeps them from fulfilling the specific needs of LGBTQ+ youth. The purpose of this review is to frame the most important aspects of LGBTQ+ youths’ lives, including risks, difficulties and needs, that pediatricians should investigate and meet to provide these youth with better and more individualizedassistance regarding their health. A literature analysis showed that pediatricians have insufficient knowledge of and comfort with several items regarding the management of LGBTQ+ youths. Increased awareness and knowledge of the specific and exclusive needs of LGBTQ+ adolescents are mandatory, including dedicated pediatric LGBTQ+ health care training. This would give them the opportunity to forward an inclusive health care system, thus reducing the risks related to stigma, bullying and family rejection and promoting sex education. Further studies are needed to better evaluate the prevalence of LGBTQ+ youths, gender-based medicine in pediatrics and the effects of COVID-19 on the LGBTQ+ younth population due to increased risks of psychosocial suffering, isolation and mental diseases.
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Babu R. Changing Paradigms in Intersex Management: Legal, Ethical, and Medical Implications. J Indian Assoc Pediatr Surg 2022; 27:372-375. [PMID: 36238319 PMCID: PMC9552657 DOI: 10.4103/jiaps.jiaps_41_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 03/13/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ramesh Babu
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Past Chairman of Society of Pediatric Urology (IAPS), Chennai, Tamil Nadu, India,Address for correspondence: Dr. Ramesh Babu, Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu, India. E-mail:
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Ahmed SF, Achermann J, Alderson J, Crouch NS, Elford S, Hughes IA, Krone N, McGowan R, Mushtaq T, O'Toole S, Perry L, Rodie ME, Skae M, Turner HE. Society for Endocrinology UK Guidance on the initial evaluation of a suspected difference or disorder of sex development (Revised 2021). Clin Endocrinol (Oxf) 2021; 95:818-840. [PMID: 34031907 DOI: 10.1111/cen.14528] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/30/2021] [Accepted: 05/13/2021] [Indexed: 11/26/2022]
Abstract
It is paramount that any child or adolescent with a suspected difference or disorder of sex development (DSD) is assessed by an experienced clinician with adequate knowledge about the range of conditions associated with DSD and is discussed with the regional DSD service. In most cases, the paediatric endocrinologist within this service acts as the first point of contact but involvement of the regional multidisciplinary service will also ensure prompt access to specialist psychology and nursing care. The underlying pathophysiology of DSD and the process of delineating this should be discussed with the parents and affected young person with all diagnostic tests undertaken in a timely fashion. Finally, for rare conditions such as these, it is imperative that clinical experience is shared through national and international clinical and research collaborations.
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Affiliation(s)
- S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
- Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, UK
- Office for Rare Conditions, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - John Achermann
- Genetics & Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Julie Alderson
- Psychological Health Services, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | - Naomi S Crouch
- Department of Women's Health, St Michael's Hospital, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | | | - Ieuan A Hughes
- DSDFamilies, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Ruth McGowan
- Developmental Endocrinology Research Group, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
- West of Scotland Centre for Genomic Medicine, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Talat Mushtaq
- Department of Paediatric Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Stuart O'Toole
- Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, UK
- Department of Paediatric Urology, Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Leslie Perry
- Department of Clinical Biochemistry, Croydon University Hospital, London, UK
| | - Martina E Rodie
- Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, UK
- Office for Rare Conditions, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
- Department of Neonatology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mars Skae
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Helen E Turner
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Alkhzouz C, Bucerzan S, Miclaus M, Mirea AM, Miclea D. 46,XX DSD: Developmental, Clinical and Genetic Aspects. Diagnostics (Basel) 2021; 11:1379. [PMID: 34441313 PMCID: PMC8392837 DOI: 10.3390/diagnostics11081379] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 11/17/2022] Open
Abstract
Differences in sex development (DSD) in patients with 46,XX karyotype occur by foetal or postnatal exposure to an increased amount of androgens. These disorders are usually diagnosed at birth, in newborns with abnormal genitalia, or later, due to postnatal virilization, usually at puberty. Proper diagnosis and therapy are mostly based on the knowledge of normal development and molecular etiopathogenesis of the gonadal and adrenal structures. This review aims to describe the most relevant data that are correlated with the normal and abnormal development of adrenal and gonadal structures in direct correlation with their utility in clinical practice, mainly in patients with 46,XX karyotype. We described the prenatal development of structures together with the main molecules and pathways that are involved in sex development. The second part of the review described the physical, imaging, hormonal and genetic evaluation in a patient with a disorder of sex development, insisting more on patients with 46,XX karyotype. Further, 95% of the etiology in 46,XX patients with disorders of sex development is due to congenital adrenal hyperplasia, by enzyme deficiencies that are involved in the hormonal synthesis pathway. The other cases are explained by genetic abnormalities that are involved in the development of the genital system. The phenotypic variability is very important in 46,XX disorders of sex development and the knowledge of each sign, even the most discreet, which could reveal such disorders, mainly in the neonatal period, could influence the evolution, prognosis and life quality long term.
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Affiliation(s)
- Camelia Alkhzouz
- Mother and Child Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.A.); (S.B.)
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Simona Bucerzan
- Mother and Child Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.A.); (S.B.)
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Maria Miclaus
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Andreea-Manuela Mirea
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Diana Miclea
- Mother and Child Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.A.); (S.B.)
- Molecular Science Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Felicien MTF, Gacelle FK, Sadjo SA, Dikongue Dikongue EC, Gorduza DB, Dahoun S, Le Coultre C, Boniface M, Gervais AO, Aurelien SM, Pierre-Yves M. [Feminizing genitoplasty for prepubertal children and teenagers female]. Prog Urol 2021; 31:1093-1100. [PMID: 34272179 DOI: 10.1016/j.purol.2021.01.002] [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: 06/26/2019] [Revised: 05/14/2020] [Accepted: 01/14/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this study was to report our experience after 10 years of practice of feminizing genitoplasty in prepubertal and adolescent patients with disorders of sex development (DSD) assigned females as females in a developing country. METHODOLOGY This was a cross-sectional, descriptive and retrospective study over a period of 9 years. All pre-pubertal (8-12 years) and adolescent patients female sex assigned with DSD who had willfully consented to the surgery with their guardians and underwent feminizing genital surgery were enrolled in the study. Data collection included: age at presentation, precise diagnosis, surgical procedures, complications, cosmetic result and duration of follow-up. Each patient had a precise diagnosis and the surgery was planned after discussion with the multidisciplinary team. Cosmetic results were assessed based on: appearance of the clitoris and separation of the vaginal and urethral openings. RESULTS Nine patients raised as females with a median age of 8 years (IR: 10.75) were recorded. Surgery was performed at a median age of 11 years (IR: 9.5). In this series, 6 had a 46, XY karyotype with varying diagnoses: partial androgen insensitivity syndrome (n=2); 5-alphareductase insufficiency (n=2); 17-ketoreductase insufficiency (n=2); gonadal dysgenesis with a mutation in the NR5A1 gene (n=2), 2 had ovostesticular DSD, (karyotypes 46, XX), and 1 had mixed gonadal dysgenesis (karyotype 45, X/46, XY). Partial or total gonad(s) removal in accordance with assigned gender was the most common associated procedure. It was bilateral in 7 cases and unilateral in 2 cases. Follow-up ranged from 3 months to 4.5 years (median: 26 months, IR:18.25). One patient had acute urinary retention in the early follow-up. No other complication such as incision bleeding was recorded. The cosmetic appearance of the external genitalia was satisfactory in all patients. CONCLUSION Feminizing genital surgery in Cameroon remains a major challenge and should seldom be realized without a precise diagnosis. Late age at presentation is peculiar to our setting; however, it gives room for the patients' participation and input to decisions that will have a life-long personal impact on their lives in terms of psychosocial development and fertility. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- M T F Felicien
- Service de chirurgie pédiatrique, hôpital gynéco-obstétrique et pédiatrique de Yaoundé (HGOPY), Yaoundé, Cameroun; Département de chirurgie et spécialités, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun.
| | - F K Gacelle
- Service de chirurgie pédiatrique, hôpital gynéco-obstétrique et pédiatrique de Yaoundé (HGOPY), Yaoundé, Cameroun
| | - S A Sadjo
- Service de chirurgie pédiatrique, hôpital gynéco-obstétrique et pédiatrique de Yaoundé (HGOPY), Yaoundé, Cameroun
| | - E C Dikongue Dikongue
- Service de chirurgie pédiatrique, hôpital gynéco-obstétrique et pédiatrique de Yaoundé (HGOPY), Yaoundé, Cameroun
| | - D B Gorduza
- Hospices civils de Lyon, Université Claude-Bernard Lyon I, Lyon, France
| | - S Dahoun
- Hôpitaux universitaires de Genève, université de Genève, Genève, Suisse
| | - C Le Coultre
- Hôpitaux universitaires de Genève, université de Genève, Genève, Suisse
| | - M Boniface
- Département de chirurgie et spécialités, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun; Service d'imagerie médicale, hôpital gynéco-obstétrique et pédiatrique de Yaoundé (HGOPY), Yaoundé, Cameroun
| | - A O Gervais
- Service de chirurgie pédiatrique, hôpital gynéco-obstétrique et pédiatrique de Yaoundé (HGOPY), Yaoundé, Cameroun
| | - S M Aurelien
- Département de chirurgie et spécialités, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun
| | - M Pierre-Yves
- Hospices civils de Lyon, Université Claude-Bernard Lyon I, Lyon, France
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Marzuki NS, Idris FP, Kartapradja H, Renata S, Harahap A, Batubara JRL. Accuracy of Urinary Etiocholanolone/Androsterone Ratio as Alternative to Serum Testosterone/Dihydrotestosterone Ratio for Diagnosis of 5 Alpha-reductase Type 2 Deficiency Patients and Carriers in Indonesia. Int J Endocrinol Metab 2021; 19:e109510. [PMID: 34149847 PMCID: PMC8198621 DOI: 10.5812/ijem.109510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/03/2021] [Accepted: 03/10/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The 5 Alpha-reductase type 2 deficiency (5ARD2) is an inherited condition, which clinically presents as variable degrees of under virilization in affected 46,XY individuals. In the diagnostic pathway of 5ARD2, the testosterone/dihydrotestosterone (T/DHT) ratio is broadly employed before molecular analysis of the SRD5A2 gene. However, due to cost-benefit considerations, the DHT test in our country is routinely lacking in clinical settings; therefore, we considered applying the urinary etiocholanolone/androsterone (Et/An) ratio as an alternative test. OBJECTIVES We aimed to determine the diagnostic value of the urinary Et/An ratio versus the T/DHT ratio in diagnosing 5ARD2 patients and carriers. METHODS Sixty-six suspected 5ARD2 46,XY disorders of sex development (DSD) individuals and 95 family members were recruited in the study. Their clinical manifestations, T/DHT and urinary Et/An ratios, and SRD5A2 genes were analyzed. Using molecular analysis of the SRD5A2 gene as the gold standard, we compared the accuracy of both ratios in diagnosing 5ARD2 patients and carriers with receiver operating characteristic (ROC) curve analysis. RESULTS Thirty-seven patients were confirmed molecularly to have 5ARD2, and the rest (n = 29) were assessed as normal controls, while in the carrier group, 53 were molecularly confirmed as carriers and 42 as controls. The AUCs (areas under the curve) of the T/DHT and urinary Et/An ratios were 57.7% (95% CI 43.0 - 72.4%, P > 0.05) and 79.7% (95% CI 69.0 - 90.4%, P < 0.001), respectively, in diagnosing 5ARD2 patients and 54.1% (95% CI 42.4 - 65.8%, P > 0.05) and 75.1% (95% CI 65.1 - 85.1%, P < 0.001), respectively, in diagnosing carriers. The cutoff value of the urinary Et/An ratio was set at ≥ 0.95 for detecting 5ARD2 patients and ≥ 0.99 for detecting carriers. CONCLUSIONS The testosterone/DHT ratio was inaccurate in diagnosing 5ARD2 patients. When molecular analysis for the SRD5A2 gene is lacking, the urinary Et/An ratio may be a useful test to diagnose 5ARD2 patients and carriers.
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Affiliation(s)
- Nanis Sacharina Marzuki
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
- Corresponding Author: Eijkman Institute for Molecular Biology, Jakarta, Indonesia.
| | | | | | - Shirley Renata
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Alida Harahap
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
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Santos-Neto OO, Mariano MH, Marques-de-Faria AP, Andrade JGR, Vieira TAP, Viguetti-Campos NL, Dos Santos AP, Mello MP, Mazzola TN, Guaragna MS, Fabbri-Scallet H, Damiani D, Steinmetz L, Ferreira MR, Saito PA, Sievert JC, Maciel-Guerra AT, Guerra-Junior G. Association between Down Syndrome and Disorders of Sex Development: Report of Three Cases and Review of 188 Cases in the Literature. Sex Dev 2021; 14:3-11. [PMID: 33652437 DOI: 10.1159/000513415] [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: 06/20/2020] [Accepted: 09/16/2020] [Indexed: 11/19/2022] Open
Abstract
In this study, we present 3 cases of Down syndrome (DS) associated with disorders/differences of sex development (DSD) and review the literature on this topic. Case 1: 1-year-old child with male genitalia and DS phenotype, 47,XX,+21 karyotype and testicular DSD. Case 2: 11-month-old child with male genitalia and few DS dysmorphisms, 45,X/47,XY,+21 karyotype, and mixed gonadal dysgenesis. Case 3: 4-month-old child with female genitalia and DS phenotype, 47,XY,+21 karyotype and XY complete gonadal dysgenesis. In the literature, among 188 patients, 107 (57%) had Klinefelter syndrome and 61 (33%) Turner syndrome, 12 (6%) had mixed gonadal dysgenesis, 2 (1%) had partial androgen insensitivity, 2 (1%) ovotesticular DSD, and the others had congenital adrenal hyperplasia, XY partial gonadal dysgenesis, XY complete gonadal dysgenesis, and complete androgen insensitivity (1 case each). A typical DS phenotype was found in all individuals of the revision, with the exception of one case, but DSD features were not always reported. In conclusion, the association of DS with sex chromosome DSD is the most frequently observed, whereas associations with 46,XX and 46,XY DSD is extremely rare.
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Affiliation(s)
- Octavio O Santos-Neto
- Interdisciplinary Group for the Study of Gender Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - Marina H Mariano
- Interdisciplinary Group for the Study of Gender Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - Antonia P Marques-de-Faria
- Interdisciplinary Group for the Study of Gender Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil.,Department of Medical Genetics and Genomic Medicine, FCM, UNICAMP, Campinas, Brazil
| | - Juliana G R Andrade
- Interdisciplinary Group for the Study of Gender Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil
| | - Tarsis A P Vieira
- Department of Medical Genetics and Genomic Medicine, FCM, UNICAMP, Campinas, Brazil.,Cytogenetics Laboratory, FCM, UNICAMP, Campinas, Brazil
| | | | - Ana P Dos Santos
- Department of Medical Genetics and Genomic Medicine, FCM, UNICAMP, Campinas, Brazil.,Cytogenetics Laboratory, FCM, UNICAMP, Campinas, Brazil.,Human Molecular Genetics Laboratory, Molecular Biology and Genetic Engineering Center (CBMEG), UNICAMP, Campinas, Brazil
| | - Maricilda P Mello
- Interdisciplinary Group for the Study of Gender Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil.,Human Molecular Genetics Laboratory, Molecular Biology and Genetic Engineering Center (CBMEG), UNICAMP, Campinas, Brazil
| | - Tais N Mazzola
- Human Molecular Genetics Laboratory, Molecular Biology and Genetic Engineering Center (CBMEG), UNICAMP, Campinas, Brazil
| | - Mara S Guaragna
- Human Molecular Genetics Laboratory, Molecular Biology and Genetic Engineering Center (CBMEG), UNICAMP, Campinas, Brazil
| | - Helena Fabbri-Scallet
- Human Molecular Genetics Laboratory, Molecular Biology and Genetic Engineering Center (CBMEG), UNICAMP, Campinas, Brazil
| | - Durval Damiani
- Pediatric Endocrinology Unit, Child's Institute, University of Sao Paulo (USP), Sao Paulo, Brazil
| | - Leandra Steinmetz
- Pediatric Endocrinology Unit, Child's Institute, University of Sao Paulo (USP), Sao Paulo, Brazil
| | - Marianna R Ferreira
- Pediatric Endocrinology Unit, Child's Institute, University of Sao Paulo (USP), Sao Paulo, Brazil
| | - Paula A Saito
- Pediatric Endocrinology Unit, Child's Institute, University of Sao Paulo (USP), Sao Paulo, Brazil
| | | | - Andrea T Maciel-Guerra
- Interdisciplinary Group for the Study of Gender Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil.,Department of Medical Genetics and Genomic Medicine, FCM, UNICAMP, Campinas, Brazil
| | - Gil Guerra-Junior
- Interdisciplinary Group for the Study of Gender Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Brazil, .,Pediatric Endocrinology Unit, Department of Pediatrics, FCM, UNICAMP, Campinas, Brazil,
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10
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Manyas H, Eroğlu Filibeli B, Ayrancı İ, Güvenç MS, Dündar BN, Çatlı G. Early and late diagnoses of 17β-Hydroxysteroid dehydrogenase type-3 deficiency in two unrelated patients. Andrologia 2021; 53:e14017. [PMID: 33586216 DOI: 10.1111/and.14017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 11/30/2022] Open
Abstract
17β-hydroxysteroid dehydrogenase type 3 deficiency is a rare cause of 46 XY disorders of sexual development. Mutations in the HSD17B3 gene result in reduced activity of the 17β-HSD3 enzyme, decreasing the conversion of androstenedione to testosterone. In this report, two cases, admitted with different clinical findings in the neonatal and adolescent periods and were decided to be raised in different genders are presented. The first case who had complete female external genitalia presented on the third postnatal day with the complaint of swelling in the groin. He was decided to be raised as a male and was treated successfully with parenteral testosterone in order to increase phallus size before surgical correction of the external genitalia. The second case was an adolescent girl who presented due to pubertal virilisation and primary amenorrhoea and chose female gender. Molecular genetic analyses of the HSD17B3 gene revealed two different previously reported homozygous variants. We emphasise that patients with 17β-hydroxysteroid dehydrogenase type 3 deficiency can present with heterogeneous clinical findings in different age groups. Early diagnosis is important to prevent future gender confusion and related problems.
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Affiliation(s)
- Hayrullah Manyas
- Department of Pediatric Endocrinology, Tepecik Training and Research Hospital, University of Medical Science, Izmir, Turkey
| | - Berna Eroğlu Filibeli
- Department of Pediatric Endocrinology, Tepecik Training and Research Hospital, University of Medical Science, Izmir, Turkey
| | - İlkay Ayrancı
- Department of Pediatric Endocrinology, Tepecik Training and Research Hospital, University of Medical Science, Izmir, Turkey
| | - Merve S Güvenç
- Genetic Diseases Diagnostic Center, Tepecik Training and Research Hospital, University of Medical Science, Izmir, Turkey
| | - Bumin N Dündar
- Department of Pediatric Endocrinology, Izmir Katip Celebi University, Izmir, Turkey
| | - Gönül Çatlı
- Department of Pediatric Endocrinology, Izmir Katip Celebi University, Izmir, Turkey
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11
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Ambulkar PS, Waghmare JE, Verma Shivkumar P, Narang P, Pal AK. A missense mutation (c.226C>A) in HMG box SRY gene affects nNLS function in 46,XY sex reversal female. Andrologia 2021; 53:e14011. [PMID: 33570214 DOI: 10.1111/and.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 11/30/2022] Open
Abstract
The SRY initiates cascade of gene expression that transforms the undifferentiated gonad, genital ridge into testis. Mutations of the SRY gene is associated with complete gonadal dysgenesis in females with 46,XY karyotype. Primary amenorrhea is one of the clinical findings to express the genetic cause in 46,XY sex reversal. Here, we report a 26-year-old married woman presenting with primary amenorhea and complete gonadal dysgenesis. The clinical phenotypes were hypoplastic uterus with streak gonad and underdeveloped secondary sexual characters. The cytogenetic analysis confirmed 46,XY sex reversal karyotype of a female. Using molecular approach, we screened open reading frame of the SRY gene by PCR and targeted DNA Sanger sequencing. The patient was confirmed with nucleotide substitution (c.226C>A; p.Arg76Ser) at in HMG box domain of SRY gene that causes 46,XY sex reversal female. Mutation prediction algorithms suggest that alteration might be disease causing mutation and mutated (p.Arg76Ser) amino acid deleteriously affects HMG box nNLS region of SRY protein. Clinical phenotypes and in silico analysis confirmed that missense substitution (p.Arg76Ser) impaired nNLS binding Calmodulin-mediated nuclear transport of SRY from cytoplasm to nucleus. The mutation affects down regulation of male sex differentiation pathway and is responsible for 46,XY sex reversal female with gonadal dysgenesis.
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Affiliation(s)
- Prafulla S Ambulkar
- Centre for Genetics & Genomics, Department of Anatomy, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India
| | - Jwalant E Waghmare
- Centre for Genetics & Genomics, Department of Anatomy, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India
| | - Poonam Verma Shivkumar
- Department of Obstetrics & Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India
| | - Pratibha Narang
- Centre for Genetics & Genomics, Department of Anatomy, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India.,Department of Microbiology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India
| | - Asoke K Pal
- Centre for Genetics & Genomics, Department of Anatomy, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India
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12
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Babu R, Shah U. Gender identity disorder (GID) in adolescents and adults with differences of sex development (DSD): A systematic review and meta-analysis. J Pediatr Urol 2021; 17:39-47. [PMID: 33246831 DOI: 10.1016/j.jpurol.2020.11.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/24/2020] [Accepted: 11/08/2020] [Indexed: 12/19/2022]
Abstract
UNLABELLED Gender assignment in infants born with a difference in sexual development (DSD) remains one of the many difficult decisions faced by the multi-disciplinary treatment team as some of these children develop gender identity disorder (GID) when they become adults. In this systematic review and meta-analysis we have analyzed the prevalence of GID in adolescent and adults with DSD. The secondary outcome of this review is to help physicians in appropriate sex assignment of DSD children so that development of GID in later life can be reduced. METHODS Pubmed/Index medicus were searched for "intersex" [All fields] OR "disorders of sexual differentiation AND "gender identity disorder OR gender dysphoria" [MeSH] for articles published between 2005 and 2020. Typical diagnoses included were congenital adrenal hyperplasia (CAH); complete androgen insensitivity syndrome (CAIS); partial androgen insensitivity syndrome (PAIS); 5 alpha reductase deficiency (5ARD); 17-hydroxysteroid dehydrogenase deficiency (17HSD); mixed gonadal dysgenesis (MGD) and complete gonadal dysgenesis (CGD). GID or gender dysphoria (a strong feeling of dissatisfaction about oneself as male or female) prevalence in DSD patients older than 12 years of age was extracted. Within each condition, GID percentage was compared between female and male rearing. RESULTS The I2statistics for prevalence of GID in DSD showed high heterogeneity with I2 of 93% (95% C.I 90-95%) among the 20 articles included. The overall prevalence of GID among those with DSD was 15% (95% C.I 13-17%). CAH reared females had 4% GID while CAH reared males had significantly higher GID at 15% (p = 0.0056). All CAIS patients were raised as females and the prevalence of GID was 1.7%. GID prevalence was 12% in PAIS raised as females while 25% in those raised as males with no significant difference (p = 0.134). GID was significantly high in 5ARD (53%) and 17HSD (53%) reared as females with half of them virilizing at puberty forcing a gender change. Among sex chromosome DSD 22% of those reared as females had GID while none in those raised as male with no significant difference. CONCLUSIONS GID is low in women with CAH, CAIS and CGD favoring female sex of rearing in these conditions. GID is high in women with 5ARD/17HSD favoring male sex of rearing in these conditions. GID is variable in PAIS or MGD and no recommendations on sex of rearing could be made in these conditions. Each DSD patient is unique and they warrant multi-disciplinary care and long term psycho sexual support.
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Affiliation(s)
- Ramesh Babu
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India.
| | - Utsav Shah
- Department of Pediatric Urology, Sri Ramachandra Institute of Higher Education & Research, Chennai, 600116, India
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13
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Madsen A, Bruserud IS, Bertelsen BE, Roelants M, Oehme NHB, Viste K, Bjerknes R, Almås B, Rosendahl K, Mellgren G, Sagen JV, Juliusson PB. Hormone References for Ultrasound Breast Staging and Endocrine Profiling to Detect Female Onset of Puberty. J Clin Endocrinol Metab 2020; 105:5910099. [PMID: 32961560 PMCID: PMC7571452 DOI: 10.1210/clinem/dgaa679] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/18/2020] [Indexed: 11/24/2022]
Abstract
CONTEXT Application of ultrasound (US) to evaluate attainment and morphology of glandular tissue provides a new rationale for evaluating onset and progression of female puberty, but currently no hormone references complement this method. Furthermore, previous studies have not explored the predictive value of endocrine profiling to determine female puberty onset. OBJECTIVE To integrate US breast staging with hypothalamic-pituitary-gonadal hormone references and test the predictive value of an endocrine profile to determine thelarche. DESIGN SETTING AND PARTICIPANTS Cross-sectional sample of 601 healthy Norwegian girls, ages 6 to 16 years. MAIN OUTCOME MEASURES Clinical and ultrasound breast evaluations were performed for all included girls. Blood samples were analyzed by immunoassay and ultrasensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) to quantify estradiol (E2) and estrone (E1) from the subpicomolar range. RESULTS References for E2, E1, luteinizing hormone, follicle-stimulating hormone, and sex hormone-binding globulin were constructed in relation to chronological age, Tanner stages, and US breast stages. An endocrine profile index score derived from principal component analysis of these analytes was a better marker of puberty onset than age or any individual hormone, with receiver-operating characteristic area under the curve 0.91 (P < 0.001). Ultrasound detection of nonpalpable glandular tissue in 14 out of 264 (5.3%) girls with clinically prepubertal presentation was associated with significantly higher median serum levels of E2 (12.5 vs 4.9 pmol/L; P < 0.05) and a distinct endocrine profile (arbitrary units; P < 0.001). CONCLUSIONS We provide the first hormone references for use with US breast staging and demonstrate the application of endocrine profiling to improve detection of female puberty onset.
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Affiliation(s)
- Andre Madsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Correspondence and Reprint Requests: André Madsen, PhD, Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, N-5021 Bergen, Norway. E-mail:
| | - Ingvild S Bruserud
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Bjørn-Erik Bertelsen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Mathieu Roelants
- Environment and Health, Department of Public Health and Primary Care, KU Leuven, University of Leuven, Leuven, Belgium
| | - Ninnie Helen Bakken Oehme
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Kristin Viste
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Robert Bjerknes
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Bjørg Almås
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Karen Rosendahl
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Gunnar Mellgren
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Mohn Nutrition Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jørn V Sagen
- Hormone Laboratory, Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Petur B Juliusson
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- Department of Health Registries, Norwegian Institute of Public Health, Bergen, Norway
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14
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Varianten der Geschlechtsentwicklung bei Kindern und Jugendlichen. GYNAKOLOGISCHE ENDOKRINOLOGIE 2020. [DOI: 10.1007/s10304-020-00352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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15
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Oliveira LR, Longui CA, Guaragna-Filho G, Costa JL, Lanaro R, Silva DA, Chiamolera MI, de Mello MP, Morcillo AM, Maciel-Guerra AT, Guerra-Junior G. Androgens by immunoassay and mass spectrometry in children with 46,XY disorder of sex development. Endocr Connect 2020; 9:1085-1094. [PMID: 33112837 PMCID: PMC7774763 DOI: 10.1530/ec-20-0454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/07/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Steroid measurement is a challenge in pediatric endocrinology. Currently, liquid chromatography with tandem mass spectrometry (LC-MS/MS) is considered a gold standard for this purpose. The aim of this study was to compare both LC-MS/MS and immunoassay (IA) for androgens before and after human recombinant chorionic gonadotropin (rhCG) stimulus in children with 46,XY disorders of sex development (DSD). METHODS Nineteen patients with 46,XY DSD were evaluated; all of them were prepubertal and non-gonadectomized. Testosterone, dihydrotestosterone (DHT), DHEA and androstenedione were measured by IA and LC-MS/MS before and 7 days after rhCG injection. The correlation between IA and LC-MS/MS was analyzed by the intraclass correlation coefficient (ICC) and Spearman's rank correlation coefficient (SCC). For concordance analysis the Passing and Bablok (PB) regression and the Bland and Altman (BA) method were used. RESULTS Testosterone showed excellent correlation (ICC = 0.960 and SCC = 0.964); DHT showed insignificant and moderate correlations as indicated by ICC (0.222) and SCC (0.631), respectively; DHEA showed moderate correlation (ICC = 0.585 and SCC = 0.716); and androstenedione had poor and moderate correlations in ICC (0.363) and SCC (0.735), respectively. Using the PB method, all hormones showed a linear correlation, but proportional and systematic concordance errors were detected for androstenedione, systematic errors for testosterone and no errors for DHEA and DHT. By the BA method, there was a trend of IA to overestimate testosterone and androstenedione and underestimate DHEA and DHT when compared to LC-MS/MS. CONCLUSION Traditional IA should be replaced by LC-MS/MS for the androgens measurement in prepubertal children whenever is possible.
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Affiliation(s)
- Letícia Ribeiro Oliveira
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
- Department of Pediatrics, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil
| | - Carlos Alberto Longui
- Pediatric Endocrinology Unit, School of Medical Sciences, Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil
| | - Guilherme Guaragna-Filho
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
- Department of Pediatrics, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - José Luiz Costa
- School of Pharmaceutical Sciences, UNICAMP, Campinas, Sao Paulo, Brazil
- Poison Control Center, FCM, UNICAMP, Campinas, Sao Paulo, Brazil
| | - Rafael Lanaro
- Poison Control Center, FCM, UNICAMP, Campinas, Sao Paulo, Brazil
| | - David Antônio Silva
- Laboratory of Physiology, Division of Clinical Pathology, Clinical Hospital, UNICAMP, Campinas, Sao Paulo, Brazil
| | | | - Maricilda Palandi de Mello
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
- Laboratory of Human Molecular Genetics, Center for Molecular Biology and Genetics Engineering (CBMEG), UNICAMP, Campinas, Sao Paulo, Brazil
| | | | - Andrea Trevas Maciel-Guerra
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
- Department of Medical Genetics and Genomic Medicine, FCM, UNICAMP, Campinas, Sao Paulo, Brazil
| | - Gil Guerra-Junior
- Interdisciplinary Group for Studies of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences (FCM), State University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
- Department of Pediatrics, FCM, UNICAMP, Campinas, Sao Paulo, Brazil
- Correspondence should be addressed to G Guerra-Junior:
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16
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Beck MDSE, Germano CW, Barros BA, Andrade JGR, Guaragna-Filho G, Paula GB, Miranda ML, Guaragna MS, Fabbri-Scallet H, Mazzola TN, Viguetti-Campos NL, Vieira TAP, Lemos-Marini SHV, Marques-de-Faria AP, Silva RBPE, Mello MP, Maciel-Guerra AT, Guerra-Júnior G. Why pediatricians need to know the disorders of sex development: experience of 709 cases in a specialized service. J Pediatr (Rio J) 2020; 96:607-613. [PMID: 31254527 PMCID: PMC9432188 DOI: 10.1016/j.jped.2019.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate, in a sample of patients with disorders of sex development (DSD), data related to the age at referral and their correlation with the initial complaints, gender at referral, defined gender after diagnosis and etiological diagnosis. METHODS Retrospective review of the age at the first consultation and the reason for it, initial social gender and gender after the diagnosis, karyotype and etiological diagnosis of all cases treated at a DSD outpatient clinic between 1989 and 2016. Cases that did not involve DSD and DSD diagnoses that do not usually involve ambiguous genitalia, thus not requiring specialized monitoring, were excluded. RESULTS Of the 1793 treated cases, 1139 were diagnosed with some type of DSD. This study excluded 430 cases (272 with Turner's syndrome, 66 with Klinefelter syndrome, and 92 with pure gonadal dysgenesis), thus a total 709 individuals were included. Of these, 82.9% were referred due to ambiguous genitalia; only one-quarter were still in the first month of life, and 6.6% were referred due to pubertal delay, with most of them aged 10 years or older. Of these patients, 68.6% had a diagnosis of XY DSD, 22.4% of XX DSD, and 9% of sex chromosome abnormalities. CONCLUSIONS This study presents the largest series in the literature of patients with DSD treated in a single center. The time of referral of the majority of patients with ambiguous genitalia fell short of the ideal, and milder cases of ambiguous genitalia and many with pubertal manifestations were referred even later. The results reinforce the importance of continuing education for professionals who will have the first contact with these patients, mainly pediatricians and neonatologists.
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Affiliation(s)
- Mayra de Souza El Beck
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil.
| | - Carlos W Germano
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Beatriz A Barros
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Juliana G R Andrade
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Guilherme Guaragna-Filho
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Georgette B Paula
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Márcio L Miranda
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Mara S Guaragna
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Helena Fabbri-Scallet
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Tais N Mazzola
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Nilma L Viguetti-Campos
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Társis A P Vieira
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Sofia H V Lemos-Marini
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Antonia P Marques-de-Faria
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Roberto B Paiva E Silva
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Maricilda P Mello
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Andréa T Maciel-Guerra
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
| | - Gil Guerra-Júnior
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Grupo Interdisciplinar de Estudos da Determinação e Diferenciação do Sexo (GIEDDS), Campinas, SP, Brazil
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17
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Why pediatricians need to know the disorders of sex development: experience of 709 cases in a specialized service. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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18
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Das S, Saikia UK, Saikia KK, Sarma D, Choudhury BK, Bhuyan AK, Baro A, Das DV, Appaiah S. "Spectrum of 46 XY Disorders of Sex Development": A Hospital-based Cross-sectional Study. Indian J Endocrinol Metab 2020; 24:360-365. [PMID: 33088761 PMCID: PMC7540835 DOI: 10.4103/ijem.ijem_98_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/25/2020] [Accepted: 06/26/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Disorders of sex development (DSD) are a wide range of relatively rare conditions having diverse pathophysiology. Identification of an underlying cause can help in treating any coexisting hormone deficiencies and can help with anticipating any other immediate or long-term health concerns. OBJECTIVE To study the clinical and biochemical profile of patients with 46 XY DSD along with androgen receptor (AR) gene mutation status in selected group of patients. METHODS A cross-sectional study was conducted after enrolling the eligible DSD patients. Thorough elicitation of history and detailed clinical examination was done. Assays for luteinizing hormone, follicle-stimulating hormone, testosterone, dihydrotestosterone, androstenedione, AMH & Inhibin B (where indicated), and human chorionic gonadotropin stimulation were done as per protocol. RESULTS In total, 48 patients were included in the study. Ambiguous genitalia (58.3%) followed by hypospadias (33.3%) were common presentation. Androgen biosynthetic defect were the most commonly encountered diagnosis followed by androgen insensitivity syndrome (AIS). Swyer syndrome was diagnosed in 4.2% of cases; partial gonadal dysgenesis, ovotesticular DSD, and vanishing testis syndrome contributed to 2% of cases each. Eight cases (16.7%) who presented with isolated proximal and midshaft hypospadias for whom no diagnosis was found were categorized in the "etiology unclear" group. AR gene mutation analysis designed against specific exons did not yield any results. CONCLUSION 46 XY DSD is a heterogeneous group of patients with a varying age of presentation and a diverse clinical profile. Most patients are reared as males and maintained the same gender identity except in isolated cases. Diagnosis of AIS remains a clinical challenge as a definite hormonal criterion does not exist and genetic mutations in AR gene may be negative. Flanking region sequencing, whole genome sequencing, and promoter region sequencing may reveal pathogenic variants. Variations in other genes regulating AR pathway may also be candidates to be studied.
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Affiliation(s)
- Samiran Das
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Uma K. Saikia
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Kandarpa K. Saikia
- Department of Bioengineering and Technology, GUIST, Gauhati University, Assam, India
| | - Dipti Sarma
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | | | - Ashok K. Bhuyan
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Abhamoni Baro
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Darvin V. Das
- Department of Endocrinology, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
| | - Sonali Appaiah
- Department of Endocrinology, St Johns Medical College, Banglore, Karnataka, India
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Lucas-Herald AK, Kyriakou A, Alimussina M, Guaragna-Filho G, Diver LA, McGowan R, Smith K, McNeilly JD, Ahmed SF. Serum Anti-Müllerian Hormone in the Prediction of Response to hCG Stimulation in Children With DSD. J Clin Endocrinol Metab 2020; 105:5722325. [PMID: 32016383 PMCID: PMC7096311 DOI: 10.1210/clinem/dgaa052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/03/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The relationship between serum anti-Müllerian hormone (AMH) and the testosterone response to human chorionic gonadotropin (hCG) stimulation test is unclear. METHODS Children who had hCG stimulation tests in one tertiary centre from 2001 to 2018 were included (n = 138). Serum testosterone was measured before (day 1 [D1]) and after 3 days (D4) of hCG stimulation. Sixty-one of these children also had prolonged hCG stimulation for 2 more weeks and serum testosterone measured after 21 days (D22). All children had a serum AMH measured on D1. RESULTS Of the 138 children, D4 testosterone was normal in 104 (75%). AMH was low in 24/138 (17%) children, and 16 (67%) of these had a low D4 testosterone. Median AMH in those who had a normal vs low D4 testosterone was 850 pmol/L (24, 2280) and 54 pmol/L (0.4, 1664), respectively (P < 0.0001). An AMH > 5th centile was associated with a low D4 testosterone in 18/118 (13%; P < 0.0001). Of the 61 children who had prolonged hCG stimulation, D22 testosterone was normal in 39 (64%). AMH was low in 10/61(16%) children and 9 (90%) of these had a low D22 testosterone. Median AMH in children who responded and did not respond by D22 was 639 pmol/L (107, 2280) and 261 pmol/L (15, 1034) (P < 0.0001). CONCLUSION A normal AMH may provide valuable information on overall testicular function. However, a low AMH does not necessarily predict a suboptimal testosterone response to hCG stimulation.
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Affiliation(s)
- Angela K Lucas-Herald
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
- British Heart Foundation Centre for Research Excellence, University of Glasgow, Glasgow, UK
- Correspondence and Reprint Requests: Professor S Faisal Ahmed MD FRCPCH, School of Medicine, Dentistry & Nursing, University of Glasgow, Office Block, Royal Hospital For Children, 1345 Govan Road, Glasgow, G51 4TF. E-mail:
| | - Andreas Kyriakou
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | - Malika Alimussina
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
| | | | - Louise A Diver
- West of Scotland Molecular and Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ruth McGowan
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
- West of Scotland Molecular and Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen Smith
- Department of Biochemistry, Glasgow Royal Infirmary, Glasgow, UK
| | - Jane D McNeilly
- Department of Biochemistry, Queen Elizabeth University Hospital, Glasgow, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, UK
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20
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Sap SNU, Mbono Betoko R, Etoa Etoga M, Mure PY, Morel Y, Dahoun S, Mouafo Tambo F, Moiffo B, Sobngwi E, Koki Ndombo P. Observational study of disorders of sex development in Yaounde, Cameroon. J Pediatr Endocrinol Metab 2020; 33:417-423. [PMID: 32069241 DOI: 10.1515/jpem-2019-0458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/18/2019] [Indexed: 11/15/2022]
Abstract
Introduction According to the current classification of the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the European Society for Pediatric Endocrinology (ESPE) of Disorders of Sex Development (DSD), etiologies vary around the world. Ethnic or genetic diversity probably explains this variability. We therefore conducted the present study on etiologies of DSDs in a country from central Africa. Methods We carried out an observational retrospective study at the Pediatric Endocrinology Unit of the Mother and Child Centre of the Chantal Biya Foundation in Yaounde, Cameroon from May 2013 to December 2019. All patients diagnosed with a DSD were included, and incomplete files excluded. Results We included 80 patients diagnosed with DSD during the study period. The 46,XX DSD were the most frequent in our study population (n = 41, 51.25%), with congenital adrenal hyperplasia (CAH) as the main diagnosis. The 46,XY DSD accounted for 33.75% and sex chromosome DSD group represented 15% of the study population. Conclusions DSDs are not an exceptional diagnosis in a Sub-Saharan context. 46,XX DSD are the most prevalent diagnosis in our setting. The diagnosis of all these affections is late compared to other centers, justifying advocacy for neonatal screening of DSDs in our context.
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Affiliation(s)
- Suzanne Ngo Um Sap
- Mother and Child Center of the Chantal Biya Foundation of Yaounde, Faculty of Medicine and Biomedical Sciences of the University of Yaounde I, Yaounde, Cameroon, Phone: +237 677594797
| | - Ritha Mbono Betoko
- District Hospital of Nylon, Douala, Faculty of Medicine and Pharmaceutical Sciences of the University of Douala, Douala, Cameroon
| | - Martine Etoa Etoga
- Central Hospital of Yaounde, Faculty of Medicine and Pharmaceutical Sciences of the University of Douala, Douala, Cameroon
| | - Pierre Yves Mure
- Hospices civils de Lyon, Hôpital Femme Mère Enfant, Chirurgie Pédiatrique, Lyon, France
| | - Yves Morel
- Hospices Civils de Lyon, GH Est, Centre de Biologie et Pathologie, Lyon, France
| | - Sophie Dahoun
- Department of Genetics, University Hospital of Geneva, Geneva, Switzerland
| | - Faustin Mouafo Tambo
- Gyneco-Obstetric Hospital of Yaounde, Faculty of Medicine and Biomedical Sciences of the University of Yaounde I, Yaounde, Cameroon
| | - Boniface Moiffo
- Gyneco-Obstetric Hospital of Yaounde, Faculty of Medicine and Biomedical Sciences of the University of Yaounde I, Yaounde, Cameroon
| | - Eugène Sobngwi
- Central Hospital of Yaounde, Faculty of medicine and biomedical sciences of the University of Yaounde I, Yaounde, Cameroon
| | - Paul Koki Ndombo
- Mother and Child Center of the Chantal Biya Foundation Yaounde, Faculty of Medicine and Biomedical Sciences, Department of Paediatrics, Yaounde, Cameroon
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García-Acero M, Moreno O, Suárez F, Rojas A. Disorders of Sexual Development: Current Status and Progress in the Diagnostic Approach. Curr Urol 2020; 13:169-178. [PMID: 31998049 DOI: 10.1159/000499274] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/14/2018] [Indexed: 12/13/2022] Open
Abstract
Disorders of sexual development (DSD) are conditions with an atypical chromosomal, gonadal or phenotypic sex, which leads to differences in the development of the urogenital tract and different clinical phenotypes. Some genes have been implicated in the sex development during gonadal and functional differentiation where the maintenance of the somatic sex of the gonad as either male or female is achieved by suppression of the alternate route. The diagnosis of DSD requires a structured approach, involving a multidisciplinary team and different molecular techniques. We discuss the dimorphic genes and the specific pathways involved in gonadal differentiation, as well as new techniques for genetic analysis and their diagnostic value including epigenetic mechanisms, expanding the evidence in the diagnostic approach of individuals with DSD to increase knowledge of the etiology.
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Affiliation(s)
- Mary García-Acero
- Human Genetic Institute, Medicine Faculty, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Olga Moreno
- Human Genetic Institute, Medicine Faculty, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Fernando Suárez
- Human Genetic Institute, Medicine Faculty, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Adriana Rojas
- Human Genetic Institute, Medicine Faculty, Pontificia Universidad Javeriana, Bogotá, Colombia
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22
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Hiort O, Marshall L, Bacia A, Bouteleux M, Wünsch L. Besonderheiten der Geschlechtsentwicklung bei Kindern und Jugendlichen. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0718-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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23
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Chawla R, Weidler EM, Hernandez J, Grimbsy G, van Leeuwen K. Utilization of a shared decision-making tool in a female infant with congenital adrenal hyperplasia and genital ambiguity. J Pediatr Endocrinol Metab 2019; 32:643-646. [PMID: 31145695 DOI: 10.1515/jpem-2018-0567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/08/2019] [Indexed: 12/11/2022]
Abstract
Background Shared decision-making (SDM) is the process by which patients/families and providers make healthcare decisions together. Our team of multidisciplinary disorders of sex development (DSD) has developed an SDM tool for parents and female patients with congenital adrenal hyperplasia (CAH) and associated genital atypia. What is new Elective genital surgery is considered controversial. SDM in a patient with genital atypia will allow patient/family to make an informed decision regarding surgical intervention. Case presentation Our patient is a 2.5-year-old female with CAH and genital atypia. Initially, her parents had intended to proceed with surgery; however, after utilizing the SDM checklist, they made an informed decision to defer urogenital sinus surgery for their daughter. Conclusions We successfully utilized an SDM tool with parents of a female infant with CAH and genital atypia, which allowed them to make an informed decision regarding surgery for their daughter. Future directions include a prospective enrolling study to determine the generalizability and applicability of SDM with families of children diagnosed with CAH.
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Affiliation(s)
- Reeti Chawla
- Attending Physician, Division of Pediatric Endocrinology, Phoenix Children's Hospital, Clinical Assistant Professor - Child Health, UA College of Medicine - Phoenix, 1920 East Cambridge Ave, Suite 301, Phoenix, AZ 85016, USA
| | - Erica M Weidler
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Janett Hernandez
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Gwen Grimbsy
- Division of Pediatric Urology, Phoenix Children's Hospital, Phoenix, AZ, USA
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24
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Abstract
The term primary gonadal failure encompasses not only testicular insufficiency in 46,XY males and ovarian insufficiency in 46,XX females, but also those disorders of sex development (DSD) which result in gender assignment that is at variance with the genotype and gonadal type. In boys, causes of gonadal failure include Klinefelter and other aneuploidy syndromes, bilateral cryptorchidism, testicular torsion, and forms of 46,XY DSD such as partial androgen insensitivity. Causes in girls include Turner syndrome and other aneuploidies, galactosemia, and autoimmune ovarian failure. Iatrogenic causes in both boys and girls include the late effects of childhood cancer treatment, total body irradiation prior to bone marrow transplantation, and iron overload in transfusion-dependent thalassaemia. In this paper, a brief description of the physiology of testicular and ovarian development is followed by a section on the causes and practical management of gonadal impairment in boys and girls. Protocols for pubertal induction and post-pubertal hormone replacement - intramuscular, oral and transdermal testosterone in boys; oral and transdermal oestrogen in girls - are then given. Finally, current and future strategies for assisted conception and fertility preservation are discussed.
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Affiliation(s)
- Asmahane Ladjouze
- Faculté de Médecine d'Alger, Service de Pédiatrie, Centre Hospitalo-Universitaire Bad El Oued, 1 Boulevard Said Touati, Algiers, Algeria.
| | - Malcolm Donaldson
- Section of Child Health, School of Medicine, Queen Elizabeth University Hospital, Govan Road, Glasgow, G51 4TF, United Kingdom.
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25
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Krege S, Eckoldt F, Richter-Unruh A, Köhler B, Leuschner I, Mentzel HJ, Moss A, Schweizer K, Stein R, Werner-Rosen K, Wieacker P, Wiesemann C, Wünsch L, Richter-Appelt H. Variations of sex development: The first German interdisciplinary consensus paper. J Pediatr Urol 2019; 15:114-123. [PMID: 30713084 DOI: 10.1016/j.jpurol.2018.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/10/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The term variations of sex development subsumes a large number of congenital conditions including chromosomal mosaics and variations of chromosomal, gonadal, and phenotypic sex. A situation of this nature may cause severe distress to both, parents and affected persons. One of the reasons for this is the binary form of gender classification in the society. In the past, because of a fear of possible stigmatization and an inability to cope with complex situations, it has been medical policy and practice for newborns to undergo early, mostly 'feminizing' elective surgery with the aim of achieving an outer genital appearance that is unambiguously male or female. Protests by advocacy groups for the most part as well as the results of outcome studies have shown that the development of affected persons may be very different to what has been expected and often does not result in the intended clear female or male gender identity as had been intended. It, therefore, seemed a matter of urgency to implement this new awareness as well as the ethical and personal human rights perspectives in the recommendations for the medical and psychosocial management of diverse sex development (DSD) in the future. STUDY DESIGN In 2012, an interdisciplinary group of German academics engaged in the field of DSD decided to work on a consensus paper for this topic. It involved the participation of all faculties and non-scientific groups dealing with DSD, in particular advocacy and service-user groups. In a structured consensus, process recommendations were developed based on scientific literature as well as personal experiences of clinicians and affected individuals. RESULTS Finally, 37 recommendations were agreed on. The strength of consensus is reflected in the degree of agreement as expressed in percentages. CONCLUSION The introduction of the consensus paper reflects on the emerging paradigm shift and the necessity for a more open view of gender within society. The paper is intended to aid the performance of appropriate diagnostics in DSD-affected newborns and especially to help parents and affected persons cope with the biological and social consequences of DSD. With regard to medical or surgical therapy, it gives information about the most recent treatment trends.
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Affiliation(s)
- S Krege
- Dept. of Urology, Kliniken Essen-Mitte, Germany.
| | - F Eckoldt
- Dept. of Pediatric Surgery, University of Jena, Germany
| | - A Richter-Unruh
- Dept. of Pediatric Endocrinology, University of Münster, Germany
| | - B Köhler
- Dept. of Pediatric Endocrinology and Diabetology, Charite - University of Berlin, Germany
| | - I Leuschner
- Dept. of Pathology, University of Kiel, Germany
| | - H-J Mentzel
- Section of Pediatric Radiology, University of Jena, Germany
| | - A Moss
- Division of Pediatric Endocrinology and Diabetes, Dept. of Pediatrics and Adolescent Medicine, University of Ulm, Germany
| | - K Schweizer
- Institute for Sex Research and Forensic Psychiatry, University Medical Center, Hamburg-Eppendorf, Germany
| | - R Stein
- Department of Pediatric, Adolescent and reconstructive Urology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - P Wieacker
- Institute of Human Genetics, University of Münster, Germany
| | - C Wiesemann
- Institute of Medical Ethics and History of Medicine, University of Göttingen, Germany
| | - L Wünsch
- Dept. of Pediatric Surgery, University of Lübeck, Germany
| | - H Richter-Appelt
- Institute for Sex Research and Forensic Psychiatry, University Medical Center, Hamburg-Eppendorf, Germany
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26
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Maciejewska-Jeske M, Rojewska-Madziala P, Broda K, Drabek K, Szeliga A, Czyzyk A, Malinger S, Kostrzak A, Podfigurna A, Bala G, Meczekalski B, Malcher A, Kurpisz M. New mutation causing androgen insensitivity syndrome - a case report and review of literature. Gynecol Endocrinol 2019; 35:294-297. [PMID: 30449224 DOI: 10.1080/09513590.2018.1529160] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Androgen insensitivity syndrome (AIS) is a congenital disorder in which a defect in the androgen receptor (AR) gene leads to cellular resistance to androgens. Defects in the AR gene, located on the X chromosome, result in the development of a feminine phenotype in chromosomally male (46, XY) individuals. In this case report, we present a 44 years old patient with complete androgen insensitivity syndrome (CAIS) initially presenting with primary amenorrhea. The patient underwent a full clinical evaluation, revealing hypoplastic vagina and a lack of uterus and ovaries. Hormonal evaluation revealed markedly elevated testosterone, FSH, and LH serum concentrations. Diagnostic imaging, including pelvic MRI, confirmed the presence of two solid masses in the inguinal canals (right 26 × 13 mm, left 25 × 15 mm). The patient underwent genetic testing, revealing a 46 XY karyotype and an as of yet unprecedented androgen receptor mutation. The type of the mutation was a single-base exchange - the substitution from cytosine to thymine in chromosome X:66942710 position (referred to human reference genome GRCh37), which has resulted in an amino acid changes from leucine (CTT) to phenyloalanine (TTT) in ligand-binding domain.
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Affiliation(s)
- Marzena Maciejewska-Jeske
- a Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | | | - Karolina Broda
- b Students Scientific Society of the Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | - Karolina Drabek
- b Students Scientific Society of the Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | - Anna Szeliga
- a Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | - Adam Czyzyk
- a Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | - Stanislaw Malinger
- c Department of General and Endocrine Surgery and Gastroenterological Oncology , Poznan University of Medical Sciences , Poznan , Poland
| | - Anna Kostrzak
- a Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | - Agnieszka Podfigurna
- a Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | - Gregory Bala
- b Students Scientific Society of the Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | - Blazej Meczekalski
- a Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznan , Poland
| | - Agnieszka Malcher
- d Department of Reproductive Biology and Stem Cells , Institute of Human Genetics, Polish Academy of Sciences , Poznan , Poland
| | - Maciej Kurpisz
- d Department of Reproductive Biology and Stem Cells , Institute of Human Genetics, Polish Academy of Sciences , Poznan , Poland
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Hughes LA, McKay-Bounford K, Webb EA, Dasani P, Clokie S, Chandran H, McCarthy L, Mohamed Z, Kirk JMW, Krone NP, Allen S, Cole TRP. Next generation sequencing (NGS) to improve the diagnosis and management of patients with disorders of sex development (DSD). Endocr Connect 2019; 8:100-110. [PMID: 30668521 PMCID: PMC6373624 DOI: 10.1530/ec-18-0376] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 01/16/2019] [Indexed: 11/08/2022]
Abstract
Disorders of sex development (DSDs) are a diverse group of conditions where the chromosomal, gonadal or anatomical sex can be atypical. The highly heterogeneous nature of this group of conditions often makes determining a genetic diagnosis challenging. Prior to next generation sequencing (NGS) technologies, genetic diagnostic tests were only available for a few of the many DSD-associated genes, which consequently had to be tested sequentially. Genetic testing is key in establishing the diagnosis, allowing for personalised management of these patients. Pinpointing the molecular cause of a patient's DSD can significantly impact patient management by informing future development needs, altering management strategies and identifying correct inheritance pattern when counselling family members. We have developed a 30-gene NGS panel, designed to be used as a frontline test for all suspected cases of DSD (both 46,XX and 46,XY cases). We have confirmed a diagnosis in 25 of the 80 patients tested to date. Confirmed diagnoses were linked to mutations in AMH, AMHR2, AR, HSD17B3, HSD3B2, MAMLD1, NR5A1, SRD5A2 and WT1 which have resulted in changes to patient management. The minimum diagnostic yield for patients with 46,XY DSD is 25/73. In 34/80 patients, only benign or likely benign variants were identified, and in 21/80 patients only variants of uncertain significance (VOUS) were identified, resulting in a diagnosis not being confirmed in these individuals. Our data support previous studies that an NGS panel approach is a clinically useful and cost-effective frontline test for patients with DSDs.
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Affiliation(s)
- L A Hughes
- West Midlands Regional Genetics Service, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - K McKay-Bounford
- West Midlands Regional Genetics Service, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - E A Webb
- Department of Endocrinology & Diabetes, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - P Dasani
- West Midlands Regional Genetics Service, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - S Clokie
- West Midlands Regional Genetics Service, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - H Chandran
- Department of Endocrinology & Diabetes, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - L McCarthy
- Department of Endocrinology & Diabetes, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Z Mohamed
- Department of Endocrinology & Diabetes, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - J M W Kirk
- Department of Endocrinology & Diabetes, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - N P Krone
- Department of Endocrinology & Diabetes, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - S Allen
- West Midlands Regional Genetics Service, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
| | - T R P Cole
- West Midlands Regional Genetics Service, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK
- Correspondence should be addressed to T R P Cole:
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Khanna K, Sharma S, Gupta DK. A Clinical Approach to Diagnosis of Ambiguous Genitalia. J Indian Assoc Pediatr Surg 2019; 24:162-169. [PMID: 31258263 PMCID: PMC6568146 DOI: 10.4103/jiaps.jiaps_70_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Disorders of sex development (DSD) are a sensitive and stressful condition for the family as well as the treating physician to deal with. The main issue in managing such cases is sex assignment. The decision is influenced by the cultural background, the sex of rearing, clinical features, the biochemical parameters including hormonal studies, the imaging reports, parental preference, fertility potential, and the assessment of mental make-up of the child when possible. In third world countries, there is diagnostic dilemma as most children with DSD present late and a detailed-lengthy work-up often delay their definitive treatment. In this article, the authors try to identify the important clinical features in children presenting with various types of DSD, which may aid in making a quick provisional clinical diagnosis and expediting the diagnostic work-up. The data have been gathered from 38 years of experience of the senior author while managing about 1200 cases of DSD in the pediatric intersex clinic at the tertiary care level institute.
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Affiliation(s)
- Kashish Khanna
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shilpa Sharma
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra K Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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29
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Rochmah N, Faizi M, Andriani IR, Pasulu SS. Case Report: Medical Aspect, Growth, and Quality of Life in Children with 46,XX Testicular Disorder of Sex Development (DSD). FOLIA MEDICA INDONESIANA 2018. [DOI: 10.20473/fmi.v54i3.10021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
46,XX testicular disorder of sexual development (DSD) is characterized by male phenotype with 46,XX karyotype. The incidence rate is 1:25,000 in male newborn. Infants with ambiguous external genitals will be confronted with issue of gender assigment and may result in a stressful condition in the parents. Since gender assignment is inevitable, several factors should be considered in DSD management. The management approach for children born with DSD is individualized and multidisciplinary. Gender assignment aims to facilitate the patient to obtain the best quality of life. Adaptation of children with 46,XX testicular DSD as a determinant of quality of life is also influenced by psychological and family conditions. The purpose of this report was to observe medical growth and development aspects of the child with 46,XX terticular DSD as indicated by the aspects of growth and development, and health related quality of life, as well as the influential aspects. PA, 18 months, was diagnosed with 46,XX testicular DSD. The patient routinely visited to endocrinology clinic, urologic surgery, and child psychiatry clinic from the age of 6 months. The parents decided to raise patient as male. The patient had undergone surgery for hypospadias correction, hormone injections, child growth monitoring, and psychological monitoring (medical records of Dr. Soetomo Hospital, Surabaya in 2015). Management should consider individual and multidiciplinary accompaniment of the patient and parents, the importance of group support, and follow-up to adulthood, as well as possible longterm outcomes that will occur in the future so that the patients and the parents need to be prepared.
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Khorashad BS, Aghili Z, Kreukels BPC, Reid AG, Roshan GM, Hiradfar M, Talaei A, Cohen Kettenis PT. Mental Health and Disorders of Sex Development/Intersex Conditions in Iranian Culture: Congenital Adrenal Hyperplasia, 5-α Reductase Deficiency-Type 2, and Complete Androgen Insensitivity Syndrome. ARCHIVES OF SEXUAL BEHAVIOR 2018; 47:931-942. [PMID: 29294229 DOI: 10.1007/s10508-017-1139-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 09/12/2017] [Accepted: 12/14/2017] [Indexed: 06/07/2023]
Abstract
Sixty-one patients (22 patients with congenital adrenal hyperplasia [CAH] with a mean age of 14.86 years [range, 5-23], 20 patients with 5-α reductase deficiency type 2 [5α-RD-2] with a mean age of 19.5 years [range, 5-29], and 19 patients with complete androgen insensitivity syndrome [CAIS] with a mean age of 18.26 years [range, 5-28]) were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia, the Structured Clinical Interview for DSM-IV Axis I, Axis II, and the Global Assessment Functioning Scale. All participants were female-assigned at birth. Ten patients (16.4%) transitioned to the male gender. Overall, 68% of patients had one or more lifetime Axis I disorders, including 63.6% of the CAH participants, 90% of 5α-RD-2 participants, and 52.6% of the CAIS participants. The most commonly observed were affective disorders (27.9%), gender identity disorder (27.9%), and anxiety (16.4%). Our study demonstrates that mental health of Iranian patients with DSD is at risk. This might be due to the fact that patients with DSD conditions are mostly treated medically and their mental health is often superficially addressed in developing countries such as Iran, at least in the past. We argue that it is important to pay attention to the mental health issues of patients with DSD and focus on specific issues, which may vary cross-culturally.
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Affiliation(s)
- Behzad S Khorashad
- Transgender Studies Center, Mashhad University of Medical Sciences, No. 17, Toufigh 9 Lane, Shahid Sadeghi Blvd., Mashhad, 91858-84714, Iran.
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran.
| | - Zahra Aghili
- Transgender Studies Center, Mashhad University of Medical Sciences, No. 17, Toufigh 9 Lane, Shahid Sadeghi Blvd., Mashhad, 91858-84714, Iran
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | - Alistair G Reid
- Molecular Pathology Unit, Liverpool Clinical Laboratories, Liverpool, UK
| | - Ghasem M Roshan
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran
| | - Mehran Hiradfar
- Department of Pediatric Surgery, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Talaei
- Transgender Studies Center, Mashhad University of Medical Sciences, No. 17, Toufigh 9 Lane, Shahid Sadeghi Blvd., Mashhad, 91858-84714, Iran
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Horeameli Avenue, Mashhad, 91959, Iran
| | - Peggy T Cohen Kettenis
- Department of Medical Psychology and Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
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Regulation of masculinization: androgen signalling for external genitalia development. Nat Rev Urol 2018; 15:358-368. [DOI: 10.1038/s41585-018-0008-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Tafazzoli K, Wünsch L, Bouteleux M, Lindert J, Schulz T, Birnbaum W, Marshall L, Hiort O, Tüshaus L. Endoscopy and Laparoscopy in Disorders of Sex Development. Sex Dev 2018; 12:100-105. [DOI: 10.1159/000486871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Griffiths DA. Shifting syndromes: Sex chromosome variations and intersex classifications. SOCIAL STUDIES OF SCIENCE 2018; 48:125-148. [PMID: 29424285 PMCID: PMC5808814 DOI: 10.1177/0306312718757081] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The 2006 'Consensus statement on management of intersex disorders' recommended moving to a new classification of intersex variations, framed in terms of 'disorders of sex development' or DSD. Part of the rationale for this change was to move away from associations with gender, and to increase clarity by grounding the classification system in genetics. While the medical community has largely accepted the move, some individuals from intersex activist communities have condemned it. In addition, people both inside and outside the medical community have disagreed about what should be covered by the classification system, in particular whether sex chromosome variations and the related diagnoses of Turner and Klinefelter's syndromes should be included. This article explores initial descriptions of Turner and Klinefelter's syndromes and their subsequent inclusion in intersex classifications, which were increasingly grounded in scientific understandings of sex chromosomes that emerged in the 1950s. The article questions the current drive to stabilize and 'sort out' intersex classifications through a grounding in genetics. Alternative social and historical definitions of intersex - such as those proposed by the intersex activists - have the potential to do more justice to the lived experience of those affected by such classifications and their consequences.
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Hannema SE, de Rijke YB. Improving Laboratory Assessment in Disorders of Sex Development through a Multidisciplinary Network. Sex Dev 2018; 12:135-139. [PMID: 29339667 DOI: 10.1159/000486329] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The aim of the European Reference Network for Rare Endocrine Disorders (Endo-ERN) is to ensure equal access to high-quality care for all those affected by a rare endocrine condition across Europe, such as a disorder/difference of sex development (DSD), both for children and adults. Although differences in resources, health care systems, and health insurances between the European countries are challenging and require political action, a European laboratory network within Endo-ERN could improve the diagnostic process in individuals with DSD, building on the work done by previous European collaborations such as the COST action DSDnet. In close collaboration, clinicians and laboratory specialists must make every effort to standardize diagnostic protocols, achieve necessary harmonization of various laboratory tests, e.g., the hCG stimulation test, and implement an external quality control system. This should ideally result in comparable quality across the network centers allowing the sharing of reference values. This would not only improve patient care but also greatly facilitate research.
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Affiliation(s)
- Sabine E Hannema
- Department of Pediatric Endocrinology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Chowdhury MAK, Anwar R, Saha A. Ambiguous genitalia-A social dilemma in Bangladesh: A case report. Int J Surg Case Rep 2017; 42:98-101. [PMID: 29232631 PMCID: PMC5730421 DOI: 10.1016/j.ijscr.2017.11.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Ambiguous Genitalia is a form of birth defect in which sex of the newborn cannot be readily distinguishable because of atypical appearance of the external genitalia. CASE REPORT-CLINICAL FINDINGS The patient, an 8 months old baby, was identified as a female baby since birth; but, some senior members of their neighborhood raised confusion regarding sex differentiation of the child. On examination, there was enlarged clitoris or micropenis, bifid scrotum or labioscrotal fold, and separate presence of urethral and vaginal orifices. Right testis was found in the middle of right inguinal canal and left testis was found near the deep inguinal ring. CASE REPORT-DIAGNOSIS, THERAPEUTIC INTERVENTION AND OUTCOME The ultrasonogram showed a rudimentary uterus measuring 26.7×7.27mm with no ovary and the right testis was found in the mid inguinal canal while the left testis was in the deep inguinal ring. Diagnostic endoscopic procedure showed normal appearing testes in deep inguinal ring, about 2cm vaginal remnant with normal urethra and bladder. Hormonal study revealed low serum testosterone with normal DHT and high oestradiol while the karyotyping revealed 46XY. After 3 months of hormonal treatment, multiple surgical interventions were taken to correctly determine the sex of the child. Later on the patient was discharged with follow up advices. CONCLUSION 'Ambiguous genitalia' is considered as a taboo in Bangladesh; hence, the social awareness regarding this curable disorder is a timely need in Bangladesh.
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Affiliation(s)
| | - Rashidul Anwar
- International Centre for Diarrhoeal Diseases Research, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Arnab Saha
- Interfaith Medical Center, 1545 Atlantic Ave, Brooklyn, NY 11213, United States
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Recommendations for the Establishment of Disorders/Differences of Sex Development Interdisciplinary Care Clinics for Youth. J Pediatr Nurs 2017; 37:79-85. [PMID: 28888337 DOI: 10.1016/j.pedn.2017.08.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 08/14/2017] [Accepted: 08/31/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE Provide recommendations for the development of an interdisciplinary care (IDC) clinic for the treatment of youth with disorders/differences of sex development (DSD). DSD consist of a group of complex congenital medical disorders in which the development of chromosomal, gonadal, or anatomical sex is atypical. Youth with DSD require care from multiple specialized healthcare disciplines, including several medical specialties, surgery, nursing, and mental health. METHOD Recommendations are based on an interdisciplinary care clinic model that allows for a team of relevant professionals who share knowledge, ideas, and responsibility of care. The framework established in this article is based largely on experiences at an established DSD clinic, as well as observations of multiple clinics across the United States. RESULTS Preliminary outcome data on clinic adherence to treatment protocol under an IDC model are provided. CONCLUSIONS To meet the diverse healthcare needs of youth with DSD, comprehensive care clinics are recommended; however, few such clinics exist in the United States. Establishing new comprehensive DSD clinics can be challenging due to the highly unique treatment of DSD, but the current paper expands the literature available to guide clinic development in the United States.
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Chivers C, Burns J, Deiros Collado M. Disorders of sex development: Mothers' experiences of support. Clin Child Psychol Psychiatry 2017; 22:675-690. [PMID: 28752770 DOI: 10.1177/1359104517719114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND An increasing body of research has sought to determine the impact of Disorders of Sex Development (DSD) on the family of the affected child. Little is currently understood about the support needs of the family and how well these needs are met. METHODS Interpretive Phenomenological Analysis was used to analyse semi-structured interviews with eight mothers of children with DSD about their experiences of support. RESULTS Four master themes emerged which encapsulated (a) the stages in their child's development when mothers most needed support, (b) the importance of developing an understanding of the child's condition, (c) the lack of acknowledgement of the emotional needs of the parent and (d) the importance of having close and trusted networks for support. Continuity and availability of support were considered important and while all participants prioritised maintaining privacy about the condition, a minority felt that this impacted the level of support they received. CONCLUSIONS Key time points for support were identified and while some felt that they were well supported others felt that the support available did not meet their emotional needs. Clinical implications and directions for future research were considered.
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Affiliation(s)
- Clare Chivers
- 1 Greenwich Child and Adolescent Mental Health Services, Oxleas NHS Foundation Trust, UK.,2 Faculty of Social and Applied Sciences, Canterbury Christ Church University, UK
| | - Jan Burns
- 2 Faculty of Social and Applied Sciences, Canterbury Christ Church University, UK
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Indyk JA. Disorders/differences of sex development (DSDs) for primary care: the approach to the infant with ambiguous genitalia. Transl Pediatr 2017; 6:323-334. [PMID: 29184813 PMCID: PMC5682373 DOI: 10.21037/tp.2017.10.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The initial management of the neonate with ambiguous genitalia can be a very stressful and anxious time for families, as well as for the general practitioner or neonatologist. A timely approach must be sensitive and attend to the psychosocial needs of the family. In addition, it must also effectively address the diagnostic dilemma that is frequently seen in the care of patients with disorders of sex development (DSDs). One great challenge is assigning a sex of rearing, which must take into account a variety of factors including the clinical, biochemical and radiologic clues as to the etiology of the atypical genitalia (AG). However, other important aspects cannot be overlooked, and these include parental and cultural views, as well as the future outlook in terms of surgery and fertility potential. Achieving optimal outcomes requires open and transparent dialogue with the family and caregivers, and should harness the resources of a multidisciplinary team. The multiple facets of this approach are outlined in this review.
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Affiliation(s)
- Justin A Indyk
- Section of Endocrinology, Nationwide Children's Hospital, the Ohio State University, Columbus, Ohio 43205, USA
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Biochemical Analysis of Four Missense Mutations in the HSD17B3 Gene Associated With 46,XY Disorders of Sex Development in Egyptian Patients. J Sex Med 2017; 14:1165-1174. [DOI: 10.1016/j.jsxm.2017.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/15/2017] [Accepted: 07/11/2017] [Indexed: 11/21/2022]
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40
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Yatsenko SA, Witchel SF. Genetic approach to ambiguous genitalia and disorders of sex development: What clinicians need to know. Semin Perinatol 2017; 41:232-243. [PMID: 28545654 DOI: 10.1053/j.semperi.2017.03.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Genetic tools such as microarray and next-generation sequencing have initiated a new era for the diagnosis and management of patients with disorders of sex development (DSDs). These tools supplement the traditional approach to the evaluation and care of infants, children, and adolescents with DSDs. These tests can detect genetic variations known to be associated with DSDs, discover novel genetic variants, and elucidate novel mechanisms of gene regulation. Herein, we discuss these tests and their role in the management of patients with DSDs.
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Affiliation(s)
- Svetlana A Yatsenko
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, School of Medicine, Pittsburgh, PA; Department of Pathology, University of Pittsburgh, School of Medicine, Pittsburgh, PA; Department of Human Genetics, University of Pittsburgh, School of Public Health, Pittsburgh, PA
| | - Selma Feldman Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224.
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41
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Bangalore Krishna K, Houk CP, Lee PA. Pragmatic approach to intersex, including genital ambiguity, in the newborn. Semin Perinatol 2017; 41:244-251. [PMID: 28535943 DOI: 10.1053/j.semperi.2017.03.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The evaluation and management of a newborn with ambiguous genitalia must be undertaken as quickly as possible and with great sensitivity for the child's family. Where possible, a comprehensive team approach with a pediatric urologist, endocrinologist, geneticist, neonatologist, and child psychiatrist/psychologist should work closely with the family to establish the diagnosis and determine gender. Although the preferred gender assignment is not always clear, a thorough examination of endocrine function, karyotype, and potential for fertility should guide the determination. While some disorders of sex development (DSD) sex assignments are relatively straightforward, those with more advanced genital ambiguity and unclear gonadal function represent a major challenge. A child's phenotypic sex results from the differentiation of internal ducts and external genitalia under the influence of hormones and transcription factors. Any discordance among these processes results in ambiguous genitalia or DSD. Currently, the main categories of DSD are 46,XX DSD, 46,XY DSD, sex chromosome DSD, ovotesticular DSD, and 46,XX testicular DSD. Priority is given to rule out more immediate life-threatening disorders like salt wasting CAH. Many centers in the United States lack the comprehensive "team members" and not all conditions necessitate this team approach. This article aims to provide guidance for initial workup and identify the specific conditions for which expert guidance is needed.
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Affiliation(s)
- Kanthi Bangalore Krishna
- Division of Pediatric Endocrinology, Department of Pediatrics, Penn State College of Medicine, 905 West Governor Rd, Suite 300, Hershey, PA 17033-0850.
| | | | - Peter A Lee
- Division of Pediatric Endocrinology, Department of Pediatrics, Penn State College of Medicine, 905 West Governor Rd, Suite 300, Hershey, PA 17033-0850
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Rolston AM, Gardner M, van Leeuwen K, Mohnach L, Keegan C, Délot E, Vilain E, Sandberg DE. Disorders of sex development (DSD): Clinical service delivery in the United States. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:268-278. [PMID: 28557237 DOI: 10.1002/ajmg.c.31558] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 03/21/2017] [Accepted: 03/29/2017] [Indexed: 11/06/2022]
Abstract
Following the principles of care recommended in the 2006 Consensus Statement on Disorders of Sex Development (DSD), along with input from representatives of peer support and advocacy groups, this study surveyed DSD clinical management practices at healthcare facilities in the United States. DSD are congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical. Facilities providing care for patients with DSD were targeted for participation. Specialty providers completed a survey with questions in six broad categories: Institution Information, Nomenclature and Care Guidelines, Interdisciplinary Services, Staff and Community Education, DSD Management, and Research. Twenty-two of 36 targeted sites (61%) participated. Differences were observed between sites with regard to what conditions were considered to be DSD. All sites reported some degree of involvement of pediatric urology and/or surgery and pediatric endocrinology in the care of DSD patients. Gynecology and neonatology were most frequently not represented. Wide variation was observed across sites in continuing education standards, obtaining informed consent for clinical procedures, and in specific clinical management practices. This survey is the first to assess DSD clinical management practices in the United States. The findings establish a baseline of current practices against which providers delivering care to these patients and their families can benchmark their efforts. Such surveys also provide a practical framework for collaboration in identifying opportunities for change that enhance health and quality of life outcomes for patients and families affected by DSD.
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Affiliation(s)
- Aimee M Rolston
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Melissa Gardner
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Lauren Mohnach
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan.,Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Catherine Keegan
- Division of Genetics, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.,Department of Human Genetics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Emmanuèle Délot
- Department of Human Genetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Eric Vilain
- Department of Human Genetics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David E Sandberg
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor, Michigan
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Teasdale SL, Morton A. Adrenarche unmasks compound heterozygous 3β-hydroxysteroid dehydrogenase deficiency: c.244G>A (p.Ala82Thr) and the novel 931C>T (p.Gln311*) variant in a non-salt wasting, severely undervirilised 46XY. J Pediatr Endocrinol Metab 2017; 30:355-360. [PMID: 28207417 DOI: 10.1515/jpem-2016-0348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/19/2016] [Indexed: 11/15/2022]
Abstract
3β-Hydroxysteroid dehydrogenase type II deficiency (3βHSD2) congenital adrenal hyperplasia is a rare cause of ambiguous genitalia, resulting in abnormal virilisation in both 46XY and 46XX. We describe a case of 46XY ambiguous genitalia that was misdiagnosed as androgen insensitivity syndrome. The correct diagnosis was made after adrenarche. Genotyping demonstrated compound heterozygosity in two alleles, the previously described c.244G>A (p.Ala82Thr), and a novel 931C>T(p.Gln311*) variant. We suggest that adrenarche unmasked the condition by driving cortisol production to rates that caused the mutant 3bHSD2 enzyme to become rate limiting for cortisol production. This case illustrates how markedly different the effects of this condition may be on androgen production compared with glucocorticoid and mineralocorticoid production. It also demonstrates how current guidelines based on urinary steroids and cortisol sufficiency may not arrive at the correct diagnosis, and underlines the importance of gene testing in the work-up of disorders of sexual differentiation.
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Kulkarni M, Glanville J, Phillot S, Balen A. A review of paediatric and adolescent gynaecology services in a tertiary outpatient clinic. HUM FERTIL 2017; 20:168-178. [PMID: 28152641 DOI: 10.1080/14647273.2017.1283067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Adolescence is a distinctive stage in human development during which many simple and complex medical conditions can present for the first time. Paediatric and adolescent gynaecological conditions need careful multidisciplinary clinical management with a sensitive approach understanding the patients' psychological and physiological circumstances. The objective of this study is to review the tertiary paediatric and adolescent gynaecology service in Leeds, United Kingdom and to present an overview of the various conditions that present to such a clinic. A total of 985 patients were seen over a 16-year period and the increasing number of patients seen over this time establishes the need for such a service to exist. Complex developmental anomalies of the genital tract and disorders of sexual differentiation formed a major portion of the referrals. Presence of a significant number of referrals for simple gynaecological conditions including menstrual irregularities, gynaecological pain, vulvovaginitis, polycystic ovary syndrome and concerns about labial appearance indicates the reluctance of general gynaecologists and general practitioners to manage such conditions in young patients. This emphasizes the need for continued education of primary health care professionals and establishment of clear guidelines and care pathways for the management of this special patient group.
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Affiliation(s)
- Mugdha Kulkarni
- a Leeds Centre for Reproductive Medicine, Seacroft Hospital , Leeds , UK
| | - Julie Glanville
- a Leeds Centre for Reproductive Medicine, Seacroft Hospital , Leeds , UK
| | - Sally Phillot
- a Leeds Centre for Reproductive Medicine, Seacroft Hospital , Leeds , UK
| | - Adam Balen
- a Leeds Centre for Reproductive Medicine, Seacroft Hospital , Leeds , UK
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Lee PA, Nordenström A, Houk CP, Ahmed SF, Auchus R, Baratz A, Baratz Dalke K, Liao LM, Lin-Su K, Looijenga LHJ, Mazur T, Meyer-Bahlburg HFL, Mouriquand P, Quigley CA, Sandberg DE, Vilain E, Witchel S. Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care. Horm Res Paediatr 2016; 85:158-80. [PMID: 26820577 DOI: 10.1159/000442975] [Citation(s) in RCA: 356] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/01/2015] [Indexed: 11/19/2022] Open
Abstract
The goal of this update regarding the diagnosis and care of persons with disorders of sex development (DSDs) is to address changes in the clinical approach since the 2005 Consensus Conference, since knowledge and viewpoints change. An effort was made to include representatives from a broad perspective including support and advocacy groups. The goal of patient care is focused upon the best possible quality of life (QoL). The field of DSD is continuously developing. An update on the clinical evaluation of infants and older individuals with ambiguous genitalia including perceptions regarding male or female assignment is discussed. Topics include biochemical and genetic assessment, the risk of germ cell tumor development, approaches to psychosocial and psychosexual well-being and an update on support groups. Open and on-going communication with patients and parents must involve full disclosure, with the recognition that, while DSD conditions are life-long, enhancement of the best possible outcome improves QoL. The evolution of diagnosis and care continues, while it is still impossible to predict gender development in an individual case with certainty. Such decisions and decisions regarding surgery during infancy that alters external genital anatomy or removes germ cells continue to carry risk.
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Affiliation(s)
- Peter A Lee
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pa., USA
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Lindert J, Hiort O, Tüshaus L, Tafazzoli-Lari K, Wünsch L. Perineal ultrasound offers useful information in girls with congenital adrenal hyperplasia. J Pediatr Urol 2016; 12:427.e1-427.e6. [PMID: 27751833 DOI: 10.1016/j.jpurol.2016.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 08/22/2016] [Indexed: 10/21/2022]
Abstract
A variable spectrum of urogenital malformations exists in girls with congenital adrenal hyperplasia (CAH). The vagina may enter the urethra at a variable level, and relations to the sphincter complex vary accordingly. Furthermore, an enlarged clitoris and variations in the bladder sphincter anatomy can be found. Endoscopy, genitography or magnetic resonance imaging (MRI) are commonly used for the assessment of these anomalies, and to provide information for counselling and treatment. When surgery is planned, introitoplasty cosmetical reduction of the clitoris and labioplasty are discussed with the families; introitoplasty is the most demanding aspect. In order to plan the most appropriate surgical approach, the entrance level of the vagina into the urethra and its relation to the bladder sphincter must be known. Thus, imaging has an important role in CAH. The imaging techniques mentioned above require sedation, anaesthesia or involve ionizing radiation of the gonads and, thus, are relatively invasive. It would therefore be highly desirable to have a minimally invasive and accurate technique that provides images of the individual anatomic situation. The present paper describes experience with perineal ultrasound in the initial imaging evaluation of girls with CAH. Ultrasound findings were compared to the results of endoscopy that was performed before surgery. From 2006 to 2012, 11 girls had perineal ultrasound and endoscopy. Measurements of clinical relevance for introitoplasty were: the length of the urogenital sinus, the distance to the vaginal opening into the urogenital sinus, and the length of the bladder neck. This retrospective analysis showed that the entrance point of the vagina into the urogenital sinus could be identified in 10 of 11 girls. In some cases, the correlation of endoscopic and ultrasound data showed a correlation between endoscopic and sonographic findings. The length of the bladder neck and the length of the urogenital sinus could be measured by ultrasound in 10 of 11 girls, and were subsequently confirmed by endoscopy. This showed, for the first time, that perineal ultrasound could provide the information required for surgical correction of the urogenital sinus anomaly in CAH. Advantages of these techniques are the minimal invasiveness and wide availability. Because long-term problems are not uncommon, perineal ultrasound may also be of value during follow-up. Widespread use of this technique has the potential to reduce costs and morbidity associated with endoscopy and genitography.
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Affiliation(s)
- J Lindert
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany.
| | - O Hiort
- Division of Paediatric Endocrinology and Diabetes, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany
| | - L Tüshaus
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany
| | - K Tafazzoli-Lari
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany
| | - L Wünsch
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Alle 160, 23538 Lübeck, Germany
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Gazdagh G, Tobias ES, Ahmed SF, McGowan R. Novel Genetic Associations and Range of Phenotypes in Children with Disorders of Sex Development and Neurodevelopment: Insights from the Deciphering Developmental Disorders Study. Sex Dev 2016; 10:130-5. [PMID: 27598577 PMCID: PMC5079067 DOI: 10.1159/000447958] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2016] [Indexed: 11/30/2022] Open
Abstract
A range of phenotypes that are associated with disorders of sex development (DSD) may also be encountered in patients with neurodevelopmental delay. In this study we have undertaken a collaborative retrospective review of anonymised phenotypic and genotypic data from the UK-wide Deciphering Developmental Disorders (DDD) study. Our objectives were to determine the frequency and range of DSD phenotypes observed in participants in the DDD study and to identify novel genetic associations. We found that of 7,439 DDD participants, 603 (8%) had at least one genital abnormality. In addition, we found that DSD occurs in 5% of patients with learning difficulties. Causative mutations were found in 13 developmental genes, of which, crucially, 6 had no previous reported association with DSD. Our findings indicate that recognition of these associations should not be overlooked in the management of patients with complex conditions and that exomic sequencing through projects like DDD increases diagnostic yield.
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Affiliation(s)
- Gabriella Gazdagh
- West of Scotland Regional Genetics Service, Laboratory Medicine Building, Queen Elizabeth University Hospital, Glasgow, UK
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Lucas-Herald AK, Cann F, Crawford L, Morrison H, Boroujerdi M, Nelson SM, Ahmed SF, McGowan R. The outcome of prenatal identification of sex chromosome abnormalities. Arch Dis Child Fetal Neonatal Ed 2016; 101:F423-7. [PMID: 26764426 DOI: 10.1136/archdischild-2015-309681] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/04/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The outcome of a pregnancy following identification of a sex chromosome abnormality (SCA) is unclear. The aims of this study were to ascertain the prevalence of SCA detected prenatally in Scotland and to determine the outcomes for these cases. DESIGN Following retrospective identification of all prenatal karyotypes performed in Scotland between 2000 and 2012, data linkage was performed to obtain information regarding maternal characteristics and pregnancy outcomes. Detailed outcome data were also collected for all affected offspring in the West of Scotland and Grampian regions within Scotland. RESULTS Of the 28 145 pregnancies that had a karyotype over the study period, records were available for 27 152 (96%). Karyotype abnormalities were identified in 2139 (8%), with SCA being identified in 321(1%) tests. 45,X was identified as the commonest SCA in 135 pregnancies. Of 121 pregnancies with SCA in the West of Scotland and Grampian, 64 (53%), 52 (43%) and 5 (4%) led to a live birth, termination and intrauterine death, respectively. Of the 64 live births, 21 (33%) had a postnatal karyotype and 35 (54%) received specialist follow-up for the SCA that was identified prenatally. CONCLUSIONS Abnormalities of sex chromosomes are identified in approximately 1% of all pregnancies that undergo a prenatal karyotype. There is a need to review the prenatal as well as postnatal care of the affected mother and offspring.
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Affiliation(s)
| | - Fiona Cann
- North of Scotland Regional Genetics Service, Clinical Genetics Centre, Aberdeen, UK
| | - Lorna Crawford
- Cytogenetics Department, West of Scotland Genetics Laboratory, Southern General Hospital, Glasgow, UK
| | - Holly Morrison
- Department of Clinical Genetics, Southern General Hospital, Glasgow, UK
| | - Massoud Boroujerdi
- Developmental Endocrinology Research Group, University of Glasgow, RHC, Glasgow, UK
| | - Scott M Nelson
- School of Medicine, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, UK
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, RHC, Glasgow, UK
| | - Ruth McGowan
- Department of Clinical Genetics, Southern General Hospital, Glasgow, UK
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Juniarto AZ, van der Zwan YG, Santosa A, Ariani MD, Eggers S, Hersmus R, Themmen APN, Bruggenwirth HT, Wolffenbuttel KP, Sinclair A, White SJ, Looijenga LHJ, de Jong FH, Faradz SMH, Drop SLS. Hormonal evaluation in relation to phenotype and genotype in 286 patients with a disorder of sex development from Indonesia. Clin Endocrinol (Oxf) 2016; 85:247-57. [PMID: 26935236 DOI: 10.1111/cen.13051] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 01/22/2016] [Accepted: 02/28/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of this study was to determine the aetiological spectrum of disorders of sex development (DSD) in a large cohort of underprivileged and undiagnosed patients from Indonesia. METHODS A total of 286 patients with atypical external and/or internal genitalia were evaluated using clinical, hormonal, molecular genetic and histological parameters. RESULTS The age (years) at presentation was 0-0·5 in 41 (14·3%), >0·5-12 in 181 (63·3%) and >12 in 64 cases (22·4%). 46,XY DSD was most common (68·2%, n = 195), 46,XX DSD was found in 23·4% (n = 67) and sex chromosomal DSD in 8·4% (n = 24). In 61·2% of 46,XX DSD patients, 17·9% of 46,XY DSD patients and all sex chromosome DSD patients (29·4% in total), a final diagnosis was reached based on genetic or histological gonadal tissue evaluation. 17-hydroxyprogesterone and androstenedione levels were the most distinctive parameters in 46,XX DSD patients. In 46,XY DSD, diagnostic groups were identified based on the external masculinization score: androgen action disorder (AAD), unknown male undermasculinization (UMU), and gonadal dysgenesis (GD). LH, FSH and testosterone levels were most informative especially in the older age group. HCG tests were of no additional value as no patients with androgen synthesis disorders were found. Hormonal profiles of patients with sex chromosome DSD and a Y-chromosome sequence containing karyotype showed high levels of LH and FSH, and low levels of AMH, inhibin B and testosterone compared with the normal male range. Gene mutations were found in all patients with CAH, but in only 24·5% and 1·8% of patients with AAD and UMU. In 32% of 46,XY GD patients, copy number variants of different genes were found. CONCLUSION A stepwise diagnostic approach led to a molecularly or histologically proven final diagnosis in 29·4% of the patients. The most informative parameters were serum levels of 17-hydroxyprogesterone and androstenedione in 46,XX DSD patients, and serum LH, FSH and testosterone levels in 46,XY DSD patients.
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Affiliation(s)
- A Zulfa Juniarto
- Division of Human Genetics, Center for Biomedical Research Faculty of Medicine Diponegoro University (FMDU), Semarang, Indonesia
| | - Yvonne G van der Zwan
- Department of Paediatrics, Division of Endocrinology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Pathology, Josephine Nefkens Institute, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ardy Santosa
- Department of Urology, Dr Kariadi Hospital, Semarang, Indonesia
| | - Mahayu Dewi Ariani
- Division of Human Genetics, Center for Biomedical Research Faculty of Medicine Diponegoro University (FMDU), Semarang, Indonesia
| | - Stefanie Eggers
- Murdoch Children's Research Institute, Royal Children's Hospital and Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Remko Hersmus
- Department of Pathology, Josephine Nefkens Institute, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Axel P N Themmen
- Department of Internal Medicine, Section of Endocrinology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Hennie T Bruggenwirth
- Department of Clinical Genetics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Katja P Wolffenbuttel
- Department of Paediatric Urology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Andrew Sinclair
- Murdoch Children's Research Institute, Royal Children's Hospital and Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Stefan J White
- Centre for Genetic Diseases, MIMR-PHI Institute of Medical Research, Monash University, Clayton, Australia
| | - Leendert H J Looijenga
- Department of Pathology, Josephine Nefkens Institute, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank H de Jong
- Division of Human Genetics, Center for Biomedical Research Faculty of Medicine Diponegoro University (FMDU), Semarang, Indonesia
| | - Sultana M H Faradz
- Division of Human Genetics, Center for Biomedical Research Faculty of Medicine Diponegoro University (FMDU), Semarang, Indonesia
| | - Stenvert L S Drop
- Department of Paediatrics, Division of Endocrinology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Abstract
Sex assignment in newborns depends on the anatomy of the external genitalia, despite this stage being the final in embryogenesis. According to the current view, the genital tubercle is the embryonic precursor of penis and clitoris. It originates from mesenchymal tissue, but mesenchymal cells are arranged across the embryonal body and do not have specific androgen receptors. The nature of the signal that initiates early derivation of the indifferent genital tubercle is unknown at present. The aims of this article are to improve surgical management of intersex disorders and investigate the development of the genital tubercle. Clinical examination of 114 females with various forms of DSD revealed ambiguous (bisexual) external genitalia in 73 patients, and 51 of them underwent feminizing surgery. Intersexuality (ambiguity) in 46,XY patients results from disruptors in the pathways of sex steroid hormones or receptors; in 46,XX females arises from excessive levels of androgens. Systematization of intersex disorders distinguishes the karyotype, gonadal morphology, and genital anatomy to provide a differential diagnosis and guide appropriate surgical management. Modified feminizing clitoroplasty with preservation of the dorsal and ventral neurovascular bundles to retain erogenous sensitivity was performed in females with severe virilization (Prader degree III-V). The outgrowth of the genital tubercle and the fusion of the urethral fold proceed in an ordered fashion; but in some cases of ambiguity, there was discordance due to different pathways. Speculation about the derivation of the genital tubercle have discussed with a literature review. The genital tubercle derives from the following 3 layers: the ectodermal glans of the tubercle, the mesodermal corpora cavernosa and the endodermal urogenital groove. According to the new hypothesis, during the indifferent stages, the 5 sacral somites have to recede from their segmentation and disintegrate: the sclerotomes form the pelvic bones, the fused myotomes follow with their genuine neurotomes and the angiotomes join to the corpora cavernosa of the genital tubercle. Sexual differentiation of external genitalia is final in gender embryogenesis, but surprisingly derivation of the indifferent genital tubercle from 5 somites occurs before gonadal and internal organs development.
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Affiliation(s)
- Zograb Makiyan
- a Department of Operative Gynaecology , Federal State Scientific Centre of Obstetrics, Gynaecology and Perinatology after V.I. Kulakov , Moscow , Russia
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