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Zangene D, Moravej H, Ilkhanipoor H, Amirhakimi A, Afshar Z, Entezam M. CYP21A2 Gene Analysis in Southern Iranian CAH Patients and a Brief Review of the Mutation Spectrum. Avicenna J Med Biotechnol 2024; 16:130-135. [PMID: 38618509 PMCID: PMC11007372 DOI: 10.18502/ajmb.v16i2.14864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/18/2023] [Indexed: 04/16/2024] Open
Abstract
Background CYP21A2 gene mutations are responsible for more than 95% of Congenital Adrenal Hyperplasia (CAH) disorders with autosomal recessive inheritance. Most of these pathogenic mutations originate from the CYP21A1P, a neighboring pseudogene with 98% homology, due to unequal crossing over or gene conversion events. Mutation identification of the gene could be beneficial for accurate diagnosis and outcome prediction. Methods Twelve unrelated patients with CAH diagnosis were recruited for genetic counseling. To ensure distinct amplification of the CYP21A2 gene rather than its pseudogene, the complete sequence of the gene was amplified through two overlapping fragments by specific primers. The entire sequences were screened by direct Sanger sequencing using new sequencing primers. Results Only two pathogenic point mutations were identified. The c.293-13C>G, also known as In2G, and the c.955C>T mutations were found in 37.5 and 33.3% of alleles, respectively. One patient showed homozygous gene deletion. We also reviewed recent reports on CYP21A2 gene mutations in Iran. Conclusion Evaluating the ethnicity-specific gene mutation data is significant for populations with diverse ethnic groups including the Iranian population. Although several common mutations have been reported as causative mutations among CAH patients, identifying only two common point mutations in Fars province would help prioritize exon sequencing and reduce the cost and time of genotyping.
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Affiliation(s)
- Danial Zangene
- Department of Medical Genetics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Moravej
- Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Homa Ilkhanipoor
- Department of Pediatric Endocrinology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Anis Amirhakimi
- Department of Pediatric Endocrinology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zhila Afshar
- Department of Pediatric Endocrinology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mona Entezam
- Department of Medical Genetics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Taieb A, Farid H, Zarrouk O, Ben Abdessalem F, Layouni S. Identifying the First Val281L Mutation Causing Nonclassic Congenital Adrenal Hyperplasia in the Central-East Region of Tunisia. Cureus 2024; 16:e57124. [PMID: 38681304 PMCID: PMC11055564 DOI: 10.7759/cureus.57124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
Nonclassic congenital adrenal hyperplasia (NCAH) is a genetic disorder characterized by mutations in the genes encoding enzymes involved in cortisol production, most commonly the 21-hydroxylase enzyme. Unlike classic congenital adrenal hyperplasia (CAH), NCAH typically presents later in life with milder symptoms. The diagnosis of NCAH can be challenging due to its nonspecific symptoms and variable presentation. Early detection is crucial for timely intervention and management, particularly in families with a history of the condition. We report a case of NCAH in a patient from the Central-East Region of Tunisia, in whom the subsequent genetic testing revealed a Val281Leu (V281L) mutation in the CYP21A2 gene. A 26-year-old female presented with facial hirsutism and irregular menstrual cycles. Physical examination revealed mild hirsutism and laboratory tests showed elevated levels of testosterone and 17-hydroxyprogesterone (17-OHP). A provisional diagnosis of NCAH was made, subsequently confirmed by an adrenocorticotropic hormone (ACTH) stimulation test demonstrating an exaggerated 17-OHP response. Genetic testing revealed heterozygosity for the V281L mutation. Family testing showed the patient's mother to be homozygous and the father heterozygous for the mutation. This report highlights the importance of recognizing subtle symptoms of NCAH for early diagnosis and management. Genetic testing aids in confirming the diagnosis and identifying carriers within families. Treatment with glucocorticoids aims to suppress adrenal androgen production and manage symptoms. Regular follow-up is essential to monitor treatment response and adjust medication as needed. NCAH can present with subtle symptoms, necessitating a high index of suspicion for a proper diagnosis. Genetic testing plays a crucial role in confirming the diagnosis and identifying carriers within families. Early intervention and regular follow-up improve outcomes in affected individuals. This report also underscores the significance of genetic testing in the management of NCAH and highlights the need for increased awareness about this condition among healthcare providers.
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Affiliation(s)
- Ach Taieb
- Endocrinology, Farhat Hached University Hospital, Sousse, TUN
| | - Hayfa Farid
- Endocrinology, Farhat Hached University Hospital, Sousse, TUN
| | - Oumayma Zarrouk
- Endocrinology, Farhat Hached University Hospital, Sousse, TUN
| | | | - Saoussen Layouni
- Physical Medicine and Rehabilitation, Sahloul University Hospital, Sousse, TUN
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Zwayne N, Chawla R, van Leeuwen K. Caring for Patients With Congenital Adrenal Hyperplasia Throughout the Lifespan. Obstet Gynecol 2023; 142:257-268. [PMID: 37473408 DOI: 10.1097/aog.0000000000005263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/30/2023] [Indexed: 07/22/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder affecting cortisol and aldosterone biosynthesis, which can lead to virilization in fetuses with a 46,XX karyotype. 21-hydroxylase deficiency is the most common cause of CAH, accounting for 90-99% of all patients with the condition. The management of patients with CAH should be done with a multidisciplinary team, which would address all of the complex components of their care throughout their lifespans. Many multidisciplinary teams have adopted shared decision-making approaches to genital surgery in which parents and patients can be part of the decision-making process. Continued research is needed to best serve these patients throughout their lifespans.
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Affiliation(s)
- Noor Zwayne
- Division of Pediatric and Adolescent Gynecology, Women's Health Department, University of Texas at Austin, Dell Medical School, Austin, Texas; and the Division of Pediatric Endocrinology and the Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona
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Thibaut D, Walter MR, McGonegal C, Daniel R, Goodman J. Congenital Adrenal Hyperplasia and Human Leukocyte Antigen B: A Meta-Analysis. Cureus 2023; 15:e35900. [PMID: 37033531 PMCID: PMC10081860 DOI: 10.7759/cureus.35900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
The link between specific human leukocyte antigen (HLA)-B genes and congenital adrenal hyperplasia (CAH) has been a subject of interest. This study investigates the association between specific HLA-B haplotypes and CAH through a meta-analysis. Google Scholar was used as a database. Articles were included if the research was conducted between 1970 and 2022, was not a meta-analysis, and had odds ratios or enough data points to calculate an odds ratio. The National Institutes of Health (NIH) quality assessment tool of case-control studies was used to evaluate the risk of bias in individual studies, and MetaXL was used to generate data and create a forest plot for analysis. Twelve studies met the selection criteria and were included in the study (641 patients and 3,614 controls). Two HLA-B haplotypes showed increased odds of CAH compared to controls: B14 (OR=3.81; 95%CI=2.88, 5.05; I2=3%) and B35 (OR=1.88; 95%CI=1.22, 2.90; I2=25%). All other HLAs either showed no significant effect or had high heterogeneity. The results suggest that specific HLA-B haplotypes have increased odds of developing CAH, specifically B14 and B35. These findings may prove helpful in the pre- and post-natal diagnosis of CAH as well as the identification of carriers and prediction of patient prognosis.
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Affiliation(s)
- Dylan Thibaut
- Osteopathic Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Madison R Walter
- Osteopathic Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Courtney McGonegal
- Osteopathic Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Ryan Daniel
- Osteopathic Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Jerry Goodman
- Obstetrics and Gynecology, Lake Erie College of Osteopathic Medicine, Bradenton, USA
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Saminathan T, Dhivyalakshmi J, Sneha LM, Joseph LD. Precocious puberty in a child: A rare cause and review of literature. J Family Med Prim Care 2022; 11:6523-6525. [PMID: 36618181 PMCID: PMC9810850 DOI: 10.4103/jfmpc.jfmpc_376_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 11/11/2022] Open
Abstract
Precocious puberty (PP) in pediatric office practice is challenging as the cause varies from benign to malignant conditions. Adrenocortical tumors are rare in childhood and pseudo-precocious puberty is the most common clinical presentation in children. We report a case of a 5-year-old boy who presented with features of abdominal distention and virilization, and his abdominal magnetic resonance imaging (MRI) revealed an adrenal tumor which was confirmed as adrenocortical carcinoma by biopsy. This case report highlights the importance of the awareness among general practioners and pediatricians to rule out adrenocortical tumors while evaluating a child with PP.
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Affiliation(s)
- Thulasiraj Saminathan
- Department of Pediatrics, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - J Dhivyalakshmi
- Department of Pediatrics, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Latha M. Sneha
- Department of Division of Pediatric Hematology and Oncology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India,Address for correspondence: Dr. Latha M. Sneha, No. 1, Ramachandra Nagar, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu, India. E-mail:
| | - Leena D. Joseph
- Department of Pathology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
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Nordenström A, Falhammar H, Lajic S. Current and Novel Treatment Strategies in Children with Congenital Adrenal Hyperplasia. Horm Res Paediatr 2022; 96:560-572. [PMID: 35086098 DOI: 10.1159/000522260] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The standard treatment for congenital adrenal hyperplasia (CAH) in children is still hydrocortisone. Improved strategies for timing of the dose during the day and the dose per square meter body surface area used in children of different ages and developmental phases have improved the situation and outcome for the patients. Neonatal screening enables an earlier diagnosis and initiation of treatment, prevents from adrenal crisis, and improves growth and development also for children with the less severe forms of CAH. SUMMARY This review describes the current treatment strategies for children with CAH and discusses some potential treatment options that have been developed with the primary aim to decrease the adrenal androgen production. Novel modified release glucocorticoid therapies are also discussed. KEY MESSAGES The long-term effects of the new adjunct therapies are unknown, and some are not suitable for use in children and adolescents. The effects of the new therapies on bone mineral density, gonadal functions, and long-term cognitive development are yet to be assessed. It is not known what levels of adrenal androgens are optimal for normal growth, puberty, and bone health. The basis of using glucocorticoids and mineralocorticoids in the treatment of CAH remains, and in some individuals, it may be beneficial to add therapies to reduce the androgen load during certain life stages.
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Affiliation(s)
- Anna Nordenström
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Department of Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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7
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Marino R, Moresco A, Perez Garrido N, Ramirez P, Belgorosky A. Congenital Adrenal Hyperplasia and Ehlers-Danlos Syndrome. Front Endocrinol (Lausanne) 2022; 13:803226. [PMID: 35282436 PMCID: PMC8913572 DOI: 10.3389/fendo.2022.803226] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase deficiency is an autosomal recessive disorder. The 21-hydroxylase enzyme P450c21 is encoded by the CYP21A2 gene located on chromosome 6p21.33 within the HLA major histocompatibility complex. This locus also contains the CYP21A1P, a non-functional pseudogene, that is highly homologous to the CYP21A2 gene. Other duplicated genes are C4A and C4B, that encode two isoforms of complement factor C4, the RP1 gene that encodes a serine/threonine protein kinase, and the TNXB gene that, encodes the extracellular matrix glycoprotein tenascin-X (TNX). TNX plays a role in collagen deposition by dermal fibroblasts and is expressed in the dermis of the skin and the connective tissue of the heart and skeletal muscle. During meiosis, misalignment may occur producing large gene deletions or gene conversion events resulting in chimeric genes. Chimeric recombination may occur between TNXB and TNXA. Three TNXA/TNXB chimeras have been described that differ in the junction site (CH1 to CH3) and result in a contiguous CYP21A2 and TNXB gene deletion, causing CAH-X syndrome. TNXB deficiency is associated with Ehlers Danlos syndrome (EDS). EDS comprises a clinically and genetically heterogeneous group of connective tissue disorders. As molecular analysis of the TNXB gene is challenging, the TNX-deficient type EDS is probably underdiagnosed. In this minireview, we will address the different strategies of molecular analysis of the TNXB-gene, as well as copy number variations and genetic status of TNXB in different cohorts. Furthermore, clinical features of EDS and clinical recommendations for long-term follow-up are discussed.
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Affiliation(s)
- Roxana Marino
- Molecular Biology Laboratory, Endocrinology Service, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Angélica Moresco
- Genetics Service, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Natalia Perez Garrido
- Molecular Biology Laboratory, Endocrinology Service, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Pablo Ramirez
- Molecular Biology Laboratory, Endocrinology Service, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Alicia Belgorosky
- Endocrinology Service, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
- *Correspondence: Alicia Belgorosky,
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Golubnitschaja O, Liskova A, Koklesova L, Samec M, Biringer K, Büsselberg D, Podbielska H, Kunin AA, Evsevyeva ME, Shapira N, Paul F, Erb C, Dietrich DE, Felbel D, Karabatsiakis A, Bubnov R, Polivka J, Polivka J, Birkenbihl C, Fröhlich H, Hofmann-Apitius M, Kubatka P. Caution, "normal" BMI: health risks associated with potentially masked individual underweight-EPMA Position Paper 2021. EPMA J 2021; 12:243-264. [PMID: 34422142 PMCID: PMC8368050 DOI: 10.1007/s13167-021-00251-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023]
Abstract
An increasing interest in a healthy lifestyle raises questions about optimal body weight. Evidently, it should be clearly discriminated between the standardised "normal" body weight and individually optimal weight. To this end, the basic principle of personalised medicine "one size does not fit all" has to be applied. Contextually, "normal" but e.g. borderline body mass index might be optimal for one person but apparently suboptimal for another one strongly depending on the individual genetic predisposition, geographic origin, cultural and nutritional habits and relevant lifestyle parameters-all included into comprehensive individual patient profile. Even if only slightly deviant, both overweight and underweight are acknowledged risk factors for a shifted metabolism which, if being not optimised, may strongly contribute to the development and progression of severe pathologies. Development of innovative screening programmes is essential to promote population health by application of health risks assessment, individualised patient profiling and multi-parametric analysis, further used for cost-effective targeted prevention and treatments tailored to the person. The following healthcare areas are considered to be potentially strongly benefiting from the above proposed measures: suboptimal health conditions, sports medicine, stress overload and associated complications, planned pregnancies, periodontal health and dentistry, sleep medicine, eye health and disorders, inflammatory disorders, healing and pain management, metabolic disorders, cardiovascular disease, cancers, psychiatric and neurologic disorders, stroke of known and unknown aetiology, improved individual and population outcomes under pandemic conditions such as COVID-19. In a long-term way, a significantly improved healthcare economy is one of benefits of the proposed paradigm shift from reactive to Predictive, Preventive and Personalised Medicine (PPPM/3PM). A tight collaboration between all stakeholders including scientific community, healthcare givers, patient organisations, policy-makers and educators is essential for the smooth implementation of 3PM concepts in daily practice.
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Affiliation(s)
- Olga Golubnitschaja
- Predictive, Preventive and Personalised (3P) Medicine, Department of Radiation Oncology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, 53127 Bonn, Germany
| | - Alena Liskova
- Clinic of Obstetrics and Gynaecology, Jessenius Faculty of Medicine, Comenius University, in Bratislava, 03601 Martin, Slovakia
| | - Lenka Koklesova
- Clinic of Obstetrics and Gynaecology, Jessenius Faculty of Medicine, Comenius University, in Bratislava, 03601 Martin, Slovakia
| | - Marek Samec
- Clinic of Obstetrics and Gynaecology, Jessenius Faculty of Medicine, Comenius University, in Bratislava, 03601 Martin, Slovakia
| | - Kamil Biringer
- Clinic of Obstetrics and Gynaecology, Jessenius Faculty of Medicine, Comenius University, in Bratislava, 03601 Martin, Slovakia
| | - Dietrich Büsselberg
- Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, 24144 Doha, Qatar
| | - Halina Podbielska
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wrocław University of Science and Technology, 50-370 Wrocław, Poland
| | - Anatolij A. Kunin
- Departments of Maxillofacial Surgery and Hospital Dentistry, Voronezh N.N. Burdenko State Medical University, Voronezh, Russian Federation
| | | | - Niva Shapira
- Nutrition Department, Ashkelon Academic College, Ashkelon, Tel Aviv, Israel
| | - Friedemann Paul
- NeuroCure Clinical Research Centre, Experimental and Clinical Research Centre, Max Delbrueck Centre for Molecular Medicine and Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Carl Erb
- Private Institute of Applied Ophthalmology, Berlin, Germany
| | - Detlef E. Dietrich
- European Depression Association, Brussels, Belgium
- AMEOS Clinical Centre for Psychiatry and Psychotherapy, 31135 Hildesheim, Germany
| | - Dieter Felbel
- Fachklinik Kinder und Jugendliche Psychiatrie, AMEOS Klinikum Hildesheim, Akademisches Lehrkrankenhaus für Pflege der FOM Hochschule Essen, Hildesheim, Germany
| | - Alexander Karabatsiakis
- Institute of Psychology, Department of Clinical Psychology II, University of Innsbruck, Innsbruck, Austria
| | - Rostyslav Bubnov
- Ultrasound Department, Clinical Hospital “Pheophania”, Kyiv, Ukraine
- Zabolotny Institute of Microbiology and Virology, National Academy of Sciences of Ukraine, Kyiv, Ukraine
| | - Jiri Polivka
- Department of Neurology, Faculty of Medicine in Pilsen, Charles University and University Hospital Pilsen, Pilsen, Czech Republic
| | - Jiri Polivka
- Department of Histology and Embryology, Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Staré Město, Czech Republic
| | - Colin Birkenbihl
- Department of Bioinformatics, Fraunhofer Institute for Algorithms and Scientific Computing (SCAI), Schloss Birlinghoven, 53757 Sankt Augustin, Germany
- Bonn-Aachen International Centre for IT, Rheinische Friedrich-Wilhelms-Universität Bonn, 53115 Bonn, Germany
| | - Holger Fröhlich
- Department of Bioinformatics, Fraunhofer Institute for Algorithms and Scientific Computing (SCAI), Schloss Birlinghoven, 53757 Sankt Augustin, Germany
- Bonn-Aachen International Centre for IT, Rheinische Friedrich-Wilhelms-Universität Bonn, 53115 Bonn, Germany
- UCB Biosciences GmbH, Alfred-Nobel Str. 10, 40789 Monheim am Rhein, Germany
| | - Martin Hofmann-Apitius
- Department of Bioinformatics, Fraunhofer Institute for Algorithms and Scientific Computing (SCAI), Schloss Birlinghoven, 53757 Sankt Augustin, Germany
- Bonn-Aachen International Centre for IT, Rheinische Friedrich-Wilhelms-Universität Bonn, 53115 Bonn, Germany
| | - Peter Kubatka
- Department of Medical Biology, Jessenius Faculty of Medicine, Comenius University in Bratislava, 03601 Martin, Slovakia
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Roberts EC, Nealon SW, Dhillon J, Tourtelot JB, McIver B, Sexton WJ. Bilateral testicular adrenal rest tumors in a patient with nonclassical congenital adrenal hyperplasia. IJU Case Rep 2021; 4:243-246. [PMID: 34258539 PMCID: PMC8255286 DOI: 10.1002/iju5.12299] [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] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/14/2021] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Solid testis tumors in post-pubertal males usually represent germ cell malignancies; however, other uncommon or rare histologies must be considered. CASE PRESENTATION We present a case of an 18-year-old male undergoing attempted bilateral partial orchiectomies for suspected germ cell tumors. Tumor pathology, laboratory results, radiographic studies, and post-surgical elevated adrenocorticotropic hormone levels supported the diagnosis of testicular adrenal rest tumors secondary to previously undiagnosed nonclassical congenital adrenal hyperplasia. CONCLUSION Testicular adrenal rest tumors are rare in patients with nonclassical congenital adrenal hyperplasia and may be accompanied by adrenal insufficiency and hypogonadism, which can be treated with glucocorticoid therapy and testosterone replacement. Differential diagnosis of tumors is challenging but necessary for proper symptom-based management.
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Affiliation(s)
- Erica C Roberts
- Department ofGenitourinary OncologyH. Lee Moffitt Cancer CenterTampaFloridaUSA
| | - Samantha W Nealon
- Department ofGenitourinary OncologyH. Lee Moffitt Cancer CenterTampaFloridaUSA
| | - Jasreman Dhillon
- Department ofAnatomic PathologyH. Lee Moffitt Cancer CenterTampaFloridaUSA
| | - John B Tourtelot
- Department ofEndocrinologyH. Lee Moffitt Cancer CenterTampaFloridaUSA
| | - Bryan McIver
- Department ofEndocrinologyH. Lee Moffitt Cancer CenterTampaFloridaUSA
| | - Wade J Sexton
- Department ofGenitourinary OncologyH. Lee Moffitt Cancer CenterTampaFloridaUSA
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Non-Classical Congenital Adrenal Hyperplasia-Causing Alleles in Adolescent Girls with PCOS and in Risk Group for PCOS Development. Diagnostics (Basel) 2021; 11:diagnostics11060980. [PMID: 34071512 PMCID: PMC8228442 DOI: 10.3390/diagnostics11060980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women. Depending on the diagnostic criteria applied, it occurs in up to 16.6% of the general female population. Congenital adrenal hyperplasia includes a group of autosomal recessive disorders, the most common of which is non-classical congenital adrenal hyperplasia (NCAH) caused by mutations in the CYP21A2 gene. PCOS and NCAH have similar clinical manifestations (hyperandrogenemia, i.e., hirsutism, acne, alopecia, and increased androgen levels in the blood) and potential impact on long-term health (infertility, increased risk of type 2 diabetes, and cardiovascular disease. Consequently, it is thought that NCAH mutations in the heterozygous state may play a role in PCOS development and phenotypic expression. OBJECTIVE To determine the prevalence of the most common pathogenic alleles of the CYP21A2 gene in adolescents with PCOS and adolescents at risk of PCOS development, and to compare the results with healthy adolescents matched for gynecological age. METHODS A cross-sectional study was conducted with 55 PCOS patients, 23 risk patients (with hyperandrogenism but a normal menstrual cycle), and 49 healthy adolescents. Genetic variations in the CYP21A2 gene were analyzed using a standard Multiplex Ligation-dependent Probe Amplification test (SALSA MLPA Probemix P050-C1 CAH; MRC Holland). RESULTS No significant differences were found among the three groups regarding the frequency of carriers of NCAH variations in the heterozygous state. It was found that the I172N carrier in the PCOS group had a significantly higher Global Acne Grading Scale score than PCOS patients without this variation (p = 0.038). Within the control group of healthy adolescents, compound heterozygous carriers (IVS2-12A > G and -113G > A) had a significantly higher body mass index than non-carriers (p = 0.036). CONCLUSION We found no differences in the incidence of NCAH-causing variations in the heterozygous state in adolescent PCOS patients, risk adolescents (with hirsutism but normal menstruation), and healthy adolescents. Future studies of larger cohorts and rarer pathogenic CYP21A2 gene variations are required.
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11
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Espinosa Reyes TM, Collazo Mesa T, Lantigua Cruz PA, Agramonte Machado A, Domínguez Alonso E, Falhammar H. Genotype-Phenotype Correlation in Patients with Congenital Adrenal Hyperplasia due to 21-Hydroxylase Deficiency in Cuba. Int J Endocrinol 2021; 2021:9316284. [PMID: 33505466 PMCID: PMC7806372 DOI: 10.1155/2021/9316284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 12/24/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND There are several studies that show a good genotype-phenotype correlation in congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD). However, there is well-documented evidence of inconsistency in some cases. OBJECTIVES To determine if there is a correlation between the identified mutations and the clinical manifestations of 21OHD in the Cuban population. METHODS A cross-sectional descriptive study of all patients referred for a molecular diagnosis of 21OHD in Cuba from January 2000 to December 2018. The clinical manifestations of each patient were identified and classified according to the phenotype. The CYP21A2 gene was analyzed for the presence of 5 point mutations involved in the pathogenesis of 21OHD (intron 2, deletion of 8bp, I172N, P30L, and Q318X); correlation was sought between the phenotypic characteristics and the frequencies of point mutations in the patients using the Spearman test. RESULTS A total of 55 patients underwent direct analysis of the CYP21A2 gene in order to determine the presence of the 5 point mutations. Point mutations were identified in 31 patients, which corresponded to 56%. A statistically significant genotype-phenotype correlation was found. CONCLUSIONS The correlation between the detected molecular defect and the clinical expression of 21OHD was reasonable in the Cuban population, which could allow phenotypic predictions to be made from the genotype.
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Affiliation(s)
| | - Teresa Collazo Mesa
- National Institute of Endocrinology, Zapata Street and D. Vedado, Havana, Cuba
| | | | | | | | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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Livadas S, Macut D, Bothou C, Kuliczkowska-Płaksej J, Vryonidou A, Bjekic-Macut J, Mouslech Z, Milewicz A, Panidis D. Insulin resistance, androgens, and lipids are gradually improved in an age-dependent manner in lean women with polycystic ovary syndrome: insights from a large Caucasian cohort. Hormones (Athens) 2020; 19:531-539. [PMID: 32451980 DOI: 10.1007/s42000-020-00211-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/14/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Polycystic ovary syndrome (PCOS), considered a lifelong condition, manifests mainly as a cluster of hyperandrogenic symptoms during the early reproductive years, with the affected woman gradually developing an adverse cardiometabolic profile over the years. However, some data point to the possibility of differences in the evolution of PCOS according to a woman's weight. The aim of the present study was to evaluate the metabolic and hormonal profiles of women with PCOS over time. METHODS A total of 763 lean women with PCOS (BMI 20-25 kg/m2) and 376 controls were included. The study group was further divided into three age groups representing women post-adolescence, of reproductive age, and of late reproductive age. All subjects were assessed clinically, biochemically, and hormonally. RESULTS Waist circumference, lipids, androgens, and insulin resistance index (homeostasis model assessment of IR index (HOMA-IR)) were significantly higher in the PCOS group compared with controls. Age subgroup analysis showed a progressive decrease of HOMA-IR and waist circumference, and lipid levels were comparable between PCOS and controls in all age groups. Androgens remained significantly higher in PCOS, but they gradually decreased through time. A significant negative association of age with waist circumference, androgens, insulin, and HOMA-IR was revealed. Univariate and multivariate regression analysis disclosed a strong correlation of HOMA-IR with age (p = 0.014, β - 0.19, SE coefficient 0.008) as a single parameter or in combination with total cholesterol (TC) (p < 0.001, age: β - 0.023, SE 0.10; TC: β 0.084, SE 0.027). CONCLUSION Insulin resistance, androgens, and lipids are gradually improved in an age-dependent manner in lean PCOS women. We hypothesize that if these women do not gain weight with the passage of time, there is a high probability that their cardiometabolic risk will be attenuated.
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Affiliation(s)
- S Livadas
- Endocrine Unit, Metropolitan Hospital, 6 Ermou Str, 10563, Athens, Greece.
| | - D Macut
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - C Bothou
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital of Zurich, Zurich, Switzerland
| | - J Kuliczkowska-Płaksej
- Department of Endocrinology, Diabetology and Isotope Therapy, University of Medicine, Wrocław, Poland
| | - A Vryonidou
- Department of Endocrinology and Diabetes, Hellenic Red Cross Hospital, Athens, Greece
| | - J Bjekic-Macut
- Department of Endocrinology, UMC Bežanijska kosa, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Z Mouslech
- 1st Medical Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Milewicz
- Department of Endocrinology, Diabetology and Isotope Therapy, University of Medicine, Wrocław, Poland
| | - D Panidis
- Gynecological Endocrinology Infirmary of the Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Soveizi M, Mahdieh N, Setoodeh A, Sayarifard F, Abbasi F, Bose HS, Rabbani B, Rabbani A. p.Gln318X and p.Val281Leu as the Major Variants of CYP21A2 Gene in Children with Idiopathic Premature Pubarche. Int J Endocrinol 2020; 2020:4329791. [PMID: 32714392 PMCID: PMC7355357 DOI: 10.1155/2020/4329791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/16/2020] [Accepted: 04/13/2020] [Indexed: 12/02/2022] Open
Abstract
Premature pubarche (PP) is the appearance of sexual hair in children before puberty. The PP phenotype may attribute to nonclassic congenital adrenal hyperplasia (NC-CAH). In this study, we investigated the role of CYP21A2 gene variants in patients with PP in the Iranian population. Forty patients (13 males and 27 females), clinically diagnosed with PP, were analyzed for molecular testing of CYP21A2 gene variants. Direct sequencing was performed for the samples. Also, gene dosage analysis was performed for the cases. Fourteen patients (35%) had a mutation of p.Gln318X and p.Val281Leu, out of which 10% had regulatory variants. Approximately 10% of the patients were homozygous (NC-CAH). 78.5% (11/14) of patients had trimodular RCCX of which 5 patients had two copies of CYP21A1P pseudogene. The prevalence of p.Val281Leu was higher than p.Gln318X in PP patients. In conclusion, CYP21A2 variant detection has implications in the genetic diagnosis of PP phenotype. The genetic characterization of the CYP21A2 gene is important for characterizing the variable phenotype of carriers and genetic counseling of PP and NC-CAH patients.
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Affiliation(s)
- Mahdieh Soveizi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nejat Mahdieh
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardigenetic Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Aria Setoodeh
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Children's Medical Center Hospital, Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Sayarifard
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Children's Medical Center Hospital, Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Abbasi
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Children's Medical Center Hospital, Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
| | - Himangshu S. Bose
- Biomedical Sciences, Mercer University School of Medicine, Savannah, GA, USA
| | - Bahareh Rabbani
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Cardigenetic Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Rabbani
- Growth and Development Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Children's Medical Center Hospital, Center of Excellence, Tehran University of Medical Sciences, Tehran, Iran
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Kafi SE, Alagha E, Shazly MA, Al-Agha A. Pseudo-precocious Puberty Associated with an Adrenocortical Tumor in a Young Child. Cureus 2019; 11:e6440. [PMID: 31998569 PMCID: PMC6973539 DOI: 10.7759/cureus.6440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/21/2019] [Indexed: 12/20/2022] Open
Abstract
Precocious puberty is commonly observed in pediatric practice due to different causes, including adrenal tumors. Adrenocortical tumors are rare in children and are characterized by an androgenic hormonal excess that causes pseudo-precocious puberty. We present the case of a four-year-old boy with a history of penile enlargement associated with the growth of pubic hair, facial acne, and three-years advanced bone age. Based on hormonal assays, the diagnosis of pseudo-precocious puberty was confirmed. Abdominal magnetic resonance imaging (MRI) revealed a right-sided, retroperitoneal, well-defined adrenal tumor. This case report emphasizes the aim to increase the awareness of adrenocortical tumor as a rare cause of pseudo-precocious puberty in young children.
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Affiliation(s)
- Shahd E Kafi
- Pediatrics, King Abdulaziz University Hospital, Jeddah, SAU
| | - Eid Alagha
- Pediatrics, King Abdulaziz University Hospital, Jeddah, SAU
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Livadas S, Bothou C. Management of the Female With Non-classical Congenital Adrenal Hyperplasia (NCCAH): A Patient-Oriented Approach. Front Endocrinol (Lausanne) 2019; 10:366. [PMID: 31244776 PMCID: PMC6563652 DOI: 10.3389/fendo.2019.00366] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/22/2019] [Indexed: 12/02/2022] Open
Abstract
Non-classical congenital adrenal hyperplasia (NCCAH) is considered to be a common monogenic inherited disease, with an incidence range from 1:500 to 1:100 births worldwide. However, despite the high incidence, there is a low genotype-phenotype correlation, which explains why NCCAH diagnosis is usually delayed or even never carried out, since many patients remain asymptomatic or are misdiagnosed as suffering from other hyperandrogenic disorders. For affected adolescent and adult women, it is crucial to investigate any suspicion of NCCAH and determine a firm and accurate diagnosis. The Synacthen test is a prerequisite in the event of clinical suspicion, and molecular testing will establish the diagnosis. In most cases occurring under 8 years of age, the first symptom is premature pubarche. In some cases, due to advanced bone age and/or severe signs of hyperandrogenism, initiation of hydrocortisone treatment prepubertally may be considered. Our unifying theory of the hyperandrogenic signs system and its regulation by internal (hormones, enzymes, tissue sensitivity) and external (stress, insulin resistance, epigenetic, endocrine disruptors) factors is presented in an attempt to elucidate both the prominent genotype-phenotype heterogeneity of this disease and the resultant wide variation of clinical findings. Treatment should be initiated not only to address the main cause of the patient's visit but additionally to decrease abnormally elevated hormone concentrations. Goals of treatment include restoration of regular menstrual cyclicity, slowing the progression of hirsutism and acne, and improvement of fertility. Hydrocortisone supplementation, though not dexamethasone administration, could, as a general rule, be helpful, however, at minimum doses, and also for a short period of time and, most likely, not lifelong. On the other hand, in cases where severe hirsutism and/or acne are present, prescription of oral contraceptives and/or antiandrogens may be advisable. Furthermore, women with NCCAH commonly experience subfertility, therefore, there will be analysis of the appropriate approach for these patients, including during pregnancy, based mainly on genotype. Besides, we should keep in mind that since the same patient will have changing requirements through the years, the attending physician should undertake a tailor-made approach in order to cover her specific needs at different stages of life.
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Affiliation(s)
- Sarantis Livadas
- Metropolitan Hospital, Pireas, Greece
- *Correspondence: Sarantis Livadas
| | - Christina Bothou
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
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Pignatelli D, Carvalho BL, Palmeiro A, Barros A, Guerreiro SG, Macut D. The Complexities in Genotyping of Congenital Adrenal Hyperplasia: 21-Hydroxylase Deficiency. Front Endocrinol (Lausanne) 2019; 10:432. [PMID: 31333583 PMCID: PMC6620563 DOI: 10.3389/fendo.2019.00432] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 06/17/2019] [Indexed: 12/13/2022] Open
Abstract
The deficiency of 21-hydroxylase due to CYP21A2 pathogenic variants is a rather frequent disease with serious consequences, going from a real mortality risk to infertility and to milder symptoms, nevertheless important for affecting the patients' self-esteem. In the most severe cases life-threatening adrenal salt wasting crises may occur. Significant morbidity including the possibility of mistaken gender determination, precocious puberty, infertility and growth arrest with consequent short stature may also affect these patients. In the less severe cases milder symptoms like hirsutism will likely affect the image of the self with strong psychological consequences. Its diagnosis is confirmed by 17OH-progesterone dosages exceeding the cut-off value of 10/15 ng/ml but genotyping is progressively assuming an essential role in the study of these patients particularly in confirming difficult cases, determining some aspects of the prognosis and allowing a correct genetic counseling. Genotyping is a difficult process due to the occurrence of both a gene and a highly homologous pseudo gene. However, new tools are opening new possibilities to this analysis and improving the chances of a correct diagnosis and better understanding of the underlying mechanisms of the disease. Beyond the 10 classic pathogenic variants usually searched for in most laboratories, a correct analysis of 21OH-deficiency cases implies completely sequencing of the entire gene and the determination of gene duplications. These are now recognized to occur frequently and can be responsible for some false positive cases. And finally, because gene conversions can include several pathogenic variants one cannot be certain of identifying that both alleles are affected without studying parental DNA samples. A complete genotype characterization should be considered essential in the preparation for pregnancy, even in the case of parents with milder forms of the disease, or even just carriers, since it has been reported that giving birth to progeny with the severe classic forms occurs with a much higher frequency than expected.
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Affiliation(s)
- Duarte Pignatelli
- Hospital S. João, Porto, Portugal
- Department of Biomedicine, Faculty of Medicine of Porto, Porto, Portugal
- IPATIMUP/I3S Research Institute, University of Porto, Porto, Portugal
- *Correspondence: Duarte Pignatelli
| | - Berta L. Carvalho
- Genetics, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
- I3S Research Institute, University of Porto, Porto, Portugal
| | | | - Alberto Barros
- Genetics, Department of Pathology, Faculty of Medicine, University of Porto, Porto, Portugal
- I3S Research Institute, University of Porto, Porto, Portugal
| | - Susana G. Guerreiro
- Department of Biomedicine, Faculty of Medicine of Porto, Porto, Portugal
- IPATIMUP/I3S Research Institute, University of Porto, Porto, Portugal
| | - Djuro Macut
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Macut D, Zdravković V, Bjekić-Macut J, Mastorakos G, Pignatelli D. Metabolic Perspectives for Non-classical Congenital Adrenal Hyperplasia With Relation to the Classical Form of the Disease. Front Endocrinol (Lausanne) 2019; 10:681. [PMID: 31632355 PMCID: PMC6783496 DOI: 10.3389/fendo.2019.00681] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 09/19/2019] [Indexed: 12/17/2022] Open
Abstract
Non-classical congenital adrenal hyperplasia (NC-CAH) represents mild form of CAH with the prevalence of 0. 6 to 9% in women with androgen excess. Clinical and hormonal findings in females with NC-CAH are overlapping with other hyperandrogenic entities such as polycystic ovary syndrome hence causing difficulties in diagnostic approach. Metabolic consequences in subjects with NC-CAH are relatively unknown. We are lacking longitudinal follow of these patients regarding natural course of the disease or the therapeutic effects of the different drug regiments. Patients with NC-CAH similarly to those with classical form are characterized with deteriorated cardiovascular risk factors that are probably translated into cardiometabolic diseases and events. An increased preponderance of obesity and insulin resistance in patients with NC-CAH begin at young age could result in increased rates of metabolic sequelae and cardiovascular disease later during adulthood in both sexes. On the other hand, growth disorder was not proven in patients with NC-CAH in comparison to CAH patients of both gender characterized with reduced final adult height. Similarly, decreased bone mineral density and osteoporosis are not constant findings in patients with NC-CAH and could depend on the sex, and type or dose of corticosteroids applied. It could be concluded that NC-CAH represent a particular form of CAH that is characterized with specificities in clinical presentation, diagnosis, therapeutic approach and metabolic outcomes.
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Affiliation(s)
- Djuro Macut
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- *Correspondence: Djuro Macut
| | - Vera Zdravković
- Division of Endocrinology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelica Bjekić-Macut
- Department of Endocrinology, UMC Bežanijska kosa, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - George Mastorakos
- Unit of Endocrine Diseases, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Duarte Pignatelli
- Faculty of Medicine, Instituto de Patologia e Imunologia Molecular da Universidade do Porto/I3S Research Institute, Hospital S João, University of Porto, Porto, Portugal
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18
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Michelle M A, Jensen CT, Habra MA, Menias CO, Shaaban AM, Wagner-Bartak NA, Roman-Colon AM, Elsayes KM. Adrenal cortical hyperplasia: diagnostic workup, subtypes, imaging features and mimics. Br J Radiol 2017; 90:20170330. [PMID: 28707538 DOI: 10.1259/bjr.20170330] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Adrenal cortical hyperplasia manifests radiologically as a non-malignant growth, or enlargement, of the adrenal glands, specifically the cortex, although the cortex cannot be definitively identified by conventional imaging. Controlled by the pituitary gland, the adrenal cortex drives critical processes, such as the production of cortisol, mineralocorticoid and sex hormones. Any disruption in the multiple enzymes and hormones involved in these pathways may cause serious or life-threatening symptoms, often associated with anatomical changes in the adrenal glands. Diagnosis and treatment of adrenal cortical hyperplasia requires a thorough clinical evaluation. As imaging has become more robust so has its role in the diagnosis and treatment of adrenal conditions. CT has been the primary modality for adrenal imaging owing to reproducibility, temporal and spatial resolution and broad access. MRI serves a complimentary role in adrenal imaging and can be used to further evaluate indeterminate CT findings or serve as an adjunct tool without the use of ionizing radiation. Ultrasound and fluoroscopy (genitography) are most commonly used in children and foetuses to evaluate congenital adrenal hyperplasia. This article will discuss the clinical presentation, laboratory workup and imaging features of adrenal cortical hyperplasia, both congenital and acquired.
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Affiliation(s)
- Agrons Michelle M
- 1 Department of Diagnostic Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Corey T Jensen
- 2 Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mouhammed Amir Habra
- 3 Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Akram M Shaaban
- 5 Department of Diagnostic Radiology, University of Utah, Salt Lake City, UT, USA
| | | | - Alicia M Roman-Colon
- 1 Department of Diagnostic Radiology, Baylor College of Medicine, Houston, TX, USA.,6 Department of Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Khaled M Elsayes
- 1 Department of Diagnostic Radiology, Baylor College of Medicine, Houston, TX, USA
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Grodnitskaya E, Kurtser M. The prevalence of non-classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency in Russian women with hyperandrogenism. HUM FERTIL 2017; 21:281-287. [PMID: 28669219 DOI: 10.1080/14647273.2017.1344360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The aim of the study was to determine the prevalence of non-classic congenital adrenal hyperplasia (NCAH) due to 21-hydroxylase (21-OH) deficiency among hyperandrogenic women in a Russian population and to evaluate diagnostic value of basal serum 17-hydroxyprogesterone (17-OHP) level to diagnose this disease. A total of 800 consecutive Caucasian women presenting with elevation of at least one serum androgen and/or manifestation of one of the clinical androgenic symptoms were prospectively recruited and evaluated by basal 17-OHP. The diagnosis of NCAH due to 21-OH deficiency was considered in patients when basal level exceeded 5.0 nmol/L and CYP21A2 gene mutation analysis was performed in this case. Eight (1.0%) of the patients had NCAH due to 21-OH deficiency confirmed by genotyping. These women had a V281L mutation: five homozygous and three compound heterozygous with genotypes V281L/P453S, V281L/I2splice and V281L/I2splice. One patient was diagnosed with NCAH (genotype V281L/I2splice) before the study and was excluded from the analysis. Thus, the unbiased prevalence of NCAH was 0.9%. The 17-OHP basal level ranges from 16.8 to 17.7 nmol/L predicted NCAH with 100% sensitivity and 100% specificity.
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Affiliation(s)
- Elena Grodnitskaya
- a Outpatient Department, Centre of Family Planning and Reproduction, Moscow City Healthcare Department , Moscow , Russia
| | - Mark Kurtser
- b Department of Obstetrics and Gynecology , N.I. Pirogov Russian National Research Medical University , Moscow , Russia
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Testicular Adrenal Rest Tumors in Boys and Young Adults with Congenital Adrenal Hyperplasia. J Urol 2016; 197:931-936. [PMID: 27840017 DOI: 10.1016/j.juro.2016.09.072] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE Testicular adrenal rest tumors are a well-known complication in males who have congenital adrenal hyperplasia with potential infertility in adulthood. We assessed the prevalence of testicular adrenal rest tumors in infants to young men presenting to a congenital adrenal hyperplasia Comprehensive Care Center. MATERIALS AND METHODS A total of 35 males with congenital adrenal hyperplasia due to 21-hydroxylase deficiency underwent scrotal ultrasonography, including 7 younger than 5 years, 9 who were 5 to 12 years old and 19 who were older than 12 years. Three and 35 patients had classic and nonclassic congenital adrenal hyperplasia, respectively. Bone age x-ray or advanced bone age x-ray history, glucocorticoid dose, fludrocortisone dose, and serum 17-hydroxyprogesterone, testosterone and androstenedione levels within 3 months of ultrasound were also recorded. RESULTS Testicular adrenal rest tumors were detected in 5 of 35 patients (14%), including 1 of 9 (11%) who were 5 to 12 years old and 4 of 19 (21%) who were older than 12 years. The tumors were not detected in any patients younger than 5 years, including 1 infant with poor hormonal control. The youngest patient with positive findings was 6.6 years old. All patients with positive findings had bilateral disease and only 1 had suspicious physical findings. The glucocorticoid dose and 17-hydroxyprogesterone did not differ between patients with vs without a testicular adrenal rest tumor. Those with a tumor were more likely to have advanced bone age x-ray results (100% vs 42%, p = 0.04) and higher fludrocortisone dose (p <0.01). All males with nonclassic congenital adrenal hyperplasia had negative tumor findings. CONCLUSIONS Testicular adrenal rest tumors were present in young males with classic congenital adrenal hyperplasia but not in infants or toddlers. These tumors were associated with higher fludrocortisone requirements and a history of advanced bone age x-ray results. However, the tumors did not develop in all poorly controlled males. Longitudinal studies are needed to understand the individual predisposition to testicular adrenal rest tumors and the age at which to begin screening patients with congenital adrenal hyperplasia.
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Pearce M, DeMartino L, McMahon R, Hamel R, Maloney B, Stansfield DM, McGrath EC, Occhionero A, Gearhart A, Caggana M, Tavakoli NP. Newborn screening for congenital adrenal hyperplasia in New York State. Mol Genet Metab Rep 2016; 7:1-7. [PMID: 27331001 PMCID: PMC4908061 DOI: 10.1016/j.ymgmr.2016.02.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 02/19/2016] [Accepted: 02/20/2016] [Indexed: 11/17/2022] Open
Abstract
From 2007 to 2014 the New York State (NYS) Newborn Screening (NBS) program screened 2 million newborns for congenital adrenal hyperplasia (CAH). The data was analyzed to determine factors that affect 17α-hydroxyprogesterone levels and assist in developing algorithm changes that would improve the positive predictive value of the methodology being used. The concentration of 17-OHP in dried blood spots was measured using the AutoDELFIA Neonatal 17-OHP kit (Perkin Elmer, Turku, Finland). During the 8 year period of this study 2476 babies were referred, 105 babies were diagnosed with CAH (90 with the salt-wasting (SW), 8 with simple virilizing (SV), 5 with non-classical CAH, and 2 with another enzyme deficiency) and, 14 with possible CAH. Three false negative cases with SV-CAH were reported to the program. Of the total 108 known cases, 74 (69%) infants were detected by newborn screening in the absence of clinical information, or, known family history. The incidence of CAH in NYS is 1 in 18,170 with a ratio of SW to SV of 8.2:1. The incidence of CAH is lower in Black infants than in White, Hispanic and Asian infants. Despite a lower mean birth weight, female infants have a lower mean 17-OHP value than male infants and are under-represented in the referred category. As per other NBS programs the false positive rate is exacerbated by prematurity/low birth weight and by over-early specimen collection.
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Affiliation(s)
- Melissa Pearce
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Lenore DeMartino
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rebecca McMahon
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rhonda Hamel
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Breanne Maloney
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | | | - Emily C McGrath
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Amanda Occhionero
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Adam Gearhart
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Michele Caggana
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Norma P Tavakoli
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA; Department of Biomedical Sciences, School of Public Health, State University of New York, Albany, NY, USA
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Mishra VV, Pritti K, Aggarwal R, Choudhary S. Nonclassic congenital adrenal hyperplasia misdiagnosed as Turner syndrome. J Hum Reprod Sci 2016; 8:239-41. [PMID: 26751945 PMCID: PMC4691978 DOI: 10.4103/0974-1208.170416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We present a patient with nonclassic congenital adrenal hyperplasia (NCAH) misdiagnosed as mosaic Turner syndrome. She presented with complaints of primary infertility. Short stature, the presence of facial hair and hoarse voice was also noted. She had primary amenorrhea and was advised for karyotype at 16 years of age, which was reported as 45, X[20]/46, XX[80], stating her as a case of mosaic Turner syndrome. Clitoroplasty was done at 21 years of age for clitoromegaly, which was noticed during puberty. The diagnosis of mosaic Turner could not explain the virilization. Therefore, we repeated the karyotype, which revealed 46, XX in more than 100 metaphases and was sufficient to exclude mosaicism. Furthermore, the endocrinological evaluation revealed high testosterone level with a normal 17 alpha-hydroxyprogesterone (17-OHP). The presence of pubertal onset virilization with a karyotype of 46, XX and raised testosterone level with normal 17-OHP level, raised the suspicion of NCAH for which adrenocorticotropic hormone stimulation test was done which confirmed the diagnosis of NCAH.
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Affiliation(s)
- Vineet V Mishra
- Department of Obstetrics and Gynecology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre, Dr. H.L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Kumari Pritti
- Department of Obstetrics and Gynecology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre, Dr. H.L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Rohina Aggarwal
- Department of Obstetrics and Gynecology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre, Dr. H.L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
| | - Sumesh Choudhary
- Department of Obstetrics and Gynecology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre, Dr. H.L. Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
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Debono M, Mallappa A, Gounden V, Nella AA, Harrison RF, Crutchfield CA, Backlund PS, Soldin SJ, Ross RJ, Merke DP. Hormonal circadian rhythms in patients with congenital adrenal hyperplasia: identifying optimal monitoring times and novel disease biomarkers. Eur J Endocrinol 2015; 173:727-37. [PMID: 26340969 PMCID: PMC4623929 DOI: 10.1530/eje-15-0064] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 09/04/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The treatment goal in congenital adrenal hyperplasia (CAH) is to replace glucocorticoids while avoiding androgen excess and iatrogenic Cushing's syndrome. However, there is no consensus on how to monitor disease control. Our main objectives were to evaluate hormonal circadian rhythms and use these profiles to identify optimal monitoring times and novel disease biomarkers in CAH adults on intermediate- and long-acting glucocorticoids. DESIGN This was an observational, cross-sectional study at the National Institutes of Health Clinical Center in 16 patients with classic CAH. METHODS Twenty-four-hour serum sampling for ACTH, 17-hydroxyprogesterone (17OHP), androstenedione (A4), androsterone, DHEA, testosterone, progesterone and 24-h urinary pdiol and 5β-pdiol was carried out. Bayesian spectral analysis and cosinor analysis were performed to detect circadian rhythmicity. The number of hours to minimal (TminAC) and maximal (TmaxAC) adrenocortical hormone levels after dose administration was calculated. RESULTS A significant rhythm was confirmed for ACTH (r(2), 0.95; P<0.001), 17OHP (r(2), 0.70; P=0.003), androstenedione (r(2), 0.47; P=0.043), androsterone (r(2), 0.80; P<0.001), testosterone (r(2), 0.47; P=0.042) and progesterone (r(2), 0.64; P=0.006). The mean (s.d.) TminAC and TmaxAC for 17OHP and A4 were: morning prednisone (4.3 (2.3) and 9.7 (3.5) h), evening prednisone (4.5 (2.0) and 10.3 (2.4) h), and daily dexamethasone (9.2 (3.5) and 16.4 (7.2) h). AUC0-24 h progesterone, androsterone and 24-h urine pdiol were significantly related to 17OHP. CONCLUSION In CAH patients, adrenal androgens exhibit circadian rhythms influenced by glucocorticoid replacement. Measurement of adrenocortical hormones and interpretation of results should take into account the type of glucocorticoid and time of dose administration. Progesterone and backdoor metabolites may provide alternative disease biomarkers.
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Affiliation(s)
- Miguel Debono
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Ashwini Mallappa
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Verena Gounden
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Aikaterini A Nella
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Robert F Harrison
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Christopher A Crutchfield
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Peter S Backlund
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Steven J Soldin
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Richard J Ross
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
| | - Deborah P Merke
- National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK National Institutes of Health Clinical CenterBuilding 10, Room 1-2742, 10 Center Drive, Bethesda, Maryland 20892, USAThe Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, Maryland, USADepartment of Automatic Control and Systems EngineeringUniversity of Sheffield, Sheffield, UKAcademic Unit of EndocrinologyUniversity of Sheffield, Sheffield, UK
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Abstract
Congenital adrenal hyperplasia, one of the most frequent autosome recessive disorders, is caused by defects in steroidogenic enzymes involved in the cortisol biosynthesis. Approximately 95% of the cases are caused by abnormal function of the 21-hydroxylase enzyme. This deficiency leads to androgen excess, consequently, to virilization and rapid somatic growth with accelerated skeletal maturation. Mutations in CYP21A2 are responsible for different forms of 21-hydroxylase deficiency. Mild impairment in the enzymatic activity causes the non-classic or late-onset congenital adrenal hyperplasia that is observed with a prevalence of 1 in 1000 subjects in different populations. The present paper describes a de novo mutation that occurred in the paternal meiosis. The child, who was conceived by in vitro fertilization, presented with precocious puberty and diagnosed with non-classical 21-hydroxylase deficiency. DNA sequencing showed the compound heterozygosis for a de novo CYP21A1P/A2 chimeric gene and the p.Val281Leu mutation inherited from her mother, who was heterozygous for the mutation. The chimeric gene showed pseudogene-derived sequence from 5′-end to intron 3 and CYP21A2 sequences from intron 3 to 3′-end of the gene. Sequencing analysis of the father did not show any mutation. The multiplex ligation-dependent probe amplification (MLPA) assay did not indicate loss of DNA discarding gene deletion but confirmed the chimeric gene. In addition, supernumerary copies of CYP21A1P were observed for both parents and for the affect child. Since paternity has been confirmed, those results suggest that a de novo large gene conversion in the paternal meiosis could have occurred by misalignment of alleles bearing different copy numbers of genes in CYP21 locus.
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25
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Witchel SF, Oberfield S, Rosenfield RL, Codner E, Bonny A, Ibáñez L, Pena A, Horikawa R, Gomez-Lobo V, Joel D, Tfayli H, Arslanian S, Dabadghao P, Garcia Rudaz C, Lee PA. The Diagnosis of Polycystic Ovary Syndrome during Adolescence. Horm Res Paediatr 2015; 83:000375530. [PMID: 25833060 DOI: 10.1159/000375530] [Citation(s) in RCA: 164] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/26/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The diagnostic criteria for polycystic ovary syndrome (PCOS) in adolescence are controversial, primarily because the diagnostic pathological features used in adult women may be normal pubertal physiological events. Hence, international pediatric and adolescent specialty societies have defined criteria that have sufficient evidence to be used for the diagnosis of PCOS in adolescents. METHODS The literature has been reviewed and evidence graded to address a series of questions regarding the diagnosis of PCOS during adolescence including the following: clinical and biochemical evidence of hyperandrogenism, criteria for oligo-anovulation and polycystic ovary morphology, diagnostic criteria to exclude other causes of hyperandrogenism and amenorrhea, role of insulin resistance, and intervention. RESULTS AND CONCLUSION Features of PCOS overlap normal pubertal development. Hence, caution should be taken before diagnosing PCOS without longitudinal evaluation. However, treatment may be indicated even in the absence of a definitive diagnosis. While obesity, insulin resistance, and hyperinsulinemia are common findings in adolescents with hyperandrogenism, these features should not be used to diagnose PCOS among adolescent girls. © 2015 S. Karger AG, Basel.
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Affiliation(s)
- Selma F Witchel
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pa., USA
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Gacaferri Lumezi B, Goci A, Lokaj V, Latifi H, Karahoda N, Minci G, Telaku D, Gercari A, Kocinaj A. Mixed form of hirsutism in an adolescent female and laser therapy. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e9410. [PMID: 25068069 PMCID: PMC4103002 DOI: 10.5812/ircmj.9410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 06/05/2013] [Accepted: 02/12/2014] [Indexed: 11/18/2022]
Abstract
Introduction: Hirsutism is a common disorder of excess growth of terminal hair in an androgen-dependent male distribution in women, including the chin, upper lip, breasts, back, and abdomen. It is very important to identify the etiology of hirsutism and adequate treat is prior to any cosmetic therapy. Case Presentation: The case was a 17-year-old female with severe hirsutism, oligomenorrhea, and obesity. She was evaluated to identify the etiology and diagnosed as a case of polycystic ovarian syndrome (PCOS), nonclassic congenital adrenal hyperplasia (NC-CAH), and hyperandrogenic insulin-resistant acanthosis nigricans (HAIR-AN) syndrome, which is a rare combination of hirsutism etiology. She was successfully treated according to the underlying pathology, and laser photoepilation was used as the preferred hair removal method. Discussion: Establishing the etiology, using the evidence–based strategies to improve hirsutism, and treating the underlying disorder, are essential for proper management of women with hirsutism.
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Affiliation(s)
- Besa Gacaferri Lumezi
- Department of Physiology and Immunology, University Clinical Center of Kosovo, Pristina, Kosovo
- Corresponding Author: Besa Gacaferri Lumezi, Department of Physiology and Immunology, University Clinical Center of Kosovo, Bulevardi i deshmoreve p.n. 10 000, Prishtina, Kosovo. Tel/Fax: +37-744186036, E-mail:
| | - Aferdita Goci
- Child and Adolescent Mental Health Center, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Violeta Lokaj
- Department of Physiology and Immunology, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Hatixhe Latifi
- Department of Physiology and Immunology, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Natyra Karahoda
- Department of Physiology and Immunology, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Ganimete Minci
- Department of Physiology and Immunology, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Drita Telaku
- Department of Pediatrics, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Antigona Gercari
- Department of Dermatology, University Clinical Center of Kosovo, Pristina, Kosovo
| | - Allma Kocinaj
- Department of Dermatology, University Clinical Center of Kosovo, Pristina, Kosovo
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Binay C, Simsek E, Cilingir O, Yuksel Z, Kutlay O, Artan S. Prevalence of nonclassic congenital adrenal hyperplasia in Turkish children presenting with premature pubarche, hirsutism, or oligomenorrhoea. Int J Endocrinol 2014; 2014:768506. [PMID: 24778650 PMCID: PMC3981121 DOI: 10.1155/2014/768506] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 11/25/2022] Open
Abstract
Background. Nonclassic congenital adrenal hyperplasia (NCAH), caused by mutations in the gene encoding 21-hydroxylase, is a common autosomal recessive disorder. In the present work, our aim was to determine the prevalence of NCAH presenting as premature pubarche (PP), hirsutism, or polycystic ovarian syndrome (PCOS) and to evaluate the molecular spectrum of CYP21A2 mutations in NCAH patients. Methods. A total of 126 patients (122 females, 4 males) with PP, hirsutism, or PCOS were included in the present study. All patients underwent an ACTH stimulation test. NCAH was considered to be present when the stimulated 17-hydroxyprogesterone plasma level was >10 ng/mL. Results. Seventy-one of the 126 patients (56%) presented with PP, 29 (23%) with PCOS, and 26 (21%) with hirsutism. Six patients (4,7%) were diagnosed with NCAH based on mutational analysis. Four different mutations (Q318X, P30L, V281L, and P453S) were found in six NCAH patients. One patient with NCAH was a compound heterozygote for this mutation, and five were heterozygous. Conclusion. NCAH should be considered as a differential diagnosis in patients presenting with PP, hirsutism, and PCOS, especially in countries in which consanguineous marriages are prevalent.
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Affiliation(s)
- Cigdem Binay
- Division of Paediatric Endocrinology, Department of Paediatrics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
- *Cigdem Binay:
| | - Enver Simsek
- Division of Paediatric Endocrinology, Department of Paediatrics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
| | - Oguz Cilingir
- Department of Medical Genetics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
| | - Zafer Yuksel
- Department of Medical Genetics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
| | - Ozden Kutlay
- Department of Medical Genetics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
| | - Sevilhan Artan
- Department of Medical Genetics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
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28
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O’Connor TG, Barrett ES. Mechanisms of prenatal programing: identifying and distinguishing the impact of steroid hormones. Front Endocrinol (Lausanne) 2014; 5:52. [PMID: 24782831 PMCID: PMC3995034 DOI: 10.3389/fendo.2014.00052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/28/2014] [Indexed: 12/12/2022] Open
Abstract
Developmental programing is gaining considerable leverage as a conceptual framework for understanding individual variability in human behavioral and somatic health. The current mini-review examines some of the key conceptual and methodological challenges for developmental programing research focused on fetal sex steroid exposure and physical, behavioral, physiological, and health outcomes. Specifically, we consider the bases for focusing on sex steroids, methods for assessing prenatal steroid hormone exposure, confounding factors, and the most relevant postnatal outcomes. We conclude with a brief consideration, based on current knowledge, of the applications of the existing findings for further research and practice.
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Affiliation(s)
- Thomas G. O’Connor
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
- *Correspondence: Thomas G. O’Connor, Department of Psychiatry, University of Rochester Medical Center, 300 Crittenden Blvd, Rochester, NY 14642, USA e-mail:
| | - Emily S. Barrett
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, USA
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29
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Fang B, Cho F, Lam W. Prostate gland development and adrenal tumor in a female with congenital adrenal hyperplasia: a case report and review from radiology perspective. J Radiol Case Rep 2013; 7:21-34. [PMID: 24421935 DOI: 10.3941/jrcr.v7i12.1933] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We describe a case of a female with simple virilizing congenital adrenal hyperplasia (CAH) reared as a male diagnosed at the late age of 64. Computed Tomography (CT) demonstrated a large adrenal mass, bilateral diffuse adrenal enlargement, female pelvic organs as well as a clearly visualized prostate gland. This is to the best of our knowledge the first case of such a sizable prostate gland in a female CAH patient documented on CT. We review the literature regarding aspects where radiologists may encounter CAH and the finding of presence of a prostate gland in female CAH patients.
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Affiliation(s)
- Benjamin Fang
- Department of Radiology, Queen Mary Hospital, Hong Kong
| | - Francis Cho
- Department of Radiology, Queen Mary Hospital, Hong Kong
| | - Wendy Lam
- Department of Radiology, Queen Mary Hospital, Hong Kong
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Varma T, Panchani R, Goyal A, Maskey R. A case of androgen-secreting adrenal carcinoma with non-classical congenital adrenal hyperplasia. Indian J Endocrinol Metab 2013; 17:S243-S245. [PMID: 24251173 PMCID: PMC3830319 DOI: 10.4103/2230-8210.119585] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Androgen excess is one of the most common and disturbing endocrine disorder of reproductive-aged women, affecting approximately 7% of this population Androgen excess results in the development of androgenic features in the women affected, with the development of hirsutism, androgenic alopecia, ovulatory dysfunction, and, if extreme, even virilization and masculinization. Adrenocortical carcinoma (ACC) is a rare malignancy accounting for 0.02% of all annual cancers reported. About 60% are functional tumors secreting hormones, with its consequent clinical manifestations, the Cushing's syndrome due to cortisone, virilization due to androgens, feminization due to estrogens, or hypertension due to aldosterone. Adrenal tumors that secrete androgens exclusively are extremely rare. Here, we present a rare case of androgen-secreting adrenocortical carcinoma with non-classical congenital adrenal hyperplasia.
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Affiliation(s)
- Tarun Varma
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
| | - Roopal Panchani
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashutosh Goyal
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
| | - Robin Maskey
- Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India
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Abstract
The most common form of congenital adrenal hyperplasia is steroid 21-hydroxylase deficiency (21OHD). When the nonclassical (mild) form is included, 21OHD is the most common genetic disease in human beings. With the advent of pharmaceutical preparation of glucocorticoids starting in the 1960s and newborn screening starting in the 1990s, the majority of children with 21OHD are reaching adulthood, which has yielded a cohort of patients with, in essence, a new disease. Only recently have some data emerged from cohorts of adults with 21OHD, and in some centers, experience with the management of these patients is growing. These patients suffer from poor health, infertility, characteristic tumors in the adrenal glands and gonads, and consequences of chronic glucocorticoid therapy. Their care is fragmented and inconsistent, and many stop taking their medications out of frustration. Internal medicine residents and endocrinology fellows receive little training in their care, which further discourages their seeking medical attention. Adults with 21OHD have a different physiology from patients with Addison's disease or other androgen excess states, and their needs are different than those of young children with 21OHD. Consequently, their care requires unorthodox treatment and monitoring strategies foreign to most endocrine practitioners. Our goal for this article is to review their physiology, complications, and needs in order to develop rational and effective treatment and monitoring strategies.
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Affiliation(s)
- Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine and the Program for Disorders of Sexual Development, University of Michigan, Room 5560A, MSRBII, 1150 West Medical Center Drive, Ann Arbor, Michigan 48109, USA.
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32
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Trapp CM, Oberfield SE. Recommendations for treatment of nonclassic congenital adrenal hyperplasia (NCCAH): an update. Steroids 2012; 77:342-6. [PMID: 22186144 PMCID: PMC3638754 DOI: 10.1016/j.steroids.2011.12.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 11/22/2011] [Indexed: 12/15/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a family of autosomal recessive disorders. 21-Hydroxylase deficiency, in which there are mutations in CYP21A2 (the gene encoding the adrenal 21-hydroxylase enzyme), is the most common form (90%) of CAH. In classic CAH there is impaired cortisol production with diagnostic increased levels of 17-OH progesterone. Excess androgen production results in virilization and in the newborn female may cause development of ambiguous external genitalia. Three-fourths of patients with classic CAH also have aldosterone insufficiency, which can result in salt-wasting; in infancy this manifests as shock, hyponatremia and hyperkalemia. CAH has a reported incidence of 1:10,000-1:20,000 births although there is an increased prevalence in certain ethnic groups. Nonclassic CAH (NCCAH) is a less severe form of the disorder, in which there is 20-50% of 21-hydroxylase enzyme activity (vs. 0-5% in classic CAH) and no salt wasting. The degree of symptoms related to androgen excess is variable and may be progressive with age, although some individuals are asymptomatic. NCCAH has an incidence of 1:1000-1:2000 births (0.1-0.2% prevalence) in the White population; an even higher prevalence is noted in certain ethnic groups such as Ashkenazi Jews (1-2%). As many as two-thirds of persons with NCCAH are compound heterozygotes and carry a severe and mild mutation on different alleles. This paper discusses the genetics of NCCAH, along with its variable phenotypic expression, and reviews the clinical course in untreated patients, which includes rapid early childhood growth, advanced skeletal age, premature adrenarche, acne, impaired reproductive function in both sexes and hirsutism as well as menstrual disorders in females. Finally, it addresses treatment with glucocorticoids vs. non treatment and other therapies, particularly with respect to long term issues such as adult metabolic disease including insulin resistance, cardiovascular disease, metabolic syndrome, and bone mineral density.
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Affiliation(s)
- Christine M. Trapp
- Division of Pediatric Endocrinology, Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, USA
| | - Sharon E. Oberfield
- Division of Pediatric Endocrinology, Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, USA
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Marino R, Ramirez P, Galeano J, Perez Garrido N, Rocco C, Ciaccio M, Warman DM, Guercio G, Chaler E, Maceiras M, Bergadá I, Gryngarten M, Balbi V, Pardes E, Rivarola MA, Belgorosky A. Steroid 21-hydroxylase gene mutational spectrum in 454 Argentinean patients: genotype-phenotype correlation in a large cohort of patients with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2011; 75:427-35. [PMID: 21609351 DOI: 10.1111/j.1365-2265.2011.04123.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report genotype-phenotype correlation in a large cohort of patients. CONTEXT Study of the CYP21A2 gene in 866 unrelated chromosomes of 21-hydroxylase deficiency in Argentinean patients with classic and nonclassic (NC) forms of congenital adrenal hyperplasia (CAH). METHODS Eleven most common mutations were analysed by allele-specific polymerase chain reaction, restriction fragment length polymorphism (RFLP) or southern blot analysis. Gene sequencing was performed when no mutation was detected in one allele or the genotype-phenotype correlation was lacking. RESULTS The 11-most-common-mutation screening allowed for the detection of 88·1% of affected alleles (80·3% in the NC and 95·2% in the classic forms). p.V281L, IVS2-13A/C>G (In2) and gene deletions and large gene conversions were the most prevalent mutations. In2 (35·2%) in salt wasting (SW), p.I172N (37·3%) in simple virilizing and p.V281L (54·1%) in NC CAH were the most prevalent mutations within the clinical forms. In 7/15 p.P30L mutation alleles, a chimeric CYP21A1P/CYP21A2 gene [PromCYP21A1P; p.P30L] was detected, while 6/15 represented a single-nucleotide substitution, and in 2/15 linkage with mutations, p.[P30L; V281L] and [p.P30L; IVS2-13A/C > G; p.Q318X] was found. In two SW patients, a novel nonsense mutation, p.Q41X, was observed. In three p.V281L mutation patients, the phenotype was more severe than predicted by genotype. Sequence analysis revealed an intronic alteration in the allele carrying the p.V281L mutation [IVS2 + 5G > A; p.V281L]. An aberrant splicing in this p.V281L mutated allele explains the clinical phenotype. CONCLUSIONS A high percentage of CYP21A2 affected alleles is detected by the 11-mutation screening study. Genotype-phenotype correlation was high, but when the phenotype is more severe than predicted by genotype, presence of two alterations in one allele should be ruled out.
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Affiliation(s)
- Roxana Marino
- Endocrinology Service, Hospital de Pediatria Garrahan, Buenos Aires, Argentina
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Abstract
PURPOSE OF REVIEW Congenital adrenal hyperplasia (CAH) in children, the majority of which is due to 21-hydroxylase deficiency, represents a group of disorders in which there is impaired cortisol synthesis and abnormalities in adrenal hormonal profiles. There continues to be debate regarding the optimal management of and treatment for these children. This review will highlight the most recent advances in neonatal screening for CAH, as well as the timeliest recommendations for the treatment and management of 21-hydroxylase deficiency, both the classic and nonclassic forms of the disorder. RECENT FINDINGS Substantive advancements have been made with regard to neonatal screening for CAH, allowing for earlier diagnosis, while minimizing the morbidity and mortality associated with delayed detection. Although the achievement of normal growth and development remains the ultimate goal of treatment, recent studies have provided further insight into the management and refinement of therapy in these children. SUMMARY The optimal management and treatment for children with CAH is still unclear. Although there have been recent advances in the diagnosis and treatment of this group of disorders, there is still much to learn in order to optimize therapy for these individuals.
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Affiliation(s)
- Christine M. Trapp
- Division of Pediatric Endocrinology, Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032
| | - Phyllis W. Speiser
- Division of Pediatric Endocrinology, Cohen Children’s Medical Center of New York, Hofstra University School of Medicine, New Hyde Park, New York 11040
| | - Sharon E. Oberfield
- Division of Pediatric Endocrinology, Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032
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