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Tajouri A, Kharrat M, Hizem S, Zaghdoudi H, M'rad R, Simic-Schleicher G, Kaiser FJ, Hiort O, Werner R. In vitro functional characterization of the novel DHH mutations p.(Asn337Lysfs*24) and p.(Glu212Lys) associated with gonadal dysgenesis. Hum Mutat 2018; 39:2097-2109. [PMID: 30298535 DOI: 10.1002/humu.23664] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/17/2018] [Accepted: 10/04/2018] [Indexed: 12/16/2022]
Abstract
In humans, mutations of Desert Hedgehog gene (DHH) have been described in patients with 46,XY gonadal dysgenesis (GD), associated or not with polyneuropathy. In this study, we describe two patients diagnosed with GD, both harboring novel DHH compound heterozygous mutations p.[Tyr176*];[Asn337Lysfs*24] and p.[Tyr176*];[Glu212Lys]. To investigate the functional consequences of p.(Asn337Lysfs*24) and p.(Glu212Lys) mutations, located within the C-terminal part of DHh on auto-processing, we performed in vitro cleavage assays of these proteins in comparison with Drosophila melanogaster Hedgehog (Hh). We found that p.(Glu212Lys) mutation retained 50% of its activity and led to a partially abolished DHh auto-processing. In contrast, p.(Asn337Lysfs*24) mutation resulted in a complete absence of auto-proteolysis. Furthermore, we found a different auto-processing profile between Drosophila Hh and human DHh, which suggests differences in the processing mechanism between the two species. Review of the literature shows that proven polyneuropathy and GD is associated with complete disruption of DHh-N, whereas disruption of the DHh auto-processing is only described with GD. We propose a model that may explain the differences between Schwann and Leydig cell development by autocrine versus paracrine DHh signaling. To our knowledge, this is the first study investigating the effect of DHH mutations on DHh in vitro auto-processing.
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Affiliation(s)
- Asma Tajouri
- University of Tunis El Manar, Faculty of Medicine of Tunis, LR99ES10 Human Genetics Laboratory, Tunis, Tunisia.,Department of Paediatric and Adolescent Medicine, Division of Paediatric Endocrinology and Diabetes, University of Luebeck, Luebeck, Germany
| | - Maher Kharrat
- University of Tunis El Manar, Faculty of Medicine of Tunis, LR99ES10 Human Genetics Laboratory, Tunis, Tunisia
| | - Syrine Hizem
- University of Tunis El Manar, Faculty of Medicine of Tunis, LR99ES10 Human Genetics Laboratory, Tunis, Tunisia
| | - Hajer Zaghdoudi
- University of Tunis El Manar, Faculty of Medicine of Tunis, LR99ES10 Human Genetics Laboratory, Tunis, Tunisia
| | - Ridha M'rad
- University of Tunis El Manar, Faculty of Medicine of Tunis, LR99ES10 Human Genetics Laboratory, Tunis, Tunisia.,Department of Congenital and Hereditary Diseases, Charles Nicolle Hospital, Tunis, Tunisia
| | | | - Frank J Kaiser
- Section for Functional Genetics at the Institute of Human Genetics, University of Luebeck, Luebeck, Germany
| | - Olaf Hiort
- Department of Paediatric and Adolescent Medicine, Division of Paediatric Endocrinology and Diabetes, University of Luebeck, Luebeck, Germany
| | - Ralf Werner
- Department of Paediatric and Adolescent Medicine, Division of Paediatric Endocrinology and Diabetes, University of Luebeck, Luebeck, Germany
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2
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Non-Syndromic 46,XY Disorders of Sex Development. ACTA MEDICA MARTINIANA 2018. [DOI: 10.2478/acm-2018-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Non-syndromic 46,XY DSD (disorders of sex development) represent a phenotypically diversiform group of disorders. We focus on the association between gene variants and the most frequent types of non-syndromic 46,XY DSD, options of molecular genetic testing which has surely taken its place in diagnostics of DSD in the past couple of years. We emphasize the need of molecular genetic testing in individuals with non-syndromic 46,XY DSD in Slovak Republic.
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3
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Ruiz-Arana IL, H�bner A, Cetingdag C, Krude H, Gr�ters A, Fukami M, Biebermann H, K�hler B. A Novel Hemizygous Mutation of MAMLD1 in a Patient with 46,XY Complete Gonadal Dysgenesis. Sex Dev 2015; 9:80-5. [DOI: 10.1159/000371603] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2014] [Indexed: 11/19/2022] Open
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4
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Svechnikov K, Stukenborg JB, Savchuck I, Söder O. Similar causes of various reproductive disorders in early life. Asian J Androl 2014; 16:50-9. [PMID: 24369133 PMCID: PMC3901882 DOI: 10.4103/1008-682x.122199] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
During the past few decades, scientific evidence has been accumulated concerning the possible adverse effects of the exposure to environmental chemicals on the well-being of wildlife and human populations. One large and growing group of such compounds of anthropogenic or natural origin is referred to as endocrine-disrupting chemicals (EDCs), due to their deleterious action on the endocrine system. This concern was first focused on the control of reproductive function particularly in males, but has later been expanded to include all possible endocrine functions. The present review describes the underlying physiology behind the cascade of developmental events that occur during sexual differentiation of males and the specific role of androgen in the masculinization process and proper organogenesis of the external male genitalia. The impact of the genetic background, environmental exposures and lifestyle factors in the etiology of hypospadias, cryptorchidism and testicular cancer are reviewed and the possible role of EDCs in the development of these reproductive disorders is discussed critically. Finally, the possible direct and programming effects of exposures in utero to widely use therapeutic compounds, environmental estrogens and other chemicals on the incidence of reproductive abnormalities and poor semen quality in humans are also highlighted.
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Affiliation(s)
| | | | | | - Olle Söder
- Department of Women's and Children's Health, Paediatric Endocrinology Unit, Karolinska Institutet and University Hospital, Stockholm, Sweden
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5
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Hutson JM, Grover SR, O'Connell M, Pennell SD. Malformation syndromes associated with disorders of sex development. Nat Rev Endocrinol 2014; 10:476-87. [PMID: 24913517 DOI: 10.1038/nrendo.2014.83] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
When embryological development of the internal and/or external genitalia is disrupted, the patient presents with a disorder of sex development (DSD) in the neonatal period or sometime later in life. Some of these patients have other, nongenital malformations, which makes their overall management more complex than if they just had a DSD. This Review summarises these malformation syndromes and discusses the recent research into their aetiology. The genetic causes of these malformation syndromes, when they are known, will also be described. Many specific genetic mutations are now known in malformation syndromes with a defect in hormonal function. By contrast, the genetic causes remain unknown in many nonhormonal morphological anomalies that affect the genitalia.
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Affiliation(s)
- John M Hutson
- Department of Urology, The Royal Children's Hospital, Flemington Road, Melbourne, VIC 3051, Australia
| | - Sonia R Grover
- Department of Gynaecology, The Royal Children's Hospital, Flemington Road, Melbourne, VIC 3051, Australia
| | - Michele O'Connell
- Department of Endocrinology, The Royal Children's Hospital, Flemington Road, Melbourne, VIC 3051, Australia
| | - Samuel D Pennell
- Department of Surgery, Austin Hospital, Studley Park Road, Heidelberg, Melbourne, VIC 3058, Australia
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6
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Ching ST, Cunha GR, Baskin LS, Basson MA, Klein OD. Coordinated activity of Spry1 and Spry2 is required for normal development of the external genitalia. Dev Biol 2013; 386:1-11. [PMID: 24361260 DOI: 10.1016/j.ydbio.2013.12.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 12/05/2013] [Accepted: 12/10/2013] [Indexed: 11/16/2022]
Abstract
Development of the mammalian external genitalia is controlled by a network of signaling molecules and transcription factors. Because FGF signaling plays a central role in this complicated morphogenetic process, we investigated the role of Sprouty genes, which are important intracellular modulators of FGF signaling, during embryonic development of the external genitalia in mice. We found that Sprouty genes are expressed by the urethral epithelium during embryogenesis, and that they have a critical function during urethral canalization and fusion. Development of the genital tubercle (GT), the anlage of the prepuce and glans penis in males and glans clitoris in females, was severely affected in male embryos carrying null alleles of both Spry1 and Spry2. In Spry1(-/-);Spry2(-/-) embryos, the internal tubular urethra was absent, and urothelial morphology and organization was abnormal. These effects were due, in part, to elevated levels of epithelial cell proliferation in Spry1(-/-);Spry2(-/-) embryos. Despite changes in overall organization, terminal differentiation of the urothelium was not significantly affected. Characterization of the molecular pathways that regulate normal GT development confirmed that deletion of Sprouty genes leads to elevated FGF signaling, whereas levels of signaling in other cascades were largely preserved. Together, these results show that levels of FGF signaling must be tightly regulated during embryonic development of the external genitalia in mice, and that this regulation is mediated in part through the activity of Sprouty gene products.
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Affiliation(s)
- Saunders T Ching
- Department of Orofacial Sciences, University of California, San Francisco, United States; Department of Urology, University of California, San Francisco, United States
| | - Gerald R Cunha
- Department of Urology, University of California, San Francisco, United States
| | - Laurence S Baskin
- Department of Urology, University of California, San Francisco, United States
| | - M Albert Basson
- Department of Craniofacial Development and Stem Cell Biology, King's College, London, UK
| | - Ophir D Klein
- Department of Orofacial Sciences, University of California, San Francisco, United States; Program in Craniofacial and Mesenchymal Biology, University of California, San Francisco, United States; Institute for Human Genetics, University of California, San Francisco, United States; Department of Pediatrics, University of California, San Francisco, United States.
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7
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Adamovic T, Thai H, Liedén A, Nordenskjöld A. Association of a Tagging Single Nucleotide Polymorphism in theAndrogen ReceptorGene Region with Susceptibility to Severe Hypospadias in a Caucasian Population. Sex Dev 2013; 7:173-9. [DOI: 10.1159/000348882] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2012] [Indexed: 11/19/2022] Open
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8
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Adamovic T, Chen Y, Thai HTT, Zhang X, Markljung E, Zhao S, Nordenskjöld A. The p.G146A and p.P125P polymorphisms in the steroidogenic factor-1 (SF-1) gene do not affect the risk for hypospadias in Caucasians. Sex Dev 2012; 6:292-7. [PMID: 23154282 DOI: 10.1159/000343782] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2012] [Indexed: 11/19/2022] Open
Abstract
Hypospadias is a frequent congenital malformation in boys and is characterized by incomplete fusion of the urethral folds. The steroidogenic factor-1 (SF-1, NR5A1) gene plays a key role in hypothalamic-pituitary-steroidogenic organ development, and has previously been reported to be mutated in individuals with 46,XY disorder of sex development. Here, we investigated the role of SF-1 in hypospadias, a milder form of 46,XY disorder of sex development. We performed direct sequencing analysis of the SF-1 gene in 2 male Caucasian twins exhibiting very severe hypospadias, and in 95 Caucasian boys with mild and severe hypospadias. We further extended the analysis by investigating 332 mild and severe hypospadias cases and 422 male controls using TaqMan assays. Our sequencing revealed a novel heterozygous p.R313H (c.938G>A) missense mutation in each twin, and no mutations in the 95 Caucasian cases. Instead, a missense p.G146A (c.437G>C), and a silent known p.P125P (c.375C>T) polymorphism, respectively, was found in several of the latter cases. Further investigation of the 2 polymorphisms in the larger material of cases and controls showed no significant genotypic or allelic association. In conclusion, the SF-1 gene may not play a significant role in the development of hypospadias in Caucasians.
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Affiliation(s)
- T Adamovic
- Department of Women's and Children's Health and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.
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9
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Oliveira J, Oliveira ME, Kress W, Taipa R, Pires MM, Hilbert P, Baxter P, Santos M, Buermans H, den Dunnen JT, Santos R. Expanding the MTM1 mutational spectrum: novel variants including the first multi-exonic duplication and development of a locus-specific database. Eur J Hum Genet 2012; 21:540-9. [PMID: 22968136 DOI: 10.1038/ejhg.2012.201] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Myotubular myopathy (MIM#310400), the X-linked form of Centronuclear myopathy (CNM) is mainly characterized by neonatal hypotonia and inability to maintain unassisted respiration. The MTM1 gene, responsible for this disease, encodes myotubularin - a lipidic phosphatase involved in vesicle trafficking regulation and maturation. Recently, it was shown that myotubularin interacts with desmin, being a major regulator of intermediate filaments. We report the development of a locus-specific database for MTM1 using the Leiden Open Variation database software (http://www.lovd.nl/MTM1), with data collated for 474 mutations identified in 472 patients (by June 2012). Among the entries are a total of 25 new mutations, including a large deletion encompassing introns 2-15. During database implementation it was noticed that no large duplications had been reported. We tested a group of eight uncharacterized CNM patients for this specific type of mutation, by multiple ligation-dependent probe amplification (MLPA) analysis. A large duplication spanning exons 1-5 was identified in a boy with a mild phenotype, with results pointing toward possible somatic mosaicism. Further characterization revealed that this duplication causes an in-frame deletion at the mRNA level (r.343_444del). Results obtained with a next generation sequencing approach suggested that the duplication extends into the neighboring MAMLD1 gene and subsequent cDNA analysis detected the presence of a MTM1/MAMLD1 fusion transcript. A complex rearrangement involving the duplication of exon 10 has since been reported, with detection also enabled by MLPA analysis. It is thus conceivable that large duplications in MTM1 may account for a number of CNM cases that have remained genetically unresolved.
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Affiliation(s)
- Jorge Oliveira
- Unidade de Investigação e Desenvolvimento, Departamento de Genética, Centro de Genética Médica Dr Jacinto Magalhães, Instituto Nacional de Saúde Dr Ricardo Jorge, IP, Porto, Portugal
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10
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Abstract
In 2005, the Lawson Wilkins Pediatric Endocrine Society and the European Society for Pediatric Endocrinology convened a conference on intersex to review clinical management practices and data from long-term health-related and gender-related outcomes research and to identify key areas for future research. Romao and colleagues provide an overview of the evolving changes after publication of this guidance, informed by experiences in their multidisciplinary clinic. This commentary highlights and expands on several of the topics explored, with a special emphasis on the psychosocial aspects of care for persons affected by disorders of sex development and their families.
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11
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Cools M, Hoebeke P, Wolffenbuttel KP, Stoop H, Hersmus R, Barbaro M, Wedell A, Brüggenwirth H, Looijenga LHJ, Drop SLS. Pubertal androgenization and gonadal histology in two 46,XY adolescents with NR5A1 mutations and predominantly female phenotype at birth. Eur J Endocrinol 2012; 166:341-9. [PMID: 22080441 DOI: 10.1530/eje-11-0392] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Most patients with NR5A1 (SF-1) mutations and poor virilization at birth are sex-assigned female and receive early gonadectomy. Although studies in pituitary-specific Sf-1 knockout mice suggest hypogonadotropic hypogonadism, little is known about endocrine function at puberty and on germ cell tumor risk in patients with SF-1 mutations. This study reports on the natural course during puberty and on gonadal histology in two adolescents with SF-1 mutations and predominantly female phenotype at birth. DESIGN AND METHODS Clinical and hormonal data and histopathological studies are reported in one male and one female adolescent with, respectively, a nonsense mutation (c.9T>A, p.Tyr3X) and a deletion of the first two coding exons (NCBI36/hg18 Chr9:g.(126306276-126307705)_(126303229-126302828)del) of NR5A1, both predicted to fully disrupt gene function. RESULTS LH and testosterone concentrations were in the normal male range, virilization was disproportionate to the neonatal phenotype. In the girl, gonadectomy at 13 years revealed incomplete spermatogenesis and bilateral precursor lesions of testicular carcinoma in situ. In the boy, at the age of 12, numerous germ cells without signs of malignancy were present in bilateral testicular biopsy specimen. CONCLUSIONS In SF-1 mutations, the neonatal phenotype poorly predicts virilization at puberty. Even in poorly virilized cases at birth, male gender assignment may allow spontaneous puberty without signs of hypogonadotropic hypogonadism, and possibly fertility. Patients with SF-1 mutations are at increased risk for malignant germ cell tumors. In case of preserved gonads, early orchidopexy and germ cell tumor screening is warranted. The finding of premalignant and/or malignant changes should prompt gonadectomy or possibly irradiation.
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Affiliation(s)
- M Cools
- Division of Pediatric Endocrinology, Department of Pediatrics, University Hospital Ghent, Ghent University, Building 3K12D, De Pintelaan 185, 9000 Ghent, Belgium.
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12
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Toppari J, Virtanen HE, Main KM, Skakkebaek NE. Cryptorchidism and hypospadias as a sign of testicular dysgenesis syndrome (TDS): environmental connection. ACTA ACUST UNITED AC 2011; 88:910-9. [PMID: 20865786 DOI: 10.1002/bdra.20707] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cryptorchidism and hypospadias are common genital birth defects that affect 2-9% and 0.2-1% of male newborns, respectively. The incidence of both defects shows large geographic variation, and in several countries increasing trends have been reported. The conditions share many risk factors, and they are also interlinked to the risk of testis cancer and poor semen quality. Testicular Dysgenesis Syndrome (TDS) may underlie many cases of all these male reproductive health problems. Genetic defects in androgen production or action can cause both cryptorchidism and hypospadias, but these are not common. A monogenic reason for cryptorchidism or hypospadias has been identified only in a small proportion of all cases. Environmental effects appear to play a major role in TDS. Exposure to several persistent chemicals has been found to be associated with the risk of cryptorchidism, and exposure to anti-androgenic phthalates has been shown to be associated with hormonal changes predisposing to male reproductive problems. Despite progress in identification of endocrine-disrupting substances, we are still far from knowing all the risk factors for these birth defects, and advice for prevention must be based on precautionary principles.
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Affiliation(s)
- Jorma Toppari
- Departments of Physiology and Pediatrics, University of Turku, Kiinamyllynkatu 10, Turku, Finland.
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Moriya K, Mitsui T, Tanaka H, Nakamura M, Nonomura K. Long-Term Outcome of Pituitary-Gonadal Axis and Gonadal Growth in Patients With Hypospadias at Puberty. J Urol 2010; 184:1610-4. [DOI: 10.1016/j.juro.2010.04.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Indexed: 10/19/2022]
Affiliation(s)
- Kimihiko Moriya
- Department of Urology, Hokkaido University Graduate School of Medicine
| | - Takahiko Mitsui
- Department of Urology, Hokkaido University Graduate School of Medicine
| | - Hiroshi Tanaka
- Department of Urology, Hokkaido University Graduate School of Medicine
| | - Michiko Nakamura
- Department of Urology, Hokkaido University Graduate School of Medicine
| | - Katsuya Nonomura
- Department of Urology, Hokkaido University Graduate School of Medicine
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Genetic pathway of external genitalia formation and molecular etiology of hypospadias. J Pediatr Urol 2010; 6:346-54. [PMID: 19995686 DOI: 10.1016/j.jpurol.2009.11.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Accepted: 11/10/2009] [Indexed: 11/23/2022]
Abstract
Hypospadias is one of the most common congenital disorders in males. Impaired fetal androgen action interferes with masculinization, including external genitalia formation, and can result in this anomaly; however, the molecular etiology remains unknown. Recent molecular approaches, including gene-targeting approaches in mice and single nucleotide polymorphisms analyses in humans, might provide an opportunity to identify the causative and risk factors of this anomaly. Several genes, such as sonic hedgehog, fibroblast growth factors, bone morphogenetic proteins, homeobox genes, and the Wnt family regulate external genitalia formation. Mastermind-like domain containing 1/chromosome X open reading frame 6 mutation and activating transcription factor 3 variants have been shown to be associated with the incidence of isolated hypospadias. In addition, this anomaly may be associated with a specific haplotype of the gene for estrogen receptor alpha, which mediates the estrogenic effects of environmental endocrine disruptors, and the effects of these disruptors on external genitalia formation might depend on individual genetic susceptibility. These molecular studies will refine our knowledge of the genetic mechanism involved in external genitalia formation, and lead to new strategies for the clinical management of hypospadias.
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Paliwal P, Sharma A, Sahoo J, Ammini AC. An unusual association of hypospadias with partial deletion of chromosome 1q. Fertil Steril 2010; 93:2413.e11-3. [PMID: 20079893 DOI: 10.1016/j.fertnstert.2009.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Revised: 11/23/2009] [Accepted: 12/01/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To report an unusual finding of chromosome 1q deletion in a man with failed multiple hypospadias repair. DESIGN Case report and discussion. SETTING An academic tertiary care hospital. PATIENT(S) A 32-year-old man with failed multiple hypospadias repair. INTERVENTION(S) Clinical, hormonal, cytogenetic evaluation, fluorescent in situ hybridization (FISH), and ultrasonography. MAIN OUTCOME MEASURE(S) Serum gonadotropin and testosterone levels, and karyotype showing structural abnormality of long arm of chromosome 1. RESULT(S) Ultrasonography showed the absence of the left testis and a hypoechoic right testis. Serum luteinizing hormone and follicular stimulating hormone levels were raised, but testosterone and prolactin levels were within the normal range for adult men. Karyotype analysis revealed an interstitial deletion of the long arm of chromosome 1, which was confirmed by FISH. CONCLUSION(S) Chromosome 1 may harbor a critical domain that is essential for male fertility.
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Affiliation(s)
- Preeti Paliwal
- Laboratory of Cyto-Molecular Genetics, Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
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