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Lang T, Geaghan S, Loh TP, Mak C, Papassotiriou I, Kyriakopoulou LG. Considerations for applying emerging technologies in paediatric laboratory medicine. Clin Chem Lab Med 2024; 62:1938-1949. [PMID: 39044644 DOI: 10.1515/cclm-2023-1408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/18/2024] [Indexed: 07/25/2024]
Abstract
Emerging technology in laboratory medicine can be defined as an analytical method (including biomarkers) or device (software, applications, and algorithms) that by its stage of development, translation into broad routine clinical practice, or geographical adoption and implementation has the potential to add value to clinical diagnostics. Paediatric laboratory medicine itself may be considered an emerging area of specialisation that is established relatively recently following increased appreciation and understanding of the unique physiology and healthcare needs of the children. Through four clinical (neonatal hypoglycaemia, neonatal hyperbilirubinaemia, sickle cell disorder, congenital adrenal hyperplasia) and six technological (microassays, noninvasive testing, alternative matrices, next generation sequencing, exosome analysis, machine learning) illustrations, key takeaways of application of emerging technology for each area are summarised. Additionally, nine key considerations when applying emerging technology in paediatric laboratory medicine setting are discussed.
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Affiliation(s)
- Tim Lang
- Department of Blood Sciences, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Sharon Geaghan
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tze Ping Loh
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Chloe Mak
- Division of Chemical Pathology, Hong Kong Children's Hospital, Kowloon, Hong Kong SAR, China
| | - Ioannis Papassotiriou
- First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, "Aghia Sophia" Children's Hospital, Athens, Greece
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Greaves RF, Gruson D. Six years of progress - highlights from the IFCC Emerging Technologies Division. Clin Chem Lab Med 2024; 62:1877-1879. [PMID: 39141007 DOI: 10.1515/cclm-2024-0922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Affiliation(s)
- Ronda F Greaves
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
- Division on Emerging Technologies of the International Federation of Laboratory Medicine (IFCC), Milan, Italy
| | - Damien Gruson
- Division on Emerging Technologies of the International Federation of Laboratory Medicine (IFCC), Milan, Italy
- Department of Laboratory Medicine, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
- Pôle de recherche en Endocrinologie, Diabète et Nutrition, Institut de Recherche Expérimentale et Clinique, Cliniques Universitaires St-Luc and UCLouvain, Brussels, Belgium
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Fiet J, Bachelot G, Sow C, Farabos D, Helin N, Eguether T, Dufourg MN, Bellanne-Chantelot C, Ribaut B, Bachelot A, Young J, Houang M, Lamazière A. Plasma 21-deoxycortisone: a sensitive additive tool in 21-hydroxylase deficiency in newborns. Eur J Endocrinol 2024; 191:204-210. [PMID: 39137138 DOI: 10.1093/ejendo/lvae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/31/2024] [Accepted: 05/01/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE, DESIGN, AND METHODS Although 17-hydroxyprogesterone (17OHP) has historically been the steroid assayed in the diagnosis of congenital adrenal 21-hydroxylase deficiency (CAH-21D), its C11-hydroxylated metabolite, 21-deoxycortisol (21DF), which is strictly of adrenal origin, is assayed in parallel in this pathology. This steroid (21DF) is oxidized by 11beta-hydroxysteroid dehydrogenase type 2 into 21-deoxycortisone (21DE). In the context of CAH-21D confirmation testing, confounding factors (such as intensive care unit admission, stress, prematurity, early sampling, and variations of sex development) can interfere with the interpretation of the gold-standard biomarkers (17OHP and 21DF). Since its tissue concentrations are especially high in the placenta, we hypothesized that 21DE quantification in the neonatal periods could be an interesting biomarker in addition to 17OHP and 21DF. To verify this hypothesis, we developed a new mass spectrometry-based assay for 21DE in serum and applied it to newborns screened for CAH-21D. RESULTS In newborns with CAH-21D, the mean serum levels of 21DE reached 17.56 ng/mL (ranging from 8.58 ng/mL to 23.20 ng/mL), and the mean 21DE:21DF ratio was 4.99. In contrast, in newborns without CAH-21D, the 21DE serum levels were low and not statistically different from the analytical 21DE limit of quantification (0.01 ng/mL). CONCLUSION Basal serum 21DE appears to be a novel sensitive and specific biomarker of CAH-21D in newborns.
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Affiliation(s)
- Jean Fiet
- Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP.Sorbonne Université, 27 Rue Chaligny, 75012 Paris, France
| | - Guillaume Bachelot
- Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP.Sorbonne Université, 27 Rue Chaligny, 75012 Paris, France
- Sorbonne Université, Saint Antoine Research Center, INSERM UMR 938, 75012 Paris, France
- Service de Biologie de La Reproduction-CECOS, Hôpital Tenon, AP-HP.Sorbonne Université, 75020 Paris, France
| | - Coumba Sow
- Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP.Sorbonne Université, 27 Rue Chaligny, 75012 Paris, France
| | - Dominique Farabos
- Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP.Sorbonne Université, 27 Rue Chaligny, 75012 Paris, France
| | - Nicolas Helin
- Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP.Sorbonne Université, 27 Rue Chaligny, 75012 Paris, France
| | - Thibaut Eguether
- Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP.Sorbonne Université, 27 Rue Chaligny, 75012 Paris, France
- Sorbonne Université, Saint Antoine Research Center, INSERM UMR 938, 75012 Paris, France
| | - Marie-Noelle Dufourg
- Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | | | - Bettina Ribaut
- Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP.Sorbonne Université, 27 Rue Chaligny, 75012 Paris, France
| | - Anne Bachelot
- Sorbonne Université, Service d'endocrinologie et médecine de la reproduction, IE3M, Hôpital Pitié-Salpêtrière, AP-HP, F-75013 Paris, France
| | - Jacques Young
- University Paris-Saclay, Paris-Sud Medical School, F-91405 Orsay, France
- Department of Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, F-94275 Le Kremlin-Bicêtre, France
- INSERM UMR-S 1185, Paris-Saclay University, Le Kremlin Bicêtre F-94276, France
| | - Muriel Houang
- Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | - Antonin Lamazière
- Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP.Sorbonne Université, 27 Rue Chaligny, 75012 Paris, France
- Sorbonne Université, Saint Antoine Research Center, INSERM UMR 938, 75012 Paris, France
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Ho CS, Hoad K, Cooke BR, Andersen T, Graham P, van den Berg SAA, Hartmann MF, Lo CWS, Loh TP, de Rijke YB, van Zelst BD, Wudy SA, Zakaria R, Greaves RF. Ensuring quality in 17OHP mass spectrometry measurement: an international study assessing isomeric steroid interference. Clin Chem Lab Med 2024; 62:911-918. [PMID: 38063179 DOI: 10.1515/cclm-2023-0864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/26/2023] [Indexed: 04/05/2024]
Abstract
OBJECTIVES Interference from isomeric steroids is a potential cause of disparity between mass spectrometry-based 17-hydroxyprogesterone (17OHP) results. We aimed to assess the proficiency of mass spectrometry laboratories to report 17OHP in the presence of known isomeric steroids. METHODS A series of five samples were prepared using a previously demonstrated commutable approach. These samples included a control (spiked to 15.0 nmol/L 17OHP) and four challenge samples further enriched with equimolar concentrations of 17OHP isomers (11α-hydroxyprogesterone, 11β-hydroxyprogesterone, 16α-hydroxyprogesterone or 21-hydroxyprogesterone). These samples were distributed to 38 participating laboratories that reported serum 17OHP results using mass spectrometry in two external quality assurance programs. The result for each challenge sample was compared to the control sample submitted by each participant. RESULTS Twenty-six laboratories (68 % of distribution) across three continents returned results. Twenty-five laboratories used liquid chromatography-tandem mass spectrometry (LC-MS/MS), and one used gas chromatography-tandem mass spectrometry to measure 17OHP. The all-method median of the control sample was 14.3 nmol/L, ranging from 12.4 to 17.6 nmol/L. One laboratory had results that approached the lower limit of tolerance (minus 17.7 % of the control sample), suggesting the isomeric steroid caused an irregular result. CONCLUSIONS Most participating laboratories demonstrated their ability to reliably measure 17OHP in the presence of the four clinically relevant isomeric steroids. The performance of the 12 (32 %) laboratories that did not engage in this activity remains unclear. We recommend that all laboratories offering LC-MS/MS analysis of 17OHP in serum, plasma, or dried bloodspots determine that the isomeric steroids are appropriately separated.
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Affiliation(s)
- Chung Shun Ho
- Department of Chemical Pathology, Biomedical Mass Spectrometry Unit, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR China
| | - Kirsten Hoad
- Department of Clinical Biochemistry, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Brian R Cooke
- Department of Clinical Biochemistry, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | | | - Peter Graham
- Royal College of Pathologists of Australasia Quality Assurance Programs, Sydney, NSW, Australia
| | - Sjoerd A A van den Berg
- Department Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
- Department Clinical Chemistry, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Michaela F Hartmann
- Steroid Research & Mass Spectrometry Unit of the Laboratory for Translational Hormone Analytics in Pediatric Endocrinology at the Justus Liebig University in Giessen, Giessen, Germany
| | - Clara W S Lo
- Department of Chemical Pathology, Biomedical Mass Spectrometry Unit, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR China
| | - Tze Ping Loh
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Yolanda B de Rijke
- Department Clinical Chemistry, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Bertrand D van Zelst
- Department Internal Medicine, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit of the Laboratory for Translational Hormone Analytics in Pediatric Endocrinology at the Justus Liebig University in Giessen, Giessen, Germany
| | - Rosita Zakaria
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Ronda F Greaves
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, The Royal Children's Hospital Melbourne, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
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Ravichandran L, Asha HS, Mathai S, Thomas N, Chapla A. Congenital Adrenal Hyperplasia - A Comprehensive Review of Genetic Studies on 21-Hydroxylase Deficiency from India. Indian J Endocrinol Metab 2024; 28:117-128. [PMID: 38911104 PMCID: PMC11189293 DOI: 10.4103/ijem.ijem_303_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/23/2023] [Accepted: 02/06/2024] [Indexed: 06/25/2024] Open
Abstract
Congenital adrenal hyperplasia (CAH) comprises a heterogeneous group of autosomal recessive disorders impairing adrenal steroidogenesis. Most cases are caused by mutations in the CYP21A2 gene resulting in 21-hydroxylase (21-OH) deficiency (21-OHD). The genetics of 21-OH CAH is complexed by a highly homologous pseudogene CYP21A1P imposing several limitations in the molecular analysis. Therefore, genetic testing is still not a part of routine CAH diagnosis and is mainly dependent on 17-hydroxy progesterone (OHP) measurements. There are very few reports of CYP21A2 gene analysis from India and there is no comprehensive review available on genetic testing and the spectrum of CYP21A2 mutations from the country. This review focuses on the molecular aspects of 21-OHD and the genetic studies on CYP21A2 gene reported from India. The results of these studies insist the compelling need for large-scale CYP21A2 genetic testing and newborn screening (NBS) in India. With a high disease prevalence and consanguinity rates, robust and cost-effective genetic testing for 21-OH CAH would enable an accurate diagnosis in routine clinical practice. Whereas establishing affordable genotyping assays even in secondary care or resource-poor settings of the country can identify 90% of the mutations that are pseudogene derived, initiatives on reference laboratories for CAH across the nation with comprehensive genetic testing facilities will be beneficial in those requiring extended analysis of CYP21A2 gene. Further to this, incorporating genetic testing in NBS and carrier screening programmes will enable early diagnosis, better risk assessment and community-based management.
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Affiliation(s)
- Lavanya Ravichandran
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
- DBT-Regional Centre for Biotechnology (RCB), Faridabad, Haryana, India
| | - Hesarghatta S. Asha
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sarah Mathai
- Department of Pediatric Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
- DBT-Regional Centre for Biotechnology (RCB), Faridabad, Haryana, India
| | - Aaron Chapla
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
- DBT-Regional Centre for Biotechnology (RCB), Faridabad, Haryana, India
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Gurpinar Tosun B, Guran T. Rare forms of congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2023. [PMID: 38126084 DOI: 10.1111/cen.15009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/10/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders due to pathogenic variants in genes encoding enzymes and cofactors involved in adrenal steroidogenesis. Although 21-hydroxylase, 11β-hydroxylase, 3β-hydroxysteroid dehydrogenase type 2, 17α-hydroxylase/17,20-lyase, P450 oxidoreductase, steroidogenic acute regulatory protein, cholesterol side-chain cleavage enzyme deficiencies are considered within the definition of CAH, the term 'CAH' is often used to refer to '21-hydroxylase deficiency (21OHD)' since 21OHD accounts for approximately 95% of CAH in most populations. The prevalence of the rare forms of CAH varies according to ethnicity and geographical location. In most cases, the biochemical fingerprint of impaired steroidogenesis points to the specific subtypes of CAH, and genetic testing is usually required to confirm the diagnosis. Despite there are significant variations in clinical characteristics and management, most data about the rare CAH forms are extrapolated from 21OHD. This review article aims to collate the currently available data about the diagnosis and the management of rare forms of CAH.
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Affiliation(s)
- Busra Gurpinar Tosun
- Department of Paediatric Endocrinology and Diabetes, School of Medicine, Marmara University, Istanbul, Turkey
| | - Tulay Guran
- Department of Paediatric Endocrinology and Diabetes, School of Medicine, Marmara University, Istanbul, Turkey
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Shim J, Ahn CH, Park SS, Noh J, Lee C, Lee SW, Kim JH, Choi MH. Multiplexed Serum Steroid Profiling Reveals Metabolic Signatures of Subtypes in Congenital Adrenal Hyperplasia. J Endocr Soc 2023; 8:bvad155. [PMID: 38130465 PMCID: PMC10735290 DOI: 10.1210/jendso/bvad155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Indexed: 12/23/2023] Open
Abstract
Context Altered metabolic signatures on steroidogenesis may characterize individual subtypes of congenital adrenal hyperplasia (CAH), but conventional diagnostic approaches are limited to differentiate subtypes. Objective We explored metabolic characterizations and identified multiple diagnostic biomarkers specific to individual subtypes of CAH. Methods Liquid chromatography-mass spectrometry-based profiling of 33 adrenal steroids was developed and applied to serum samples obtained from 67 CAH patients and 38 healthy volunteers. Results Within- and between-run precisions were 95.4% to 108.3% and 94.1% to 110.0%, respectively, while all accuracies were <12% and the correlation coefficients (r2) were > 0.910. Metabolic ratios corresponding to 21-hydroxylase characterized 21-hydroxylase deficiency (21-OHD; n = 63) from healthy controls (area under the curve = 1.0, P < 1 × 10-18 for all) and other patients with CAH in addition to significantly increased serum 17α-hydroxyprogesterone (P < 1 × 10-16) and 21-deoxycortisol (P < 1 × 10-15) levels. Higher levels of mineralocorticoids, such as corticosterone (B) and 18-hydroxyB, were observed in 17α-hydroxylase deficiency (17α-OHD; N = 3), while metabolic ratio of dehydroepiandrosterone sulfate to pregnenolone sulfate was remarkably decreased against all subjects. A patient with 11β-hydroxylase deficiency (11β-OHD) demonstrated significantly elevated 11-deoxycortisol and its metabolite tetrahydroxy-11-deoxyF, with reduced metabolic ratios of 11β-hydroxytestosterone/testosterone and 11β-hydroxyandrostenedione/androstenedione. The steroid profiles resulted in significantly decreased cortisol metabolism in both 21-OHD and 17α-OHD but not in 11β-OHD. Conclusion The metabolic signatures with specific steroids and their corresponding metabolic ratios may reveal individual CAH subtypes. Further investigations with more substantial sample sizes should be explored to enhance the clinical validity.
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Affiliation(s)
- Jaeyoon Shim
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul 02792, Korea
- Department of Chemistry, Korea University, Seoul 02841, Korea
| | - Chang Ho Ahn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do 13620, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Seung Shin Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea
| | - Jongsung Noh
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul 02792, Korea
| | - Chaelin Lee
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul 02792, Korea
| | - Sang Won Lee
- Department of Chemistry, Korea University, Seoul 02841, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea
| | - Man Ho Choi
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul 02792, Korea
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Greaves R, Kricka L, Gruson D, Ferrari M, Martin H, Loh TP, Bernardini S. Toolkit for emerging technologies in laboratory medicine. Clin Chem Lab Med 2023; 61:2102-2114. [PMID: 37314970 DOI: 10.1515/cclm-2023-0571] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/16/2023]
Abstract
An emerging technology (ET) for laboratory medicine can be defined as an analytical method (including biomarkers) or device (software, applications, and algorithms) that by its stage of development, translation into broad routine clinical practice, or geographical adoption and implementation has the potential to add value to clinical diagnostics. Considering the laboratory medicine-specific definition, this document examines eight key tools, encompassing clinical, analytical, operational, and financial aspects, used throughout the life cycle of ET implementation. The tools provide a systematic approach starting with identifying the unmet need or identifying opportunities for improvement (Tool 1), forecasting (Tool 2), technology readiness assessment (Tool 3), health technology assessment (Tool 4), organizational impact map (Tool 5), change management (Tool 6), total pathway to method evaluation checklist (Tool 7), and green procurement (Tool 8). Whilst there are differences in clinical priorities between different settings, the use of this set of tools will help support the overall quality and sustainability of the emerging technology implementation.
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Affiliation(s)
- Ronda Greaves
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Larry Kricka
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Damien Gruson
- Cliniques Universitaires Saint Luc, Département des Laboratoires Cliniques, Biochimie Médicale, Brussels, Belgium
| | | | | | - Tze Ping Loh
- National University Hospital, Singapore, Singapore
| | - Sergio Bernardini
- Department of Experimental Medicine, University Tor Vergata, Rome, Italy
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Ahn CH, Shim J, Jang HN, Lee YA, Lee SW, Choi MH, Kim JH. Serum steroid profile captures metabolic phenotypes in adults with classic congenital adrenal hyperplasia. J Steroid Biochem Mol Biol 2023; 234:106374. [PMID: 37572762 DOI: 10.1016/j.jsbmb.2023.106374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES Adult patients with classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency have an increased risk of metabolic diseases. We aimed to investigate whether liquid chromatography-mass spectrometry (LC-MS)-based serum steroid profiling reveals metabolic phenotypes in adults with classic CAH. DESIGN AND METHODS This study prospectively enrolled 63 adult patients with CAH and 38 healthy volunteers. The levels of the 24 steroids were quantified in the morning serum using LC-MS. Unsupervised clustering algorithms were applied to the serum steroid profiles to identify unique patterns associated with metabolic syndrome. RESULTS Serum steroid profiles of patients with CAH were clearly delineated from those of healthy controls with a higher degree of interindividual heterogeneity. The unsupervised clustering algorithm divided CAH patients into two clusters based on serum steroid profile. Cluster 2 showed higher serum levels of glucocorticoids and androgens than cluster 1. The prevalence of metabolic syndrome was significantly higher in cluster 2 than in cluster 1 (37.8 % vs. 5.6 %, P = 0.011). Other clinical characteristics, including age, sex, body mass index, CAH subtypes, and glucocorticoid dose, did not differ between the two clusters. The multivariate logistic regression model of selective 15 steroids could discriminate metabolic syndrome in patients with CAH with an area under the receiver operating characteristic curve of 0.832 (95 % confidence interval:0.732-0.933). CONCLUSIONS Serum steroid profiles can be valuable biomarkers for estimating metabolic risk in adult patients with CAH.
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Affiliation(s)
- Chang Ho Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea; Department of Internal Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Jaeyoon Shim
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Republic of Korea; Department of Chemistry, Korea University, Republic of Korea
| | - Han Na Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea; Department of Internal Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University College of Medicine, Republic of Korea; Department of Pediatrics, Seoul National University Hospital, Republic of Korea
| | - Sang-Won Lee
- Department of Chemistry, Korea University, Republic of Korea
| | - Man Ho Choi
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Republic of Korea.
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Republic of Korea; Department of Internal Medicine, Seoul National University Hospital, Republic of Korea.
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Cantu M, Kandhal P. Neonatal Endocrine Diseases. Emerg Med Clin North Am 2023; 41:821-832. [PMID: 37758426 DOI: 10.1016/j.emc.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Endocrine diseases are rare and can present very subtly in the neonatal period. Most are diagnosed using newborn screening in the United States; however, some infants may present with false negatives or more subtle findings. Endocrine etiologies should be considered during the management of critically ill infants. This article will give an overview of endocrine emergencies encountered in the neonatal period, including disorders of glucose metabolism, thyroid disorders, adrenal disorders, and pituitary disorders.
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Affiliation(s)
- Marissa Cantu
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229, USA
| | - Prianka Kandhal
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229, USA.
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Greaves RF, Kumar M, Mawad N, Francescon A, Le C, O’Connell M, Chi J, Pitt J. Best Practice for Identification of Classical 21-Hydroxylase Deficiency Should Include 21 Deoxycortisol Analysis with Appropriate Isomeric Steroid Separation. Int J Neonatal Screen 2023; 9:58. [PMID: 37873849 PMCID: PMC10594498 DOI: 10.3390/ijns9040058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/18/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
There are mixed reports on the inclusion and use of 21 deoxycortisol (21DF) as the primary decision marker for classical 21-hydroxylase deficiency. We hypothesize that this may be due to insufficient recognition of the presence and chromatographic separation of isomeric steroids. The aim of this study was to determine the comparative utility of 21DF for screening and diagnosis of CAH due to classical 21-hydroxylase deficiency using a second-tier LC-MS/MS method that included the separation of isomeric steroids to 17OHP and 21DF. For each baby sample, one 3.2 mm dried blood spot was eluted in a methanolic solution containing isotopically matched internal standards. Data were interrogated by univariate and receiver operator characteristic analysis. Steroid profile results were generated for 924 non-CAH baby samples (median gestational age 37 weeks, range 22 to 43 weeks) and 17 babies with 21-hydroxylase deficiency. The ROC curves demonstrated 21DF to have the best sensitivity and specificity for the diagnosis of classical 21-hydroxylase deficiency with an AUC = 1.0. The heatmap showed the very strong correlation (r = 0.83) between 17OHP and 21DF. Our data support 21DF as a robust marker for CAH due to 21-hydroxylase deficiency. We recommend that 21DF be incorporated into routine newborn screening panels as part of the second-tier LC-MS/MS method, follow-up plasma steroid panels, and external quality assurance material.
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Affiliation(s)
- Ronda F. Greaves
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia;
| | - Monish Kumar
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - Nazha Mawad
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - Alberto Francescon
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - Chris Le
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - Michele O’Connell
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia;
- Department of Endocrinology, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
| | - James Chi
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - James Pitt
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia;
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12
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de Hora M, Heather N, Webster D, Albert B, Hofman P. The use of liquid chromatography-tandem mass spectrometry in newborn screening for congenital adrenal hyperplasia: improvements and future perspectives. Front Endocrinol (Lausanne) 2023; 14:1226284. [PMID: 37850096 PMCID: PMC10578435 DOI: 10.3389/fendo.2023.1226284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/12/2023] [Indexed: 10/19/2023] Open
Abstract
Newborn screening for congenital adrenal hyperplasia using 17-hydroxyprogesterone by immunoassay remains controversial despite screening been available for almost 40 years. Screening is confounded by poor immunoassay specificity, fetal adrenal physiology, stress, and illness which can result in a large number of false positive screening tests. Screening programmes apply higher screening thresholds based on co-variates such as birthweight or gestational age but the false positive rate using immunoassay remains high. Mass spectrometry was first applied to newborn screening for congenital adrenal hyperplasia over 15 years ago. Elevated 17-hydroxprogesterone by immunoassay can be retested with a specific liquid chromatography tandem mass spectrometry assay that may include additional steroid markers. Laboratories register with quality assurance programme providers to ensure accurate steroid measurements. This has led to improvements in screening but there are additional costs and added laboratory workload. The search for novel steroid markers may inform further improvements to screening. Studies have shown that 11-oxygenated androgens are elevated in untreated patients and that the adrenal steroidogenesis backdoor pathway is more active in babies with congenital adrenal hyperplasia. There is continual interest in 21-deoxycortisol, a specific marker of 21-hydroxylase deficiency. The measurement of androgenic steroids and their precursors by liquid chromatography tandem mass spectrometry in bloodspots may inform improvements for screening, diagnosis, and treatment monitoring. In this review, we describe how liquid chromatography tandem mass spectrometry has improved newborn screening for congenital adrenal hyperplasia and explore how future developments may inform further improvements to screening and diagnosis.
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Affiliation(s)
- Mark de Hora
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Natasha Heather
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Dianne Webster
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Benjamin Albert
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Paul Hofman
- Clinical Research Unit, Liggins Institute, University of Auckland, Auckland, New Zealand
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13
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Finkielstain GP, Rey RA. Challenges in managing disorders of sex development associated with adrenal dysfunction. Expert Rev Endocrinol Metab 2023; 18:427-439. [PMID: 37694439 DOI: 10.1080/17446651.2023.2256393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Disorders of Sex Development (DSD) associated with adrenal dysfunction occur due to different defects in the proteins involved in gonadal and adrenal steroidogenesis. AREAS COVERED The deficiencies in 21-hydroxylase and 11β-hydroxylase lead to DSD in 46,XX patients, defects in StAR, P450scc, 17α-hydroxylase and 17,20-lyase lead to 46,XY DSD, and 3β-HSD2 and POR deficiencies cause both 46,XX and 46,XY DSD. Challenges in diagnosis arise from the low prevalence and the variability in serum steroid profiles. Replacement therapy with hydrocortisone and fludrocortisone helps to minimize life-threatening adrenal crises; however, availability is still an unresolved problem in many countries. Adverse health outcomes, due to the disease or its treatment, are common and include adult short stature, hypertension, osteoporosis, obesity, cardiometabolic risk, and reproductive health issues. Potential biomarkers to improve monitoring and novel treatment options that have been developed with the primary aim to decrease adrenal androgen production are promising tools to help improve the health and quality of life of these patients. EXPERT OPINION Steroid profiling by mass spectrometry and next-generation sequencing technologies represent useful tools for establishing an etiologic diagnosis and drive personalized management. Nonetheless, access to health care still remains an issue requiring urgent solutions in many resource-limited settings.
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Affiliation(s)
- Gabriela P Finkielstain
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Rodolfo A Rey
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
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14
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Bacila IA, Lawrence NR, Badrinath SG, Balagamage C, Krone NP. Biomarkers in congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2023. [PMID: 37608608 DOI: 10.1111/cen.14960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/25/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
Monitoring of hormone replacement therapy represents a major challenge in the management of congenital adrenal hyperplasia (CAH). In the absence of clear guidance and standardised monitoring strategies, there is no consensus among clinicians regarding the relevance of various biochemical markers used in practice, leading to wide variability in their application and interpretation. In this review, we summarise the published evidence on biochemical monitoring of CAH. We discuss temporal variations of the most commonly measured biomarkers throughout the day, the interrelationship between different biomarkers, as well as their relationship with different glucocorticoid and mineralocorticoid treatment regimens and clinical outcomes. Our review highlights significant heterogeneity across studies in both aims and methodology. However, we identified key messages for the management of patients with CAH. The approach to hormone replacement therapy should be individualised, based on the individual hormonal profile throughout the day in relation to medication. There are limitations to using 17-hydroxyprogesterone, androstenedione and testosterone, and the role of additional biomarkers such 11-oxygenated androgens which are more disease specific should be further established. Noninvasive monitoring via salivary and urinary steroid measurements is becoming increasingly available and should be considered, especially in the management of children with CAH. Additionally, this review indicates the need for large scale longitudinal studies analysing the interrelation between different monitoring strategies used in clinical practice and health outcomes in children and adults with CAH.
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Affiliation(s)
| | - Neil R Lawrence
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Chamila Balagamage
- Department of Endocrinology, Birmingham Women's & Children's Hospital, Birmingham, UK
- Department of Endocrinology, Sheffield Children's Hospital, Sheffield, UK
| | - Nils P Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Endocrinology, Sheffield Children's Hospital, Sheffield, UK
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15
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Conlon TA, Hawkes CP, Brady JJ, Loeber JG, Murphy N. International Newborn Screening Practices for the Early Detection of Congenital Adrenal Hyperplasia. Horm Res Paediatr 2023; 97:113-125. [PMID: 37231960 DOI: 10.1159/000530754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/11/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Newborn screening (NBS) programmes vary internationally in their approach to screening. Guidelines for congenital adrenal hyperplasia (CAH) screening recommend the use of two-tier testing and gestational age cutoffs to minimise false-positive results. The aims of this study were to describe (1) the approaches; (2) protocols used; and (3) available outcomes for CAH screening internationally. METHODS All members of the International Society for Neonatal Screening were asked to describe their CAH NBS protocols, with an emphasis on the use of second-tier testing, 17-hydroxyprogesterone (17OHP) cutoffs, and gestational age and birth weight adjustments. If available, screening outcomes were requested. RESULTS Representatives from 23 screening programmes provided data. Most (n = 14; 61%) recommend sampling at 48-72 h of life. Fourteen (61%) use single-tier testing and 9 have a two-tier testing protocol. Gestational age cutoffs are used in 10 programmes, birth weight cutoffs in 3, and a combination of both in 9. One programme does not use either method of adjusting 17OHP cutoffs. Case definition of a positive test and the response to a positive test differed between programmes. CONCLUSIONS We have demonstrated significant variation across all aspects of NBS for CAH, including timing, the use of single versus two-tier testing and cutoff interpretation. Collaboration between international screening programmes and implementation of new techniques to improve screen efficacy will facilitate ongoing expansion and quality improvement in CAH NBS.
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Affiliation(s)
- Tracey A Conlon
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Colin P Hawkes
- INFANT Research Centre, University College Cork, Cork, Ireland
- Perelman School of Medicine, University of Pennsylvania, PA, Philadelphia, USA
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jennifer J Brady
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Paediatric Laboratory Medicine, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - J Gerard Loeber
- Office of the International Society for Neonatal Screening, Maarssen, The Netherlands
| | - Nuala Murphy
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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16
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Ponzetto F, Parasiliti-Caprino M, Gesmundo I, Marinelli L, Nonnato A, Nicoli R, Kuuranne T, Mengozzi G, Ghigo E, Settanni F. Single-run UHPLC-MS/MS method for simultaneous quantification of endogenous steroids and their phase II metabolites in serum for anti-doping purposes. Talanta 2023; 255:124218. [PMID: 36603442 DOI: 10.1016/j.talanta.2022.124218] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/20/2022] [Accepted: 12/24/2022] [Indexed: 12/29/2022]
Abstract
Anti-doping rule violations related to the abuse of endogenous anabolic androgenic steroids can be currently discovered by the urinary steroidal module of Athlete Biological Passport. Since this powerful tool is still subjected to some limitations due to various confounding factors altering the steroid profile, alternative strategies have been constantly proposed. Among these, the measurement of blood concentrations of endogenous steroid hormones by LC-MS is currently of increasing interest in anti-doping, bringing significant advantages for the detection of testosterone abuse in females and in individuals with deletion of UGT2B17 enzyme. Although various research groups have made significant efforts in method development, there is currently no accepted or harmonized anti-doping method for quantitative analysis of the various testosterone doping markers in blood. In this study we present a UHPLC-MS/MS method for the quantification of major circulating steroid hormones together with an extended panel of glucuro- and sulpho-conjugated phase II metabolites of androgens. Chromatographic setup was optimized by comparing the performance of three different C18 stationary phases and by the careful selection of mobile phases with the aim of separating all the target steroids, including numerous isomeric/isobaric compounds. MS parameters were fine-tuned to obtain the sensitivity needed for measuring the target analytes, that show specific serum concentrations ranging from low pg/mL for less abundant compounds to μg/mL for sulpho-conjugated steroids. Finally, sample preparation protocol was developed for the extraction of steroid hormones from 200 μL of serum and the performance was evaluated in terms of extraction recovery and matrix effect. The final method was then applied to authentic serum samples collected from healthy volunteers (40 males and 40 females) at the Blood Bank of the City of Health and Science University Hospital of Turin. The analysis of these samples allowed to obtain results on serum concentrations of the targeted steroids, with particular emphasis on previously undiscovered phase II metabolites, such as the isomers of 5-androstane-3,17-diol glucuronide. This preliminary application also enabled measuring dihydrotestosterone sulphate in male samples, efficiently separating this analyte from its isomer, epiandrosterone sulphate, which circulates in blood at high concentrations. The promising results of this study are encouraging for the measurement of blood steroid profile markers in serum and plasma samples for Athlete Biological Passport purposes.
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Affiliation(s)
- Federico Ponzetto
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin; Turin, Italy.
| | - Mirko Parasiliti-Caprino
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin; Turin, Italy
| | - Iacopo Gesmundo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin; Turin, Italy
| | - Lorenzo Marinelli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin; Turin, Italy
| | - Antonello Nonnato
- Clinical Biochemistry Laboratory; City of Health and Science University Hospital; Turin, Italy
| | - Raul Nicoli
- Swiss Laboratory for Doping Analyses, University Center of Legal Medicine Geneva and Lausanne, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland
| | - Tiia Kuuranne
- Swiss Laboratory for Doping Analyses, University Center of Legal Medicine Geneva and Lausanne, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland
| | - Giulio Mengozzi
- Clinical Biochemistry Laboratory; City of Health and Science University Hospital; Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin; Turin, Italy
| | - Fabio Settanni
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin; Turin, Italy; Clinical Biochemistry Laboratory; City of Health and Science University Hospital; Turin, Italy
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17
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Auer MK, Nordenström A, Lajic S, Reisch N. Congenital adrenal hyperplasia. Lancet 2023; 401:227-244. [PMID: 36502822 DOI: 10.1016/s0140-6736(22)01330-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 05/17/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders leading to multiple complex hormonal imbalances caused by various enzyme deficiencies in the adrenal steroidogenic pathway. The most common type of congenital adrenal hyperplasia is due to steroid 21-hydroxylase (21-OHase, henceforth 21OH) deficiency. The rare, classic (severe) form caused by 21OH deficiency is characterised by life-threatening adrenal crises and is the most common cause of atypical genitalia in neonates with 46,XX karyotype. After the introduction of life-saving hormone replacement therapy in the 1950s and neonatal screening programmes in many countries, nowadays neonatal survival rates in patients with congenital adrenal hyperplasia are high. However, disease-related mortality is increased and therapeutic management remains challenging, with multiple long-term complications related to treatment and disease affecting growth and development, metabolic and cardiovascular health, and fertility. Non-classic (mild) forms of congenital adrenal hyperplasia caused by 21OH deficiency are more common than the classic ones; they are detected clinically and primarily identified in female patients with hirsutism or impaired fertility. Novel treatment approaches are emerging with the aim of mimicking physiological circadian cortisol rhythm or to reduce adrenal hyperandrogenism independent of the suppressive effect of glucocorticoids.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Division of Paediatrics, Unit for Paediatric Endocrinology and Metabolic Disorders, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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18
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Miller WL, White PC. History of Adrenal Research: From Ancient Anatomy to Contemporary Molecular Biology. Endocr Rev 2023; 44:70-116. [PMID: 35947694 PMCID: PMC9835964 DOI: 10.1210/endrev/bnac019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 01/20/2023]
Abstract
The adrenal is a small, anatomically unimposing structure that escaped scientific notice until 1564 and whose existence was doubted by many until the 18th century. Adrenal functions were inferred from the adrenal insufficiency syndrome described by Addison and from the obesity and virilization that accompanied many adrenal malignancies, but early physiologists sometimes confused the roles of the cortex and medulla. Medullary epinephrine was the first hormone to be isolated (in 1901), and numerous cortical steroids were isolated between 1930 and 1949. The treatment of arthritis, Addison's disease, and congenital adrenal hyperplasia (CAH) with cortisone in the 1950s revolutionized clinical endocrinology and steroid research. Cases of CAH had been reported in the 19th century, but a defect in 21-hydroxylation in CAH was not identified until 1957. Other forms of CAH, including deficiencies of 3β-hydroxysteroid dehydrogenase, 11β-hydroxylase, and 17α-hydroxylase were defined hormonally in the 1960s. Cytochrome P450 enzymes were described in 1962-1964, and steroid 21-hydroxylation was the first biosynthetic activity associated with a P450. Understanding of the genetic and biochemical bases of these disorders advanced rapidly from 1984 to 2004. The cloning of genes for steroidogenic enzymes and related factors revealed many mutations causing known diseases and facilitated the discovery of new disorders. Genetics and cell biology have replaced steroid chemistry as the key disciplines for understanding and teaching steroidogenesis and its disorders.
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Affiliation(s)
- Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Perrin C White
- Division of Pediatric Endocrinology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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19
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Rodrigues F, Zacharin M. Congenital adrenal hyperplasia: The importance of screening and clinical assessment. J Paediatr Child Health 2023; 59:182-184. [PMID: 36129252 DOI: 10.1111/jpc.16225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/27/2022] [Accepted: 09/05/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Farrah Rodrigues
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Margaret Zacharin
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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20
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Ermakhanova T, Bazarbekova R, Svyatova G, Dossanova A. Genotype-phenotype association in congenital adrenal hyperplasia due to 21-hydroxylase deficiency in children. Clin Endocrinol (Oxf) 2022; 98:654-661. [PMID: 36494191 DOI: 10.1111/cen.14859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/30/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the clinical manifestation of various forms of congenital adrenal hyperplasia (CAH) in children of the Republic of Kazakhstan, depending on their genotype. DESIGN The study analysed 50 patients diagnosed with CAH from 7 regions of Kazakhstan with different ethnic origins: 35 Kazakhs (70.0%), 8 Russians (16.0%), 2 Turks (4.0%), 2 Ukrainians (4.0%), 2 Uzbeks (4%), 1 Uighur (2%). All the children studied were from 0 to 18 years old, and their average age was 5.7 years ±3.9. In addition, all children were divided into groups depending on the form of the disease according to the phenotypic manifestation of the disease: salt-wasting (SW) and simple virile (SV) forms. Most of the patients suffered from SW - 32 (64.0%), and a smaller group had SV - 18 (36.0%), also one boy with SW was diagnosed with TART syndrome. MEASUREMENTS 50 Kazakh children with the classical form of CAH were analysed. Depending on the severity of the mutations, patients were divided into 4 groups: zero groups (the most severe mutations), A, B, and C. RESULTS According to the results of the study, the salt-wasting form of CAH turned out to be more common than the simple virile form. A high correlation was observed in groups with mutations of high and moderate severity - 0 and A, while group C showed a strong variability of the phenotype. Thus, the correspondence between genotype and phenotype decreased along with the decrease in the severity of the disease. CONCLUSIONS The relationship between the genotype and the phenotype of both forms of CAH exists indirectly, through the activity of the 21-hydroxylase enzyme. Mutations in the CYP21A2 gene affect the level of the synthesized enzyme, which, in turn, determines the degree of hormone production in the blood.
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Affiliation(s)
- Tamara Ermakhanova
- Department of Endocrinology, Asfendiyarov Kazakh National Medical University, Almaty, Republic of Kazakhstan
- Department of Endocrinology, Kazakh-Russian Medical University, Almaty, Republic of Kazakhstan
| | - Rimma Bazarbekova
- Department of Endocrinology, Kazakh-Russian Medical University, Almaty, Republic of Kazakhstan
| | - Gulnara Svyatova
- Republican Medical Genetic Consultation, JSC 'Scientific Center of Obstetrics, Gynecology and Perinatology', Almaty, Republic of Kazakhstan
| | - Ainur Dossanova
- Department of Endocrinology, Kazakh-Russian Medical University, Almaty, Republic of Kazakhstan
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21
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Watanabe K, Tsuji-Hosokawa A, Hashimoto A, Konishi K, Ishige N, Yajima H, Sutani A, Nakatani H, Gau M, Takasawa K, Tajima T, Hasegawa T, Morio T, Kashimada K. The High Relevance of 21-Deoxycortisol, (Androstenedione + 17α-Hydroxyprogesterone)/Cortisol, and 11-Deoxycortisol/17α-Hydroxyprogesterone for Newborn Screening of 21-Hydroxylase Deficiency. J Clin Endocrinol Metab 2022; 107:3341-3352. [PMID: 36071550 DOI: 10.1210/clinem/dgac521] [Citation(s) in RCA: 2] [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: 06/04/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT There are limited reports on the detailed examination of steroid profiles for setting algorithms for 21-hydroxylase deficiency (21OHD) screening by liquid chromatography-tandem mass spectrometry (LC-MS/MS). OBJECTIVE We aimed to define an algorithm for newborn screening of 21OHD by LC-MS/MS, measuring a total of 2077 dried blood spot samples in Tokyo. METHODS Five steroids (17α-hydroxyprogesterone [17αOHP], 21-deoxycortisol [21DOF], 11-deoxycortisol [11DOF], androstenedione [4AD], and cortisol [F]) were included in the panel of LC-MS/MS. Samples from 2 cohorts were assayed: Cohort A, 63 "screening positive" neonates who were referred to an endocrinologist (n = 26 with 21OHD; n = 37 false-positive; obtained from 2015 to 2020); and Cohort B, samples (n = 2014) with 17αOHP values in the 97th percentile or above, in the first-tier test with 17αOHP ELISA from 2020 to 2021. RESULTS Analysis of Cohort A revealed that the 3 indexes 21DOF, 11DOF/17αOHP, and (4AD + 17αOHP)/F had higher area under the curve (AUC) values (0.999, 0.997, 0.989, respectively), while the 17αOHP AUC was lower (0.970). Accordingly, in addition to 17αOHP, the 3 markers were included for defining the screening algorithm. The assay of Cohort B revealed that the new algorithm gave 92% of predicted positive predictive value without false-negative cases. We also determined the reference values for the 5 steroids at 4 to 7 days after birth, according to sex and gestational age (GA), revealing extremely low levels of 21DOF at any GA irrespective of sex differences. CONCLUSION Our study demonstrated the high relevance of 21DOF, (4AD + 17αOHP)/F, and 11DOF/17αOHP, rather than 17αOHP, for 21OHD screening.
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Affiliation(s)
| | - Atsumi Tsuji-Hosokawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Atsuko Hashimoto
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Kaoru Konishi
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Nobuyuki Ishige
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Harumi Yajima
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Akito Sutani
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Hisae Nakatani
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Maki Gau
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Toshihiro Tajima
- Department of Pediatrics, Jichi Medical University, Tochigi 329-0498, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University, School of Medicine, Tokyo 160-8582, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Kenichi Kashimada
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
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22
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Lawrence N, Bacila I, Dawson J, Bryce J, Ali SR, van den Akker ELT, Bachega TASS, Baronio F, Birkebæk NH, Bonfig W, van der Grinten HC, Costa EC, de Vries L, Elsedfy H, Güven A, Hannema S, Iotova V, van der Kamp HJ, Clemente M, Lichiardopol CR, Milenkovic T, Neumann U, Nordenström A, Poyrazoğlu Ş, Probst‐Scheidegger U, De Sanctis L, Tadokoro‐Cuccaro R, Thankamony A, Vieites A, Yavaş Z, Faisal Ahmed S, Krone N. Analysis of therapy monitoring in the International Congenital Adrenal Hyperplasia Registry. Clin Endocrinol (Oxf) 2022; 97:551-561. [PMID: 35781728 PMCID: PMC9796837 DOI: 10.1111/cen.14796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Congenital adrenal hyperplasia (CAH) requires exogenous steroid replacement. Treatment is commonly monitored by measuring 17-OH progesterone (17OHP) and androstenedione (D4). DESIGN Retrospective cohort study using real-world data to evaluate 17OHP and D4 in relation to hydrocortisone (HC) dose in CAH patients treated in 14 countries. PATIENTS Pseudonymized data from children with 21-hydroxylase deficiency (21OHD) recorded in the International CAH Registry. MEASUREMENTS Assessments between January 2000 and October 2020 in patients prescribed HC were reviewed to summarise biomarkers 17OHP and D4 and HC dose. Longitudinal assessment of measures was carried out using linear mixed-effects models (LMEM). RESULTS Cohort of 345 patients, 52.2% female, median age 4.3 years (interquartile range: 3.1-9.2) were taking a median 11.3 mg/m2 /day (8.6-14.4) of HC. Median 17OHP was 35.7 nmol/l (3.0-104.0). Median D4 under 12 years was 0 nmol/L (0-2.0) and above 12 years was 10.5 nmol/L (3.9-21.0). There were significant differences in biomarker values between centres (p < 0.05). Correlation between D4 and 17OHP was good in multiple regression with age (p < 0.001, R2 = 0.29). In longitudinal assessment, 17OHP levels did not change with age, whereas D4 levels increased with age (p < 0.001, R2 = 0.08). Neither biomarker varied directly with dose or weight (p > 0.05). Multivariate LMEM showed HC dose decreasing by 1.0 mg/m2 /day for every 1 point increase in weight standard deviation score. DISCUSSION Registry data show large variability in 17OHP and D4 between centres. 17OHP correlates with D4 well when accounting for age. Prescribed HC dose per body surface area decreased with weight gain.
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Affiliation(s)
- Neil Lawrence
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
- Sheffield Children's Hospital NHS Foundation TrustSheffieldUK
| | - Irina Bacila
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
| | - Jeremy Dawson
- Institute of Work Psychology, Management SchoolUniversity of SheffieldSheffieldUK
- School of Health and Related Research, University of SheffieldSheffieldUK
| | - Jillian Bryce
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
| | - Salma R. Ali
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Developmental Endocrinology Research GroupUniversity of GlasgowGlasgowUK
| | - Erica L. T. van den Akker
- Department of Pediatric Endocrinology, Sophia Children's HospitalErasmus Medical CentreRotterdamthe Netherlands
| | - Tânia A. S. S. Bachega
- Hormones and Molecular Genetics Laboratory LIM 42, Department of Internal MedicineUniversity of Sao PauloSao PauloBrazil
| | - Federico Baronio
- Department of Medical and Surgical Sciences, Pediatric Unit, Endo‐ERN Center for Rare Endocrine DiseasesS. Orsola‐Malpighi University HospitalBolognaItaly
| | | | - Walter Bonfig
- Department of PediatricsTechnical University MunichMunichGermany
- Department of PediatricsKlinikum Wels‐GrieskirchenWelsAustria
| | - Hedi C. van der Grinten
- Department of Pediatric EndocrinologyRadboud University Medical CentreNijmegenthe Netherlands
- Amalia Children's HospitalRadboud University Medical CentreNijmegenthe Netherlands
| | - Eduardo C. Costa
- Pediatric Surgery ServiceHospital de Clínicas de Porto AlegrePorto AlegreBrazil
| | - Liat de Vries
- Institute for Diabetes and EndocrinologySchneider's Children Medical Center of IsraelPetah‐TikvahIsrael
| | - Heba Elsedfy
- Pediatrics DepartmentAin Shams UniversityCairoEgypt
| | - Ayla Güven
- Baskent University Istanbul HospitalPediatric EndocrinologyIstanbulTurkey
| | - Sabine Hannema
- Department of Paediatric Endocrinology, Erasmus MC, Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamthe Netherlands
- Department of PaediatricsLeiden University Medical CentreLeidenthe Netherlands
| | - Violeta Iotova
- Department of PaediatricsMedical University of VarnaVarnaBulgaria
| | - Hetty J. van der Kamp
- Pediatric Endocrinology Wilhelmina Children's HospitalUniversity Medical Centre UtrechtUtrechtthe Netherlands
| | - María Clemente
- Paediatric Endocrinology, Hospital Universitario Vall d'HebronCIBER de Enfermedades Raras (CIBERER) ISCIIIBarcelonaSpain
| | | | - Tatjana Milenkovic
- Department of EndocrinologyInstitute for Mother and Child Healthcare of Serbia “Dr Vukan Čupić”BelgradeSerbia
| | - Uta Neumann
- Institute for Experimental Pediatric Endocrinology and Center for Chronically Sick Children, Charite‐UniversitätsmedizinBerlinGermany
| | - Ana Nordenström
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Paediatric Endocrinology, Astrid Lindgren Children HospitalKarolinska University HospitalStockholmSweden
| | - Şukran Poyrazoğlu
- Istanbul Faculty of Medicine, Paediatric Endocrinology UnitIstanbul UniversityIstanbulTurkey
| | | | - Luisa De Sanctis
- Paediatric EndocrinologyRegina Margherita Children's HospitalTorinoItaly
- Department of Public Sciences and PediatricsUniversity of TorinoTorinoItaly
| | - Rieko Tadokoro‐Cuccaro
- Department of PediatricsUniversity of Cambridge, Cambridge, United Kingdom Biomedical CampusCambridgeUK
| | - Ajay Thankamony
- Department of PediatricsUniversity of Cambridge, Cambridge, United Kingdom Biomedical CampusCambridgeUK
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas (CEDIE‐CONICET), Hospital de Niños Ricardo GutiérrezBuenos AiresArgentina
| | - Zehra Yavaş
- Pediatric Endocrinology and DiabetesMarmara UniversityIstanbulTurkey
| | - Syed Faisal Ahmed
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Office for Rare ConditionsRoyal Hospital for Children & Queen Elizabeth University HospitalGlasgowUK
- Developmental Endocrinology Research GroupUniversity of GlasgowGlasgowUK
| | - Nils Krone
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
- Sheffield Children's Hospital NHS Foundation TrustSheffieldUK
- Department of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität DresdenDresdenGermany
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De Clercq E, Starke G, Rost M. "Waking up" the sleeping metaphor of normality in connection to intersex or DSD: a scoping review of medical literature. HISTORY AND PHILOSOPHY OF THE LIFE SCIENCES 2022; 44:50. [PMID: 36282442 PMCID: PMC9596528 DOI: 10.1007/s40656-022-00533-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 08/31/2022] [Indexed: 06/16/2023]
Abstract
The aim of the study is to encourage a critical debate on the use of normality in the medical literature on DSD or intersex. For this purpose, a scoping review was conducted to identify and map the various ways in which "normal" is used in the medical literature on DSD between 2016 and 2020. We identified 75 studies, many of which were case studies highlighting rare cases of DSD, others, mainly retrospective observational studies, focused on improving diagnosis or treatment. The most common use of the adjective normal was in association with phenotypic sex. Overall, appearance was the most commonly cited criteria to evaluate the normality of sex organs. More than 1/3 of the studies included also medical photographs of sex organs. This persistent use of normality in reference to phenotypic sex is worrisome given the long-term medicalization of intersex bodies in the name of a "normal" appearance or leading a "normal" life. Healthcare professionals should be more careful about the ethical implications of using photographs in publications given that many intersex persons describe their experience with medical photography as dehumanizing.
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Affiliation(s)
- Eva De Clercq
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
- Institute of Biomedical Ethics and History of Medicine, University of Zürich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
| | - Georg Starke
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
- College of Humanities, École Polytechnique Fédérale de Lausanne, Rte Cantonale, 1015 Lausanne, Switzerland
| | - Michael Rost
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
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Evaluation of a New Laboratory Protocol for Newborn Screening for Congenital Adrenal Hyperplasia in New Zealand. Int J Neonatal Screen 2022; 8:ijns8040056. [PMID: 36278626 PMCID: PMC9590017 DOI: 10.3390/ijns8040056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
Between 2005 and 2021, 49 cases of classical congenital adrenal hyperplasia were diagnosed in New Zealand, 39 were detected in newborns and 10 were not detected by screening. Currently, for every case of CAH detected by screening, 10 false-positive tests are encountered. Second-tier liquid chromatography-tandem mass spectrometry (LCMSMS) has the potential to improve screening sensitivity and specificity. A new laboratory protocol for newborn screening for CAH was evaluated. Birthweight-adjusted thresholds for first- and second-tier 17-hydroxyprogesterone, second-tier 21-deoxycortisol and a steroid ratio were applied to 4 years of newborn screening data. The study was enriched with 35 newborn screening specimens from confirmed CAH cases. Newborn screening was conducted on 232,542 babies, and 11 cases of classical CAH were detected between 2018 and 2021. There were 98 false-positive tests (specificity 99.96%, PPV = 10.1%) using the existing protocol. Applying the new protocol, the same 11 cases were detected, and there were 13 false-positive tests (sensitivity > 99.99%, PPV = 45.8%, (X2 test p < 0.0001). Incorporating the retrospective specimens, screening sensitivity for classical CAH was 78% (existing protocol), compared to 87% for the new protocol (X2 test p = 0.1338). Implementation of LCMSMS as a second-tier test will improve newborn screening for classical CAH in New Zealand.
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Nicola AG, Carsote M, Gheorghe AM, Petrova E, Popescu AD, Staicu AN, Țuculină MJ, Petcu C, Dascălu IT, Tircă T. Approach of Heterogeneous Spectrum Involving 3beta-Hydroxysteroid Dehydrogenase 2 Deficiency. Diagnostics (Basel) 2022; 12:diagnostics12092168. [PMID: 36140569 PMCID: PMC9497988 DOI: 10.3390/diagnostics12092168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/23/2022] Open
Abstract
We aim to review data on 3beta-hydroxysteroid dehydrogenase type II (3βHSD2) deficiency. We identified 30 studies within the last decade on PubMed: 1 longitudinal study (N = 14), 2 cross-sectional studies, 1 retrospective study (N = 16), and 26 case reports (total: 98 individuals). Regarding geographic area: Algeria (N = 14), Turkey (N = 31), China (2 case reports), Morocco (2 sisters), Anatolia (6 cases), and Italy (N = 1). Patients’ age varied from first days of life to puberty; the oldest was of 34 y. Majority forms displayed were salt-wasting (SW); some associated disorders of sexual development (DSD) were attendant also—mostly 46,XY males and mild virilisation in some 46,XX females. SW pushed forward an early diagnosis due to severity of SW crisis. The clinical spectrum goes to: premature puberty (80%); 9 with testicular adrenal rest tumours (TARTs); one female with ovarian adrenal rest tumours (OARTs), and some cases with adrenal hyperplasia; cardio-metabolic complications, including iatrogenic Cushing’ syndrome. More incidental (unusual) associations include: 1 subject with Barter syndrome, 1 Addison’s disease, 2 subjects of Klinefelter syndrome (47,XXY/46,XX, respective 47,XXY). Neonatal screening for 21OHD was the scenario of detection in some cases; 17OHP might be elevated due to peripheral production (pitfall for misdiagnosis of 21OHD). An ACTH stimulation test was used in 2 studies. Liquid chromatography tandem–mass spectrometry unequivocally sustains the diagnostic by expressing high baseline 17OH-pregnenolone to cortisol ratio as well as 11-oxyandrogen levels. HSD3B2 gene sequencing was provided in 26 articles; around 20 mutations were described as “novel pathogenic mutation” (frameshift, missense or nonsense); many subjects had a consanguineous background. The current COVID-19 pandemic showed that CAH-associated chronic adrenal insufficiency is at higher risk. Non-adherence to hormonal replacement contributed to TARTs growth, thus making them surgery candidates. To our knowledge, this is the largest study on published cases strictly concerning 3βHSD2 deficiency according to our methodology. Adequate case management underlines the recent shift from evidence-based medicine to individualized (patient-oriented) medicine, this approach being particularly applicable in this exceptional and challenging disorder.
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Affiliation(s)
- Andreea Gabriela Nicola
- Department of Oro-Dental Prevention, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 011863 Bucharest, Romania
- Department of Endocrinology, C.I. Parhon National Institute of Endocrinology, Aviatorilor Ave 34-38, Sector 1, 011863 Bucharest, Romania
- Correspondence: (M.C.); (A.-M.G.); Tel.: +40-744-851-934 (M.C.)
| | - Ana-Maria Gheorghe
- Department of Endocrinology, C.I. Parhon National Institute of Endocrinology, Aviatorilor Ave 34-38, Sector 1, 011863 Bucharest, Romania
- Correspondence: (M.C.); (A.-M.G.); Tel.: +40-744-851-934 (M.C.)
| | - Eugenia Petrova
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 011863 Bucharest, Romania
- Department of Endocrinology, C.I. Parhon National Institute of Endocrinology, Aviatorilor Ave 34-38, Sector 1, 011863 Bucharest, Romania
| | - Alexandru Dan Popescu
- Department of Endodontics, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Adela Nicoleta Staicu
- Department of Endodontics, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mihaela Jana Țuculină
- Department of Endodontics, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Cristian Petcu
- Department of Endodontics, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Ionela Teodora Dascălu
- Department of Orthodontics, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Tiberiu Tircă
- Department of Oro-Dental Prevention, Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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26
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Zhan X, Han L, Qiu W, Gu X, Guo J, Chang S, Wang Y, Zhang H. Steroid profile in dried blood spots by liquid chromatography tandem mass spectrometry: Application to newborn screening for congenital adrenal hyperplasia in China. Steroids 2022; 185:109056. [PMID: 35660382 DOI: 10.1016/j.steroids.2022.109056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 04/09/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Newborn screening for congenital adrenal hyperplasia (CAH) using 17-hydroxyprogesterone dissociation-enhanced, lanthanide fluorescence immunoassay (DELFIA) generates a large number of false-positive results. The present study aimed to improve the sensitivity of the CAH neonatal screening by including second-tier steroid profiling in dried blood spots (DBS) using liquid chromatography tandem mass spectrometry (LC-MS/MS). METHODS We developed and validated a LC-MS/MS method for simultaneous determination of six steroids in DBS, including androstenedione, testosterone, 17-hydroxyprogesterone, 11-deoxycortisol, 21-deoxycortisol, and cortisol. Two 5-mm blood spots were eluted by internal standard working solution. We analyzed 1170 DBS samples from neonates to determine gestational age-specific reference intervals. In order to test the specificity of the second-tier method, we analyzed 707 cards with a positive screening by DELFIA. RESULTS Values of intra- and inter-day precision coefficients of variance and accuracy were 2.0%-13.3% and 85.8%-114.5%, respectively. Recovery ranged from 85.0% to 106.9%. The lower limit of quantification was 0.5 ng/mL for 21-deoxycortisol, 0.25 ng/mL for 17-hydroxyprogesterone and cortisol, and 0.1 ng/mL for testosterone, androstenedione, and 11-deoxycortisol. In addition, the linearity range was 0.25-50 ng/mL (R2 > 0.99). According to the 17-hydroxyprogesterone levels and ratios of (androstenedione + 17-hydroxyprogesterone)/cortisol in the 707 positive screening samples, 77 neonates should receive recall visit. The number of false-positive results reduced by 89.1%. Totally, 18 newborns were diagnosed with 21-hydroxylase deficiency, one with P450 oxidoreductase deficiency and one with 11β-hydroxylase deficiency. With two-tier screening, the positive predictive value increased to 26.0%. CONCLUSIONS The second-tier steroid profiling by LC-MS/MS reduced the false-positive rate and improved the positive predictive value of CAH screening. We suggest applying this steroid profiling assay as a second-tier test for CAH screening in China.
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Affiliation(s)
- Xia Zhan
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Lianshu Han
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Wenjuan Qiu
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Xuefan Gu
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Jun Guo
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Siyu Chang
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Yu Wang
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China
| | - Huiwen Zhang
- Pediatric Endocrinology and Genetic, Xinhua Hospital, Shanghai Institute for Pediatric Research, Shanghai Jiao Tong University School of Medicine, China.
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27
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Choi MH. Clinical and Technical Aspects in Free Cortisol Measurement. Endocrinol Metab (Seoul) 2022; 37:599-607. [PMID: 35982612 PMCID: PMC9449105 DOI: 10.3803/enm.2022.1549] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/22/2022] [Accepted: 07/28/2022] [Indexed: 11/11/2022] Open
Abstract
Accurate measurement of cortisol is critical in adrenal insufficiency as it reduces the risk associated with misdiagnosis and supports the optimization of stress dose. Comprehensive assays have been developed to determine the levels of bioactive free cortisol and their clinical and analytical efficacies have been extensively discussed because the level of total cortisol is affected by changes in the structure or circulating levels of corticoid-binding globulin and albumin, which are the main reservoirs of cortisol in the human body. Antibody-based immunoassays are routinely used in clinical laboratories; however, the lack of molecular specificity in cortisol assessment limits their applicability to characterize adrenocortical function. Improved specificity and sensitivity can be achieved by mass spectrometry coupled with chromatographic separation methods, which is a cutting-edge technology to measure individual as well as a panel of steroids in a single analytical run. The purpose of this review is to introduce recent advances in free cortisol measurement from the perspectives of clinical specimens and issues associated with prospective analytical technologies.
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Affiliation(s)
- Man Ho Choi
- Center for Advanced Biomolecular Recognition, Korea Institute of Science and Technology, Seoul, Korea
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28
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Houang M, Nguyen-Khoa T, Eguether T, Ribault B, Brabant S, Polak M, Netchine I, Lamazière A. Analysis of a pitfall in congenital adrenal hyperplasia newborn screening: evidence of maternal use of corticoids detected on dried blood spot. Endocr Connect 2022; 11:EC-22-0101. [PMID: 35521805 PMCID: PMC9254290 DOI: 10.1530/ec-22-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/29/2022] [Indexed: 11/08/2022]
Abstract
Neonatal screening for congenital adrenal hyperplasia (CAH) faces many specific challenges. It must be done using a performant analytical approach that combines sensitivity and specificity to capture the potential causes of mortality during the first week of life, such as salt wasting and glucocorticoid deficiency. Here, we confirm that maternal inhaled corticosteroid intake during pregnancy is a possible cause of missed CAH diagnosis. Thanks to liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) analysis, we were able to quantify endogenous steroid metabolites and also detect the presence of exogenous steroids in the dried blood spot of a newborn. Adding LC-MS/MS analysis as second-tier test, especially one that includes both 17-hydroxyprogesterone and 21-deoxycortisol measurements, would probably improve CAH diagnosis. In familial neonatal screening one could also look for maternal corticosteroid therapies that are hidden to prevent false-negative tests.
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Affiliation(s)
- Muriel Houang
- Laboratoire des Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP Sorbonne Université, Paris, France
| | - Thao Nguyen-Khoa
- Centre Régional de Dépistage Néonatal-Ile de France, Hôpital Necker-Enfants Malades, AP-HP Centre Université de Paris, Paris, France
| | - Thibaut Eguether
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, Paris, France
- Département de Métabolomique Clinique, Hôpital Saint-Antoine, AP-HP Sorbonne Université, Paris, France
| | - Bettina Ribault
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, Paris, France
- Département de Métabolomique Clinique, Hôpital Saint-Antoine, AP-HP Sorbonne Université, Paris, France
| | - Séverine Brabant
- Laboratoire d’Explorations Fonctionnelles, Hôpital Necker-Enfants Malades, AP-HP Centre Université de Paris, Paris, France
| | - Michel Polak
- Centre Régional de Dépistage Néonatal-Ile de France, Hôpital Necker-Enfants Malades, AP-HP Centre Université de Paris, Paris, France
- Université de Paris, INSERM, Institut IMAGINE, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Irène Netchine
- Laboratoire des Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP Sorbonne Université, Paris, France
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, Paris, France
- Hôpital Armand Trousseau, AP-HP Sorbonne Université, Paris, France
| | - Antonin Lamazière
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, Paris, France
- Département de Métabolomique Clinique, Hôpital Saint-Antoine, AP-HP Sorbonne Université, Paris, France
- Correspondence should be addressed to A Lamazière:
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29
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Agnani H, Bachelot G, Eguether T, Ribault B, Fiet J, Le Bouc Y, Netchine I, Houang M, Lamazière A. A proof of concept of a machine learning algorithm to predict late-onset 21-hydroxylase deficiency in children with premature pubic hair. J Steroid Biochem Mol Biol 2022; 220:106085. [PMID: 35292353 DOI: 10.1016/j.jsbmb.2022.106085] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
In children with premature pubarche (PP), late onset 21-hydroxylase deficiency (21-OHD), also known as non-classical congenital adrenal hyperplasia (NCCAH), can be routinely ruled out by an adrenocorticotropic hormone (ACTH) test. Using liquid chromatography-tandem mass spectrometry (LC-MS/MS), a quantitative assay of the circulating steroidome can be obtained from a single blood sample. We hypothesized that, by applying multivariate machine learning (ML) models to basal steroid profiles and clinical parameters of 97 patients, we could distinguish children with PP from those with NCCAH, without the need for ACTH testing. Every child presenting with PP at the Trousseau Pediatric Endocrinology Unit between 2016 and 2018 had a basal and stimulated steroidome. Patients with central precocious puberty were excluded. The first set of patients (year 1, training set, n = 58), including 8 children with NCCAH verified by ACTH test and genetic analysis, was used to train the model. Subsequently, a validation set of an additional set of patients (year 2, n = 39 with 5 NCCAH) was obtained to validate our model. We designed a score based on an ML approach (orthogonal partial least squares discriminant analysis). A metabolic footprint was assigned for each patient using clinical data, bone age, and adrenal steroid levels recorded by LC-MS/MS. Supervised multivariate analysis of the training set (year 1) and validation set (year 2) was used to validate our score. Based on selected variables, the prediction score was accurate (100%) at differentiating premature pubarche from late onset 21-OHD patients. The most significant variables were 21-deoxycorticosterone, 17-hydroxyprogesterone, and 21-deoxycortisol steroids. We proposed a new test that has excellent sensitivity and specificity for the diagnosis of NCCAH, due to an ML approach.
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Affiliation(s)
- Héléna Agnani
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Sorbonne Université, Paris, France; Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | - Guillaume Bachelot
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France
| | - Thibaut Eguether
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France
| | - Bettina Ribault
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France
| | - Jean Fiet
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France
| | - Yves Le Bouc
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Sorbonne Université, Paris, France; Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | - Irène Netchine
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Sorbonne Université, Paris, France; Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | - Muriel Houang
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Sorbonne Université, Paris, France; Explorations Fonctionnelles Endocriniennes, Hôpital Armand Trousseau, AP-HP, 26 Av Dr Netter, Paris 75012, France
| | - Antonin Lamazière
- Sorbonne Université, Saint Antoine Research center, CRSA, INSERM, Département de Métabolomique Clinique, Hôpital Saint Antoine, AP-HP/Sorbonne Université, Paris, France.
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Lind-Holst M, Bækvad-Hansen M, Berglund A, Cohen AS, Melgaard L, Skogstrand K, Duno M, Main KM, Hougaard DM, Gravholt CH, Hansen D. Neonatal Screening for Congenital Adrenal Hyperplasia in Denmark: 10 Years of Experience. Horm Res Paediatr 2022; 95:35-42. [PMID: 35114680 DOI: 10.1159/000522230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/14/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Early detection of salt-wasting congenital adrenal hyperplasia (SW-CAH) is important to reduce CAH-related morbidity. However, neonatal screening has shown to have a low positive predictive value (PPV), especially among preterm newborns. Here, the Danish CAH screening is evaluated by comparing incidence and morbidity of SW-CAH 10 years before and after introduction of screening. Furthermore, sensitivity, specificity, and PPV are determined. METHODS All newborns in Denmark born during 1999-2018 and diagnosed with SW-CAH were identified in the Danish National Patient Registry and/or at the Department of Clinical Genetics, Rigshospitalet. Newborns with a positive neonatal CAH screening were identified at Statens Serum Institut. Correct diagnosis was evaluated by medical record review. RESULTS A total of 65 newborns with SW-CAH were identified. The incidence of SW-CAH was 5:100,000 both before and after introduction of screening. Performance of sensitivity and specificity of the screening were 97% and 100%, respectively, and the PPV was 55% for the given period. Stratified according to gestational age, the PPV was 33% and 61% for pre -and fullterm newborns, respectively. Though not significant, the proportion of newborns presenting with SW-crisis decreased after introduction of screening from 29% versus 10% (p = 0.07). DISCUSSION AND CONCLUSION Neonatal screening for SW-CAH has not led to an increase in the incidence of newborns diagnosed with SW-CAH. The screening algorithm has effectively identified newborns with SW-CAH. After 2009, there was a tendency toward a lower proportion of newborns with SW-crisis at diagnosis. Finally, the study emphasizes the benefits of using second-tier screening as well as repeated screening of premature newborns.
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Affiliation(s)
- Marie Lind-Holst
- Department of Pediatrics, Hans Christian Andersen Children's Hospital, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Marie Bækvad-Hansen
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Agnethe Berglund
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Arieh S Cohen
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Lars Melgaard
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Kristin Skogstrand
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Morten Duno
- Department of Clinical Genetics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Katharina M Main
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
| | - David Michael Hougaard
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Claus Højbjerg Gravholt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Dorte Hansen
- Department of Pediatrics, Hans Christian Andersen Children's Hospital, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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31
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Held PK, Bialk ER, Lasarev MR, Allen DB. 21-Deoxycortisol is a Key Screening Marker for 21-Hydroxylase Deficiency. J Pediatr 2022; 242:213-219.e1. [PMID: 34780778 DOI: 10.1016/j.jpeds.2021.10.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/11/2021] [Accepted: 10/31/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To assess whether 21-deoxycortisol (21deoxy) can be used to predict 21-hydroxylase deficiency (21OHD) in newborns and to evaluate the influence of gestational age and the timing of collection on 21deoxy concentrations. STUDY DESIGN 17-hydroxyprogesterone (17OHP) and 21deoxy levels were measured in 906 newborn screening specimens (851 unaffected newborns, 55 confirmed cases of 21OHD) to compare their ability to identify babies with 21OHD. In addition, these 2 steroids were assessed in the unaffected cohort to determine the influence of gestational age (ranging from 23 to 42 weeks) and the timing of specimen collection on the measured concentrations. RESULTS The gestational age of the newborn impacted both 17OHP and 21deoxy concentrations, but the degree of influence was more substantial for 17OHP. Timing of collection did not affect 21deoxy concentration. Moreover, 21deoxy was a better predictor of 21OHD status compared with 17OHP, with little overlap in concentrations between the unaffected population and confirmed cases of 21OHD. A streamlined decision tree using solely 21deoxy (cutoff value, 0.85 ng/mL) yielded a 91.7% positive predictive value for 21OHD screening. CONCLUSIONS Our findings demonstrate that 21deoxy is a key disease marker of 21OHD and can be used to improve the accuracy of newborn screening for this disorder.
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Affiliation(s)
- Patrice K Held
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI; Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Eric R Bialk
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michael R Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - David B Allen
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
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32
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 176] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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Maternal Signatures of Cortisol in First Trimester Small-for-Gestational Age. Reprod Sci 2022; 29:1498-1505. [PMID: 35001327 DOI: 10.1007/s43032-021-00822-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
The objective of this study was to identify predictable maternal serum signatures of cortisol metabolism during the first trimester of women who are expected to deliver small-for-gestational-age (SGA) neonates. This prospective cohort study included 112 pregnant women (with and without SGA, n = 56 each). Maternal serum samples were collected at 10-14 gestational weeks to quantify the levels of cortisol and its precursors and metabolites by liquid chromatography-mass spectrometry. Increased maternal serum levels of tetrahydrocortisol (11.82 ± 8.16 ng/mL vs. 7.51 ± 2.90 ng/mL, P < 0.005) and decreased 21-deoxycortisol (2.98 ± 1.36 ng/mL vs. 4.33 ± 2.06 ng/mL, P < 0.0001) were observed in pregnant women carrying SGA fetus. In conjunction with individual steroid levels, metabolic ratios corresponding to the activity of related enzymes were calculated. In addition to increased tetrahydrocortisol/cortisol ratio (P < 0.006), the SGA group showed a significant increase in the two metabolic ratios including cortisol/11-deoxycortisol (P < 0.03) and cortisol/21-deoxycortisol (P < 0.0003). The receiver operating characteristic (ROC) curve generated in combination with three variables of 21-deoxycortisol concentration and two metabolic ratios of cortisol/21-deoxycortisol and tetrahydrocortisol/cortisol resulted in an area under the ROC curve = 0.824 (95% confidence interval, 0.713-0.918). A significant decrease in maternal serum levels of 21-deoxycortisol and an increase in two metabolic ratios of cortisol/21-deoxycortisol and tetrahydrocortisol/cortisol, indicating cortisol biosynthetic rate, represent potential biomarkers for the prediction of SGA in the first trimester.
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Sahlander F, Bensing S, Falhammar H. Congenital adrenal hyperplasia is a very rare cause of adrenal incidentalomas in Sweden. Front Endocrinol (Lausanne) 2022; 13:1017303. [PMID: 36545328 PMCID: PMC9760763 DOI: 10.3389/fendo.2022.1017303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Undiagnosed congenital adrenal hyperplasia (CAH) can cause adrenal incidentalomas, but the frequency is unclear. OBJECTIVES This study aimed to investigate the prevalence of CAH in a population with adrenal incidentalomas and report the clinical characterization. MATERIAL AND METHODS This was a prospective study performed at a regional hospital from 2016 to 2021. Patients with adrenal incidentalomas were investigated with an adrenocorticotropic hormone (ACTH)-stimulation test in addition to hormonal workup. Serum cortisol and 17-hydroxyprogesterone (17OHP) were analyzed. Individuals with a basal or stimulated 17OHP ≥30 nmol/L were classified as suspicious non-classic CAH, and a CYP21A2-gene analysis was performed in these subjects. RESULTS In total, 320 individuals with adrenal incidentalomas were referred to the center, and of these individuals, an ACTH-stimulation test was performed in 222 (median age, 67 (24-87) years; 58.6% women; and 11.7% with bilateral lesions). None of the individuals presented a basal 17OHP ≥30 nmol/L, but there were 8 (3.6%) who did after ACTH stimulation. Four of these subjects (50%) presented bilateral lesions, and the tumor size was larger compared to that of the individuals with a stimulated 17OHP <30 nmol/L (median, 38 (19-66) vs. 19 (11-85) mm, p=0.001). A CYP21A2 variation (p.Val282Leu) was detected in one of the eight subjects with a stimulated 17OHP ≥30 nmol/L, i.e., the patient was a heterozygotic carrier. None of the eight subjects presented with cortisol insufficiency or clinical signs of hyperandrogenism. CONCLUSIONS The prevalence of non-classic CAH in an adrenal incidentaloma cohort was 3.6% based on stimulated 17OHP and 0% based on gene analysis. CAH should be considered in AI management in selected cases and confirmed by genetic analysis.
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Affiliation(s)
- Fredrik Sahlander
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Falu Hospital, Falun, Sweden
- Center for Clinical Research Dalarna-Uppsala University, Falun, Sweden
- *Correspondence: Fredrik Sahlander,
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
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Finkielstain GP, Vieites A, Bergadá I, Rey RA. Disorders of Sex Development of Adrenal Origin. Front Endocrinol (Lausanne) 2021; 12:770782. [PMID: 34987475 PMCID: PMC8720965 DOI: 10.3389/fendo.2021.770782] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 12/01/2021] [Indexed: 01/24/2023] Open
Abstract
Disorders of Sex Development (DSD) are anomalies occurring in the process of fetal sexual differentiation that result in a discordance between the chromosomal sex and the sex of the gonads and/or the internal and/or external genitalia. Congenital disorders affecting adrenal function may be associated with DSD in both 46,XX and 46,XY individuals, but the pathogenic mechanisms differ. While in 46,XX cases, the adrenal steroidogenic disorder is responsible for the genital anomalies, in 46,XY patients DSD results from the associated testicular dysfunction. Primary adrenal insufficiency, characterized by a reduction in cortisol secretion and overproduction of ACTH, is the rule. In addition, patients may exhibit aldosterone deficiency leading to salt-wasting crises that may be life-threatening. The trophic effect of ACTH provokes congenital adrenal hyperplasia (CAH). Adrenal steroidogenic defects leading to 46,XX DSD are 21-hydroxylase deficiency, by far the most prevalent, and 11β-hydroxylase deficiency. Lipoid Congenital Adrenal Hyperplasia due to StAR defects, and cytochrome P450scc and P450c17 deficiencies cause DSD in 46,XY newborns. Mutations in SF1 may also result in combined adrenal and testicular failure leading to DSD in 46,XY individuals. Finally, impaired activities of 3βHSD2 or POR may lead to DSD in both 46,XX and 46,XY individuals. The pathophysiology, clinical presentation and management of the above-mentioned disorders are critically reviewed, with a special focus on the latest biomarkers and therapeutic development.
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Affiliation(s)
- Gabriela P. Finkielstain
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ignacio Bergadá
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Rodolfo A. Rey
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CEDIE), CONICET – FEI – División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
- Universidad de Buenos Aires, Facultad de Medicina, Departamento de Biología Celular, Histología, Embriología y Genética, Buenos Aires, Argentina
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Abstract
PURPOSE OF REVIEW The aim of this study was to provide a basic overview on human sex development with a focus on involved genes and pathways, and also to discuss recent advances in the molecular diagnostic approaches applied to clinical workup of individuals with a difference/disorder of sex development (DSD). RECENT FINDINGS Rapid developments in genetic technologies and bioinformatics analyses have helped to identify novel genes and genomic pathways associated with sex development, and have improved diagnostic algorithms to integrate clinical, hormonal and genetic data. Recently, massive parallel sequencing approaches revealed that the phenotype of some DSDs might be only explained by oligogenic inheritance. SUMMARY Typical sex development relies on very complex biological events, which involve specific interactions of a large number of genes and pathways in a defined spatiotemporal sequence. Any perturbation in these genetic and hormonal processes may result in atypical sex development leading to a wide range of DSDs in humans. Despite the huge progress in the understanding of molecular mechanisms underlying DSDs in recent years, in less than 50% of DSD individuals, the genetic cause is currently solved at the molecular level.
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Affiliation(s)
- Idoia Martinez de LaPiscina
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital
- Department of Biomedical Research, University of Bern, Bern, Switzerland
- Biocruces Bizkaia Health Research Institute, Cruces University Hospital, UPV/EHU, CIBERER, CIBERDEM, ENDO-ERN, Barakaldo, Spain
| | - Christa E Flück
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital
- Department of Biomedical Research, University of Bern, Bern, Switzerland
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Ahmed SF, Achermann J, Alderson J, Crouch NS, Elford S, Hughes IA, Krone N, McGowan R, Mushtaq T, O'Toole S, Perry L, Rodie ME, Skae M, Turner HE. Society for Endocrinology UK Guidance on the initial evaluation of a suspected difference or disorder of sex development (Revised 2021). Clin Endocrinol (Oxf) 2021; 95:818-840. [PMID: 34031907 DOI: 10.1111/cen.14528] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/30/2021] [Accepted: 05/13/2021] [Indexed: 11/26/2022]
Abstract
It is paramount that any child or adolescent with a suspected difference or disorder of sex development (DSD) is assessed by an experienced clinician with adequate knowledge about the range of conditions associated with DSD and is discussed with the regional DSD service. In most cases, the paediatric endocrinologist within this service acts as the first point of contact but involvement of the regional multidisciplinary service will also ensure prompt access to specialist psychology and nursing care. The underlying pathophysiology of DSD and the process of delineating this should be discussed with the parents and affected young person with all diagnostic tests undertaken in a timely fashion. Finally, for rare conditions such as these, it is imperative that clinical experience is shared through national and international clinical and research collaborations.
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Affiliation(s)
- S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
- Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, UK
- Office for Rare Conditions, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - John Achermann
- Genetics & Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Julie Alderson
- Psychological Health Services, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | - Naomi S Crouch
- Department of Women's Health, St Michael's Hospital, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | | | - Ieuan A Hughes
- DSDFamilies, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Ruth McGowan
- Developmental Endocrinology Research Group, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
- West of Scotland Centre for Genomic Medicine, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Talat Mushtaq
- Department of Paediatric Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Stuart O'Toole
- Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, UK
- Department of Paediatric Urology, Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Leslie Perry
- Department of Clinical Biochemistry, Croydon University Hospital, London, UK
| | - Martina E Rodie
- Royal Hospital for Children, NHS Greater Glasgow & Clyde, Glasgow, UK
- Office for Rare Conditions, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
- Department of Neonatology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mars Skae
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Helen E Turner
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Granada ML, Audí L. El laboratorio en el diagnóstico multidisciplinar del desarrollo sexual anómalo o diferente (DSD). ADVANCES IN LABORATORY MEDICINE 2021; 2:481-493. [PMCID: PMC10197318 DOI: 10.1515/almed-2020-0119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/24/2021] [Indexed: 06/28/2023]
Abstract
Objetivos El desarrollo de las características sexuales femeninas o masculinas acontece durante la vida fetal, determinándose el sexo genético, el gonadal y el sexo genital interno y externo (femenino o masculino). Cualquier discordancia en las etapas de diferenciación ocasiona un desarrollo sexual anómalo o diferente (DSD) que se clasifica según la composición de los cromosomas sexuales del cariotipo. Contenido En este capítulo se abordan la fisiología de la determinación y el desarrollo de las características sexuales femeninas o masculinas durante la vida fetal, la clasificación general de los DSD y su estudio diagnóstico clínico, bioquímico y genético que debe ser multidisciplinar. Los estudios bioquímicos deben incluir, además de las determinaciones bioquímicas generales, análisis de hormonas esteroideas y peptídicas, en condiciones basales o en pruebas funcionales de estimulación. El estudio genético debe comenzar con la determinación del cariotipo al que seguirá un estudio molecular en los cariotipos 46,XX ó 46,XY, orientado a la caracterización de un gen candidato. Además, se expondrán de manera específica los marcadores bioquímicos y genéticos en los DSD 46,XX, que incluyen el desarrollo gonadal anómalo (disgenesias, ovotestes y testes), el exceso de andrógenos de origen fetal (el más frecuente), fetoplacentario o materno y las anomalías del desarrollo de los genitales internos. Perspectivas El diagnóstico de un DSD requiere la contribución de un equipo multidisciplinar coordinado por un clínico y que incluya los servicios de bioquímica y genética clínica y molecular, un servicio de radiología e imagen y un servicio de anatomía patológica.
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Affiliation(s)
- Maria Luisa Granada
- Department of Clinical Biochemistry, Hospital Germans Trias i Pujol, Autonomous University of Barcelona, Badalona, España
| | - Laura Audí
- Growth and Development Research Group, Vall d’Hebron Research Institute (VHIR), Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Barcelona, Catalonia, España
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Granada ML, Audí L. The laboratory in the multidisciplinary diagnosis of differences or disorders of sex development (DSD): I) Physiology, classification, approach, and methodologyII) Biochemical and genetic markers in 46,XX DSD. ADVANCES IN LABORATORY MEDICINE 2021; 2:468-493. [PMID: 37360895 PMCID: PMC10197333 DOI: 10.1515/almed-2021-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/24/2021] [Indexed: 06/28/2023]
Abstract
Objectives The development of female or male sex characteristics occurs during fetal life, when the genetic, gonadal, and internal and external genital sex is determined (female or male). Any discordance among sex determination and differentiation stages results in differences/disorders of sex development (DSD), which are classified based on the sex chromosomes found on the karyotype. Content This chapter addresses the physiological mechanisms that determine the development of female or male sex characteristics during fetal life, provides a general classification of DSD, and offers guidance for clinical, biochemical, and genetic diagnosis, which must be established by a multidisciplinary team. Biochemical studies should include general biochemistry, steroid and peptide hormone testing either at baseline or by stimulation testing. The genetic study should start with the determination of the karyotype, followed by a molecular study of the 46,XX or 46,XY karyotypes for the identification of candidate genes. Summary 46,XX DSD include an abnormal gonadal development (dysgenesis, ovotestes, or testes), an androgen excess (the most frequent) of fetal, fetoplacental, or maternal origin and an abnormal development of the internal genitalia. Biochemical and genetic markers are specific for each group. Outlook Diagnosis of DSD requires the involvement of a multidisciplinary team coordinated by a clinician, including a service of biochemistry, clinical, and molecular genetic testing, radiology and imaging, and a service of pathological anatomy.
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Affiliation(s)
- Maria Luisa Granada
- Department of Clinical Biochemistry, Hospital Germans Trias i Pujol, Autonomous University of Barcelona, Badalona, Spain
| | - Laura Audí
- Growth and Development Research Group, Vall d’Hebron Research Institute (VHIR), Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Barcelona, Catalonia, Spain
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Costa-Barbosa FA, Carvalho VM, Oliveira KC, Vieira JGH, Kater CE. Reassessment of predictive values of ACTH-stimulated serum 21-deoxycortisol and 17-hydroxyprogesterone to identify CYP21A2 heterozygote carriers and nonclassic subjects. Clin Endocrinol (Oxf) 2021; 95:677-685. [PMID: 34231242 DOI: 10.1111/cen.14550] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Heterozygotes (HZs) for 21-hydroxylase deficiency (21OHD) are highly prevalent, ranging from 1:60 to 1:11 for classic and nonclassic (NC) forms, respectively. Detection of HZ and asymptomatic NC by CYP21A2 genotyping is valuable for genetic counselling, but costly, complex and narrowly available. Adrenocorticotropic hormone (ACTH)-stimulated serum 17-hydroxyprogesterone (17P) and 21-deoxycortisol (21DF) discriminate 21OHD phenotypes effectively, notably if measured simultaneously by liquid chromatography-tandem mass spectrometry (LC-MS/MS). OBJECTIVE This study was performed to reassess former LC-MS/MS-defined post-ACTH 21DF, 17P and cortisol (F) cutoffs in family members at risk for 21OHD. DESIGN AND PATIENTS Prospective study in which we screened 58 asymptomatic relatives from families with 21OHD patients and compared post-ACTH steroid phenotypes with subsequent genotypes. RESULTS Post-ACTH 21DF, 17P, F and (21DF + 17P)/F ratio segregate NC, HZ and wild-type (WT) phenotypes (subsequently genotyped) with some overlap. New receiver operating characteristic curve-defined cutoffs for post-ACTH 21DF, 17P and (21DF + 17P)/F ratio are 60 ng/dl, 310 ng/dl and 12 (unitless). Twenty-six of 33 HZ and all 6 NC (82.1%) had post-ACTH 21DF > 60 and 17P > 310 ng/dl, whereas 17/19 WT (89.5%) had values below cutoffs. Post-ACTH 21DF and 17P had a strong positive correlation (r = .9558; p < .001). A (21DF + 17P)/F ratio > 12 correctly identified 36 of 39 HZ plus NC (92.3% sensitivity) with 84.2% specificity (16 of 19 WT). Given the high frequency of 21OHD HZ, the negative prediction of ratio values below 12 excludes heterozygosity in 99.8% and 99.1% for classic and NC mutations, respectively. CONCLUSIONS Reassessed ACTH-stimulated 21DF and 17P cutoffs by LC-MS/MS (60 and 310 ng/dl, respectively) correctly recognised 82.5% HZ plus NC, but combined precursor-to-product ratio ([21DF + 17P]/F) cutoff of 12 was superior, identifying 92.3% HZ plus NC. Since one WT subject is an outlier (potential HZ), these values would be somewhat better reinforcing their utility for screening asymptomatic relatives at risk for 21OHD.
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Affiliation(s)
- Flávia A Costa-Barbosa
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Steroids Laboratory, Federal University of São Paulo Medical School, EPM/UNIFESP, São Paulo, Sao Paulo, Brazil
- Research and Development Division, Fleury Medicina Diagnóstica, São Paulo, Sao Paulo, Brazil
| | - Valdemir M Carvalho
- Research and Development Division, Fleury Medicina Diagnóstica, São Paulo, Sao Paulo, Brazil
| | - Kelly C Oliveira
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Steroids Laboratory, Federal University of São Paulo Medical School, EPM/UNIFESP, São Paulo, Sao Paulo, Brazil
| | - José Gilberto H Vieira
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Steroids Laboratory, Federal University of São Paulo Medical School, EPM/UNIFESP, São Paulo, Sao Paulo, Brazil
- Research and Development Division, Fleury Medicina Diagnóstica, São Paulo, Sao Paulo, Brazil
| | - Claudio E Kater
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Steroids Laboratory, Federal University of São Paulo Medical School, EPM/UNIFESP, São Paulo, Sao Paulo, Brazil
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Conlon TA, Hawkes CP, Brady JJ, Murphy NP. The presentation of congenital adrenal hyperplasia in an unscreened population. J Pediatr Endocrinol Metab 2021; 34:1123-1129. [PMID: 34167176 DOI: 10.1515/jpem-2021-0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/12/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this study was to describe the incidence and spectrum of early clinical presentations of congenital adrenal hyperplasia (CAH) in an unscreened population. METHODS A national retrospective observational study was undertaken to identify all children diagnosed with CAH in the Republic of Ireland, between January 2005 and December 2019. Reporting clinicians completed anonymized clinical questionnaires. RESULTS There were 103 cases of CAH reported and 69 cases met the study inclusion criteria. The estimated annualized incidence of CAH in the Republic of Ireland was 1:14,754 or 0.07 cases per 1,000 live births. Forty-seven children presented clinically in the first six months of life, but only 17 of these had a confirmed diagnosis by day 10. Of these early presentations, there were 28 infants with salt-wasting, 15 females presented with virilized genitalia and four infants were detected due to a family history of CAH. Female infants presented at a median age of 0 days [IQR 0-1] and males at 14 days [IQR 9-21]. Seventy-eight percent of salt-wasting presentations occurred after day 10. Delays in clinical presentation, biochemical diagnosis and treatment initiation were identified. CONCLUSIONS The incidence of CAH is higher in Ireland than in other unscreened populations. In the absence of screening, clinicians should be aware of the possibility of CAH and appropriate investigations should be urgently requested. Life-threatening salt-wasting is the most frequent clinical presentation and many cases could be detected prior to decompensation if newborn screening were introduced.
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Affiliation(s)
- Tracey A Conlon
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin 1, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Colin P Hawkes
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jennifer J Brady
- Department of Clinical Biochemistry, Children's Health Ireland at Temple Street, Dublin 1, Ireland
| | - Nuala P Murphy
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin 1, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
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Yildiz M, Isik E, Abali ZY, Keskin M, Ozbek MN, Bas F, Ucakturk SA, Buyukinan M, Onal H, Kara C, Storbeck KH, Darendeliler F, Cayir A, Unal E, Anik A, Demirbilek H, Cetin T, Dursun F, Catli G, Turan S, Falhammar H, Baris T, Yaman A, Haklar G, Bereket A, Guran T. Clinical and Hormonal Profiles Correlate With Molecular Characteristics in Patients With 11β-Hydroxylase Deficiency. J Clin Endocrinol Metab 2021; 106:e3714-e3724. [PMID: 33830237 DOI: 10.1210/clinem/dgab225] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Given the rarity of 11β-hydroxylase deficiency (11βOHD), there is a paucity of data about the differences in clinical and biochemical characteristics of classic (C-11βOHD) and nonclassic 11βOHD (NC-11βOHD). OBJECTIVE To characterize a multicenter pediatric cohort with 11βOHD. METHOD The clinical and biochemical characteristics were retrospectively retrieved. CYP11B1 gene sequencing was performed. Seventeen plasma steroids were quantified by liquid chromatography-mass spectrometry and compared to that of controls. RESULTS 102 patients (C-11βOHD, n = 92; NC-11βOHD, n = 10) from 76 families (46,XX; n = 53) had biallelic CYP11B1 mutations (novel 9 out of 30). Five 46,XX patients (10%) were raised as males. Nineteen patients (19%) had initially been misdiagnosed with 21-hydroxylase deficiency. Female adult height was 152 cm [-1.85 SD score (SDS)] and male 160.4 cm (-2.56 SDS).None of the NC-11βOHD girls had ambiguous genitalia (C-11βOHD 100%), and none of the NC-11βOHD patients were hypertensive (C-11βOHD 50%). Compared to NC-11βOHD, C-11βOHD patients were diagnosed earlier (1.33 vs 6.9 years; P < 0.0001), had higher bone age-to-chronological age (P = 0.04) and lower adult height (-2.46 vs -1.32 SDS; P = 0.05). The concentrations of 11-oxygenated androgens and 21-deoxycortisol were low in all patients. The baseline ACTH and stimulated cortisol were normal in NC-11βOHD. Baseline cortisol; cortisone; 11-deoxycortisol; 11-deoxycorticosterone and corticosterone concentrations; and 11-deoxycortisol/cortisol, 11-deoxycorticosterone/cortisol, and androstenedione/cortisol ratios were higher in C-11βOHD than NC-11βOHD patients (P < 0.05). The 11-deoxycortisol/cortisol ratio >2.2, <1.5, and <0.1 had 100% specificity to segregate C-11βOHD, NC-11βOHD, and control groups. CONCLUSION NC-11βOHD can escape from clinical attention due to relatively mild clinical presentation. However, steroid profiles enable the diagnosis, differential diagnosis, and subtyping of 11βOHD.
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Affiliation(s)
- Melek Yildiz
- Department of Pediatric Endocrinology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
- Department of Pediatric Endocrinology and Diabetes, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Emregul Isik
- Clinics of Pediatric Endocrinology, Gaziantep Children's Hospital, Gaziantep, Turkey
| | - Zehra Yavas Abali
- Department of Pediatric Endocrinology and Diabetes, Marmara University, Faculty of Medicine, Istanbul, Turkey
| | - Mehmet Keskin
- Department of Pediatric Endocrinology and Diabetes, Gaziantep University, School of Medicine , Gaziantep, Turkey
| | - Mehmet Nuri Ozbek
- Department of Pediatric Endocrinology and Diabetes, SBU Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Firdevs Bas
- Department of Pediatric Endocrinology and Diabetes, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Seyit Ahmet Ucakturk
- Department of Pediatric Endocrinology, Ankara City Hospital, Children's Hospital, Ankara, Turkey
| | - Muammer Buyukinan
- Department of Pediatric Endocrinology, Konya Training and Research Hospital, Konya, Turkey
| | - Hasan Onal
- Department of Pediatric Endocrinology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Cengiz Kara
- Department of Pediatrics, Division of Pediatric Endocrinology, Altinbas University, Faculty of Medicine, Istanbul, Turkey
| | - Karl-Heinz Storbeck
- Department of Biochemistry, Stellenbosch University, Stellenbosch, South Africa
| | - Feyza Darendeliler
- Department of Pediatric Endocrinology and Diabetes, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Atilla Cayir
- Department of Pediatric Endocrinology and Diabetes, Erzurum Training and Research Hospital, Erzurum, Turkey
| | - Edip Unal
- Department of Pediatric Endocrinology and Diabetes, SBU Diyarbakir Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey
| | - Ahmet Anik
- Department of Pediatric Endocrinology and Diabetes, Adnan Menderes University, School of Medicine , Aydin, Turkey
| | - Huseyin Demirbilek
- Department of Pediatric Endocrinology and Diabetes, Hacettepe University, School of Medicine , Ankara, Turkey
| | - Tugba Cetin
- Department of Pediatric Endocrinology, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
| | - Fatma Dursun
- Department of Pediatric Endocrinology and Diabetes, Istanbul University of Health Science, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Gonul Catli
- Department of Pediatric Endocrinology, Izmir Katip Celebi University, School of Medicine , Izmir, Turkey
| | - Serap Turan
- Department of Pediatric Endocrinology and Diabetes, Marmara University, Faculty of Medicine, Istanbul, Turkey
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Tugba Baris
- Gelisim Genetik Tani Merkezi, Istanbul, Turkey
| | - Ali Yaman
- Department of Biochemistry, Marmara University, Faculty of Medicine, Istanbul, Turkey
| | - Goncagul Haklar
- Department of Biochemistry, Marmara University, Faculty of Medicine, Istanbul, Turkey
| | - Abdullah Bereket
- Department of Pediatric Endocrinology and Diabetes, Marmara University, Faculty of Medicine, Istanbul, Turkey
| | - Tulay Guran
- Department of Pediatric Endocrinology and Diabetes, Marmara University, Faculty of Medicine, Istanbul, Turkey
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Alkhzouz C, Bucerzan S, Miclaus M, Mirea AM, Miclea D. 46,XX DSD: Developmental, Clinical and Genetic Aspects. Diagnostics (Basel) 2021; 11:1379. [PMID: 34441313 PMCID: PMC8392837 DOI: 10.3390/diagnostics11081379] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 11/17/2022] Open
Abstract
Differences in sex development (DSD) in patients with 46,XX karyotype occur by foetal or postnatal exposure to an increased amount of androgens. These disorders are usually diagnosed at birth, in newborns with abnormal genitalia, or later, due to postnatal virilization, usually at puberty. Proper diagnosis and therapy are mostly based on the knowledge of normal development and molecular etiopathogenesis of the gonadal and adrenal structures. This review aims to describe the most relevant data that are correlated with the normal and abnormal development of adrenal and gonadal structures in direct correlation with their utility in clinical practice, mainly in patients with 46,XX karyotype. We described the prenatal development of structures together with the main molecules and pathways that are involved in sex development. The second part of the review described the physical, imaging, hormonal and genetic evaluation in a patient with a disorder of sex development, insisting more on patients with 46,XX karyotype. Further, 95% of the etiology in 46,XX patients with disorders of sex development is due to congenital adrenal hyperplasia, by enzyme deficiencies that are involved in the hormonal synthesis pathway. The other cases are explained by genetic abnormalities that are involved in the development of the genital system. The phenotypic variability is very important in 46,XX disorders of sex development and the knowledge of each sign, even the most discreet, which could reveal such disorders, mainly in the neonatal period, could influence the evolution, prognosis and life quality long term.
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Affiliation(s)
- Camelia Alkhzouz
- Mother and Child Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.A.); (S.B.)
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Simona Bucerzan
- Mother and Child Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.A.); (S.B.)
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Maria Miclaus
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Andreea-Manuela Mirea
- Genetic Department, Clinical Emergency Hospital for Children Cluj-Napoca, 400370 Cluj-Napoca, Romania; (M.M.); (A.-M.M.)
| | - Diana Miclea
- Mother and Child Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (C.A.); (S.B.)
- Molecular Science Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Eshragh N, Doan LV, Connelly KJ, Denniston S, Willis S, LaFranchi SH. Outcome of Newborn Screening for Congenital Adrenal Hyperplasia at Two Time Points. Horm Res Paediatr 2021; 93:128-136. [PMID: 32659761 DOI: 10.1159/000508075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/22/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Screening newborns for congenital adrenal hyperplasia (CAH) is problematic owing to the dynamic changes in serum 17-hydroxyprogesterone (17-OHP) levels following birth. Our study objectives were to determine the accuracy of screening, severity of CAH, and biochemical and clinical outcomes of cases detected by our program which collects specimens at 2 time periods following birth. METHODS We reviewed all CAH cases detected in the Northwest Regional Newborn Screening Program from 2003 through 2017. Comparison was made of screening and confirmatory serum 17-OHP, neonatal, maternal, and follow-up auxologic data, steroid treatment doses, and 21-hydroxylase genotype in cases detected on the first versus second test. RESULTS Out of 164 cases of CAH, 25% were detected on the second screen. Infants detected on the second test had a lower screening 17-OHP (147 vs. 294 ng/mL), lower confirmatory serum 17-OHP (7,772 vs. 14,622 ng/dL), and were more likely to have simple virilizing CAH. There were no identifiable neonatal or maternal factors associated with detection on the second test. 21-Hydroxylase genotypes overlapped in first versus second screen cases. CONCLUSION Early collection of specimens necessitated by early discharge resulted in milder CAH cases falling below the screening 17-OHP cutoff. In our program 25% of cases were detected on a routine second screen.
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Affiliation(s)
- Nazaneen Eshragh
- Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon, USA
| | - Luong Van Doan
- Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon, USA,
| | - Kara J Connelly
- Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon, USA
| | - Sara Denniston
- Oregon State Public Health Laboratory, Hillsboro, Oregon, USA
| | - Sharon Willis
- Oregon State Public Health Laboratory, Hillsboro, Oregon, USA
| | - Stephen H LaFranchi
- Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon, USA
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Tsuji-Hosokawa A, Kashimada K. Thirty-Year Lessons from the Newborn Screening for Congenital Adrenal Hyperplasia (CAH) in Japan. Int J Neonatal Screen 2021; 7:ijns7030036. [PMID: 34209888 PMCID: PMC8293132 DOI: 10.3390/ijns7030036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 01/02/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) is an inherited disorder caused by the absence or severely impaired activity of steroidogenic enzymes involved in cortisol biosynthesis. More than 90% of cases result from 21-hydroxylase deficiency (21OHD). To prevent life-threatening adrenal crisis and to help perform appropriate sex assignments for affected female patients, newborn screening (NBS) programs for the classical form of CAH have been introduced in numerous countries. In Japan, the NBS for CAH was introduced in 1989, following the screenings for phenylketonuria and congenital hypothyroidism. In this review, we aim to summarize the experience of the past 30 years of the NBS for CAH in Japan, composed of four parts, 1: screening system in Japan, 2: the clinical outcomes for the patients with CAH, 3: various factors that would impact the NBS system, including timeline, false positive, and LC-MS/MS, 4: Database composition and improvement of the screening program.
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Affiliation(s)
- Atsumi Tsuji-Hosokawa
- Department of Systems BioMedicine, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan;
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
- Correspondence:
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de Hora MR, Heather NL, Patel T, Bresnahan LG, Webster D, Hofman PL. Implementing steroid profiling by liquid chromatography-tandem mass spectrometry improves newborn screening for congenital adrenal hyperplasia in New Zealand. Clin Endocrinol (Oxf) 2021; 94:904-912. [PMID: 33471388 DOI: 10.1111/cen.14422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/17/2020] [Accepted: 01/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the impact of a liquid chromatography-tandem mass spectrometry (LCMSMS) second-tier test on newborn screening for congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) in New Zealand. DESIGN In a prospective study, a LCMSMS method to measure 17-hydroxyprogesterone (17OHP) was adapted to measure four additional steroids. Steroid concentrations were collected on all second-tier CAH screening tests while protocols remained unchanged. Steroid ratio parameters with recommended or published screening cuts-offs were evaluated for their impact on newborn screening performance. MEASUREMENTS Precision, accuracy, linearity and recovery of the second-tier LCMSMS method were evaluated. Second-tier specimens were divided in 3 groups; newborn screening bloodspots from neonates with confirmed CAH (n = 7) and 2 groups specimens from neonates with a birthweight (BW) ≤1500 g (n = 795) and with a BW > 1500 g (n = 806) with a negative newborn screening test. Six protocols using four steroid ratio parameters were evaluated. The sensitivity, specificity, false positive rate and positive predictive value of screening was calculated for each protocol. RESULTS The LCMSMS method was sufficiently accurate and precise to be used as a second-tier test for CAH. Screening sensitivity remained at 100% for each protocol apart from (17OHP + androstenedione)/cortisol when the highest cut-off of 3.75 was applied. The false positive rate was significantly improved when (17OHP + androstenedione)/cortisol and (17OHP + 21-deoxycortisol)/cortisol were evaluated with cut-offs of 2.5 and 1.5 respectively (P < .01) and both with a positive predictive value of 64%. CONCLUSIONS A second-tier LCMSMS newborn screening test for CAH offers significant improvements to screening specificity without any other changes to screening protocols.
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Affiliation(s)
- Mark R de Hora
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Natasha L Heather
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Tejal Patel
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Lauren G Bresnahan
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Dianne Webster
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
| | - Paul L Hofman
- Clinical Research Unit, Liggins Institute, University of Auckland, Auckland, New Zealand
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Santi M, Graf S, Zeino M, Cools M, Van De Vijver K, Trippel M, Aliu N, Flück CE. Approach to the Virilizing Girl at Puberty. J Clin Endocrinol Metab 2021; 106:1530-1539. [PMID: 33367768 PMCID: PMC8063244 DOI: 10.1210/clinem/dgaa948] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Indexed: 11/19/2022]
Abstract
UNLABELLED Virilization is the medical term for describing a female who develops characteristics associated with male hormones (androgens) at any age, or when a newborn girl shows signs of prenatal male hormone exposure at birth. In girls, androgen levels are low during pregnancy and childhood. A first physiologic rise of adrenal androgens is observed at the age of 6 to 8 years and reflects functional activation of the zona reticularis of the adrenal cortex at adrenarche, manifesting clinically with first pubic and axillary hairs. Early adrenarche is known as "premature adrenarche." It is mostly idiopathic and of uncertain pathologic relevance but requires the exclusion of other causes of androgen excess (eg, nonclassic congenital adrenal hyperplasia) that might exacerbate clinically into virilization. The second modest physiologic increase of circulating androgens occurs then during pubertal development, which reflects the activation of ovarian steroidogenesis contributing to the peripheral androgen pool. However, at puberty initiation (and beyond), ovarian steroidogenesis is normally devoted to estrogen production for the development of secondary female bodily characteristics (eg, breast development). Serum total testosterone in a young adult woman is therefore about 10- to 20-fold lower than in a young man, whereas midcycle estradiol is about 10- to 20-fold higher. But if androgen production starts too early, progresses rapidly, and in marked excess (usually more than 3 to 5 times above normal), females will manifest with signs of virilization such as masculine habitus, deepening of the voice, severe acne, excessive facial and (male typical) body hair, clitoromegaly, and increased muscle development. Several medical conditions may cause virilization in girls and women, including androgen-producing tumors of the ovaries or adrenal cortex, (non)classical congenital adrenal hyperplasia and, more rarely, other disorders (also referred to as differences) of sex development (DSD). The purpose of this article is to describe the clinical approach to the girl with virilization at puberty, focusing on diagnostic challenges. The review is written from the perspective of the case of an 11.5-year-old girl who was referred to our clinic for progressive, rapid onset clitoromegaly, and was then diagnosed with a complex genetic form of DSD that led to abnormal testosterone production from a dysgenetic gonad at onset of puberty. Her genetic workup revealed a unique translocation of an abnormal duplicated Y-chromosome to a deleted chromosome 9, including the Doublesex and Mab-3 Related Transcription factor 1 (DMRT1) gene. LEARNING OBJECTIVES Identify the precise pathophysiologic mechanisms leading to virilization in girls at puberty considering that virilization at puberty may be the first manifestation of an endocrine active tumor or a disorder/difference of sex development (DSD) that remained undiagnosed before and may be life-threatening. Of the DSDs, nonclassical congenital adrenal hyperplasia occurs most often.Provide a step-by-step diagnostic workup plan including repeated and expanded biochemical and genetic tests to solve complex cases.Manage clinical care of a girl virilizing at puberty using an interdisciplinary team approach.Care for complex cases of DSD manifesting at puberty, such as the presented girl with a Turner syndrome-like phenotype and virilization resulting from a complex genetic variation.
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Affiliation(s)
- Maristella Santi
- Pediatric Endocrinology, Diabetology, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefanie Graf
- Pediatric Endocrinology, Diabetology, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mazen Zeino
- Department of Pediatric Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martine Cools
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | | | - Mafalda Trippel
- Institute of Pathology, Inselspital, University of Bern, Bern, Switzerland
| | - Nijas Aliu
- University Clinic for Pediatrics, Human Genetics, Inselspital, University of Bern, Bern, Switzerland
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of BioMedical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Correspondence: Christa E. Flück, Pediatric Endocrinology and Diabetology, University Children’s Hospital, Freiburgstrasse 15 / C845, 3010 Bern, Switzerland. E-mail:
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Evidence of a hormonal reshuffle in the cecal metabolome fingerprint of a strain of rats resistant to decompression sickness. Sci Rep 2021; 11:8317. [PMID: 33859311 PMCID: PMC8050073 DOI: 10.1038/s41598-021-87952-y] [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: 10/14/2020] [Accepted: 04/07/2021] [Indexed: 02/02/2023] Open
Abstract
On one side, decompression sickness (DCS) with neurological disorders lead to a reshuffle of the fecal metabolome from rat caecum. On the other side, there is high inter-individual variability in terms of occurrence of DCS. One could wonder whether the fecal metabolome could be linked to the DCS-susceptibility. We decided to study male and female rats selected for their resistance to decompression sickness, and we hypothesize a strong impregnation concerning the fecal metabolome. The aim is to verify whether the rats resistant to the accident have a fecal metabolomic signature different from the stem generations sensitive to DCS. 39 DCS-resistant animals (21 females and 18 males), aged 14 weeks, were compared to 18 age-matched standard Wistar rats (10 females and 8 males), i.e., the same as those we used for the founding stock. Conventional and ChemRICH approaches helped the metabolomic interpretation of the 226 chemical compounds analyzed in the cecal content. Statistical analysis shows a panel of 81 compounds whose expression had changed following the selection of rats based on their resistance to DCS. 63 compounds are sex related. 39 are in common. This study shows the spectral fingerprint of the fecal metabolome from the caecum of a strain of rats resistant to decompression sickness. This study also confirms a difference linked to sex in the metabolome of non-selected rats, which disappear with selective breeding. Results suggest hormonal and energetic reshuffle, including steroids sugars or antibiotic compounds, whether in the host or in the microbial community.
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Wang X, Wang Y, Ma D, Zhang Z, Li Y, Yang P, Sun Y, Jiang T. Neonatal Screening and Genotype-Phenotype Correlation of 21-Hydroxylase Deficiency in the Chinese Population. Front Genet 2021; 11:623125. [PMID: 33552137 PMCID: PMC7862715 DOI: 10.3389/fgene.2020.623125] [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: 10/29/2020] [Accepted: 12/30/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders encompassing enzyme deficiencies in the adrenal steroidogenesis pathway that leads to impaired cortisol biosynthesis. 21-hydroxylase deficiency (21-OHD) is the most common type of CAH. Severe cases of 21-OHD may result in death during the neonatal or infancy periods or sterility in later life. The early detection and timely treatment of 21-OHD are essential. This study aimed to summarize the clinical and genotype characteristics of 21-OHD patients detected by neonatal screening in Nanjing, Jiangsu province of China from 2000 to 2019. Methods: Through a retrospective analysis of medical records, the clinical presentations, laboratory data, and molecular characteristics of 21-OHD patients detected by neonatal screening were evaluated. Results: Of the 1,211,322 newborns who were screened, 62 cases were diagnosed with 21-OHD with an incidence of 1:19858. 58 patients were identified with the classical salt-wasting type (SW) 21-OHD and four patients were identified with simple virilizing type (SV) 21-OHD. Amongst these patients, 19 cases patients accepted genetic analysis, and another 40 cases were received from other cities in Eastern China. Eighteen different variants were found in the CYP21A2 gene. The most frequent variants was c.293-13A/C>G (36.29%). The most severe clinical manifestations were caused by large deletions or conversions of CYP21A2. Conclusions: This study suggested that neonatal screening effectively leads to the early diagnosis of 21-OHD and reduces fatal adrenal crisis. Our data provide additional information on the occurrence and genotype-phenotype correlation of 21-OHD in the Chinese population which can be used to better inform treatment and improve prognosis.
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Affiliation(s)
- Xin Wang
- Genetic Medicine Center, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Yanyun Wang
- Genetic Medicine Center, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Dingyuan Ma
- Genetic Medicine Center, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Zhilei Zhang
- Genetic Medicine Center, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Yahong Li
- Genetic Medicine Center, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Peiying Yang
- Genetic Medicine Center, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Yun Sun
- Genetic Medicine Center, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
| | - Tao Jiang
- Genetic Medicine Center, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
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Jha S, Turcu AF, Sinaii N, Brookner B, Auchus RJ, Merke DP. 11-Oxygenated Androgens Useful in the Setting of Discrepant Conventional Biomarkers in 21-Hydroxylase Deficiency. J Endocr Soc 2020; 5:bvaa192. [PMID: 33447690 DOI: 10.1210/jendso/bvaa192] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 11/19/2022] Open
Abstract
Context Serum 17-hydroxyprogesterone (17OHP) and androstenedione (A4) are the conventional biomarkers used to assess disease control in patients with 21-hydroxylase deficiency (21OHD). However, discrepancy between the two is not uncommon, limiting interpretation. Objective To evaluate 11-oxyandrogens in discriminating good versus poor disease control in 21OHD in the setting of discrepant 17OHP and A4. Methods Retrospective analysis of 2738 laboratory assessments obtained as part of Natural History Study of congenital adrenal hyperplasia (CAH) at the National Institutes Health Clinical Center. Patients with discrepant 17OHP and A4 and available sera were selected. A 15-steroid mass-spectrometry panel was performed in sera from patients with 21OHD and age- and sex-matched controls. Patients were categorized in "good" or "poor" control based on clinical assessment (bone age advancement, signs and symptoms of precocious puberty, menstrual irregularity, hirsutism, or hypogonadotrophic hypogonadism). Results Discrepant 17OHP and A4 was found in 469 (17%) laboratory assessments. Of these, 403 (86%) had elevated 17OHP with A4 in reference range. Of 46 patients with available sera, 30 (65%) were in good control. Median fold elevation relative to controls was higher in patients with poor versus good control for 11-hydroxytestosterone (median [interquartile range], 2.82 [1.25-5.43] vs 0.91 [0.49- 2.07], P = .003), and 11-ketotestosterone (3.57 [2.11-7.41] vs 1.76 [1.24-4.00], P = .047). Fold elevation of 11-hydroxytestosterone between 3.48 (sensitivity 97%, specificity 47%) and 3.88 (sensitivity 100%, specificity 40%) provided the best discrimination between poor vs good control. Conclusion 11-Oxyandrogens, especially 11-hydroxytestosterone, may be useful in the management of CAH when conventional biomarkers are inconclusive.
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Affiliation(s)
- Smita Jha
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD, USA.,Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health, Bethesda, MD, USA
| | - Brittany Brookner
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | - Deborah P Merke
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, MD, USA.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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