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Cui X, Li P. Clinical characteristics and treatment during preconception and perinatal period of infertile women with non-classical 21-hydroxylase deficiency. Reprod Health 2024; 21:139. [PMID: 39354633 DOI: 10.1186/s12978-024-01874-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 09/02/2024] [Indexed: 10/03/2024] Open
Abstract
OBJECTIVE A single-center observational study to determine the clinical characteristics and therapeutic dose adjustments in women of reproductive age with infertility and non-classical 21-hydroxylase deficiency (NC-21OHD). DESIGN A retrospective analysis of 20 women of reproductive age who were diagnosed with NC-21OHD during an infertility evaluation at Shengjing Hospital of China Medical University from January 2013 to May 2024 was performed. The clinical manifestations, auxiliary examinations, adjustment of glucocorticoid (GC) treatment during preconception and perinatal period, and pregnancy outcomes were analyzed. RESULTS 14 of 16 patients (87.5%) had inappropriately elevated progesterone levels during the follicular phase. The average levels of 17α-hydroxyprogesterone, testosterone, androstenedione, and dehydroepiandrosterone sulfate in the follicular phase were also significantly increased. All 20 infertile patients received GC treatment before preparing for pregnancy. During the follow-up, six of 20 patients had seven conceptions. three patients had spontaneous abortions in the first trimester and four patients delivered babies (4/20). Three patients had a GC dose that was maintained throughout pregnancy and one had an increase in the GC dose starting in the second trimester. Of the remaining 16 patients, seven are still trying to conceive and nine had discontinued treatment. CONCLUSIONS An abnormal increase in the follicular phase progesterone level is the most common serologic marker for NC-21OHD among infertile women. Ovulation can be restored after GC treatment, but the proportion of successful conceptions remains low. The dose of GCs in most pregnant women remained unchanged throughout pregnancy.
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Affiliation(s)
- Xuejiao Cui
- Department of Endocrinology, Shengjing Hospital of China Medical University, Tiexi District, 39 Huaxiang Road, Shenyang, 110022, Liaoning, China
| | - Ping Li
- Department of Endocrinology, Shengjing Hospital of China Medical University, Tiexi District, 39 Huaxiang Road, Shenyang, 110022, Liaoning, China.
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2
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Ilia G, Paltoglou G, Chatzakis C, Christopoulos P, Tzitiridou-Chatzopoulou M, Mastorakos G. Increased prevalence of negative pregnancy and fetal outcomes in women with primary adrenal insufficiency. A systematic review and meta-analysis. Endocrine 2024:10.1007/s12020-024-04023-8. [PMID: 39277840 DOI: 10.1007/s12020-024-04023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 08/27/2024] [Indexed: 09/17/2024]
Abstract
Maternal primary adrenal insufficiency (PAI) during pregnancy, due to either Addison disease (AD) or congenital adrenal hyperplasia (CAH), is rare. Only few studies have examined the subsequent important outcomes of maternal glucocorticoid and mineralocorticoid deficiencies during pregnancy upon the fetus and the neonate. Therefore, this systematic review and meta-analysis evaluated the impact of these deficiencies, with data from PubMed/Medline, Cochrane/CENTRAL, and Google Scholar. A total of 31 studies were included for qualitative analysis and 11 for quantitative analysis. Studies examining the prevalence of spontaneous abortion, preterm birth, the occurrence of small for gestational age (SGA) neonates, as well as the neonatal birth weight were included. The systematic review revealed a substantial number of spontaneous abortions, preterm births and SGA neonates in pregnant women with PAI. The meta-analysis showed a mean spontaneous abortion prevalence of 18%, 18% and 17% in women with PAI, AD or CAH, respectively. The mean preterm birth prevalence was 11% when women with AD or CAH were analyzed together, and 13% and 9% in women with AD or CAH, respectively, when these women were analyzed separately. The mean prevalence of SGA neonates was 8% when women with AD or CAH were analyzed together, and 5% and 10% in women with AD or CAH, respectively, when these women were analyzed separately. The mean fetal birth weight was within normalcy in all women with PAI, as well as in women with AD or CAH. In conclusion the executed systematic review of 31 studies followed by a meta-analysis of 11 studies in pregnant women with PAI has shown a greater prevalence of pregnancies with negative outcome (spontaneous abortion, preterm birth) and of negative fetal outcome (SGA) in women with either AD or CAH, as compared to control pregnant women.
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Affiliation(s)
- Georgia Ilia
- Unit of Endocrinology, Diabetes Mellitus and Metabolism, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
- Department of Obstetrics and Gynecology, Spital Zollikerberg, Zürich, Switzerland.
| | - George Paltoglou
- Unit of Endocrinology, Diabetes Mellitus and Metabolism, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Second Department of Pediatrics, National and Kapodistrian University of Athens, Faculty of Medicine, "P. and A. Kyriakou" Children's Hospital, Athens, Greece
| | - Christos Chatzakis
- Second Department of Obstetrics and Gynecology, School of Medicine, "Aristotle" University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Christopoulos
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - George Mastorakos
- Unit of Endocrinology, Diabetes Mellitus and Metabolism, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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3
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McCracken C, Kaabi O, Crawford M, Gardner MD, Getahun D, Goodman M, Sorouri Khorashad B, Lash TL, Roblin D, Vupputuri S, Yacoub R, Speiser PW, Lee PA, Sandberg DE. ANTHROPOMETRIC MEASURES AMONG CHILDREN AND TEENS WITH CLASSIC 46,XX CONGENITAL ADRENAL HYPERPLASIA IN RELATION TO IMPROVEMENTS IN DIAGNOSIS AND CARE. Endocr Pract 2024:S1530-891X(24)00671-2. [PMID: 39277085 DOI: 10.1016/j.eprac.2024.09.005] [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: 06/03/2024] [Revised: 09/02/2024] [Accepted: 09/09/2024] [Indexed: 09/17/2024]
Abstract
OBJECTIVES 1) To examine anthropometric changes of patients with classic 46,XX CAH and matched referents; 2) To investigate the impact of improvements in diagnosis and care on growth patterns in these patients by comparing changes in anthropometric parameters before and after CAH consensus guidelines. METHODS This was a retrospective cohort study nested within three large integrated health-systems. Seventy-six patients with classic 46XX CAH and 1,102 matched referents <21 years of age were identified. Anthropometric measurements including age-specific percentiles for height, weight, and body mass index were examined and compared between groups using linear mixed-effect models. Anthropometric trajectories were explored using latent class analyses (LCA). RESULTS CAH patients had lower height percentiles than referents at all time points. Differences ranged from 10.7% to 28.4%. After age 5 differences in height were only significant among study participants born before the publication of CAH consensus guidelines. LCA of height detected a "gradual growth increase" pattern in 28% of CAH cases and only 4% of referents, and a "growth stunting" pattern was observed in 13% of CAH cases and 6% of referents. Height percentile measures did not differ in CAH patients with or without evidence of hormonal interventions (growth hormone and/or puberty blockers) used to increase adult height. CONCLUSIONS There is substantial heterogeneity in growth trajectories of CAH patients. Although stunting may affect CAH patients, advances in diagnosis and care improved anthropometric outcomes in this population. Understanding the disease- and therapy-related mechanisms that explain the different growth patterns requires additional research.
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Affiliation(s)
- Courtney McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA.
| | - Oumaima Kaabi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - Mackenzie Crawford
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA.
| | - Melissa D Gardner
- Susan B. Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, MI.
| | - Darios Getahun
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - Behzad Sorouri Khorashad
- Susan B. Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, MI.
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlanta States, Rockville, MD.
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlanta States, Rockville, MD.
| | - Rami Yacoub
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - Phyllis W Speiser
- Division of Pediatric Endocrinology, Steven and Alexandra Cohen Children's Medical Center of New York; Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY.
| | - Peter A Lee
- Division of Endocrinology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA.
| | - David E Sandberg
- Susan B. Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, MI.
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4
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Li X, Lin S, Yang X, Chen C, Cao S, Zhang Q, Ma J, Zhu G, Zhang Q, Fang Q, Zheng C, Liang W, Wu X. When IGF-1 Meets Metabolic Inflammation and Polycystic Ovary Syndrome. Int Immunopharmacol 2024; 138:112529. [PMID: 38941670 DOI: 10.1016/j.intimp.2024.112529] [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: 04/12/2024] [Revised: 06/09/2024] [Accepted: 06/17/2024] [Indexed: 06/30/2024]
Abstract
Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder associated with insulin resistance (IR) and hyperandrogenaemia (HA). Metabolic inflammation (MI), characterized by a chronic low-grade inflammatory state, is intimately linked with chronic metabolic diseases such as IR and diabetes and is also considered an essential factor in the development of PCOS. Insulin-like growth factor 1 (IGF-1) plays an essential role in PCOS pathogenesis through its multiple functions in regulating cell proliferation metabolic processes and reducing inflammatory responses. This review summarizes the molecular mechanisms by which IGF-1, via MI, participates in the onset and progression of PCOS, aiming to provide insights for studies and clinical treatment of PCOS.
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Affiliation(s)
- Xiushen Li
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China; Department of Traditional Chinese Medicine, Jiangxi Provincial Maternal and Child Health Hospital, Nanchang, Jiangxi, China
| | - Sailing Lin
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Xiaolu Yang
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Can Chen
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Shu Cao
- Xin'an Academy, Anhui University of Chinese Medicine, Hefei, Anhui, China
| | - Qi Zhang
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Jingxin Ma
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Guli Zhu
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Qi Zhang
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Qiongfang Fang
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China
| | - Chunfu Zheng
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada.
| | - Weizheng Liang
- Central Laboratory, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, China.
| | - Xueqing Wu
- Shenzhen University Medical School, Shenzhen University, Shenzhen, Guangdong, China; Department of Obstetrics and Gynecology, Shenzhen University General Hospital, Shenzhen, Guangdong, China.
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5
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Oikonomakos I, Tedesco M, Motamedi FJ, Peitzsch M, Nef S, Bornstein SR, Schedl A, Steenblock C, Neirijnck Y. In vitro differentiation of mouse pluripotent stem cells into corticosteroid-producing adrenocortical cells. Stem Cell Reports 2024; 19:1289-1303. [PMID: 39178848 PMCID: PMC11411339 DOI: 10.1016/j.stemcr.2024.07.010] [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: 11/23/2023] [Revised: 07/25/2024] [Accepted: 07/27/2024] [Indexed: 08/26/2024] Open
Abstract
Directed differentiation of pluripotent stem cells into specialized cell types represents an invaluable tool for a wide range of applications. Here, we have exploited single-cell transcriptomic data to develop a stepwise in vitro differentiation system from mouse embryonic stem cells into adrenocortical cells. We show that during development, the adrenal primordium is embedded in an extracellular matrix containing tenascin and fibronectin. Culturing cells on fibronectin during differentiation increased the expression of the steroidogenic marker NR5A1. Furthermore, 3D cultures in the presence of protein kinase A (PKA)-pathway activators led to the formation of aggregates composed of different cell types expressing adrenal progenitor or steroidogenic markers, including the adrenocortical-specific enzyme CYP21A1. Importantly, in-vitro-differentiated cells responded to adrenocorticotropic hormone (ACTH) and angiotensin II with the production of glucocorticoids and mineralocorticoids, respectively, thus confirming the specificity of differentiation toward the adrenal lineage.
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Affiliation(s)
- Ioannis Oikonomakos
- Université Côte d'Azur, Inserm, CNRS, Institut de Biologie Valrose, 06108 Nice, France; Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Melina Tedesco
- Université Côte d'Azur, Inserm, CNRS, Institut de Biologie Valrose, 06108 Nice, France
| | - Fariba Jian Motamedi
- Université Côte d'Azur, Inserm, CNRS, Institut de Biologie Valrose, 06108 Nice, France
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Serge Nef
- Department of Genetic Medicine and Development, University of Geneva, 1211 Geneva, Switzerland
| | - Stefan R Bornstein
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Andreas Schedl
- Université Côte d'Azur, Inserm, CNRS, Institut de Biologie Valrose, 06108 Nice, France.
| | - Charlotte Steenblock
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Yasmine Neirijnck
- Université Côte d'Azur, Inserm, CNRS, Institut de Biologie Valrose, 06108 Nice, France
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Allen SK, Doyle S. Chapter 2: Non-invasive prenatal diagnosis. Best Pract Res Clin Obstet Gynaecol 2024; 97:102544. [PMID: 39255551 DOI: 10.1016/j.bpobgyn.2024.102544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 06/21/2024] [Accepted: 09/02/2024] [Indexed: 09/12/2024]
Abstract
Non-invasive prenatal diagnosis of monogenic disorders is becoming integrated into routine clinical care for many indications. This is carried out by testing cell-free DNA extracted from the plasma portion of a maternal blood sample. The cell-free DNA is low in concentration, and consists of a mixture of maternal and fetally-derived DNA which are not easy to separate. Methods used therefore need to be rapid, sensitive and specific, including real-time PCR, digital PCR and next generation sequencing with complex algorithms. Testing may be required for pregnancies with an increased chance of a monogenic disorder due to family history or carrier status, or where there are specific abnormalities identified by ultrasound scan. In these situations, testing is considered to be diagnostic and therefore does not require confirmation by invasive testing. With increased access to genomic technologies, and more diagnoses for rare disease patients, future demand for NIPD and possibilities during pregnancy will continue.
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Affiliation(s)
- Stephanie K Allen
- Birmingham Women's and Children's NHS Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TG, UK.
| | - Samantha Doyle
- The Department of Perinatal Genetics, The National Maternity Hospital, Dublin, 2, Ireland; UCD Perinatal Research Centre, University College Dublin, National Maternity Hospital, Dublin, Ireland.
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Muschialli L, Allen CL, Boy-Mena E, Malik A, Pallitto C, Nihlén Å, Gonsalves L. Perspectives on conducting "sex-normalising" intersex surgeries conducted in infancy: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003568. [PMID: 39197054 PMCID: PMC11356455 DOI: 10.1371/journal.pgph.0003568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/26/2024] [Indexed: 08/30/2024]
Abstract
Children with intersex variations continue to be subject to elective, irreversible, "sex-normalising" surgical interventions, despite multiple human rights and legislative bodies calling for their prohibition. Our systematic review aims to understand how medical literature reports rationales for "sex-normalising" surgical interventions conducted in childhood, and how they are contextualised within the medical and social controversy surrounding such interventions. PubMed, EMBASE and CINAHL were searched for English language, peer-reviewed articles reporting primary data on elective, genital, "sex-normalising" surgical interventions conducted on individuals <10 years, published 01/07/2006-30/06/2023 (PROSPERO ID: CRD42023460871). Data on outcomes reported, rationale for the conduct and timing of interventions and acknowledgement of controversy were extracted. Narrative synthesis described rationales and controversy. Risk of bias was assessed using Johanna Briggs Institute Tools. 11,042 records were retrieved, with 71 articles included for analysis. One of the most common outcomes collected in included literature were cosmetic outcomes, primarily reported by surgeons or parents. 62.0% of studies reported no rationale for intervention timing, 39.4% reported no rationale for conduct and 52.1% acknowledged no controversy in intervention conduct. Rationales included parental desire for intervention, anatomical/functional/cosmetic reasons, and a perceived goal of aligning with sex assigned by surgical teams or parents. Controversies addressed included concerns about the quality of interventions, the ethics of intervention conduct and gendered and social considerations. "Sex-normalising" interventions are conducted based largely on rationales that were not adequately supported by evidence, a desire from parents and surgeons to match genital cosmesis typically ascribed to male and female bodies, and a parental desire for intervention conduct. Legislating and medical regulatory bodies should advocate for ending the conduct of irreversible, elective, "sex-normalising" interventions conducted without the full, free and informed consent of the person concerned, to promote and protect the highest attainable standard of health for people with intersex variations.
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Affiliation(s)
- Luke Muschialli
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Connor Luke Allen
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Evelyn Boy-Mena
- Department of Gender, Rights and Equity, World Health Organization, Geneva, Switzerland
| | - Aiysha Malik
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Christina Pallitto
- Department of Sexual and Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Åsa Nihlén
- Department of Sexual and Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Lianne Gonsalves
- Department of Sexual and Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
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8
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Hashemipour M, Saleh R. The spectrum of clinical, hormonal findings in children with congenital adrenal hyperplasia in Isfahan province; a 20-year review. Horm Mol Biol Clin Investig 2024; 0:hmbci-2022-0116. [PMID: 39138818 DOI: 10.1515/hmbci-2022-0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 07/09/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVES Congenital adrenal hyperplasia is an autosomal recessive disorder caused by complete or partial defects in one of the several steroidogenic enzymes involved in synthesizing of cortisol from cholesterol in the adrenal gland. Prompt and proper treatment of the disease would reduce symptoms and the level of androgens in patients. The present study aimed to evaluate the demographic characteristics and clinical findings of these patients. METHODS This retrospective investigation was conducted in 146 patients with congenital adrenal hyperplasia participated. Their clinical and paraclinical findings were accurately recorded in the file and extracted from the records. RESULTS Among all 146 patients, 119(81.5 %) was 21-OH Deficiency type;11-OH Deficiency type was 13(8.9 %), 10(6.8 %) was 3β-HSD type, StAR was 2(1.4 %) and 17 alpha(α)-hydroxylase Deficiency was 2(1.4 %). The mean age of disease onset in these patients was 2.45 ± 1.16 years. Macropenis was the most frequent clinical finding in 39 cases of 64 boys (60.9 %), and Clitoromgaly was the most clinical presentation in 40 cases of 82 girls (48.7 %). The levels of testosterone, dehydroepiandrosterone sulfate, and 17-OHP significantly decreased in the last visit compared to the initial diagnosis. CONCLUSIONS Based on the clinical findings in every infant or child with ambiguous genitalia, macropenis, clitoromegaly, hirsutism, and premature pubarche, we should consider congenital adrenal hyperplasia. Prompt and proper treatment and disease control would reduce symptoms and the level of androgens in patients.
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Affiliation(s)
- Mahin Hashemipour
- Metabolic Liver Disease Research Center, 48455 Isfahan University of Medical Sciences , Isfahan, Iran
- Isfahan Endocrine & Metabolism Research Center, 48455 Isfahan University of Medical Sciences , Isfahan, Iran
| | - Rana Saleh
- Isfahan Endocrine & Metabolism Research Center, 48455 Isfahan University of Medical Sciences , Isfahan, Iran
- Child Growth and Development Research Center, 48455 Isfahan University of Medical Sciences , Isfahan, Iran
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Adriaansen BPH, Utari A, Westra D, Juniarto AZ, Ariani MD, Ediati A, Schröder MAM, Span PN, Sweep FCGJ, Drop SLS, Faradz SMH, van Herwaarden AE, Claahsen – van der Grinten HL. 46,XX males with congenital adrenal hyperplasia: a clinical and biochemical description. Front Endocrinol (Lausanne) 2024; 15:1410122. [PMID: 39175568 PMCID: PMC11338787 DOI: 10.3389/fendo.2024.1410122] [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: 03/31/2024] [Accepted: 07/23/2024] [Indexed: 08/24/2024] Open
Abstract
Introduction Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD) or 11-hydroxylase deficiency (11OHD) is characterized by underproduction of cortisol and overproduction of adrenal androgens. These androgens lead to a variable degree of virilization of the female external genitalia in 46,XX individuals. Especially in developing countries, diagnosis is often delayed and 46,XX patients might be assigned as males. This study aims to describe the clinical and biochemical characteristics of a unique cohort of untreated male-reared 46,XX classic CAH patients from Indonesia and discusses treatment challenges. Methods Nine untreated classic CAH patients with 46,XX genotype and 21OHD (n=6) or 11OHD (n=3), aged 3-46 years old, were included. Biometrical parameters, clinical characteristics, and biochemical measurements including glucocorticoids, renin, androgens, and the pituitary-gonadal axis were evaluated. Results All patients had low early morning serum cortisol concentrations (median 89 nmol/L) without significant increase after ACTH stimulation. Three patients with salt wasting 21OHD reported one or more periods with seizures and/or vomiting in their past until the age of 6, but not thereafter. The remaining patients reported no severe illness or hospitalization episodes, despite their decreased capacity to produce cortisol. In the 21OHD patients, plasma renin levels were elevated compared to the reference range, and in 11OHD patients renin levels were in the low-normal range. All adult patients had serum testosterone concentrations within the normal male reference range. In 21OHD patients, serum 11-oxygenated androgens comprised 41-60% of the total serum androgen concentrations. Glucocorticoid treatment was offered to all patients, but they refused after counseling as this would reduce their endogenous androgen production and they did not report complaints of their low cortisol levels. Discussion We describe a unique cohort of untreated classic 46,XX male CAH patients without overt clinical signs of cortisol deficiency despite their cortisol underproduction and incapacity to increase cortisol levels after ACTH stimulation. The described adolescent and adult patients produce androgen levels within or above the normal male reference range. Glucocorticoid treatment will lower these adrenal androgen concentrations. Therefore, in 46,XX CAH patients reared as males an individual treatment approach with careful counseling and clear instructions is needed.
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Affiliation(s)
- Bas P. H. Adriaansen
- Department of Pediatrics, Division of Pediatric Endocrinology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Agustini Utari
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
- Department of Pediatrics, Division of Pediatric Endocrinology, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Dineke Westra
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Achmad Zulfa Juniarto
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Mahayu Dewi Ariani
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | | | - Mariska A. M. Schröder
- Department of Pediatrics, Division of Pediatric Endocrinology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul N. Span
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C. G. J. Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Stenvert L. S. Drop
- Department of Pediatrics, Division of Endocrinology, Sophia Children’s Hospital, Erasmus Medical Center, Rotterdam, Netherlands
| | - Sultana M. H. Faradz
- Center for Biomedical Research, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | | | - Hedi L. Claahsen – van der Grinten
- Department of Pediatrics, Division of Pediatric Endocrinology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
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Traino KA, Ciciolla LM, Perez MN, Chaney JM, Welch G, Baskin LS, Buchanan CL, Chan YM, Cheng EY, Coplen DE, Wisniewski AB, Mullins LL. Trajectories of illness uncertainty among parents of children with atypical genital appearance due to differences of sex development. J Pediatr Psychol 2024; 49:559-570. [PMID: 38857449 PMCID: PMC11335143 DOI: 10.1093/jpepsy/jsae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 04/14/2024] [Accepted: 05/25/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVE The present study aimed to identify distinct trajectories of parental illness uncertainty among parents of children born with atypical genital appearance due to a difference of sex development over the first year following diagnosis. It was hypothesized that four trajectory classes would emerge, including "low stable," "high stable," "decreasing," and "increasing" classes, and that select demographic, familial, and medical factors would predict these classes. METHODS Participants included 56 mothers and 43 fathers of 57 children born with moderate to severe genital atypia. Participants were recruited from eleven specialty clinics across the U.S. Growth mixture modeling (GMM) approaches, controlling for parent dyad clustering, were conducted to examine classes of parental illness uncertainty ratings over time. RESULTS A three-class GMM was identified as the best-fitting model. The three classes were interpreted as "moderate stable" (56.8%), "low stable" (33.0%), and "declining" (10.3%). Findings suggest possible diagnostic differences across trajectories. CONCLUSIONS Findings highlight the nature of parents' perceptions of ambiguity and uncertainty about their child's diagnosis and treatment the year following their child's birth/diagnosis. Future research is needed to better understand how these trajectories might shift over the course of the child's development. Results support the development of tailored, evidence-based interventions to address coping with uncertainty among families raising a child with chronic health needs.
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Affiliation(s)
- Katherine A Traino
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Lucia M Ciciolla
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Megan N Perez
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - John M Chaney
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Ginger Welch
- Department of Human Development and Family Sciences, Oklahoma State University, Stillwater, OK, United States
| | - Laurence S Baskin
- Department of Urology, University of California San Francisco Medical Center, San Francisco, CA, United States
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Yee-Ming Chan
- Division of Endocrinology, and Harvard Medical School, Boston Children’s Hospital, Boston, MA, United States
| | - Earl Y Cheng
- Department of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Douglas E Coplen
- Division of Urologic Surgery, St. Louis Children’s Hospital, St Louis, MO, United States
| | - Amy B Wisniewski
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
| | - Larry L Mullins
- Department of Psychology, Center for Pediatric Psychology, Oklahoma State University, Stillwater, OK, United States
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Savage MO. Linear growth in children and adolescents with congenital adrenal hyperplasia. Curr Opin Pediatr 2024; 36:463-466. [PMID: 38747200 DOI: 10.1097/mop.0000000000001361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Congenital adrenal hyperplasia (CAH) is a relatively common disorder and one of the most challenging conditions seen by pediatric endocrinologists. Poor linear growth in CAH has been recognized for many years. There are new insights to explain this abnormality and shed light on strategies to promote normal growth. RECENT FINDINGS Published data suggest that the dose of hydrocortisone during two critical periods of rapid growth, namely infancy and at puberty, has a fundamental effect on growth velocity, and by definition adult height. To prevent over-treatment, hydrocortisone dosage should remain within the range of 10-15 mg/m 2 body surface area per day. Precursor steroids such as 17-hydroxy progesterone (17OHP) should not be suppressed to undetectable levels. In fact, 17OHP should always be measurable, as complete suppression suggests over-treatment. SUMMARY CAH is a challenging disorder. High-quality compliance within the consultation setting, with the patient seeing the same specialist at every visit, will be rewarded by improved long-term growth potential. Quality auxological monitoring can avoid phases of growth suppression. New therapy with CRH receptor antagonists may lead to a more nuanced approach by allowing fine tuning of hydrocortisone replacement without the need to suppress ACTH secretion.
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Affiliation(s)
- Martin O Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary, University of London, London, UK
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12
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Aksel S, Derpinghaus A, Cao M, Li Y, Cunha G, Baskin L. Neurovascular anatomy of the developing human fetal penis and clitoris. J Anat 2024; 245:35-49. [PMID: 38419143 PMCID: PMC11161816 DOI: 10.1111/joa.14029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/15/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
The human penile and clitoral development begins from a morphologically indifferent genital tubercle. Under the influence of androgen, the genital tubercle forms the penis by forming a tubular urethra within the penile shaft. Without the effect of the androgen, the genital tubercle differentiates into the clitoris, and a lack of formation of the urethra within the clitoris is observed. Even though there are similarities during the development of the glans penis and glans clitoris, the complex canalization occurring along the penile shaft eventually leads to a morphological difference between the penis and clitoris. Based on the morphological differences, the main goal of this study was to define the vascular and neuronal anatomy of the developing penis and clitoris between 8 and 12 weeks of gestation using laser scanning confocal microscopy. Our results demonstrated there is a co-expression of CD31, which is an endothelial cell marker, and PGP9.5, which is a neuronal marker in the penis where the fusion is actively occurring at the ventral shaft. We also identified a unique anatomical structure for the first time, the clitoral ridge, which is a fetal structure running along the clitoral shaft in the vestibular groove. Contrary to previous anatomical findings which indicate that the neurovascular distribution in the developing penis and clitoris is similar, in this study, laser scanning confocal microscopy enabled us to demonstrate finer differences in the neurovascular anatomy between the penis and clitoris.
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Affiliation(s)
- Sena Aksel
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Amber Derpinghaus
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Mei Cao
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Yi Li
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Gerald Cunha
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Laurence Baskin
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
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13
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Kim C, Jeong E, Lee YB, Kim D. Steroidogenic cytochrome P450 enzymes as drug target. Toxicol Res 2024; 40:325-333. [PMID: 38911541 PMCID: PMC11187042 DOI: 10.1007/s43188-024-00237-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 06/25/2024] Open
Abstract
Human cytochrome P450 (CYP) enzymes are composed of 57 individual enzymes that perform monooxygenase activities. They have diverse physiological roles in metabolizing xenobiotics and producing important endogenous compounds, such as steroid hormones and vitamins. At least seven CYP enzymes are involved in steroid biosynthesis. Steroidogenesis primarily occurs in the adrenal glands and gonads, connecting each reaction to substrates and products. Steroids are essential for maintaining life and significantly contribute to sexual differentiation and reproductive functions within the body. Disorders in steroid biosynthesis can frequently cause serious health problems and lead to the development of diseases, such as prostate cancer, breast cancer, and Cushing's syndrome. In this review, we provide current updated knowledge on the major CYP enzymes involved in the biosynthetic process of steroids, with respect to their enzymatic mechanisms and clinical implications for the development of new drug candidates.
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Affiliation(s)
- Changmin Kim
- Department of Biological Sciences, Konkuk University, 120 Neungdongro, Gwangjin-gu, Seoul, 05029 Republic of Korea
| | - Eunseo Jeong
- Department of Biological Sciences, Konkuk University, 120 Neungdongro, Gwangjin-gu, Seoul, 05029 Republic of Korea
| | - Yoo-bin Lee
- Department of Biological Sciences, Konkuk University, 120 Neungdongro, Gwangjin-gu, Seoul, 05029 Republic of Korea
| | - Donghak Kim
- Department of Biological Sciences, Konkuk University, 120 Neungdongro, Gwangjin-gu, Seoul, 05029 Republic of Korea
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14
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Gunawardana S, Jayarajah U, Ahmed SF, Seneviratne SN. Health-Related Quality of Life in Children and Adolescents With Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2024; 109:1618-1629. [PMID: 38332657 DOI: 10.1210/clinem/dgae068] [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: 09/06/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE To conduct a systematic review (SR) and meta-analysis (MA) on health-related quality-of-life (QoL) and associated factors among children/adolescents with congenital adrenal hyperplasia (CAH). METHOD Following registration in the PROSPERO International Prospective Register of Systematic Reviews(reg no: CRD42022313389), Google Scholar, PubMed, LILACS, Cochrane, and Scopus databases were searched up to March 5, 2022, using predefined search strategy/MESH terms to identify original studies describing/assessing self-reported/parent-reported health-related QoL in patients with CAH ≤21 years. Methodological quality was assessed by Newcastle-Ottawa Quality Assessment Scale (NOS), and heterogeneity by I2 statistics. MA assessed mean difference (MD) in QoL between children/adolescents with CAH and healthy children/adolescents. RESULTS Among 1308 publications, the 12 studies eligible for the SR (CAH n = 781) showed NOS scales of 3 to 7/9, and the 6 eligible for MA (CAH n = 227) showed moderate-considerable heterogeneity. MA showed that parent-reported psychosocial QoL (MD 9.9 [-12.6,7.3], P ≤ .001) {consisting of school (MD 7.4[-12.2, -2.5], P = .003), emotional (MD 5.6 [-10.2, -0.9], P = .02) and social domains (MD 4.3 [-8.1, -0.5], P = .03), and self-reported school domain QoL (MD 8.5 [-15.9, -1.2], P = .02) was lower in children/adolescents with CAH while parent-reported and self-reported physical QoL were similar to controls.Factors associated with lower QoL among children/ adolescents with CAH included poor disease control, poor medication compliance, and complications including hyperpigmentation, virilization, hypertension, hospital admission, and urinary incontinence. CONCLUSION Based on available data, children/adolescents with CAH had preserved physical QoL but impaired psychosocial QoL, especially in the school domain. Factors associated with lower QoL included poor disease control and disease/treatment-related complications. There is a need for further high-quality research that investigates the relationship between disease control, provision of psychosocial support, and improvement in QoL in children/adolescents with CAH.
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Affiliation(s)
| | - Umesh Jayarajah
- Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Syed Faisal Ahmed
- Samson Gemmell Chair of Child Health, University of Glasgow, Glasgow G12 8QQ, UK
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15
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Gardner M, Khorashad BS, Lee PA, Kogan BA, Sandberg DE. Recommendations for 46,XX Congenital Adrenal Hyperplasia Across Two Decades: Insights from the North American Differences of Sex Development Clinician Survey. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1695-1711. [PMID: 38684620 PMCID: PMC11106198 DOI: 10.1007/s10508-024-02853-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 05/02/2024]
Abstract
Several aspects of clinical management of 46,XX congenital adrenal hyperplasia (CAH) remain unsettled and controversial. The North American Disorders/Differences of Sex Development (DSD) Clinician Survey investigated changes, over the last two decades, in clinical recommendations by specialists involved in the management of newborns with DSD. Members of the (Lawson Wilkins) Pediatric Endocrine Society and the Societies for Pediatric Urology participated in a web-based survey at three timepoints: 2003-2004 (T1, n = 432), 2010-2011 (T2, n = 441), and 2020 (T3, n = 272). Participants were presented with two clinical case scenarios-newborns with 46,XX CAH and either mild-to-moderate or severe genital masculinization-and asked for clinical recommendations. Across timepoints, most participants recommended rearing the newborn as a girl, that parents (in consultation with physicians) should make surgical decisions, performing early genitoplasty, and disclosing surgical history at younger ages. Several trends were identified: a small, but significant shift toward recommending a gender other than girl; recommending that adolescent patients serve as the genital surgery decision maker; performing genital surgery at later ages; and disclosing surgical details at younger ages. This is the first study assessing physician recommendations across two decades. Despite variability in the recommendations, most experts followed CAH clinical practice guidelines. The observation that some of the emerging trends do not align with expert opinion or empirical evidence should serve as both a cautionary note and a call for prospective studies examining patient outcomes associated with these changes.
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Affiliation(s)
- Melissa Gardner
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Building 16/G035E, Ann Arbor, MI, 48109, USA
| | - Behzad Sorouri Khorashad
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Building 16/G035E, Ann Arbor, MI, 48109, USA
| | - Peter A Lee
- Department of Pediatrics, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
| | - Barry A Kogan
- Department of Urology, Albany Medical College and Center, Albany, NY, USA
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Building 16/G035E, Ann Arbor, MI, 48109, USA.
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA.
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16
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Concolino P. Chimeric Genes Causing 11β-Hydroxylase Deficiency: Implications in Clinical and Molecular Diagnosis. Mol Diagn Ther 2024; 28:215-224. [PMID: 38324138 DOI: 10.1007/s40291-024-00697-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
Deficiency of 11β-hydroxylase (11β-OHD) is the second most common cause of congenital adrenal hyperplasia (CAH), accounting for 0.2-8% of all cases. The disease is transmitted as an autosomal recessive trait and the underlying genetic causes of 11β-OHD are primarily small pathogenic variants affecting the CYP11B1 gene coding the 11β-hydroxylase enzyme. However, special events complicate the molecular diagnosis of 11β-OHD such as an unequal crossing over between the CYP11B2 (coding aldosterone synthase enzyme) and CYP11B1 genes. The resulting allele contains a hybrid gene, with a CYP11B2 5'-end and a CYP11B1 3'-end, where the CYP11B1 gene is under the control of the CYP11B2 promoter and thus not responding to the adrenocorticotropin (ACTH) but to angiotensin II and K+. This leads a reduction of cortisol production in 11β-OHD. In particular, CYP11B2/CYP11B1 chimeric genes can be distinguished into two groups depending on the breakpoint site: chimeras with breakpoint after the exon 5 of CYP11B2 preserve the aldosterone synthase activity, the others with breakpoint before exon 5 lose this function. In the last case, a more severe phenotype is expected. The aim of this review was to explore the setting of CYP11B2/CYP11B1 chimeras in 11β-OHD, performing a careful review of clinical literature cases.
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Affiliation(s)
- Paola Concolino
- Dipartimento di Scienze di Laboratorio e Infettivologiche, UOC Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy.
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17
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Charoensri S, Auchus RJ. Predictors of Cardiovascular Morbidities in Adults With 21-Hydroxylase Deficiency Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2024; 109:e1133-e1142. [PMID: 37878953 DOI: 10.1210/clinem/dgad628] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
CONTEXT The prevalence of cardiovascular and metabolic complications among adults with 21-hydroxylase deficiency (21OHD) is unknown. OBJECTIVE We sought to determine the prevalence of cardiovascular and metabolic morbidities among adults with 21OHD and to identify clinical factors and biomarkers associated with cardiovascular outcomes. METHODS A 10-year retrospective cross-sectional analysis was conducted on adult patients with confirmed 21OHD, aged 18 to 70 years, who had at least one clinical visit for assessment at the University of Michigan. The presence of cardiovascular diseases (CVDs) and other metabolic comorbidities was extracted from medical records based on International Classification of Diseases (ICD) codes. Medical treatments, glucocorticoid (GC) and mineralocorticoid doses, as well as specific biomarkers of disease control since age 18, were collected for analysis. RESULTS A total of 254 patients with 21OHD, median age of 35 years (interquartile range, 28.25-46 y), were included in the analysis. The prevalence of CVDs in the entire cohort was 7.5%. An increase in prevalence was seen from early adulthood, reaching 25% in patients older than 60 years. Increasing age (adjusted odds ratio [OR], 1.05; 95% CI, 1.01-1.09), hypertension (OR, 4.27; 95% CI, 1.41-12.92), and higher GC doses (OR, 1.51; 95% CI, 1.11-2.06) were significantly associated with prevalent CVDs. Higher plasma renin activity was significantly associated with CVDs (OR, 1.07; 95% CI, 1.01-1.15) but not other biochemical markers of disease. CONCLUSION Cardiometabolic morbidities are prevalent among adults with 21OHD. Hypertension, age, and GC exposure are the main predictive factors of established CVDs in our cohort.
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Affiliation(s)
- Suranut Charoensri
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
- Endocrinology & Metabolism Section, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI 48104, USA
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18
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Chong YYN, Wong JLJ, Ang XHJ, Lim YLA. Sertoli-Leydig Cell Tumor as a Cause of Elevated 17-OH Progesterone. JCEM CASE REPORTS 2024; 2:luae013. [PMID: 38317845 PMCID: PMC10843258 DOI: 10.1210/jcemcr/luae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Indexed: 02/07/2024]
Abstract
Virilizing ovarian tumors are rare but a clinically important diagnosis in a patient presenting with hyperandrogenism. Workup of hyperandrogenism is challenging with a broad range of differentials, including adrenal and ovarian pathology, tumoral or nontumoral in nature. Baseline follicular-phase 17-hydroxyprogesterone (17OHP) measurement is part of the investigation algorithm, and elevated levels are often associated with nonclassic congenital adrenal hyperplasia (NCCAH), which can have its first presentation in adolescence or adulthood. This case describes a young adult woman of reproductive age presenting with menstrual irregularity, raised testosterone, and 17OHP. After extensive workup and serial follow-up, she was found to have a Sertoli-Leydig cell tumor of the left ovary and underwent successful laparoscopic salpingo-oophorectomy with normalization of her menstrual irregularity and biochemical resolution of her testosterone and 17OHP levels.
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Affiliation(s)
- Ya Yuan Nicole Chong
- Division of Endocrinology, Division of Medicine, National University Hospital, Singapore 119228, Singapore
| | - Jing Lin Jeslyn Wong
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, National University Hospital, Singapore 119228, Singapore
| | - Xiao Hong Joella Ang
- Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore 169608, Singapore
| | - Yuan Ling Amanda Lim
- Division of Endocrinology, Division of Medicine, National University Hospital, Singapore 119228, Singapore
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Ahmad J, Ahmad A, Hadid L. Restoration of reproductive capacity in a male patient with congenital adrenal hyperplasia and bilateral testicular adrenal rest tumors (TARTs) after six months of glucocorticoid intensification: A case report. Medicine (Baltimore) 2023; 102:e36061. [PMID: 38065885 PMCID: PMC10713158 DOI: 10.1097/md.0000000000036061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/20/2023] [Indexed: 12/18/2023] Open
Abstract
RATIONALE Congenital adrenal hyperplasia (CAH) is considered one of the most common inherited disorders. In about more than 95% of all CAH cases, the deficient enzyme is 21-hydroxylase. Infertility is an important complication of this disease, and although this topic has been studied more frequently in females, cases, and literature reviews of the causes of infertility in male patients are constantly increasing. PATIENT CONCERNS A 28 old male with congenital adrenal hyperplasia (we assume to be a nonclassical type) presented to our institution with infertility and suspected bilateral testicular masses after 4 years of stopping dexamethasone. DIAGNOSIS Testicular adrenal rest tumors. INTERVENTIONS Dexamethasone was reapplied in a supraphysiologic dose (1.5 mg before bedtime) with periodic monitoring of the patient. OUTCOMES Treatment with supraphysiologic dose of dexamethasone led to regression of these tumors and significant improvement in sperm count, resulting in being capable of having a child. LESSONS There are many suspected causes of reduced male fertility in male CAH patients and the presence of testicular adrenal rest tumors is the main cause of infertility in this population. These benign tumors are believed to arise from ectopic adrenal cells in the testes, that grow under adrenocorticotropic hormone stimulation in poorly controlled patients. Annual scrotal ultrasound is recommended in all males with CAH for detection and treatment of these tumors as early as possible before they cause permanent damage to the seminiferous tubules and irreversible infertility.
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Affiliation(s)
- Jihan Ahmad
- Department of Endocrinology, Al-Assad University Hospital, Damascus University, Damascus, Syria
| | - Adnan Ahmad
- Department of Urology, Al-Assad University Hospital, Damascus University, Damascus, Syria
| | - Lama Hadid
- Department of Endocrinology, Al-Assad University Hospital, Damascus University, Damascus, Syria
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20
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Nathaniel S, Oleru O, Seyidova N, Levy L, Taub PJ, Horesh E. Vaginal Reconstruction in the Pediatric Population: An Analysis of a National Database. J Pediatr Surg 2023; 58:2405-2409. [PMID: 37633769 PMCID: PMC11000433 DOI: 10.1016/j.jpedsurg.2023.07.016] [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: 12/28/2022] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE In the pediatric population, vaginoplasties can be performed in patients with either congenital malformations or acquired conditions. To our knowledge, there has been no study to date investigating the outcomes of vaginoplasty in the pediatric population using a nationwide database. Here, we present a national cohort study of perioperative characteristics and 30-day complications of vaginoplasty in pediatric patients. METHODS A level II retrospective, prognosis cohort study was performed using the Pediatric National Surgical Quality Improvement Program (NSQIP-P) database from 2012 to 2020. Data from patients age 0 to 18 who underwent vaginoplasty was queried using CPT code 57,335. Descriptive analysis was performed to elucidate patterns in patient demographics, perioperative characteristics, and 30-day postoperative outcomes. RESULTS A total of 183 patients were identified. Median age was 2.41 years (IQR 0.9 to 12.1). In this population, 58.5% of patients had ASA class 2, and 33.3% ASA class 3. Congenital malformation was present in 75.9%. Average total length of stay was 2.7 days (SD = 3.8) and readmission rate was 7.86%. Complications included urinary tract infection (3.3%), bleeding/transfusions (2.2%), organ/space surgical site infection (1.1%), and superficial incisional surgical site infection (0.6%). The most common procedures performed simultaneously with vaginoplasty included cystourethroscopy (n = 66), clitoroplasty for intersex state (n = 58), and plastic repair of introitus (n = 22). CONCLUSION Vaginoplasties in the pediatric population were found to have low rates of 30-day readmission and low incidence of 30-day postoperative complications. Further studies focusing on prospective clinical data related to pediatric vaginoplasty can help identify factors to improve long-term outcomes in this population.
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Affiliation(s)
- Sarah Nathaniel
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Olachi Oleru
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Nargiz Seyidova
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Lior Levy
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Peter J Taub
- Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Elan Horesh
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
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21
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Hunter SK, S Angadi S, Bhargava A, Harper J, Hirschberg AL, D Levine B, L Moreau K, J Nokoff N, Stachenfeld NS, Bermon S. The Biological Basis of Sex Differences in Athletic Performance: Consensus Statement for the American College of Sports Medicine. Med Sci Sports Exerc 2023; 55:2328-2360. [PMID: 37772882 DOI: 10.1249/mss.0000000000003300] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
ABSTRACT Biological sex is a primary determinant of athletic performance because of fundamental sex differences in anatomy and physiology dictated by sex chromosomes and sex hormones. Adult men are typically stronger, more powerful, and faster than women of similar age and training status. Thus, for athletic events and sports relying on endurance, muscle strength, speed, and power, males typically outperform females by 10%-30% depending on the requirements of the event. These sex differences in performance emerge with the onset of puberty and coincide with the increase in endogenous sex steroid hormones, in particular testosterone in males, which increases 30-fold by adulthood, but remains low in females. The primary goal of this consensus statement is to provide the latest scientific knowledge and mechanisms for the sex differences in athletic performance. This review highlights the differences in anatomy and physiology between males and females that are primary determinants of the sex differences in athletic performance and in response to exercise training, and the role of sex steroid hormones (particularly testosterone and estradiol). We also identify historical and nonphysiological factors that influence the sex differences in performance. Finally, we identify gaps in the knowledge of sex differences in athletic performance and the underlying mechanisms, providing substantial opportunities for high-impact studies. A major step toward closing the knowledge gap is to include more and equitable numbers of women to that of men in mechanistic studies that determine any of the sex differences in response to an acute bout of exercise, exercise training, and athletic performance.
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Affiliation(s)
- Sandra K Hunter
- Exercise Science Program, Department of Physical Therapy, and Athletic and Human Performance Center, Marquette University, Milwaukee, WI
| | | | - Aditi Bhargava
- Department of Obstetrics and Gynecology, Center for Reproductive Sciences, University of California, San Francisco, CA
| | - Joanna Harper
- Loughborough University, Loughborough, UNITED KINGDOM
| | - Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, and Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, SWEDEN
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, and the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kerrie L Moreau
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, and Eastern Colorado Health Care System, Geriatric Research Education and Clinical Center, Aurora, CO
| | - Natalie J Nokoff
- Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nina S Stachenfeld
- The John B. Pierce Laboratory and Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Stéphane Bermon
- Health and Science Department, World Athletics, Monaco and the LAMHESS, University Côte d'Azur, Nice, FRANCE
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Gidlöf S, Hogling DE, Lönnberg H, Ritzén M, Lajic S, Nordenström A. Growth and Treatment in Congenital Adrenal Hyperplasia: An Observational Study from Diagnosis to Final Height. Horm Res Paediatr 2023; 97:445-455. [PMID: 38016434 PMCID: PMC11446323 DOI: 10.1159/000535403] [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: 02/02/2023] [Accepted: 11/17/2023] [Indexed: 11/30/2023] Open
Abstract
INTRODUCTION Congenital adrenal hyperplasia (CAH) due to 21α-hydroxylase deficiency results in inadequate cortisol and aldosterone synthesis and concomitant overproduction of adrenal androgens. Despite adequate replacement, impaired growth and overweight remain a clinical challenge. The main objective was to investigate the differences in growth, final height (FH), and body mass index (BMI) between different CYP21A2 genotype groups and glucocorticoid treatment strategies during the different phases of growth. METHODS This is a population-based observational cohort study from diagnosis to FH. A total of 86 subjects were diagnosed with CAH in Sweden during 1989-1994. Eighty subjects were followed until FH. There were no interventions apart from the clinical standard of care treatment for CAH. The main outcome measure was the corrected FH standard deviation score (cFH SDS) and its correlation with genotype, accumulated total glucocorticoid dose, and treatment strategy. In addition, BMI and growth trajectories during infancy, childhood, and adolescence were studied. RESULTS FH was shorter in patients with the more severe CYP21A2 genotypes. Treatment doses of glucocorticoid were within the international treatment recommendations (10-15 mg/m2). Patients with the null and I2 splice genotypes lost approximately 1 SD in FH, whereas patients with the milder genotypes (I172N, P30L, and V281L) were within 0.5 to 0 SDS from target height. cFH SDS was negatively affected by the use of prednisolone but did not correlate with overall glucocorticoid treatment dose calculated as hydrocortisone equivalents. BMI at 18 years was higher in patients treated with prednisolone but did not correlate with genotype. CONCLUSIONS Corrected FH was more affected in patients with severe CYP21A2 genotypes. The addition of a low dose of prednisolone to the hydrocortisone treatment, despite an equivalent total dose of glucocorticoids, was associated with shorter FH and higher BMI in growing subjects with CAH.
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Affiliation(s)
- Sebastian Gidlöf
- Department of CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Daniel Eriksson Hogling
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Hanna Lönnberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Martin Ritzén
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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Dubinski I, Bechtold-Dalla Pozza S, Debor B, Nowotny HF, Reisch N, Tschaidse L, Schmidt H. Continuous Glucose Monitoring in Children and Adolescents with Congenital Adrenal Hyperplasia. J Clin Res Pediatr Endocrinol 2023; 15:380-389. [PMID: 37218136 PMCID: PMC10683536 DOI: 10.4274/jcrpe.galenos.2023.2023-3-5] [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: 03/15/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023] Open
Abstract
Objective Patients with congenital adrenal hyperplasia (CAH) require lifelong therapy with glucocorticoids to suppress androgen excess and substitute for deficient cortisol. An important aspect of care is the prevention of metabolic sequelae. In infants, potentially lethal nocturnal hypoglycaemia has been described. In adolescence, visceral obesity, hypertension, hyperinsulinism and insulin resistance are reported. To date, systematic studies of glucose profiles in this age group with CAH are lacking. Methods This was a monocentric, prospective, observational study to determine the glucose profiles under different treatment regimens in a cohort of young patients with CAH. The continuous glucose monitoring device used was the latest generation FreeStyle Libre 3® sensor in blinded mode. Therapeutic and auxological data were obtained. Results The cohort consisted of 10 children/adolescents with a mean age of 11 years. Three patients exhibited morning fasting hyperglycaemia. Overall, 6 out of 10 patients had unacceptably few total values in the desired range of 70-120 mg/dL. Tissue glucose values above 140-180 mg/dL were found in 5 of 10 patients. The mean value for glycosylated haemoglobin for the cohort was of 5.8%. All pubertal adolescents with reverse circadian regimens had significantly higher glucose levels at night. Two adolescents showed asymptomatic nocturnal hypoglycaemia. Conclusion Most of the patients exhibited abnormalities in glucose metabolism. Two-thirds had elevated total 24h glucose values outside the age-appropriate reference values. Thus, this aspect may need to be addressed early in life by adjusting the doses, treatment regimen or dietary measures. Consequently, reverse circadian therapy regimens should be critically indicated and closely monitored due to the potential metabolic risk.
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Affiliation(s)
- Ilja Dubinski
- Dr. von Hauner Children’s Hospital; Ludwig Maximilian University, Department of Paediatrics, Division of Paediatric Endocrinology, Munich, Germany
| | - Susanne Bechtold-Dalla Pozza
- Dr. von Hauner Children’s Hospital; Ludwig Maximilian University, Department of Paediatrics, Division of Paediatric Endocrinology, Munich, Germany
| | - Belana Debor
- Dr. von Hauner Children’s Hospital; Ludwig Maximilian University, Department of Paediatrics, Division of Paediatric Endocrinology, Munich, Germany
| | | | - Nicole Reisch
- Ludwig Maximilian University, Department of Medicine IV, Munich, Germany
| | - Lea Tschaidse
- Ludwig Maximilian University, Department of Medicine IV, Munich, Germany
| | - Heinrich Schmidt
- Dr. von Hauner Children’s Hospital; Ludwig Maximilian University, Department of Paediatrics, Division of Paediatric Endocrinology, Munich, Germany
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24
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Carsote M, Gheorghe AM, Nistor C, Trandafir AI, Sima OC, Cucu AP, Ciuche A, Petrova E, Ghemigian A. Landscape of Adrenal Tumours in Patients with Congenital Adrenal Hyperplasia. Biomedicines 2023; 11:3081. [PMID: 38002081 PMCID: PMC10669095 DOI: 10.3390/biomedicines11113081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/01/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Our aim is to update the topic of adrenal tumours (ATs) in congenital adrenal hyperplasia (CAH) based on a multidisciplinary, clinical perspective via an endocrine approach. This narrative review is based on a PubMed search of full-length, English articles between January 2014 and July 2023. We included 52 original papers: 9 studies, 8 case series, and 35 single case reports. Firstly, we introduce a case-based analysis of 59 CAH-ATs cases with four types of enzymatic defects (CYP21A2, CYP17A1, CYP17B1, and HSD3B2). Secondarily, we analysed prevalence studies; their sample size varied from 53 to 26,000 individuals. AT prevalence among CAH was of 13.3-20%. CAH prevalence among individuals with previous imaging diagnosis of AT was of 0.3-3.6%. Overall, this 10-year, sample-based analysis represents one of the most complex studies in the area of CAH-ATs so far. These masses should be taken into consideration. They may reach impressive sizes of up to 30-40 cm, with compressive effects. Adrenalectomy was chosen based on an individual multidisciplinary decision. Many tumours are detected in subjects with a poor disease control, or they represent the first step toward CAH identification. We noted a left lateralization with a less clear pathogenic explanation. The most frequent tumour remains myelolipoma. The risk of adrenocortical carcinoma should not be overlooked. Noting the increasing prevalence of adrenal incidentalomas, CAH testing might be indicated to identify non-classical forms of CAH.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
| | - Ana-Maria Gheorghe
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Ph.D. Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Claudiu Nistor
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Emergency University Military Hospital, 020021 Bucharest, Romania
| | - Alexandra-Ioana Trandafir
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Ph.D. Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Oana-Claudia Sima
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Ph.D. Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Anca-Pati Cucu
- Ph.D. Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Emergency University Military Hospital, 020021 Bucharest, Romania
| | - Adrian Ciuche
- Department 4—Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Thoracic Surgery Department, “Dr. Carol Davila” Central Emergency University Military Hospital, 020021 Bucharest, Romania
| | - Eugenia Petrova
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Department of Endocrinology, Faculty of Midwifery and Nursing, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Adina Ghemigian
- Clinical Endocrinology Department, C.I. Parhon National Institute of Endocrinology, 020021 Bucharest, Romania; (A.-I.T.); (O.-C.S.); (E.P.); (A.G.)
- Department of Endocrinology, Faculty of Midwifery and Nursing, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
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25
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Borchers J, Pukkala E, Mäkitie O, Laakso S. Epidemiology and Causes of Primary Adrenal Insufficiency in Children: A Population-Based Study. J Clin Endocrinol Metab 2023; 108:2879-2885. [PMID: 37216903 PMCID: PMC10583995 DOI: 10.1210/clinem/dgad283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/25/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
CONTEXT Incidence and causes of primary adrenal insufficiency (PAI) have not been comprehensively studied in children. OBJECTIVE Our objective was to describe the epidemiology and to assess causes of PAI in Finnish children. METHODS A population-based descriptive study of PAI in Finnish patients aged 0-20 years.Diagnoses referring to adrenal insufficiency in children born in 1996-2016 were collected from the Finnish National Care Register for Health Care. Patients with PAI were identified by studying patient records. Incidence rates were calculated in relation to person-years in the Finnish population of same age. RESULTS Of the 97 patients with PAI, 36% were female. The incidence of PAI was highest during the first year of life (in females 2.7 and in males 4.0/100 000 person-years). At 1-15 years of age, the incidence of PAI in females was 0.3/100 000 and in males 0.6/100 000 person-years. Cumulative incidence was 10/100 000 persons at age of 15 years and 13/100 000 at 20 years. Congenital adrenal hyperplasia was the cause in 57% of all patients and in 88% of patients diagnosed before age of 1 year. Other causes among the 97 patients included autoimmune disease (29%), adrenoleukodystrophy (6%), and other genetic causes (6%). From the age of 5 years, most of the new cases of PAI were due to autoimmune disease. CONCLUSION After the first-year peak, the incidence of PAI is relatively constant through ages 1-15 years, and 1 out of 10 000 children are diagnosed with PAI before the age of 15 years.
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Affiliation(s)
- Joonatan Borchers
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Eero Pukkala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Finnish Cancer Registry—Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - Outi Mäkitie
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Saila Laakso
- Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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26
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Gold S, Huang C, Radi R, Gupta P, Felner EI, Haw JS, Childress K, Sokkary N, Tangpricha V, Goodman M, Yeung H. Dermatologic care of patients with differences of sex development. Int J Womens Dermatol 2023; 9:e106. [PMID: 37671254 PMCID: PMC10473340 DOI: 10.1097/jw9.0000000000000106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 08/01/2023] [Indexed: 09/07/2023] Open
Abstract
Background Differences of sex development (DSD or disorders of sex development) are uncommon congenital conditions, characterized by atypical development of chromosomal, gonadal, or anatomic sex. Objective Dermatologic care is an important component of the multidisciplinary care needed for individuals with DSD. This article discusses the most common primary dermatologic manifestations of DSD in addition to the cutaneous manifestations of hormonal and surgical therapies in individuals with DSD. Data sources Published articles including case series and case reports on PubMed. Study selections Selection was conducted by examining existing literature with a team of multidisciplinary specialists. Methods Narrative review. Limitations This article was not conducted as a systematic review. Results In Klinefelter syndrome, refractory leg ulcers and incontinentia pigmenti have been described. Turner syndrome is associated with lymphatic malformations, halo nevi, dermatitis, and psoriasis. Virilization can be seen in some forms of congenital adrenal hyperplasia, where acne and hirsutism are common. Conclusion Dermatologists should consider teratogenic risk for treatments of skin conditions in DSD depending on pregnancy potential. Testosterone replacement, commonly used for Klinefelter syndrome, androgen insensitivity syndrome, 5-alpha reductase deficiency, gonadal dysgenesis, or ovotesticular DSD, may cause acne.
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Affiliation(s)
- Sarah Gold
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Christina Huang
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Rakan Radi
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Pranav Gupta
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Eric I. Felner
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jeehea Sonya Haw
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Krista Childress
- Pediatric and Adolescent Gynecology, University of Utah, Primary Children’s Hospital, Salt Lake City, Utah
| | - Nancy Sokkary
- Pediatric and Adolescent Gynecology, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Goodman
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
- Clinical Resource Hub, Veterans Administration Veterans Integrated Service Network 7 Southeast Network, Decatur, Georgia
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27
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Liu E, Luo H, Zhou K, Zhang Y. Clinical analysis of 78 patients with nonclassical 21-hydroxylase deficiency. Arch Gynecol Obstet 2023; 308:871-882. [PMID: 36773044 DOI: 10.1007/s00404-023-06946-5] [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: 11/24/2022] [Accepted: 01/24/2023] [Indexed: 02/12/2023]
Abstract
PURPOSE Retrospectively analyze the clinical characteristics of patients with nonclassical 21-hydroxylase deficiency (NC21OHD) as well as the relationship between the gene mutations and endocrine hormones. In addition, the relationship between different basal 17-hydroxyprogesterone (17OHP) levels and patients' glucolipid metabolism, hormone levels, pregnancy, and treatment outcomes were examined. METHODS Clinical data of 78 females with NC21OHD from January 2012 to July 2022 in the Department of Endocrinology and Metabolism of the Third Affiliated Hospital of Guangzhou Medical University were retrospectively analyzed. Diagnosis was based on the 17OHP level combined with clinical manifestations, imaging, and other endocrine hormones and the cytochrome P450 c21, steroid 21-hydroxylase (CYP21A2) gene. RESULTS The age at diagnosis of the 78 patients was 29.1 ± 4.2 years; 83.3% (65/78) of the patients had menstrual abnormalities, 70 patients were of childbearing age, and 97.1% (68/70) had a history of infertility with a median time of infertility of 3.6 years. Moreover, 71.8% (56/78) of the patients had polycystic ovaries, 26.9% (21/78) had hyperandrogenemia manifestations on physical examination, 66.7% (52/78) had adrenal hyperplasia, 32.1% (25/78) had combined dyslipidemia, and 41.0% (32/78) had combined insulin resistance. Pathogenic mutations were detected in 78.2% (61/78) of the patients with both CYP21A2 alleles; 14.1% (11/78) of the patients had only one allele and 7.7% (6/78) had no pathogenic mutations. The levels of total testosterone (TT), progesterone (P) (0 min, 30 min), and 17-OHP (0 min, 30 min, 60 min) in the adrenocorticotropic hormone (ACTH) stimulation test varied between the groups. Furthermore, patients with NC21OHD were divided into 17OHP < 2 ng/ml, 2 ng/ml < 17OHP < 10 ng/ml, and 17OHP ≥ 10 ng/ml groups according to their different basal 17OHP levels. The 17OHP ≥ 10 ng/ml group had significantly higher TT, FT4, basal and post-stimulation progesterone, and 17OHP, net value added of 17-hydroxyprogesterone (△17OHP), net value added of 17-hydroxyprogesterone/net value added of cortisol ratio (△17OHP/△F), the incidence of adrenal hyperplasia, and number of gene mutations compared to those of the 17OHP < 2 ng/ml group (P < 0.05). NC21OHD infertile patients who received low-dose glucocorticoids showed a significant increase in pregnancy and live birth rates, and a significant decrease in miscarriage rate (all P < 0.05). CONCLUSION Comprehensive analysis is important as NCCAH diagnoses may be false positive or false negative based on clinical characteristics, hormone levels, and gene detection. Females with NC21OHD showed varying degrees of fertility decline; thus, low doses of glucocorticoid treatment for infertile females with NC21OHD can improve fertility and fertility outcomes.
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Affiliation(s)
- En Liu
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Higher Education Institutes, Guangzhou, Guangdong, People's Republic of China
| | - Hengcong Luo
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Higher Education Institutes, Guangzhou, Guangdong, People's Republic of China
| | - Kailv Zhou
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Higher Education Institutes, Guangzhou, Guangdong, People's Republic of China
| | - Ying Zhang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, People's Republic of China.
- Key Laboratory for Major Obstetric Diseases of Guangdong Higher Education Institutes, Guangzhou, Guangdong, People's Republic of China.
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28
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de Gusmão Ramos Marques Pinto MI, Blánquez Martínez D, Hayón Ponce M. [Congenital adrenal hyperplasia: what primary care physicians need to know?]. Semergen 2023; 49:101984. [PMID: 37182474 DOI: 10.1016/j.semerg.2023.101984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/15/2023] [Accepted: 03/30/2023] [Indexed: 05/16/2023]
Affiliation(s)
| | | | - María Hayón Ponce
- Endocrinología y Nutrición, Hospital Universitario de Ceuta, Ceuta, España
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29
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McCann-Crosby B, Liang MC, Geffner ME, Koppin CM, Fraga NR, Sutton VR, Karaviti LP, Bhullar G, Kim MS. Differences in Hyperandrogenism Related to Early Detection of Non-Classical Congenital Adrenal Hyperplasia on Second Newborn Screen. Int J Neonatal Screen 2023; 9:50. [PMID: 37754776 PMCID: PMC10531884 DOI: 10.3390/ijns9030050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023] Open
Abstract
Screening for congenital adrenal hyperplasia (CAH) remains heterogenous across geographies-we sought to determine the proportion of non-classical CAH (NCAH) detection by one vs. two newborn screens (NBS) in two U.S. regions. Data were collected at tertiary centers in Houston (HOU) and Los Angeles (LA) on 35 patients with NCAH, comparing patients identified via the NBS vs. during childhood, 17-hydroxyprogesterone (17-OHP) levels, genotype, and phenotype. The NBS filter-paper 17-OHP levels and daily cutoffs were recorded on initial and second screens. In all, 53% of patients with NCAH in the HOU cohort were identified as infants via the second NBS. Patients identified clinically later in childhood presented at a similar age (HOU: n = 9, 5.5 ± 3.1 years; LA: n = 18, 7.9 ± 4 years) with premature pubarche in almost all. Patients in LA had more virilized phenotypes involving clitoromegaly and precocious puberty and were older at treatment onset compared with those identified in HOU by the second NBS (HOU: 3.2 ± 3.9 years; LA: 7.9 ± 4.0 years, p = 0.02). We conclude that the early detection of NCAH could prevent hyperandrogenism and its adverse consequences, with half of the cases in HOU detected via a second NBS. Further studies of genotyping and costs are merited.
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Affiliation(s)
| | - Mark C. Liang
- Children’s Hospital Los Angeles (CHLA), Los Angeles, CA 90027, USA
| | - Mitchell E. Geffner
- Children’s Hospital Los Angeles (CHLA), Los Angeles, CA 90027, USA
- The Saban Research Institute at CHLA, Los Angeles, CA 90027, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | | | - Nicole R. Fraga
- Children’s Hospital Los Angeles (CHLA), Los Angeles, CA 90027, USA
| | - V. Reid Sutton
- Department of Molecular and Human Genetics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX 77030, USA
| | | | | | - Mimi S. Kim
- Children’s Hospital Los Angeles (CHLA), Los Angeles, CA 90027, USA
- The Saban Research Institute at CHLA, Los Angeles, CA 90027, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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30
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Sanz Fernández M, Mora Sitja M, Carrascón González-Pinto L, López Herce Arteta E, Rodríguez Sánchez A. Assessment of the Degree of Clinical Suspicion of 21-Hydroxylase Deficiency Prior to the Newborn Screening Result. Horm Metab Res 2023; 55:528-535. [PMID: 37328149 DOI: 10.1055/a-2111-6571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The aim of the study was to analyze the clinical suspicion and where patients were when they received the positive result of the neonatal screening for CAH 21OHD. The present data derived from a retrospective analysis of a relatively large group of patients with classical CAH 21OHD patients nosed by newborn screening in Madrid, Spain. During the period from 1990 to 2015 of this study 46 children were diagnosed with classical 21OHD [36 with the salt-wasting (SW) form and 10 with simple virilizing (SV)]. In 38 patients, the disease had not been suspected before the neonatal screening result (30 SW and 8 SV). Thirty patients (79%) were at home without suspicion of any disease, as healthy children, 3 patients (8%) were at home pending completion of the study due to clinical suspicion of any disease (ambiguous genitalia, cryptorchidism) and 5 patients (13%) were admitted to the hospital for reasons unrelated to CAH (sepsis, jaundice, hypoglycemia). It is relevant to note that 69.4% of patients (25/36) with SW form were at home with potential risk of adrenal crisis. Six females had been incorrectly labeled as male at birth. The most frequent reason for clinical suspicion was genital ambiguity in women followed by family history of the disease. Neonatal screening provided better results than clinical suspicion. In the majority of patients with 21OHD the diagnosis by screening was anticipated to the clinical suspicion of the disease even in female patients with ambiguous genitalia.
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Affiliation(s)
- María Sanz Fernández
- Department of Pediatrics & Pediatric Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marina Mora Sitja
- Department of Pediatrics & Pediatric Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Estíbaliz López Herce Arteta
- Department of Pediatrics & Pediatric Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Amparo Rodríguez Sánchez
- Department of Pediatrics & Pediatric Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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31
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Abrigo E, Munarin J, Bondone C, Tuli G, Castagno E, de Sanctis L, Matarazzo P. Adrenal insufficiency management in the pediatric emergency setting and risk factors for adrenal crisis development. Ital J Pediatr 2023; 49:63. [PMID: 37280667 PMCID: PMC10242818 DOI: 10.1186/s13052-023-01475-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/16/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND In patients with adrenal insufficiency (AI), adrenal crisis (AC) represents a clinical emergency. Early recognition and prompt management of AC or AC-risk conditions in the Emergency Department (ED) can reduce critical episodes and AC-related outcomes. The aim of the study is to report the clinical and biochemical characteristics of AC presentation to improve their timely recognition and proper management in a ED setting. METHODS Single-centre, retrospective, observational study on pediatric patients followed at the Department of Pediatric Endocrinology of Regina Margherita Children's Hospital of Turin for primary AI (PAI) and central AI (CAI). RESULTS Among the 89 children followed for AI (44 PAI, 45 CAI), 35 patients (21 PAI, 14 CAI) referred to the PED, for a total of 77 accesses (44 in patients with PAI and 33 with CAI). The main causes of admission to the PED were gastroenteritis (59.7%), fever, hyporexia or asthenia (45.5%), neurological signs and respiratory disorders (33.8%). The mean sodium value at PED admission was 137.2 ± 1.23 mmol/l and 133.3 ± 1.46 mmol/l in PAI and CAI, respectively (p = 0.05). Steroids administration in PED was faster in patients with CAI than in those with PAI (2.75 ± 0.61 and 3.09 ± 1.47 h from PED access, p = 0.83). Significant factors related to the development of AC were signs of dehydration at admission (p = 0.027) and lack of intake or increase of usual steroid therapy at home (p = 0.059). Endocrinological consulting was requested in 69.2% of patients with AC and 48.4% of subjects without AC (p = 0.032). CONCLUSION children with AI may refer to the PED with an acute life-threatening condition that needs prompt recognition and management. These preliminary data indicate how critical the education of children and families with AI is to improve the management at home, and how fundamental the collaboration of the pediatric endocrinologist with all PED personnel is in raising awareness of early symptoms and signs of AC to anticipate the proper treatment and prevent or reduce the correlated serious events.
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Affiliation(s)
- Enrica Abrigo
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Piazza Polonia 94, Turin, 10126, Italy
- Postgraduate School of Pediatrics, University of Turin, Turin, Italy
| | - Jessica Munarin
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Piazza Polonia 94, Turin, 10126, Italy.
- Postgraduate School of Pediatrics, University of Turin, Turin, Italy.
| | - Claudia Bondone
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Piazza Polonia 94, Turin, 10126, Italy
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, Turin, Italy
| | - Gerdi Tuli
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Piazza Polonia 94, Turin, 10126, Italy
| | - Emanuele Castagno
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Piazza Polonia 94, Turin, 10126, Italy
- Department of Pediatric Emergency, Regina Margherita Children's Hospital, Turin, Italy
| | - Luisa de Sanctis
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Piazza Polonia 94, Turin, 10126, Italy
| | - Patrizia Matarazzo
- Department of Pediatric Endocrinology, Regina Margherita Children's Hospital, Piazza Polonia 94, Turin, 10126, Italy
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Bowden SA. Current Screening Strategies for the Diagnosis of Adrenal Insufficiency in Children. Pediatric Health Med Ther 2023; 14:117-130. [PMID: 37051221 PMCID: PMC10084833 DOI: 10.2147/phmt.s334576] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
Adrenal insufficiency can arise from a primary adrenal disorder, secondary to adrenocorticotropic hormone deficiency, or by suppression of hypothalamic-pituitary-adrenal axis due to exogenous glucocorticoids. Diagnosis of adrenal insufficiency is usually delayed because the initial presentation is often subtle and nonspecific. Clinician awareness and recognition is crucial for timely diagnosis to avoid adrenal crisis. Current screening strategies for the diagnosis of adrenal insufficiency in children in various clinical situations are discussed in this review.
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Affiliation(s)
- Sasigarn A Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children’s Hospital/The Ohio State University College of Medicine, Columbus, OH, USA
- Correspondence: Sasigarn A Bowden, Nationwide Children’s Hospital, Division of Endocrinology, 700 Children’s Drive, Columbus, OH, 43205, USA, Tel +1 614-722-4118, Fax +1 614-722-4440, Email
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Monteiro A, Pavithran PV, Puthukulangara M, Bhavani N, Nampoothiri S, Yesodharan D, Kumaran R. Cost-effective genotyping for classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21-OHD) in resource-poor settings: multiplex ligation probe amplification (MLPA) with/without sequential next-generation sequencing (NGS). Hormones (Athens) 2023; 22:311-320. [PMID: 36952211 DOI: 10.1007/s42000-023-00445-7] [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: 10/04/2022] [Accepted: 02/28/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE Genotyping of classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21-OHD) is becoming increasingly significant beyond prenatal counseling in the current era of emerging gene therapy/editing technologies. While the knowledge of common variants helps in designing cost-effective genotyping strategies, limited data are currently available from the Indian subcontinent, especially South India, mainly due to financial constraints. The aim of this study is to assess the genotype of individuals with classic CAH from a South Indian cohort in a cost-effective manner. METHODS The genotypes of 46 unrelated subjects with classic CAH were studied through initial multiplex ligation-dependent probe amplification (MLPA) using the SALSA MLPA Probe-mix P050 CAH (MRC Holland). Next-generation sequencing (NGS) was done in 10 subjects, as their MLPA was either negative or showed heterozygous variants. RESULTS The common variants observed in our study population of 46 subjects were large deletions (35.8%), intron 2 variant [c.293-13A/C > G] (35.8%), 8 bp del [c.332_339del p.(Gly111Valfs*21)] (7.7%), and R356W [c.1069 C > T p.(Arg357Trp)] (6.6%). MLPA alone detected pathogenic variants in 78.2% of the initial study samples (36/46). Sequential NGS resulted in a 100% detection rate in our study population. CONCLUSION MLPA appears to be an effective first genotyping modality for this South Indian cohort due to the high prevalence of large deletions and common variants. MLPA as a first initial screening genotyping test with sequential NGS when required may be a cost-effective and highly sensitive approach to CYP21A2 genotyping in our part of the world and in resource-poor settings.
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Affiliation(s)
- Ana Monteiro
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Praveen V Pavithran
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India.
| | | | - Nisha Bhavani
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Sheela Nampoothiri
- Department of Paediatric Genetics, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Dhanya Yesodharan
- Department of Paediatric Genetics, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Reshma Kumaran
- Paediatric Clinical Genetics Laboratory, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Carrière C, Nguyen LS, Courtillot C, Tejedor I, Chakhtoura Z, Bellanné-Chantelot C, Tardy V, Leban M, Touraine P, Bachelot A. Fertility and pregnancy outcomes in women with nonclassic 21-hydroxylase deficiency. Clin Endocrinol (Oxf) 2023; 98:315-322. [PMID: 36325983 DOI: 10.1111/cen.14842] [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: 06/03/2022] [Revised: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Overall fertility and pregnancy outcomes in patients with nonclassic congenital adrenal hyperplasia (NCCAH) have been poorly studied. It has been suggested that hydrocortisone (HC) may decrease the time to conceive (TTC) and the rate of miscarriage in these patients. OBJECTIVES To describe fertility and pregnancy outcomes in a large cohort of NCCAH women. The secondary objective was to identify factors that could impact reproductive outcomes, with a particular focus on HC dose and genetic status. DESIGN Retrospective study in a referral center for congenital adrenal hyperplasia. PATIENTS AND MEASUREMENTS: One hundred seventy-three female patients with NCCAH confirmed by genetic testing, followed in our center between 2010 and 2019. RESULTS Among the 173 patients, 95 women had a parental project, 86 of whom presented 176 pregnancies, 56% under glucocorticoid (GC) treatment and 44% without, and 76 women obtained 128 live births. Two-thirds of the patients regularized their cycle under GC treatment, with significant decrease of androgens and progesterone levels. This treatment was associated with a shortening of TTC (coef β = -.196, information coefficient [IC] = [-10.7; -0.91], p = .021). Androgen levels and TTC were positively correlated to the rate of miscarriage (OR = 4.8, IC = [1.15; 20.34], p = .021 for testosterone, OR = 1.4, IC = [1.05; 1.81], p = .02 for androstenedione, and OR = 1.03, IC = [1.01; 1.06], p = .015 for TTC). There was no difference in terms of obstetric outcomes between patients with or without GC treatment. CYP21A2 genotype had no impact on pregnancy outcome or TTC. CONCLUSIONS Infertility is relative in patients with NCCAH. HC seems beneficial for fertility and pregnancy outcomes, especially for patients with menstrual disorders and high preconceptional androgen levels.
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Affiliation(s)
- Camille Carrière
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
| | - Lee S Nguyen
- Clinical Investigations Center, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
- Research and Innovation Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Carine Courtillot
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
| | - Isabelle Tejedor
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
| | - Zeina Chakhtoura
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
| | - Christine Bellanné-Chantelot
- Department of Medical Genetics, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université Médecine, Paris, France
| | - Véronique Tardy
- Department of Molecular Endocrinology and Rare Diseases, Center for Biology and Eastern Pathology, Civil Hospitals of Lyon, Bron, France
| | - Monique Leban
- Department of Hormonal Biochemistry, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université Médecine, Paris, France
| | - Anne Bachelot
- Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
- Sorbonne Université Médecine, Paris, France
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Krishnan K, Pillai S, Vaidyanathan G. Pregnancy in a woman with congenital adrenal hyperplasia with 11-beta-hydroxylase deficiency: A case report. Obstet Med 2023; 16:66-68. [PMID: 37139504 PMCID: PMC10150300 DOI: 10.1177/1753495x211042729] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Successful pregnancy with congenital adrenal hyperplasia due to 11-beta-hydroxylase deficiency is an extremely rare condition. Only two cases have been reported in the literature. Methods and results Described here is a 30-year-old woman diagnosed as a neonate with congenital adrenal hyperplasia related to 11-beta-hydroxylase deficiency classic type, who subsequently underwent clitoral resection and vaginoplasty. She was started on lifelong steroid therapy after surgery. She developed hypertension at 11 years of age and was on antihypertensive therapy from then on. In later life, she underwent division of vaginal scar tissue and perineal refashioning. She spontaneously conceived but her pregnancy was complicated by severe pre-eclampsia and delivery was required at 33 weeks of gestation by cesarean section. A healthy male infant was delivered. Conclusion Management of these women is similar to those with more common causes of congenital adrenal hyperplasia, with careful monitoring throughout pregnancy for complications such as gestational diabetes, gestational hypertension, and intrauterine growth restriction.
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Affiliation(s)
- Kavitha Krishnan
- Kavitha Krishnan, Department of Obstetrics and
Gynaecology, Sultan Qaboos University College of Medicine and Health Science, Muscat,
Oman.
| | - Silja Pillai
- Department of Obstetrics and Gynaecology, Sultan Qaboos University Hospital, Oman
| | - Gowri Vaidyanathan
- Department of Obstetrics and Gynaecology, Sultan Qaboos University Hospital, Oman
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36
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Cunha GR, Cao M, Derpinghaus A, Baskin LS. Androgenic induction of penile features in postnatal female mouse external genitalia from birth to adulthood: Is the female sexual phenotype ever irreversibly determined? Differentiation 2023; 131:1-26. [PMID: 36924743 DOI: 10.1016/j.diff.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/12/2023]
Abstract
Female mice were treated for 35 days from birth to 60 days postnatal (P0, [birth], P5, P10, P20 and adult [∼P60]) with dihydrotestosterone (DHT). Such treatment elicited profound masculinization the female external genitalia and development of penile features (penile spines, male urogenital mating protuberance (MUMP) cartilage, corpus cavernosum glandis, corporal body, MUMP-corpora cavernosa, a large preputial space, internal preputial space, os penis). Time course studies demonstrated that DHT elicited canalization of the U-shaped clitoral lamina to create a U-shaped preputial space, preputial lining epithelium and penile epithelium adorned with spines. The effect of DHT was likely due to signaling through androgen receptors normally present postnatally in the clitoral lamina and associated mesenchyme. This study highlights a remarkable male/female difference in specification and determination of urogenital organ identity. Urogenital organ identity in male mice is irreversibly specified and determined prenatally (prostate, penis, and seminal vesicle), whereas many aspects of the female urogenital organogenesis are not irreversibly determined at birth and in the case of external genitalia are not irreversibly determined even into adulthood, the exception being positioning of the female urethra, which is determined prenatally.
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Affiliation(s)
- Gerald R Cunha
- Department of Urology, University of California, 400 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Mei Cao
- Department of Urology, University of California, 400 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Amber Derpinghaus
- Department of Urology, University of California, 400 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Laurence S Baskin
- Department of Urology, University of California, 400 Parnassus Avenue, San Francisco, CA, 94143, USA
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Tsai MJM, Tsai WY, Lee CT, Liu SY, Chien YH, Tung YC. Adult height of children with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Formos Med Assoc 2023; 122:106-112. [PMID: 36155706 DOI: 10.1016/j.jfma.2022.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/11/2022] [Accepted: 09/05/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND/PURPOSES Congenital adrenal hyperplasia attributable to 21-hydroxylase deficiency (21-OHD) is a disorder of adrenal steroidogenesis. Achievement of optimal growth by such patients is challenging. We evaluated the adult height of Taiwanese children with 21-OHD and the effect of a gonadotropin-releasing hormone analogue (GnRHa) in patients with central precocious puberty (CPP) complicating 21-OHD. METHODS Among 116 patients with 21-OHD in Taiwan, 90 who had attained adult height were subjected to an analysis of height outcomes. Nine with progressive CPP were treated with GnRHa and the effects of this therapy on adult height were further analyzed. RESULTS In the pre-screening era, the percentage of boys with 21-OHD was lower than expected. Although neonatal screening can prevent mortality caused by adrenal crisis, some cases may be missed. The pooled mean adult height of the 78 patients treated with conventional therapy were -1.1 SD and -0.5 SD adjusting for the genetic potential. The disease features affecting height outcomes are the genetic height potential and in boys the simple virilizing type. Nine patients with CPP were treated with GnRHa in addition to conventional therapy; the mean adult height increased from the predicted -4.1 SD to -1.0 SD after 6.0 ± 2.5 years of treatment. CONCLUSION Patients with 21-OHD had poorer mean adult height. A high caregiver's index of suspicion is required for the early diagnosis of patients with 21-OHD missed on neonatal screening. Adjuvant therapy with GnRHa can improve the adult height of patients with CPP complicating 21-OHD.
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Affiliation(s)
- Meng-Ju Melody Tsai
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-Yu Tsai
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Ting Lee
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Yao Liu
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yin-Hsiu Chien
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Ching Tung
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan.
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Liao Z, Gao Y, Zhao Y, Wang Z, Wang X, Zhou J, Zhang Y. Pure androgen-secreting adrenal tumor (PASAT): A rare case report of bilateral PASATs and a systematic review. Front Endocrinol (Lausanne) 2023; 14:1138114. [PMID: 37033242 PMCID: PMC10075358 DOI: 10.3389/fendo.2023.1138114] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND Adult pure androgen-secreting adrenal tumors (PASATs) are extremely rare, and their characteristics are largely unknown. METHODS A rare case of adult bilateral PASATs was reported, and a systematic literature review of adult PASATs was conducted to summarize the characteristics of PASATs. RESULTS In total, 48 studies, including 40 case reports and 8 articles, were identified in this review. Analysis based on data of 42 patients (including current case and 41 patients from 40 case reports) showed that average age was 40.48 ± 15.80 years (range of 18-76). The incidence of adult PASAT peaked at 21-30 years old, while that of malignant PASAT peaked at 41-50 years old. Most PASAT patients were female (40/42, 95.23%), and hirsutism was the most common symptom (37/39, 94.87%). Testosterone (T) was the most commonly elevated androgen (36/42, 85.71%), and 26 of 32 tested patients presented increased dehydroepiandrosterone sulfate (DS) levels. In malignancy cases, disease duration was significantly decreased (1.96 vs. 4.51 years, P=0.025), and tumor diameter was significantly increased (8.9 vs. 4.9 cm, p=0.011). Moreover, the androgen levels, namely, T/upper normal range limit (UNRL) (11.94 vs. 4.943, P=0.770) and DS/UNRL (16.5 vs. 5.28, P=0.625), were higher in patients with malignancy. In total, 5 out of 7 patients showed an increase in DS or T in the human chorionic gonadotropin (HCG) stimulation test. Overall, 41 out of 42 patients (including current case) underwent adrenal surgery, and recurrence, metastasis, or death was reported in 5 out of 11 malignant patients even with adjuvant or rescue mitotane chemotherapy. CONCLUSION Adult PASAT, which is predominant in women, is characterized by virilism and menstrual dysfunction, especially hirsutism. Elevated T and DS may contribute to the diagnosis of adult PASAT, and HCG stimulation test might also be of help in diagnosis. Patients with malignant PASAT have a shorter disease duration, larger tumor sizes and relatively higher androgen levels. Surgery is recommended for all local PASATs, and Malignancy of PASAT should be fully considered due to the high risk of malignancy, poor prognosis and limited effective approaches.
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Affiliation(s)
- Zhangcheng Liao
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuting Gao
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yang Zhao
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhan Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jiaquan Zhou
- Department of Urology, Hainan General Hospital, Haikou, China
| | - Yushi Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Yushi Zhang,
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Ceccato F, Torchio M, Tizianel I, Peleg Falb M, Barbot M, Sabbadin C, Betterle C, Scaroni C. Renin and electrolytes indicate the mineralocorticoid activity of fludrocortisone: a 6 year study in primary adrenal insufficiency. J Endocrinol Invest 2023; 46:111-122. [PMID: 35947299 PMCID: PMC9829625 DOI: 10.1007/s40618-022-01889-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/28/2022] [Indexed: 01/13/2023]
Abstract
CONTEXT Fludrocortisone (FC) is the mineralocorticoid (MC) replacement treatment for patients with primary adrenal insufficiency (PAI). OBJECTIVE To explore the dose of FC treatment and its relationship with glucocorticoid therapy, sodium, potassium, renin and clinical parameters. SETTING Monocentric cohort. PATIENTS Data of 193 patients with PAI (130 autoimmune) were collected during baseline (T0), intermediate (T1) and last follow-up visit (T2, respectively, after a mean of 38 and 72 months). MAIN OUTCOME MEASURE Utility of endocrine and clinical parameters to titrate FC dose. RESULTS FC dose (50-75 μg/daily) was stable in the follow-up in half patients. The MC activity of FC was dose-dependent: we observed a reduced but significant positive linear correlation between FC dose and sodium (r = 0.132) and negative linear correlation between FC and potassium (r = - 0.162) or renin (r = - 0.131, all p < 0.01). An overall reduction in the FC dose was observed at T2 in the group with longer follow-up (> 60 months, p < 0.05). Higher doses of FC were observed in patients with low-normal renin, especially in autoimmune PAI (86 vs 65 μg/daily, p < 0.05). On the contrary, reduced sodium and increased potassium levels were observed in patients with high renin at T2. The number of cardiovascular events (15 in the whole cohort) was similar in patients sorted by renin levels or FC dose. CONCLUSIONS Renin and electrolytes can indicate the MC activity of FC treatment: they should be routinely evaluated and used to titrate its dose that can be reduced in the long-term follow-up.
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Affiliation(s)
- F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy.
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy.
| | - M Torchio
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - I Tizianel
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - M Peleg Falb
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - C Sabbadin
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
| | - C Betterle
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105, 35128, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padua, Italy
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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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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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Xia Y, Shi P, Gao S, Liu N, Zhang H, Kong X. Genetic analysis and novel variation identification in Chinese patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. J Steroid Biochem Mol Biol 2022; 222:106156. [PMID: 35882282 DOI: 10.1016/j.jsbmb.2022.106156] [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: 02/09/2022] [Revised: 06/30/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022]
Abstract
Congenital adrenal hyperplasia owing to 21-hydroxylase deficiency is an autosomal-recessive disorder caused by mutations in the CYP21A2 gene. The aim of the study was to analyze the molecular data of 155 21-OHD patients and retrospectively investigated the common allelic mutations of CYP21A2 in 1442 Chinese 21-OHD patients. Clinical features and mutations of CYP21A2 gene in 155 unrelated 21-OHD patients were examined. Of the 155 patients, 103 cases were salt-wasting (SW) forms, 38 were simple virilizing (SV) forms and 14 were non-classical (NC) forms. In general, two types of mutations including common allelic mutations (281/310, 90.6%) and rare mutations (29/310, 9.4%) were detected, among them four novel variants c.835G>T, c.1081C>T, c.1423C>T and c.651 + 2 T > G were identified. In 1442 Chinese 21-OHD patients, the most frequently mutations were I2G (36.2%), large deletion/conversion (20.7%) and p.I173N (17.8%), while p.V282L has the lowest frequency. In this study, we provided detailed clinical data and mutation spectrum in Chinese 21-OHD patients. Moreover, four novel CYP21A2 variants (c.835G>T, c.1081C>T, c.1423C>T and c.651 +2 T > G) were identified and computational structural modeling indicated that these novel variations probably affect structural stability. Our findings improve the understanding of CYP21A2 mutational spectrum and contribute to the precise diagnosis and prenatal counseling.
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Affiliation(s)
- Yanjie Xia
- Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan Engineering Research Center for Gene Editing of Human Genetic Disease, Zhengzhou, China
| | - Panlai Shi
- Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan Engineering Research Center for Gene Editing of Human Genetic Disease, Zhengzhou, China
| | - Shanshan Gao
- Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan Engineering Research Center for Gene Editing of Human Genetic Disease, Zhengzhou, China
| | - Ning Liu
- Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan Engineering Research Center for Gene Editing of Human Genetic Disease, Zhengzhou, China
| | - Huijuan Zhang
- Department of Endocrinology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiangdong Kong
- Genetics and Prenatal Diagnosis Center, The First Affiliated Hospital of Zhengzhou University, Henan Engineering Research Center for Gene Editing of Human Genetic Disease, Zhengzhou, China.
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43
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Zhang Q, Zhan M, Wu H, Feng P, Jin X, Wan Z, Yan J, Zhang P, Ke P, Zhuang J, Zhou J, Han L, Huang X. Simultaneous quantitation of 17 endogenous adrenal corticosteroid hormones in human plasma by UHPLC-MS/MS and their application in congenital adrenal hyperplasia screening. Front Chem 2022; 10:961660. [PMID: 36034654 PMCID: PMC9403142 DOI: 10.3389/fchem.2022.961660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Accurate investigation of adrenal hormone levels plays a vital role in pediatric endocrinology for the detection of steroid-related disorders. This study aims to develop a straightforward, sensitive UHPLC-MS/MS method to quantify 17 endogenous adrenal corticosteroid hormones in human plasma. These hormones are the main ingredients in the synthetic and metabolic pathways of adrenal corticosteroid hormones. Chromatographic separation was achieved on a C18 column before electrospray ionization triple-quadrupole mass spectrometry in multiple reaction monitoring mode with a run time of 7 min. The samples were extracted by liquid-liquid extraction and required no derivatization. Analytical performance was evaluated, including linearity, analytical sensitivity, accuracy, precision, and specificity. Plasma specimens from 32 congenital adrenal hyperplasia (CAH) patients and 30 healthy volunteers were analyzed to further reveal the diagnostic value of multiple steroid hormones in the synthetic and metabolic pathways of adrenal corticosteroid in CAH diagnosis. All hormones were effectively extracted and separated using our method. The method was essentially free from potential interference of isomers or structural analogues. The imprecisions were <10%. The lower limits of quantification varied from 0.05 to 15.0 ng/ml. Good linearity coefficients (r2 > 0.998) were also obtained for most hormones in the required concentration range, except for 21-deoxycortisol (r2 = 0.9967) and androstenediol (r2 = 0.9952). The recoveries for the steroid hormones ranged from 91.7 to 109.8%. We developed the UHPLC-MS/MS method for the simultaneous measurement of steroid hormones. The results showed that measurement of steroid hormones simultaneously could improve the diagnostic efficiency of CAH.
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Affiliation(s)
- Qiaoxuan Zhang
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Min Zhan
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Huihui Wu
- Anhui Prevention and Treatment Center for Occupational Disease, Anhui No. 2 Provincial People’s Hospital, Hefei, China
| | - Pinning Feng
- Department of Laboratory Medicine, Sun Yat-Sen University First Affiliated Hospital, Guangzhou, China
| | - Xing Jin
- The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Zemin Wan
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jun Yan
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Pengwei Zhang
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Peifeng Ke
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Junhua Zhuang
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Jiuyao Zhou
- Department of Pharmacology, School of Pharmaceutical Sciences, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Liqiao Han
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- *Correspondence: Liqiao Han, ; Xianzhang Huang,
| | - Xianzhang Huang
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- *Correspondence: Liqiao Han, ; Xianzhang Huang,
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44
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Gusmano C, Calogero AE, Cannarella R. Heterozygous POR gene mutations in a patient with congenital adrenal hyperplasia. Endocrine 2022; 77:401-402. [PMID: 35635658 DOI: 10.1007/s12020-022-03086-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/17/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Carmelo Gusmano
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Aldo E Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.
| | - Rossella Cannarella
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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45
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Cussen L, McDonnell T, Bennett G, Thompson CJ, Sherlock M, O'Reilly MW. Approach to androgen excess in women: Clinical and biochemical insights. Clin Endocrinol (Oxf) 2022; 97:174-186. [PMID: 35349173 PMCID: PMC9541126 DOI: 10.1111/cen.14710] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/15/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022]
Abstract
Androgen excess in women typically presents clinically with hirsutism, acne or androgenic alopecia. In the vast majority of cases, the underlying aetiology is polycystic ovary syndrome (PCOS), a common chronic condition that affects up to 10% of all women. Identification of women with non-PCOS pathology within large cohorts of patients presenting with androgen excess represents a diagnostic challenge for the endocrinologist, and rare pathology including nonclassic congenital adrenal hyperplasia, severe insulin resistance syndromes, Cushing's disease or androgen-secreting tumours of the ovary or adrenal gland may be missed in the absence of a pragmatic screening approach. Detailed clinical history, physical examination and biochemical phenotyping are critical in risk-stratifying women who are at the highest risk of non-PCOS disorders. Red flag features such as rapid onset symptoms, overt virilization, postmenopausal onset or severe biochemical disturbances should prompt investigations for underlying neoplastic pathology, including dynamic testing and imaging where appropriate. This review will outline a proposed diagnostic approach to androgen excess in women, including an introduction to androgen metabolism and provision of a suggested algorithmic strategy to identify non-PCOS pathology according to clinical and biochemical phenotype.
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Affiliation(s)
- Leanne Cussen
- Department of Medicine, Royal College of Surgeons in Ireland (RCSI)University of Medicine and Health SciencesDublinRepublic of Ireland
- Department of EndocrinologyBeaumont HospitalDublinRepublic of Ireland
| | - Tara McDonnell
- Department of Medicine, Royal College of Surgeons in Ireland (RCSI)University of Medicine and Health SciencesDublinRepublic of Ireland
- Department of EndocrinologyBeaumont HospitalDublinRepublic of Ireland
| | - Gillian Bennett
- Department of EndocrinologyBeaumont HospitalDublinRepublic of Ireland
| | - Christopher J. Thompson
- Department of Medicine, Royal College of Surgeons in Ireland (RCSI)University of Medicine and Health SciencesDublinRepublic of Ireland
- Department of EndocrinologyBeaumont HospitalDublinRepublic of Ireland
| | - Mark Sherlock
- Department of Medicine, Royal College of Surgeons in Ireland (RCSI)University of Medicine and Health SciencesDublinRepublic of Ireland
- Department of EndocrinologyBeaumont HospitalDublinRepublic of Ireland
| | - Michael W. O'Reilly
- Department of Medicine, Royal College of Surgeons in Ireland (RCSI)University of Medicine and Health SciencesDublinRepublic of Ireland
- Department of EndocrinologyBeaumont HospitalDublinRepublic of Ireland
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Sharif S, Tang J. Potassium Derangements: A Pathophysiological Review, Diagnostic Approach, and Clinical Management. Physiology (Bethesda) 2022. [DOI: 10.5772/intechopen.103016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Potassium is an essential cation critical in fluid and electrolyte balance, acid–base regulation, and neuromuscular functions. The normal serum potassium is kept within a narrow range of 3.5–5.2 meq/L while the intracellular concentration is approximately 140–150 meq/L. The total body potassium is about 45–55 mmol/kg; thus, a 70 kg male has an estimated ~136 g and 60 kg female has ~117 g of potassium. In total, 98% of the total body potassium is intracellular. Skeletal muscle contains ~80% of body potassium stores. The ratio of intracellular to extracellular potassium concentration (Ki/Ke) maintained by Na+/K+ ATPase determines the resting membrane potential. Disturbances of potassium homeostasis lead to hypo- and hyperkalemia, which if severe, can be life-threatening. Prompt diagnosis and management of these problems are important.
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Reddy NA, Sharma S, Das M, Kapoor A, Maskey U. Devastating salt-wasting crisis in a four-month-old male child with congenital adrenal hyperplasia, highlighting the essence of neonatal screening. Clin Case Rep 2022; 10:e6010. [PMID: 35846927 PMCID: PMC9272202 DOI: 10.1002/ccr3.6010] [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: 09/13/2021] [Revised: 05/24/2022] [Accepted: 06/07/2022] [Indexed: 11/29/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a rare condition usually referred to as a group of genetic disorders resulting due to a deficiency of steroid enzymes required by adrenal glands to produce cortisol and mineralocorticoid hormones. It has an autosomal recessive mode of inheritance and is further categorized into two types-Classic and Non-Classic. Non-Classic CAH is a more common milder form that presents late after puberty. Classic CAH, although more severe, is rare and detected at birth and is associated with the life-threatening adrenal crisis in both sexes and virilization of the external genitalia in females (46, XX) patients, whereas in males, no overt abnormality of the external genitalia is present. We present a case of a four-month-old male child with the classic form of CAH who was brought with complaints of loose stools, projectile non bilious vomiting, decreased urine output, and failure to feed for 3 days. The child had a clinical presentation of salt wasting with hypoglycemia and hyperpigmentation of his genitalia. The USG findings revealed increased anteroposterior diameter of renal pelvis indicative of a growth in the suprarenal area. 17-hydroxyprogesterone (17-OHP) was found to be elevated confirming the diagnosis. He was treated with hydrocortisone with gradual improvement in his glucose and electrolytes. The patient was discharged home on replacement therapy consisting of oral prednisolone and fludrocortisone acetate and followed up as outpatient with significant improvement in the clinical findings. The fact that the child was not screened for CAH at birth led to the critical consequences of the disease in this case. To prevent life-threatening adrenal crisis and help perform appropriate sex assignments for affected female patients, newborn screening (NBS) programs for the classical form of CAH should be made mandatory even in low- and middle-income countries.
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Affiliation(s)
| | | | - Mainak Das
- Nilratan Sircar Medical CollegeKolkataIndia
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Abstract
Patients with classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21OHD) need life-long medical treatment to replace the lacking glucocorticoids and potentially lacking mineralocorticoids and to lower elevated adrenal androgens. Long-term complications are common, including gonadal dysfunction, infertility, and cardiovascular and metabolic co-morbidity with reduced quality of life. These complications can be attributed to the exposure of supraphysiological dosages of glucocorticoids and the longstanding exposure to elevated adrenal androgens. Development of novel therapies is necessary to address the chronic glucocorticoid overexposure, lack of circadian rhythm in glucocorticoid replacement, and inefficient glucocorticoid delivery with concomitant periods of hyperandrogenism. In this review we aim to give an overview about the current treatment regimens and its limitations and describe novel therapies especially evaluated for 21OHD patients.
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Affiliation(s)
- Mariska A M Schröder
- Department of Pediatrics, Amalia Childrens Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
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Abstract
INTRODUCTION Adrenal insufficiency is a disorder characterized by the failure of adrenocortical function because of distorted function of hypothalamic-pituitary- adrenal (HPA) axis. Pregnancy is a state of a physiological glucocorticoid excess as the HPA axis is functioning at a higher level. PURPOSE OF REVIEW The aim of the present review was to shed light on current evidence of adrenal insufficiency management during pregnancy, along with maternal and neonatal outcomes. RECENT FINDINGS A recent multicenter study under the auspices of the European Network for the Study of Adrenal Tumours (ENSAT) presented real-life data of pregnant women with adrenal insufficiency documenting an increased use of hydrocortisone (or mineralocorticoids when needed according to the level of disorder) replacement treatment, increased rates of caesarean section, preterm delivery and adrenal crises along with peripartum and postpartum complications but no maternal or neonatal fatality. These data were in agreement with those obtained from previously published studies. CONCLUSION The limited published evidence is in line with the present guidelines as real-life data did not document any increased fatality among pregnant women or newborns. Prospective data with prolonged follow-up are needed to shed more light on appropriate dose adjustments to avoid the risks of under-replacement or over-replacement of glucocorticoid and/or mineralocorticoid drugs and their sequelae. SUMMARY A recent multicenter study by ENSAT presented real-life data of pregnant women with adrenal insufficiency documenting an increased use of hydrocortisone as replacement treatment during pregnancy, along with an increased rate of caesarean section and preterm delivery, adrenal crises, peripartum and postpartum complications but no maternal or neonatal fatality. These data are in agreement with those of a previously published study and also confirm the statements made by the recent guidelines. Prospective data are needed aiming to develop precise therapeutic protocols during each trimester of pregnancy according to the different causes of adrenal insufficiency.
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Affiliation(s)
| | - Gregory A Kaltsas
- Endocrine Unit, First Department of Propaedeutic Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
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50
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Karlsson L, Wallensteen L, Nordenström A, Krmar RT, Lajic S. Ambulatory Blood Pressure Monitoring in Children and Adults Prenatally Exposed to Dexamethasone Treatment. J Clin Endocrinol Metab 2022; 107:e2481-e2487. [PMID: 35148399 PMCID: PMC9113802 DOI: 10.1210/clinem/dgac081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The clinical use of dexamethasone (DEX) prenatally to reduce virilization of external genitalia in female fetuses with congenital adrenal hyperplasia (CAH) is efficient but still controversial. It remains challenging to prevent the excessive exposure of DEX in unborn healthy babies during the first trimester of pregnancy. OBJECTIVE Since endogenous glucocorticoids contribute to the maintenance of blood pressure (BP) and since events during fetal life may program the fetus and affect future metabolic health, the aim of this study was to analyze ambulatory BP measurements in CAH-unaffected children and adults that were prenatally exposed to DEX treatment. METHODS Ambulatory BP measurements were analyzed in 33 (16 female) DEX-treated participants aged 5.1 to 26.3 years (19 participants aged ≤ 18 years) and in 54 (28 female) age- and sex-matched apparently healthy controls aged 5.5 to 25.3 years (27 participants aged ≤ 18 years) with ambulatory normotension. RESULTS Participants' age, height, weight, and body mass index were similar between the DEX-treated group and the control group. Heart rate, 24-hour BP, pulse pressure, and nighttime dipping did not statistically significantly differ between DEX-treated participants and controls. CONCLUSION Our study suggests that prenatal DEX treatment in CAH-unaffected children and adults does not appear to adversely affect ambulatory BP later in life. Our observations need to be confirmed in larger studies.
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Affiliation(s)
- Leif Karlsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Wallensteen
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Rafael T Krmar
- Department of Physiology and Pharmacology, Biomedicum 5B, Karolinska Institutet, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
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