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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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Ishii T, Kashimada K, Amano N, Takasawa K, Nakamura-Utsunomiya A, Yatsuga S, Mukai T, Ida S, Isobe M, Fukushi M, Satoh H, Yoshino K, Otsuki M, Katabami T, Tajima T. Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency (2021 revision). Clin Pediatr Endocrinol 2022; 31:116-143. [PMID: 35928387 PMCID: PMC9297175 DOI: 10.1297/cpe.2022-0009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
Congenital adrenal hyperplasia is a category of disorders characterized by impaired
adrenocortical steroidogenesis. The most frequent disorder of congenital adrenal
hyperplasia is 21-hydroxylase deficiency, which is caused by pathogenic variants of
CAY21A2 and is prevalent between 1 in 18,000 and 20,000 in Japan. The
clinical guidelines for 21-hydroxylase deficiency in Japan have been revised twice since a
diagnostic handbook in Japan was published in 1989. On behalf of the Japanese Society for
Pediatric Endocrinology, the Japanese Society for Mass Screening, the Japanese Society for
Urology, and the Japan Endocrine Society, the working committee updated the guidelines for
the diagnosis and treatment of 21-hydroxylase deficiency published in 2014, based on
recent evidence and knowledge related to this disorder. The recommendations in the updated
guidelines can be applied in clinical practice considering the risks and benefits to each
patient.
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Affiliation(s)
- Tomohiro Ishii
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Kenichi Kashimada
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Naoko Amano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | | | - Shuichi Yatsuga
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
| | - Tokuo Mukai
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Shinobu Ida
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | | | | | | | | | | | | | - Toshihiro Tajima
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
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Tsuji-Hosokawa A, Kashimada K. Thirty-Year Lessons from the Newborn Screening for Congenital Adrenal Hyperplasia (CAH) in Japan. Int J Neonatal Screen 2021; 7:ijns7030036. [PMID: 34209888 PMCID: PMC8293132 DOI: 10.3390/ijns7030036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 01/02/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) is an inherited disorder caused by the absence or severely impaired activity of steroidogenic enzymes involved in cortisol biosynthesis. More than 90% of cases result from 21-hydroxylase deficiency (21OHD). To prevent life-threatening adrenal crisis and to help perform appropriate sex assignments for affected female patients, newborn screening (NBS) programs for the classical form of CAH have been introduced in numerous countries. In Japan, the NBS for CAH was introduced in 1989, following the screenings for phenylketonuria and congenital hypothyroidism. In this review, we aim to summarize the experience of the past 30 years of the NBS for CAH in Japan, composed of four parts, 1: screening system in Japan, 2: the clinical outcomes for the patients with CAH, 3: various factors that would impact the NBS system, including timeline, false positive, and LC-MS/MS, 4: Database composition and improvement of the screening program.
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Affiliation(s)
- Atsumi Tsuji-Hosokawa
- Department of Systems BioMedicine, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan;
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
- Correspondence:
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Ishii T, Tajima T, Kashimada K, Mukai T, Tanahashi Y, Katsumata N, Kanno J, Hamajima T, Miyako K, Ida S, Hasegawa T. Clinical Features of 57 Patients with Lipoid Congenital Adrenal Hyperplasia: Criteria for Nonclassic Form Revisited. J Clin Endocrinol Metab 2020; 105:5896589. [PMID: 32835366 DOI: 10.1210/clinem/dgaa557] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/14/2020] [Indexed: 02/13/2023]
Abstract
CONTEXT Lipoid congenital adrenal hyperplasia (LCAH) is caused by mutations in STAR. Classic (CLCAH) and nonclassic (NCLCAH) forms were reported as total and partial deficiencies, respectively, of adrenal and gonadal steroid hormones. The rarity of LCAH has precluded large-scale epidemiological and clinical investigations. OBJECTIVE To determine the epidemiological and clinical characteristics of 2 forms of LCAH. DESIGN A multicenter cross-sectional cohort study in Japan on December 1, 2017. PARTICIPANTS Fifty-seven patients with LCAH (median age, 23.7 years; range, 0.0-47.5 years). MAIN OUTCOME MEASURES Patient demographics, STAR genotype, Quigley grade, endocrinological and imaging data, treatment, and prognosis. RESULTS Fifty-three and 4 patients fulfilled definite and probable diagnostic criteria for LCAH, respectively. When NCLCAH was defined as either Quigley grade 1 in XY karyotype, no episode of salt losing or requirement of fludrocortisone, or onset of primary adrenal insufficiency (PAI) at 1 year or older, patients were divided into groups of 43 patients with CLCAH (75.4%), 11 with NCLCAH (19.3%), and 3 with unclassified LCAH (5.3%). All of the patients with CLCAH and 7/11 NCLCAH (63.6%) were treated with fludrocortisone. CLCAH was diagnosed at a significantly younger age than NCLCAH (median, 0.0 vs 4.0 years). STAR-Arg272Cys or -Met225Thr was identified only in NCLCAH (8/11, 72.7%). CONCLUSIONS We demonstrated the relative proportions and clinical and molecular characteristics of NCLCAH and CLCAH in Japan. These criteria for NCLCAH correspond to all previously published cases and our cases whose masculinization of the external genitalia, ability of mineralocorticoid production, and onset of PAI were described.
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MESH Headings
- Adolescent
- Adrenal Hyperplasia, Congenital/diagnosis
- Adrenal Hyperplasia, Congenital/drug therapy
- Adrenal Hyperplasia, Congenital/genetics
- Adult
- Child
- Child, Preschool
- Cross-Sectional Studies
- Disorder of Sex Development, 46,XY/diagnosis
- Disorder of Sex Development, 46,XY/drug therapy
- Disorder of Sex Development, 46,XY/genetics
- Female
- Fludrocortisone/therapeutic use
- Humans
- Infant
- Infant, Newborn
- Japan
- Middle Aged
- Mineralocorticoids/therapeutic use
- Mutation
- Phenotype
- Phosphoproteins/genetics
- Prognosis
- Young Adult
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Affiliation(s)
- Tomohiro Ishii
- Research Committee on Disorders of Adrenal Hormones, Research on Intractable Diseases, Health and Labour Sciences Research Grants, Tokyo, Japan
- Disorders of Sex Development and Adrenal Disorders Committee, the Japanese Society for Pediatric Endocrinology, Fushimi-ku, Kyoto, Japan
- Department of Pediatrics, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Toshihiro Tajima
- Research Committee on Disorders of Adrenal Hormones, Research on Intractable Diseases, Health and Labour Sciences Research Grants, Tokyo, Japan
- Department of Pediatrics, Jichi Medical University Tochigi Children's Medical Center, Shimotsuke, Tochigi, Japan
| | - Kenichi Kashimada
- Research Committee on Disorders of Adrenal Hormones, Research on Intractable Diseases, Health and Labour Sciences Research Grants, Tokyo, Japan
- Disorders of Sex Development and Adrenal Disorders Committee, the Japanese Society for Pediatric Endocrinology, Fushimi-ku, Kyoto, Japan
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tokuo Mukai
- Research Committee on Disorders of Adrenal Hormones, Research on Intractable Diseases, Health and Labour Sciences Research Grants, Tokyo, Japan
- Disorders of Sex Development and Adrenal Disorders Committee, the Japanese Society for Pediatric Endocrinology, Fushimi-ku, Kyoto, Japan
- Department of Pediatrics, Asahikawa-Kosei General Hospital, Asahikawa, Hokkaido, Japan
| | - Yusuke Tanahashi
- Research Committee on Disorders of Adrenal Hormones, Research on Intractable Diseases, Health and Labour Sciences Research Grants, Tokyo, Japan
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Noriyuki Katsumata
- Research Committee on Disorders of Adrenal Hormones, Research on Intractable Diseases, Health and Labour Sciences Research Grants, Tokyo, Japan
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Junko Kanno
- Disorders of Sex Development and Adrenal Disorders Committee, the Japanese Society for Pediatric Endocrinology, Fushimi-ku, Kyoto, Japan
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Takashi Hamajima
- Disorders of Sex Development and Adrenal Disorders Committee, the Japanese Society for Pediatric Endocrinology, Fushimi-ku, Kyoto, Japan
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Kenichi Miyako
- Disorders of Sex Development and Adrenal Disorders Committee, the Japanese Society for Pediatric Endocrinology, Fushimi-ku, Kyoto, Japan
- Department of Endocrinology and Metabolism, Fukuoka Children's Hospital, Fukuoka, Fukuoka, Japan
| | - Shinobu Ida
- Disorders of Sex Development and Adrenal Disorders Committee, the Japanese Society for Pediatric Endocrinology, Fushimi-ku, Kyoto, Japan
- Department of Pediatric Gastroenterology and Endocrinology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Tomonobu Hasegawa
- Research Committee on Disorders of Adrenal Hormones, Research on Intractable Diseases, Health and Labour Sciences Research Grants, Tokyo, Japan
- Department of Pediatrics, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Mao XM, Jing M, Tian HY. [Screening and follow-up treatment of 160 046 neonates with congenital adrenal hyperplasia in Ningxia, China]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:698-701. [PMID: 27530784 PMCID: PMC7399518 DOI: 10.7499/j.issn.1008-8830.2016.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 06/06/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To investigate the incidence of congenital adrenal hyperplasia (CAH) and treatment outcomes in neonates in Ningxia, China. METHODS The clinical data of CAH screening for 160 046 neonates who were born in midwifery institutions in Ningxia from July 2014 to March 2016 were analyzed. RESULTS Among the 160 046 neonates who underwent CAH screening, 70 (0.044%) obtained a positive result and 11 were diagnosed with CAH; the incidence rate of CAH was 1/14 550 (0.069‰). Among the 11 neonates diagnosed with CAH, 9 had the salt wasting type (2 died) and 2 had simple virilization. The 9 neonates were given glucocorticoids immediately once diagnosed and all of them achieved good growth and development. CONCLUSIONS The incidence of neonatal CAH in Ningxia is 1/14 550. It is very necessary to carry out CAH screening in Ningxia, and active treatment can improve the prognosis of neonates with CAH.
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Affiliation(s)
- Xin-Mei Mao
- Maternal and Child Health Hospital of Ningxia Hui Autonomous Region, Yinchuan 750004, China.
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Tajima T, Fukushi M. Neonatal mass screening for 21-hydroxylase deficiency. Clin Pediatr Endocrinol 2016; 25:1-8. [PMID: 26865749 PMCID: PMC4738187 DOI: 10.1297/cpe.25.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/13/2015] [Indexed: 11/27/2022] Open
Abstract
Congenital adrenal hyperplasia(CAH)due to 21-hydroxylase deficiency (21-OHD) is an
inherited autosomal recessive disorder. Its incidence is 1 in 10,000 to 20,000 worldwide.
This disease shows phenotypic differences, and it is divided into three forms i.e., the
salt wasting (SW), simple virilizing (SV), and nonclassic (NC) forms. The most severe form
of SW manifests in the first months of life with life-threatening adrenal insufficiency,
leading to death. To prevent death by adrenal insufficiency in neonates with the SW form
and wrong gender assignment of 46,XX female patients with SW and SV, neonatal mass
screening of 21-OHD is performed in several countries including Japan. However, the
positive predictive value (PPV) remains low, especially in preterm infants. To reduce the
false positive rate and increase the PPV, liquid chromatography followed by tandem mass
spectrometry (LC-MS/MS) as a second-tier test may be useful. In this review, the current
knowledge on neonatal mass screening of 21-OHD is summarized.
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Affiliation(s)
- Toshihiro Tajima
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan; Present: Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
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Tsuji A, Konishi K, Hasegawa S, Anazawa A, Onishi T, Ono M, Morio T, Kitagawa T, Kashimada K. Newborn screening for congenital adrenal hyperplasia in Tokyo, Japan from 1989 to 2013: a retrospective population-based study. BMC Pediatr 2015; 15:209. [PMID: 26671474 PMCID: PMC4681082 DOI: 10.1186/s12887-015-0529-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) cause life-threatening adrenal crisis. It also affects fetal sex development and can result in incorrect sex assignment at birth. In 1989, a newborn screening program for congenital adrenal hyperplasia (CAH) was introduced in Tokyo. Here we present the results of this screening program in order to clarify the efficiency of CAH screening and the incidence of CAH in Japan. METHOD From 1989 to 2013, a total of 2,105,108 infants were screened for CAH. The cutoff level for diagnosis of CAH was adjusted for gestational age and birth weight. RESULTS A total of 410 infants were judged positive, and of these, 106 patients were diagnosed with CAH, indicating a positive predictive value (PPV) of 25.8 %. Of the 106 patients, 94 (88.7 %) were diagnosed with 21-OHD. Of these 94 patients, 73 were diagnosed with the salt wasting form, 14 with the simple virilising form and 7 with the nonclassical form (NC21OHD). The mean birth weight and gestational age were 3192 ± 385 g and 38.9 ± 1.38 weeks. 11 out of 44 female patients were assigned as female according to their screening result. CONCLUSIONS These data suggest that the newborn screening in Tokyo was effective, especially for sex assignment and preventing fatal adrenal crisis. The incidence of CAH was similar to that measured in previous Japanese screening studies, and it was also similar to that of western countries. The incidence of NC21OHD in Japan in the present study was lower than that in western countries as previous studies reported. The screening program achieved higher PPV than previous CAH screening studies, which might be due to the use of variable cutoffs according to gestational age and birth weight. However, most of the neonates born at 37 weeks or less that were referred to hospital were false-positives. Further changes are needed to reduce the number of false positive preterm neonates.
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Affiliation(s)
- Atsumi Tsuji
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Kaoru Konishi
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
| | - Satomi Hasegawa
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
| | - Akira Anazawa
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
| | - Toshikazu Onishi
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan. .,Kinki Central Hospital, Hyogo, Japan.
| | - Makoto Ono
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Teruo Kitagawa
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan. .,Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
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Ishii T, Anzo M, Adachi M, Onigata K, Kusuda S, Nagasaki K, Harada S, Horikawa R, Minagawa M, Minamitani K, Mizuno H, Yamakami Y, Fukushi M, Tajima T. Guidelines for diagnosis and treatment of 21-hydroxylase deficiency (2014 revision). Clin Pediatr Endocrinol 2015; 24:77-105. [PMID: 26594092 PMCID: PMC4639531 DOI: 10.1297/cpe.24.77] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 03/10/2015] [Indexed: 11/07/2022] Open
Abstract
Purpose of developing the guidelines: The first guidelines for diagnosis and treatment of
21-hydroxylase deficiency (21-OHD) were published as a diagnostic handbook in Japan in
1989, with a focus on patients with severe disease. The “Guidelines for Treatment of
Congenital Adrenal Hyperplasia (21-Hydroxylase Deficiency) Found in Neonatal Mass
Screening (1999 revision)” published in 1999 were revised to include 21-OHD patients with
very mild or no clinical symptoms. Accumulation of cases and experience has subsequently
improved diagnosis and treatment of the disease. Based on these findings, the Mass
Screening Committee of the Japanese Society for Pediatric Endocrinology further revised
the guidelines for diagnosis and treatment. Target disease/conditions: 21-hydroxylase
deficiency. Users of the guidelines: Physician specialists in pediatric endocrinology,
pediatric specialists, referring pediatric practitioners, general physicians; and
patients.
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Affiliation(s)
| | | | | | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Anzo
- Department of Pediatrics, Kawasaki City Hospital, Kanagawa, Japan
| | - Masanori Adachi
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Kazumichi Onigata
- Shimane University Hospital Postgraduate Clinical Training Center, Shimane, Japan
| | - Satoshi Kusuda
- Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Keisuke Nagasaki
- Division of Pediatrics, Department of Homeostatic Regulation and Development, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shohei Harada
- Division of Neonatal Screening, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Horikawa
- Department of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | | | - Kanshi Minamitani
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Haruo Mizuno
- Departments of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yuji Yamakami
- Kanagawa Health Service Association, Kanagawa, Japan
| | | | - Toshihiro Tajima
- Department of Pediatrics, Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
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Kashimada K, Ishii T, Nagasaki K, Ono M, Tajima T, Yokota I, Hasegawa Y. Clinical, biochemical, and genetic features of non-classical 21-hydroxylase deficiency in Japanese children. Endocr J 2015; 62:277-82. [PMID: 25736066 DOI: 10.1507/endocrj.ej14-0377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Non-classical 21-hydroxylase deficiency (NC21-OHD) is a mild form of 21-hydroxylase deficiency lacking apparent symptoms of androgen excess at birth. Most NC21-OHD cases are diagnosed after the onset of puberty, while a substantial number of patients are not diagnosed during childhood. Previous studies have reported ethnic differences in the prevalence of NC21-OHD. To date, the clinical features of NC21-OHD in Japanese children have not been systemically reported. Thus, we performed 3 independent analyses: retrospective analyses of newborn screening in 2 major Japanese cities (Sapporo and Niigata) and a national surveillance collecting clinical information from pediatric endocrinologists throughout the country. During the last 10 years, one case of NC21-OHD was diagnosed by newborn screening in each city, resulting in incidences of 2.0 (95% confidence interval = 0.0-5.9) and 2.1 (0.0-6.2) per 1,000,000 in Sapporo and Niigata, respectively. We collected information from 85% of the 135 Councilors of Japanese Society of Pediatric Endocrinology. Fifteen NC21-OHD patients were diagnosed during childhood, resulting in the estimated prevalence of 0.58 (0.28-1.1) per 1,000,000. Eleven patients were discovered by newborn screening, 7 patients developed hyperandrogenism symptoms (2-8 years of age, median 7), and 9 patients were treated with hydrocortisone at the time of the survey. Ten out of 13 patients showed compound heterozygosity for the P30L mutation of CYP21A2. Our study suggests that the prevalence/incidence of NC21-OHD is lower than that in Western countries, and that the age for initial onset of androgen excess symptoms varies during the prepubertal period.
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Affiliation(s)
- Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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10
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Morikawa S, Nakamura A, Fujikura K, Fukushi M, Hotsubo T, Miyata J, Ishizu K, Tajima T. Results from 28 years of newborn screening for congenital adrenal hyperplasia in sapporo. Clin Pediatr Endocrinol 2014; 23:35-43. [PMID: 24790385 PMCID: PMC4004996 DOI: 10.1297/cpe.23.35] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 12/16/2013] [Indexed: 11/04/2022] Open
Abstract
The primary goal of newborn mass screening (MS) for congenital adrenal hyperplasia (CAH) is the prevention of life-threatening salt-wasting crisis in the most severe forms of CAH, and MS for CAH has been implemented in several countries. We summarize here our experience and results from newborn CAH MS from 1982 to 2010 in Sapporo City. During these 28 yr, the level of 17-hydroxyprogesterone (17-OHP) was determined in MS of samples from 498,147 newborns. During this period, 26 individuals (19 females and 7 males) with 21-hydroxylase deficiency (21-OHD) were detected. Of the 26 CAH, 20 were classified as having the salt-wasting (SW) form, 4 were classified as having the simple virilizing (SV) form, and 2 were classified as having the noncalssic (NC) form. Therefore, the frequency of the classical type of CAH was 1 in 20,756. In order to improve the effectiveness, we employed high-performance liquid chromatography (HPLC) as a second tier test from 2000. During this period, among the recalled babies, 75.4% were born prior to the 37th wk of gestation age, and the recall rate was 5.38% for premature neonates and 0.06% for mature neonates. MS for CAH in Sapporo is effective for the identification of the SW and SV forms of 21-OHD. However, the recall rate of premature babies is still high after the introduction of HPLC as a second tier test.
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Affiliation(s)
- Shuntaro Morikawa
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
| | - Akie Nakamura
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
| | | | | | - Tomoyuki Hotsubo
- Department of Pediatrics, NTT East Japan Sapporo Hospital, Sapporo, Japan
| | - Jun Miyata
- Sapporo City Institute of Public Health, Sapporo, Japan
| | - Katsura Ishizu
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
| | - Toshihiro Tajima
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
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Abstract
In the biosynthesis of steroid hormones the neutral lipid cholesterol, a normal constituent of lipid bilayers is transformed via a series of hydroxylation, oxidation, and reduction steps into a vast array of biologically active compounds: mineralocorticoids, glucocorticoids, and sex hormones. Glucocorticoids regulate many aspects of metabolism and immune function, whereas mineralocorticoids help maintain blood volume and control renal excretion of electrolytes. Sex hormones are essential for sex differentiation in male and support reproduction. They include androgens, estrogens, and progestins. A block in the pathway of steroid biosynthesis leads to the lack of hormones downstream and accumulation of the upstream compounds that can activate other members of the steroid receptor family. This review deals with the clinical consequences of these blocks.
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Affiliation(s)
- A Biason-Lauber
- University Children's Hospital, Division of Endocrinology and Diabetology, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland.
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12
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Silveira EL, Elnecave RH, dos Santos EP, Moura V, Pinto EM, van der Linden Nader I, Mendonca BB, Bachega TASS. Molecular analysis of CYP21A2 can optimize the follow-up of positive results in newborn screening for congenital adrenal hyperplasia. Clin Genet 2010; 76:503-10. [PMID: 19930153 DOI: 10.1111/j.1399-0004.2009.01274.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Neonatal screening for congenital adrenal hyperplasia (CAH) is useful in diagnosing salt wasting form (SW). However, there are difficulties in interpreting positive results in asymptomatic newborns. The main objective is to analyze genotyping as a confirmatory test in children with neonatal positive results. Patients comprised 23 CAH children and 19 asymptomatic infants with persistently elevated 17-hydroxyprogesterone (17OHP) levels. CYP21A2 gene was sequenced and genotypes were grouped according to the enzymatic activity of the less severe allele: A1 null, A2 < 2%, B 3-7%, C > 20%. Twenty-one children with neonatal symptoms and/or 17OHP levels > 80 ng/ml carried A genotypes, except two virilized girls (17OHP < 50 ng/ml) without CAH genotypes. Patients carrying SW genotypes (A1, A2) and low serum sodium levels presented with neonatal 17OHP > 200 ng/ml. Three asymptomatic boys carried simple virilizing genotypes (A2 and B): in two, the symptoms began at 18 months; another two asymptomatic boys had nonclassical genotypes (C). The remaining 14 patients did not present CAH genotypes, and their 17OHP levels were normalized by 14 months of age. Molecular analysis is useful as a confirmatory test of CAH, mainly in boys. It can predict clinical course, identify false-positives and help distinguish between clinical forms of CAH.
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Affiliation(s)
- E L Silveira
- Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, CEP 90430.091, Porto Alegre, Rio Grande do Sul, Brazil.
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13
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Izawa M, Aso K, Higuchi A, Ariyasu D, Hasegawa Y. The Range of 2.2-3.3 mg/gCr of Pregnanetriol in the First Morning Urine Sample as an Index of Optimal Control in CYP21 Deficiency. Clin Pediatr Endocrinol 2008; 17:75-80. [PMID: 24790367 PMCID: PMC4004858 DOI: 10.1297/cpe.17.75] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 05/26/2008] [Indexed: 11/25/2022] Open
Abstract
Auxological data are the gold standard indexes of the therapeutic conditions in patients
with CYP21 deficiency over long-term periods, whereas urinary pregnanetriol (PT) for 24 h
has been used as an index for short-term periods. We previously reported that the range of
1.2–2.1 mg/m2/day of PT for 24 h (24-h PT) could be used as an index of optimal
control in patients with CYP21 deficiency. The purpose of this study was to analyze the
range of PT in the first morning urine samples (morning PT) as an index of optimal control
in patients with CYP21 deficiency. First, the therapeutic periods of 15 participants (aged
2 yr and 5 mo to 17 yr and 4 mo) were classified into excessive, good or poor control
periods using auxological data and Cushing-like symptoms, and 24-h PT levels were analyzed
in each period, retrospectively. The 95% confidence intervals for the means of 24-h PT
levels in the excessive, good and poor control periods were 0.24–2.24 (n=25), 2.88–4.92
(n=114) and 13.26–21.28 (n=72) mg/gCr, respectively. Subsequently, 24-h PT and morning PT
levels collected on the same day were analyzed for 14 participants (aged 9 mo to 29 yr and
8 mo). There was a significant correlation between the above two PT levels (n=25,
p<0.0001). When the 24-h PT range of the good control period, 2.88–4.92 mg/gCr, was
adjusted by the correlation, the ideal morning PT range became 2.15–3.34 mg/gCr. In
conclusion, a morning PT in the range of 2.2–3.3 mg/gCr can be used as an index of optimal
control in patients with CYP21 deficiency.
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Affiliation(s)
- Masako Izawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Keiko Aso
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Asako Higuchi
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Daisuke Ariyasu
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
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14
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Torresani T, Biason-Lauber A. Congenital adrenal hyperplasia: diagnostic advances. J Inherit Metab Dis 2007; 30:563-75. [PMID: 17694353 DOI: 10.1007/s10545-007-0696-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 06/20/2007] [Accepted: 06/20/2007] [Indexed: 10/23/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders resulting from the deficiency of one of the five enzymes required for the synthesis of cortisol in the adrenal cortex. The most frequent is steroid 21-hydroxylase deficiency, accounting for more than 90% of cases. Much has been learned about the genetics of the various clinical forms of 21-hydroxylase deficiency, and correlations between the genotype and the phenotype have been studied extensively. Gene-specific diagnosis is now feasible and neonatal screening and prenatal treatment have been widely implemented. This discussion will be limited to the most common form of congenital adrenal hyperplasia, with focus on the diagnostic advances in this disease.
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Affiliation(s)
- T Torresani
- Department of Endocrinology and Diabetology, University Children's Hospitals, Zurich, Switzerland.
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15
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Izawa M, Aso K, Higuchi A, Ariyasu D, Hasegawa Y. Pregnanetriol in the Range of 1.2-2.1 mg/m(2)/day as an Index of Optimal Control in CYP21A2 Deficiency. Clin Pediatr Endocrinol 2007; 16:45-52. [PMID: 24790344 PMCID: PMC4004871 DOI: 10.1297/cpe.16.45] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Accepted: 01/18/2007] [Indexed: 11/30/2022] Open
Abstract
Auxological data is the gold standard index of the therapeutic condition in CYP21A2
deficiency over a long-range period, whereas urinary pregnanetriol for 24 h (PT) is
variable for a shorter-range period. Ideal PT levels in comparison with auxological data
have not been reported. The main purpose of this study was to analyze ideal PT values as
an index of optimal control for CYP21A2 deficiency. First, inter-daily fluctuation of PT
was analyzed in one participant. PT levels were distributed over a wide range of 0.44–14.7
mg/day (n=42) in this participant, suggesting that the therapeutic condition should be
judged by multiple PT samples. Second, the therapeutic periods of 15 participants with
CYP21A2 deficiency were classified using auxological data and Cushing-like symptoms, and
the PT levels were analyzed in each period retrospectively. The 95% confidence intervals
for the means of the PT levels in the excessive, good and poor control periods were
0.03–1.25 (n=26), 1.23–2.09 (n=116), and 5.35–8.37 (n=72) mg/m2/day,
respectively. In conclusion, 1.2–2.1 mg/m2/day of PT values can be used as an
index of optimal control in CYP21A2 deficiency.
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Affiliation(s)
- Masako Izawa
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Keiko Aso
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Asako Higuchi
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Daisuke Ariyasu
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Yukihiro Hasegawa
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
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16
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Balsamo A, Wasniewska M, Di Pasquale G, Salzano G, Baronio F, Bombaci S, De Luca F. Birth length and weight in congenital adrenal hyperplasia according to the different phenotypes. Eur J Pediatr 2006; 165:380-3. [PMID: 16520942 DOI: 10.1007/s00431-005-0075-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Accepted: 12/13/2005] [Indexed: 11/29/2022]
Abstract
UNLABELLED The aims of this study were to: (1) retrospectively investigate the birth length and weight of our patients with congenital adrenal hyperplasia (CAH); (2) compare these parameters with standards for birth length and weight recently assessed in an Italian control population; (3) evaluate whether neonatal auxological data may change depending on the different clinical forms of CAH. Birth length and weight were retrospectively evaluated in 101 children with different clinical forms of CAH and compared with standards for birth length and weight assessed in an Italian control population. In both sexes the average birth length of patients with classical CAH was greater than the mean birth length of the controls, and both length and weight were greater in children with classical CAH than in those with the non-classical form. Among the patients with classical CAH, those with the salt-wasting form were longer but also weighed less than those with the simple-virilizing form. CONCLUSIONS (1) fetal length velocity in patients with CAH may be increased only in those infants with classical forms of the syndrome, while it is unaffected in those with the non-classical form; (2) the greater the enzymatic activity impairment, the longer the birth length of newborns with CAH.
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Affiliation(s)
- Antonio Balsamo
- Department of Pediatrics, University of Bologna, Bologna, Italy
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17
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Cardoso CBMA, Fonseca AA, Oliveira MDFS, Pereira BB, Guimarães MM. Triagem neonatal para hiperplasia adrenal congênita: experiência do estado do Rio de Janeiro. ACTA ACUST UNITED AC 2005; 49:112-9. [PMID: 16544042 DOI: 10.1590/s0004-27302005000100015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Descrever a distribuição das concentrações de 17OH Progesterona (17OHP) na triagem neonatal para pesquisa de Hiperplasia Adrenal Congênita por deficiência da 21hidroxilase (HAC-D21OH). CASUÍSTICA E MÉTODO: Análise da 17OHP por método imunofluorimétrico em 76.360 amostras de sangue colhido em papel filtro no período de junho de 1992 a dezembro de 2000 no Estado do Rio de Janeiro. O valor de corte foi definido em 10ng/mL e os casos com resultados acima deste valor eram chamados para nova coleta. RESULTADOS: Foram reconvocados 38 casos para nova coleta, sendo confirmados 11 casos com a forma clássica da HAC-D21OH (4 do sexo masculino, 6 feminino e 1 indeterminado), com valores de 17OHP na primeira amostra variando de 25 a 254,5ng/mL (média de 133ng/mL) e na segunda amostra de 45,86 a 360ng/mL (média de 218,84ng/mL). Os pacientes com a forma perdedora de sal apresentaram concentrações mais elevadas que os com a forma virilizante simples, tanto na primeira amostra (média de 169,21 contra 27,46ng/mL) quanto na segunda (média de 227,16 versus 110,95ng/mL). As concentrções de 17OHP nos 27 casos não confirmados (falso-positivos) variaram de 10,27 a 27,50ng/mL (média de 14,80ng/mL) na primeira amostra e de 2,39 a 32,39ng/mL (média 10,07ng/mL) na segunda amostra. Oito mantiveram concentrações de 17OHP moderadamente elevadas, sendo que normalizaram no decorrer do primeiro ano de vida em 7 casos, e em 1 paciente, apesar de assintomático, manteve valores elevados de 17OHP durante o acompanhamento de oito anos, com teste de estímulo com ACTH compatível com a forma não clássica da HCA-D21OH. CONCLUSÃO: A dosagem da 17OHP foi um método eficaz para a triagem da HAC-D21OH sendo capaz de discriminar as crianças normais daquelas acometidas pela forma clássica da doença.
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Affiliation(s)
- Cláudia B M A Cardoso
- Associação de Pais e Amigos dos Excepcionais, Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, RJ.
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18
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Abstract
Congenital adrenal hyperplasia (CAH) is a common autosomal recessive disorder caused mainly by defects in the steroid 21-hydroxylase (CYP21) gene. More than 90% of CAH cases are caused by mutations of the CYP21 gene on chromosome 6p21.3. The wide range of CAH phenotypes is associated with multiple mutations known to affect 21-hydroxylase enzyme activity. To date, 56 different CYP21 mutations have been reported, mostly point mutations, but small deletions or insertions have been described too, as well as complete gene deletions. Fifteen mutations, constituting 90-95% of alleles, are derived from intergenic recombination of DNA sequences between the CYP21 gene and the highly homologous CYP21P pseudogene, while the remaining are spontaneous mutations. A reliable and accurate detection of CYP21 mutations is not only important for clinical diagnosis, but also for carrier detection as there is a high variability in the basal level of 17-hydroxyprogesterone between normal and heterozygous individuals. Several strategies based on polymerase chain reaction (PCR)-driven amplification with allele-specific oligonucleotides to the CYP21 gene have been developed. It has been demonstrated that one reaction for PCR amplification of the CYP21 gene and the chimeric CYP21P/CYP21 gene using mixed primers in combination with nested PCR and single-strand conformation polymorphism is considered highly efficient and accurate for molecular diagnosis of CAH due to 21-hydroxylase deficiency.
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Affiliation(s)
- H H Lee
- Kingcar Food Industrial Co, Ltd, Yuan-Shan Research Institute, Taiwan, Republic of China.
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L'Allemand D, Tardy V, Grüters A, Schnabel D, Krude H, Morel Y. How a patient homozygous for a 30-kb deletion of the C4-CYP 21 genomic region can have a nonclassic form of 21-hydroxylase deficiency. J Clin Endocrinol Metab 2000; 85:4562-7. [PMID: 11134109 DOI: 10.1210/jcem.85.12.7018] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
A case of nonclassic (NC) 21-hydroxylase deficiency, with a moderately elevated 17-hydroxyprogesterone level (145 nmol/L in filter paper blood spot), was detected in newborn screening. The newborn's phenotype was female, with no sign of virilization. Confirmatory diagnosis revealed elevated serum levels of 17-hydroxyprogesterone and of 21-desoxycortisol, whereas cortisol, PRA, and electrolytes were normal. Hydrocortisone substitution was considered at the age of 6 months, when virilization became obvious. For clinical reasons, this case had to be classified as late-onset congenital adrenal hyperplasia (CAH) with unusually early manifestation. However, the diagnosis of classic 21-hydroxylase deficiency was obtained by Southern blotting studies, showing that she was homozygous for the 30-kb deletion, including the 3' end of CYP21P pseudogene, the C4B gene, and the 5' end of the functional CYP21 gene. Further studies, using PCR and sequencing, were conducted to explain the discrepancy between this genotype, usually associated with a classic salt-wasting form, and the girl's phenotype. Typically, patients homozygous for the 30-kb deletion encoding classic CAH possess a unique CYP21P/21 hybrid gene with the junction site located after the third exon, yielding a nonfunctional pseudogene. The girl in question, however, was heterozygous for the 8-bp deletion, suggesting that the chimeric pseudogene on one allele had a junction site before the third exon. She was compound heterozygous for a 30-kb deletion encoding classic CAH on the paternal allele, and a 30-kb deletion encoding NC CAH on the maternal allele. This novel maternal CYP21P/21 hybrid gene is characterized by a junction site before intron 2 and differs from the normal CYP21 gene only by the P30L mutation in exon 1 and the promoter region of the CYP21P pseudogene. Because the P30L mutation has been described to result in an enzyme with 30-60% activity of the normal P450c21 enzyme, and the CYP21P promoter reduced the transcription to 20% of normal, this puzzling phenotype of a NC CAH with early onset may be fully explained by the genotype of the patient and considered as an intermediate form between the simple virilizing and NC form.
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Affiliation(s)
- D L'Allemand
- Department of Pediatrics, Virchow-Klinikum, Charité, Humboldt University, 13353 Berlin, Germany
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20
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Abstract
More than 90% of cases of congenital adrenal hyperplasia (CAH, the inherited inability to synthesize cortisol) are caused by 21-hydroxylase deficiency. Females with severe, classic 21-hydroxylase deficiency are exposed to excess androgens prenatally and are born with virilized external genitalia. Most patients cannot synthesize sufficient aldosterone to maintain sodium balance and may develop potentially fatal "salt wasting" crises if not treated. The disease is caused by mutations in the CYP21 gene encoding the steroid 21-hydroxylase enzyme. More than 90% of these mutations result from intergenic recombinations between CYP21 and the closely linked CYP21P pseudogene. Approximately 20% are gene deletions due to unequal crossing over during meiosis, whereas the remainder are gene conversions--transfers to CYP21 of deleterious mutations normally present in CYP21P. The degree to which each mutation compromises enzymatic activity is strongly correlated with the clinical severity of the disease in patients carrying it. Prenatal diagnosis by direct mutation detection permits prenatal treatment of affected females to minimize genital virilization. Neonatal screening by hormonal methods identifies affected children before salt wasting crises develop, reducing mortality from this condition. Glucocorticoid and mineralocorticoid replacement are the mainstays of treatment, but more rational dosing and additional therapies are being developed.
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Affiliation(s)
- P C White
- Division of Pediatric Endocrinology, University of Texas Southwestern Medical Center, Dallas 75390-9063, USA.
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21
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Lee HH, Chang JG, Tsai CH, Tsai FJ, Chao HT, Chung BC. Analysis of the Chimeric CYP21P/CYP21 Gene in Steroid 21-Hydroxylase Deficiency. Clin Chem 2000. [DOI: 10.1093/clinchem/46.5.606] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Background: A single nonfunctional chimeric gene with its 5′ and 3′ ends corresponding to CYP21P and CYP21, respectively, is caused by unequal gene crossover in the CYP21 genes during meiosis. The presence of the chimeric CYP21P/CYP21 molecule can not be detected by conventional PCR methods and therefore may be lost in PCR amplification. This leads to a false result and diagnostic discordance.
Methods: We developed a rapid and direct method to detect a chimeric CYP21P/CYP21 gene that uses a 3′-specific primer for the CYP21 gene and two different 5′ primers for both CYP21 and CYP21P to amplify the wild-type CYP21 and the chimeric CYP21P/CYP21 genes. A secondary PCR that can differentiate the chimeric from the wild-type gene was also performed. The PCR product was directly analyzed on agarose gel.
Results: After careful titration, we found that earlier failure to detect the chimeric CYP21P/CYP21 gene could be caused by unequal concentrations of two independent alleles as the PCR template or by the lack of primers to amplify chimeric molecules. We successfully amplified the chimeric gene using our improved method.
Conclusions: The chimeric CYP21P/CYP21 is present in a large portion of congenital adrenal hyperplasia patients. By adding a CYP21P/CYP21-specific primer, we were able to amplify and detect both homozygous and heterozygous chimeric genes. Therefore, our new PCR-based assay is a more effective way to analyze congenital adrenal hyperplasia mutations.
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Affiliation(s)
- Hsien-Hsiung Lee
- Department of Medical Research, Division of Molecular Medicine, China Medical College Hospital, No. 2, Yue-Der Road, Taichung 404, Taiwan, Republic of China
- King Car Food Industrial Co., Ltd., Yuan-Shan Research Institute, No. 86, Chen-Hsiang Rd., Yuan-Shan I-Lan 264, Taiwan, Republic of China
| | - Jan-Gowth Chang
- Department of Medical Research, Division of Molecular Medicine, China Medical College Hospital, No. 2, Yue-Der Road, Taichung 404, Taiwan, Republic of China
| | - Chang-Hai Tsai
- Department of Medical Research, Division of Molecular Medicine, China Medical College Hospital, No. 2, Yue-Der Road, Taichung 404, Taiwan, Republic of China
| | - Fuu-Jen Tsai
- Department of Medical Research, Division of Molecular Medicine, China Medical College Hospital, No. 2, Yue-Der Road, Taichung 404, Taiwan, Republic of China
| | - Hsiang-Tai Chao
- Department of Obstetrics and Gynecology, Veterans General Hospital-Taipei, Taipei 11217, Taiwan, Republic of China
| | - Bon-chu Chung
- Institute of Molecular Biology, Academia Sinica, Nankang, Taipei 115, Taiwan, Republic of China
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Stratakis CA, Rennert OM. Congenital adrenal hyperplasia: molecular genetics and alternative approaches to treatment. Crit Rev Clin Lab Sci 1999; 36:329-63. [PMID: 10486704 DOI: 10.1080/10408369991239222] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Several autosomal recessive disorders affecting the adrenal cortex and its development and leading to defective cortisol biosynthesis are known under the collective term "congenital adrenal hyperplasia" (CAH). Over the last two decades, the genes causing most of these disorders have been identified and molecular genetics may supplement their clinical and biochemical diagnosis. In addition, new treatments have emerged; although gene therapy has yet to be applied in humans, studies are ongoing in gene transfer in adrenocortical cell lines and animal models. In this review, after a brief introduction on the developmental biology and biochemistry of the adrenal cortex and its enzymes, we will list the new developments in the genetics and treatment of diseases causing CAH, starting with the most recent findings. This order happens to follow adrenal steroidogenesis from the mitochondrial entry of cholesterol to cortisol synthesis; it is unlike other presentations of CAH syndromes that start with the most frequently seen syndromes, because the latter were also the first to be investigated at the genetic level and have been extensively reviewed elsewhere. We will start with the latest syndrome to be molecularly investigated, congenital lipoid adrenal hyperplasia (CLAH), which is caused by mutations in the gene coding for the steroidogenic acute regulatory (StAR) protein. We will then present new developments in the genetics of 3-beta-hydroxysteroid dehydrogenase (3 beta HSD), 17 hydroxylase and 17,20-lyase (P450c17), 11 hydroxylase (P450c11 beta), and 21 hydroxylase (P450c21) deficiencies. Alternative treatment approaches and gene therapy experiments are reviewed collectively in the last section, because they are still in their infantile stages.
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Affiliation(s)
- C A Stratakis
- Unit on Genetics and Endocrinology (UGEN), National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda, Maryland 20892-1862, USA
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