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Kurt I, Eser M, Kahveci A, Ucar A, Bulus D, Ozcabi B, Guran O, Karagozlu S, Ersoy A, Demir S, Geckinli B, Guran T. Severe adrenal insufficiency in six neonates with normal newborn screening for CAH. Clin Endocrinol (Oxf) 2024; 101:108-113. [PMID: 38796770 DOI: 10.1111/cen.15080] [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: 03/08/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Newborn screening (NBS) reduces the risk of mortality in congenital adrenal hyperplasia (CAH), mainly due to the salt-wasting form of 21-hydroxylase deficiency. There is limited knowledge regarding the results of NBS in non-CAH primary adrenal insufficiency (non-CAH PAI). PATIENTS AND METHODS Clinical and NBS for CAH data of neonates who were diagnosed with non-CAH PAI between January and December 2022 were examined. RESULTS Patients (n = 6, 4 females) were presented with severe hyperpigmentation (n = 6), hypoglycemia (n = 4), hyponatremia (n = 3), hyperkalemia (n = 1), respiratory distress syndrome (n = 1) between 3rd hour to 2 months of life. All had normal NBS results. The median first-tier 17-hydroxyprogesterone (17OHP) concentration in NBS for CAH was 0.14 ng/mL (range; 0.05-0.85). Molecular studies revealed biallelic mutations in the MC2R (n = 4; 3 homozygous, 1 compound heterozygous), MRAP (n = 1) and STAR (n = 1) genes. Glucocorticoid with or without mineralocorticoid replacement was initiated once the diagnosis of non-CAH PAI was established. CONCLUSION Neonates with non-CAH PAI have always normal NBS due to persistently low 17OHP, even when these newborn infants are severely symptomatic for adrenal insufficiency. Clinicians should be alert for signs of adrenal insufficiency in neonates, even if the patient has a 'normal' screening for CAH, so as not to delay diagnosis and treatment. This fact should be kept in mind particularly in countries where these conditions are more common than elsewhere.
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Affiliation(s)
- Ilknur Kurt
- Department of Pediatric Endocrinology, Marmara University School of Medicine, Istanbul, Turkey
| | - Metin Eser
- Department of Medical Genetics, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ahmet Kahveci
- Department of Pediatric Endocrinology, Marmara University School of Medicine, Istanbul, Turkey
| | - Ahmet Ucar
- Department of Pediatric Endocrinology, Sariyer Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Derya Bulus
- Department of Pediatric Endocrinology, Kecioren Training and Research Hospital, Ankara, Turkey
| | - Bahar Ozcabi
- Department of Pediatric Endocrinology, Acibadem Atasehir Hospital, Istanbul, Turkey
| | - Omer Guran
- Department of Neonatology, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Selen Karagozlu
- Department of Pediatric Cardiology, Marmara University School of Medicine, Istanbul, Turkey
| | - Aysenur Ersoy
- Department of Medical Genetics, Marmara University School of Medicine, Istanbul, Turkey
| | - Senol Demir
- Department of Medical Genetics, Marmara University School of Medicine, Istanbul, Turkey
| | - Bilge Geckinli
- Department of Medical Genetics, Marmara University School of Medicine, Istanbul, Turkey
| | - Tulay Guran
- Department of Pediatric Endocrinology, Marmara University School of Medicine, Istanbul, Turkey
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Navarro CDC, Francisco A, Costa EFD, Dalla Costa AP, Sartori MR, Bizerra PFV, Salgado AR, Figueira TR, Vercesi AE, Castilho RF. Aging-dependent mitochondrial bioenergetic impairment in the skeletal muscle of NNT-deficient mice. Exp Gerontol 2024; 193:112465. [PMID: 38795789 DOI: 10.1016/j.exger.2024.112465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/02/2024] [Accepted: 05/22/2024] [Indexed: 05/28/2024]
Abstract
Overall health relies on features of skeletal muscle that generally decline with age, partly due to mechanisms associated with mitochondrial redox imbalance and bioenergetic dysfunction. Previously, aged mice genetically devoid of the mitochondrial NAD(P)+ transhydrogenase (NNT, encoded by the nicotinamide nucleotide transhydrogenase gene), an enzyme involved in mitochondrial NADPH supply, were shown to exhibit deficits in locomotor behavior. Here, by using young, middle-aged, and older NNT-deficient (Nnt-/-) mice and age-matched controls (Nnt+/+), we aimed to investigate how muscle bioenergetic function and motor performance are affected by NNT expression and aging. Mice were subjected to the wire-hang test to assess locomotor performance, while mitochondrial bioenergetics was evaluated in fiber bundles from the soleus, vastus lateralis and plantaris muscles. An age-related decrease in the average wire-hang score was observed in middle-aged and older Nnt-/- mice compared to age-matched controls. Although respiratory rates in the soleus, vastus lateralis and plantaris muscles did not significantly differ between the genotypes in young mice, the rates of oxygen consumption did decrease in the soleus and vastus lateralis muscles of middle-aged and older Nnt-/- mice. Notably, the soleus, which exhibited the highest NNT expression level, was the muscle most affected by aging, and NNT loss. Additionally, histology of the soleus fibers revealed increased numbers of centralized nuclei in older Nnt-/- mice, indicating abnormal morphology. In summary, our findings suggest that NNT expression deficiency causes locomotor impairments and muscle dysfunction during aging in mice.
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Affiliation(s)
- Claudia D C Navarro
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), 13083 887 Campinas, SP, Brazil
| | - Annelise Francisco
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), 13083 887 Campinas, SP, Brazil; Department of Experimental Medical Science, Faculty of Medicine, Lund University, 221 84 Lund, Sweden
| | - Ericka F D Costa
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), 13083 887 Campinas, SP, Brazil
| | - Ana P Dalla Costa
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), 13083 887 Campinas, SP, Brazil
| | - Marina R Sartori
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), 13083 887 Campinas, SP, Brazil
| | - Paulo F V Bizerra
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), 13083 887 Campinas, SP, Brazil
| | - Andréia R Salgado
- Multidisciplinary Center for Biological Investigation on Laboratory Animals Science, University of Campinas, Campinas, SP, Brazil
| | - Tiago R Figueira
- School of Physical Education and Sport of Ribeirão Preto, University of São Paulo, 14040 900 Ribeirão Preto, SP, Brazil
| | - Anibal E Vercesi
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), 13083 887 Campinas, SP, Brazil
| | - Roger F Castilho
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), 13083 887 Campinas, SP, Brazil.
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Amano N, Narumi S, Aizu K, Miyazawa M, Okamura K, Ohashi H, Katsumata N, Ishii T, Hasegawa T. Single-Exon Deletions of ZNRF3 Exon 2 Cause Congenital Adrenal Hypoplasia. J Clin Endocrinol Metab 2024; 109:641-648. [PMID: 37878959 DOI: 10.1210/clinem/dgad627] [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: 07/11/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
CONTEXT Primary adrenal insufficiency (PAI) is a life-threatening condition characterized by the inability of the adrenal cortex to produce sufficient steroid hormones. E3 ubiquitin protein ligase zinc and ring finger 3 (ZNRF3) is a negative regulator of Wnt/β-catenin signaling. R-spondin 1 (RSPO1) enhances Wnt/β-catenin signaling via binding and removal of ZNRF3 from the cell surface. OBJECTIVE This work aimed to explore a novel genetic form of PAI. METHODS We analyzed 9 patients with childhood-onset PAI of biochemically and genetically unknown etiology using array comparative genomic hybridization. To examine the functionality of the identified single-exon deletions of ZNRF3 exon 2, we performed three-dimensional (3D) structure modeling and in vitro functional studies. RESULTS We identified various-sized single-exon deletions encompassing ZNRF3 exon 2 in 3 patients who showed neonatal-onset adrenal hypoplasia with glucocorticoid and mineralocorticoid deficiencies. Reverse-transcriptase polymerase chain reaction (RT-PCR) analysis showed that the 3 distinct single-exon deletions were commonly transcribed into a 126-nucleotide deleted mRNA and translated into 42-amino acid deleted protein (ΔEx2-ZNRF3). Based on 3D structure modeling, we predicted that interaction between ZNRF3 and RSPO1 would be disturbed in ΔEx2-ZNRF3, suggesting loss of RSPO1-dependent activation of Wnt/β-catenin signaling. Cell-based functional assays with the TCF-LEF reporter showed that RSPO1-dependent activation of Wnt/β-catenin signaling was attenuated in cells expressing ΔEx2-ZNRF3 as compared with those expressing wild-type ZNRF3. CONCLUSION We provided genetic evidence linking deletions encompassing ZNRF3 exon 2 and congenital adrenal hypoplasia, which might be related to constitutive inactivation of Wnt/β-catenin signaling by ΔEx2-ZNRF3.
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Affiliation(s)
- Naoko Amano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, 160-8582, Japan
- Department of Pediatrics, Saitama City Hospital, Saitama, 336-8522, Japan
| | - Satoshi Narumi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, 160-8582, Japan
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, 157-8535, Japan
| | - Katsuya Aizu
- Division of Endocrinology and Metabolism, Saitama Children's Medical Center, Saitama, 330-8777, Japan
| | - Mari Miyazawa
- Department of Pediatrics, Kochi Health Sciences Center, Kochi, 781-8555, Japan
| | - Kohji Okamura
- Department of Systems BioMedicine, National Center for Child Health and Development, Tokyo, 157-8535, Japan
| | - Hirofumi Ohashi
- Division of Medical Genetics, Saitama Children's Medical Center, Saitama, 330-8777, Japan
| | - Noriyuki Katsumata
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, 157-8535, Japan
| | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, 160-8582, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, 160-8582, Japan
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Francisco A, Goler AMY, Navarro CDC, Onder A, Yildiz M, Kendir Demirkol Y, Karademir Yilmaz B, Seven Menevse T, Güran T, Castilho RF. Lack of NAD(P)+ transhydrogenase activity in patients with primary adrenal insufficiency due to NNT variants. Eur J Endocrinol 2024; 190:130-138. [PMID: 38261461 DOI: 10.1093/ejendo/lvae011] [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: 06/19/2023] [Revised: 11/10/2023] [Accepted: 12/28/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Pathogenic variants in the nicotinamide nucleotide transhydrogenase gene (NNT) are a rare cause of primary adrenal insufficiency (PAI), as well as functional impairment of the gonads. OBJECTIVE Despite the description of different homozygous and compound heterozygous NNT variants in PAI patients, the extent to which the function and expression of the mature protein are compromised remains to be clarified. DESIGN The activity and expression of mitochondrial NAD(P)+ transhydrogenase (NNT) were analyzed in blood samples obtained from patients diagnosed with PAI due to genetically confirmed variants of the NNT gene (n = 5), heterozygous carriers as their parents (n = 8), and healthy controls (n = 26). METHODS NNT activity was assessed by a reverse reaction assay standardized for digitonin-permeabilized peripheral blood mononuclear cells (PBMCs). The enzymatic assay was validated in PBMC samples from a mouse model of NNT absence. Additionally, the PBMC samples were evaluated for NNT expression by western blotting and reverse transcription quantitative polymerase chain reaction and for mitochondrial oxygen consumption. RESULTS NNT activity was undetectable (<4% of that of healthy controls) in PBMC samples from patients, independent of the pathogenic genetic variant. In patients' parents, NNT activity was approximately half that of the healthy controls. Mature NNT protein expression was lower in patients than in the control groups, while mRNA levels varied widely among genotypes. Moreover, pathogenic NNT variants did not impair mitochondrial bioenergetic function in PBMCs. CONCLUSIONS The manifestation of PAI in NNT-mutated patients is associated with a complete lack of NNT activity. Evaluation of NNT activity can be useful to characterize disease-causing NNT variants.
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Affiliation(s)
- Annelise Francisco
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP 13083-888, Brazil
- Department of Biochemistry, Faculty of Medicine, Genetic and Metabolic Diseases Research Center, Marmara University Faculty of Medicine, Istanbul 34854, Turkey
| | - Ayse Mine Yilmaz Goler
- Department of Biochemistry, Faculty of Medicine, Genetic and Metabolic Diseases Research Center, Marmara University Faculty of Medicine, Istanbul 34854, Turkey
| | | | - Asan Onder
- Department of Pediatric Endocrinology and Diabetes, Medeniyet University Goztepe Training and Research Hospital, Istanbul 34722, Turkey
| | - Melek Yildiz
- Pediatric Genetic Diseases, Umraniye Training and Research Hospital, Istanbul 34764, Turkey
| | - Yasemin Kendir Demirkol
- Department of Pediatric Genetics, Umraniye Research and Training Hospital, University of Health Sciences, Istanbul 34764, Turkey
| | - Betul Karademir Yilmaz
- Department of Biochemistry, Faculty of Medicine, Genetic and Metabolic Diseases Research Center, Marmara University Faculty of Medicine, Istanbul 34854, Turkey
| | - Tuba Seven Menevse
- Department of Pediatric Endocrinology and Diabetes, Marmara University Faculty of Medicine, Istanbul 34854, Turkey
| | - Tülay Güran
- Department of Pediatric Endocrinology and Diabetes, Marmara University Faculty of Medicine, Istanbul 34854, Turkey
| | - Roger Frigério Castilho
- Department of Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP 13083-888, Brazil
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Pons Fernández N, Moriano Gutiérrez A, Taberner Pazos B, Tarragon Cros A, Díez Gandía E, Zuñiga Cabrera Á. A novel mutation in the NNT gene causing familial glucocorticoid deficiency, with a literature review. ANNALES D'ENDOCRINOLOGIE 2024; 85:70-81. [PMID: 37352919 DOI: 10.1016/j.ando.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/15/2022] [Accepted: 05/29/2023] [Indexed: 06/25/2023]
Abstract
Familial glucocorticoid deficiency (FGD) is an autosomal recessive disorder characterized by low cortisol levels despite elevated adrenocorticotropin (ACTH). Mineralocorticoid secretion is classically normal. Clinical manifestations are secondary to low cortisol levels (recurrent hypoglycemia, chronic asthenia, failure to thrive, seizures) and high levels of ACTH (cutaneous-mucosal hyperpigmentation). FGD is often caused by mutations in the ACTH melanocortin 2 receptor gene (MC2R, 18p11.21, FGD type 1) or melanocortin receptor 2 accessory protein gene (MRAP, 21q22.11, FGD type 2). But mutations have also been described in other genes: the steroidogenic acute regulatory protein (STAR, 8q11.2q13.2, FGD type 3), nicotinamide nucleotide transhydrogenase (NNT, 5p12, FGD type 4) and thioredoxin reductase 2 genes (TXNRD2, 22q11.21, FGD type 5). We report the case of a 3-year-old boy recently diagnosed with FGD type 4 due to a novel mutation in NNT gene. A homozygous variant in exon 18 of the NNT gene, NM_012343.3:c.2764C>T, p.(Arg922*), determines a stop codon and, consequently, a non-functional truncated protein or absence of protein due to the nonsense-mediated decay (NMD) mechanism. We review the recent literature on NNT mutations and clinical presentations, which are broader than suspected. This disorder can result in significant morbidity and is potentially fatal if untreated. Precise diagnosis allows correct treatment and follow-up.
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Affiliation(s)
- Natividad Pons Fernández
- Department of Pediatrics, Hospital Lluís-Alcanyís, Ctra, Xàtiva a Silla km 2, 46800 Valencia, Spain.
| | - Ana Moriano Gutiérrez
- Department of Pediatrics, Hospital Lluís-Alcanyís, Ctra, Xàtiva a Silla km 2, 46800 Valencia, Spain
| | - Belén Taberner Pazos
- Department of Pediatrics, Hospital Lluís-Alcanyís, Ctra, Xàtiva a Silla km 2, 46800 Valencia, Spain
| | | | - Eva Díez Gandía
- Department of Pediatrics, Hospital Lluís-Alcanyís, Ctra, Xàtiva a Silla km 2, 46800 Valencia, Spain
| | - Ángel Zuñiga Cabrera
- Department of Genetics, Hospital Universitario y Politécnico la Fe, Valencia, Spain
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6
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Duan Y, Zheng W, Xia Y, Zhang H, Liang L, Wang R, Yang Y, Zhang K, Lu D, Sun Y, Han L, Yu Y, Gu X, Sun Y, Xiao B, Qiu W. Genetic and phenotypic spectrum of non-21-hydroxylase-deficiency primary adrenal insufficiency in childhood: data from 111 Chinese patients. J Med Genet 2023; 61:27-35. [PMID: 37586839 DOI: 10.1136/jmg-2022-108952] [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: 09/19/2022] [Accepted: 07/04/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Primary adrenal insufficiency (PAI) is a rare but life-threatening condition. Differential diagnosis of numerous causes of PAI requires a thorough understanding of the condition. METHODS To describe the genetic composition and presentations of PAI. The following data were collected retrospectively from 111 patients with non-21OHD with defined genetic diagnoses: demographic information, onset age, clinical manifestations, laboratory findings and genetic results. Patients were divided into four groups based on the underlying pathogenesis: (1) impaired steroidogenesis, (2) adrenal hypoplasia, (3) resistance to adrenocorticotropic hormone (ACTH) and (4) adrenal destruction. The age of onset was compared within the groups. RESULTS Mutations in the following genes were identified: NR0B1 (n=39), STAR (n=33), CYP11B1 (n=12), ABCD1 (n=8), CYP17A1 (n=5), HSD3B2 (n=4), POR (n=4), MRAP (n=2), MC2R (n=1), CYP11A1 (n=1), LIPA (n=1) and SAMD9 (n=1). Frequent clinical manifestations included hyperpigmentation (73.0%), dehydration (49.5%), vomiting (37.8%) and abnormal external genitalia (23.4%). Patients with adrenal hypoplasia typically presented manifestations earlier than those with adrenal destruction but later than those with impaired steroidogenesis (both p<0.01). The elevated ACTH (92.6%) and decreased cortisol (73.5%) were the most common laboratory findings. We generated a differential diagnosis flowchart for PAI using the following clinical features: 17-hydroxyprogesterone, very-long-chain fatty acid, external genitalia, hypertension and skeletal malformation. This flowchart identified 84.8% of patients with PAI before next-generation DNA sequencing. CONCLUSIONS STAR and NR0B1 were the most frequently mutated genes in patients with non-21OHD PAI. Age of onset and clinical characteristics were dependent on aetiology. Combining clinical features and molecular tests facilitates accurate diagnosis.
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Affiliation(s)
- Ying Duan
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Wanqi Zheng
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yu Xia
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Huiwen Zhang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Lili Liang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Ruifang Wang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yi Yang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Kaichuang Zhang
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Deyun Lu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yuning Sun
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Lianshu Han
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yongguo Yu
- Department of Pediatric Endocrinology and Genetic Metabolism, Clinical Genetics Center, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Xuefan Gu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Yu Sun
- Department of Pediatric Endocrinology and Genetic Metabolism, Clinical Genetics Center, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Bing Xiao
- Department of Pediatric Endocrinology and Genetic Metabolism, Clinical Genetics Center, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
| | - Wenjuan Qiu
- Department of Pediatric Endocrinology and Genetic Metabolism, Shanghai Institute for Pediatric Research, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Yangpu, Shanghai, China
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Maharaj AV. Familial Glucocorticoid Deficiency: the changing landscape of an eponymous syndrome. Front Endocrinol (Lausanne) 2023; 14:1268345. [PMID: 38189052 PMCID: PMC10771341 DOI: 10.3389/fendo.2023.1268345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/28/2023] [Indexed: 01/09/2024] Open
Abstract
Familial Glucocorticoid Deficiency encompasses a broad spectrum of monogenic recessive disorders that theoretically solely abrogate cortisol biosynthesis. In reality, delineating clear genotype-phenotype correlations in this disorder is made complicated by marked phenotypic heterogeneity even within kindreds harbouring identical variants. Phenotypes range from isolated glucocorticoid insufficiency to cortisol deficiency plus a variety of superimposed features including salt-wasting and hypoaldosteronism, primary hypothyroidism, hypogonadism and growth defects. Furthermore, mutation type, domain topology and perceived enzyme activity do not always predict disease severity. Given the high burden of disease and implications of a positive diagnosis, genetic testing is crucial in the management of patients warranting detailed delineation of genomic variants including viable functional studies.
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Affiliation(s)
- Avinaash V. Maharaj
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London (QMUL), London, United Kingdom
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8
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Wolff ASB, Kucuka I, Oftedal BE. Autoimmune primary adrenal insufficiency -current diagnostic approaches and future perspectives. Front Endocrinol (Lausanne) 2023; 14:1285901. [PMID: 38027140 PMCID: PMC10667925 DOI: 10.3389/fendo.2023.1285901] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
The adrenal glands are small endocrine glands located on top of each kidney, producing hormones regulating important functions in our body like metabolism and stress. There are several underlying causes for adrenal insufficiency, where an autoimmune attack by the immune system is the most common cause. A number of genes are known to confer early onset adrenal disease in monogenic inheritance patterns, usually genetic encoding enzymes of adrenal steroidogenesis. Autoimmune primary adrenal insufficiency is usually a polygenic disease where our information recently has increased due to genome association studies. In this review, we go through the physiology of the adrenals before explaining the different reasons for adrenal insufficiency with a particular focus on autoimmune primary adrenal insufficiency. We will give a clinical overview including diagnosis and current treatment, before giving an overview of the genetic causes including monogenetic reasons for adrenal insufficiency and the polygenic background and inheritance pattern in autoimmune adrenal insufficiency. We will then look at the autoimmune mechanisms underlying autoimmune adrenal insufficiency and how autoantibodies are important for diagnosis. We end with a discussion on how to move the field forward emphasizing on the clinical workup, early identification, and potential targeted treatment of autoimmune PAI.
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Affiliation(s)
- Anette S. B. Wolff
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Isil Kucuka
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Bergithe E. Oftedal
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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9
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del Valle I, Young MD, Kildisiute G, Ogunbiyi OK, Buonocore F, Simcock IC, Khabirova E, Crespo B, Moreno N, Brooks T, Niola P, Swarbrick K, Suntharalingham JP, McGlacken-Byrne SM, Arthurs OJ, Behjati S, Achermann JC. An integrated single-cell analysis of human adrenal cortex development. JCI Insight 2023; 8:e168177. [PMID: 37440461 PMCID: PMC10443814 DOI: 10.1172/jci.insight.168177] [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: 12/19/2022] [Accepted: 05/31/2023] [Indexed: 07/15/2023] Open
Abstract
The adrenal glands synthesize and release essential steroid hormones such as cortisol and aldosterone, but many aspects of human adrenal gland development are not well understood. Here, we combined single-cell and bulk RNA sequencing, spatial transcriptomics, IHC, and micro-focus computed tomography to investigate key aspects of adrenal development in the first 20 weeks of gestation. We demonstrate rapid adrenal growth and vascularization, with more cell division in the outer definitive zone (DZ). Steroidogenic pathways favored androgen synthesis in the central fetal zone, but DZ capacity to synthesize cortisol and aldosterone developed with time. Core transcriptional regulators were identified, with localized expression of HOPX (also known as Hop homeobox/homeobox-only protein) in the DZ. Potential ligand-receptor interactions between mesenchyme and adrenal cortex were seen (e.g., RSPO3/LGR4). Growth-promoting imprinted genes were enriched in the developing cortex (e.g., IGF2, PEG3). These findings reveal aspects of human adrenal development and have clinical implications for understanding primary adrenal insufficiency and related postnatal adrenal disorders, such as adrenal tumor development, steroid disorders, and neonatal stress.
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Affiliation(s)
- Ignacio del Valle
- Genetics and Genomic Medicine Research and Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Matthew D. Young
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, United Kingdom
| | - Gerda Kildisiute
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, United Kingdom
| | - Olumide K. Ogunbiyi
- Department of Histopathology, Great Ormond Street Hospital for Children National Health Service (NHS) Foundation Trust, London, United Kingdom
- Developmental Biology and Cancer Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Federica Buonocore
- Genetics and Genomic Medicine Research and Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Ian C. Simcock
- Department of Clinical Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- National Institute of Health Research (NIHR) Great Ormond Street Biomedical Research Centre, London, United Kingdom
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Eleonora Khabirova
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, United Kingdom
| | - Berta Crespo
- Developmental Biology and Cancer Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Nadjeda Moreno
- Developmental Biology and Cancer Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Tony Brooks
- UCL Genomics, Zayed Centre for Research, UCL Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Paola Niola
- UCL Genomics, Zayed Centre for Research, UCL Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Katherine Swarbrick
- Department of Histopathology, Great Ormond Street Hospital for Children National Health Service (NHS) Foundation Trust, London, United Kingdom
- Developmental Biology and Cancer Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Jenifer P. Suntharalingham
- Genetics and Genomic Medicine Research and Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Sinead M. McGlacken-Byrne
- Genetics and Genomic Medicine Research and Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Owen J. Arthurs
- Department of Clinical Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- National Institute of Health Research (NIHR) Great Ormond Street Biomedical Research Centre, London, United Kingdom
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
| | - Sam Behjati
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, United Kingdom
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - John C. Achermann
- Genetics and Genomic Medicine Research and Teaching Department, University College London (UCL) Great Ormond Street Institute of Child Health, UCL, London, United Kingdom
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Abstract
PURPOSE OF REVIEW Adrenal insufficiency (AI) is the clinical manifestation of deficient production of glucocorticoids with occasionally deficiency also in mineralocorticoids and adrenal androgens and constitutes a fatal disorder if left untreated. The aim of this review is to summarize the new trends in diagnostic methods used for determining the presence of AI. RECENT FINDINGS Novel aetiologies of AI have emerged; severe acute respiratory syndrome coronavirus 2 infection was linked to increased frequency of primary AI (PAI). A new class of drugs, the immune checkpoint inhibitors (ICIs) widely used for the treatment of several malignancies, has been implicated mostly with secondary AI, but also with PAI. Salivary cortisol is considered a noninvasive and patient-friendly tool and has shown promising results in diagnosing AI, although the normal cut-off values remain an issue of debate depending on the technique used. Liquid chromatography-mass spectrometry (LC-MS/MS) is the most reliable technique although not widely available. SUMMARY Our research has shown that little progress has been made regarding our knowledge on AI. Coronavirus disease 2019 and ICIs use constitute new evidence on the pathogenesis of AI. The short synacthen test (SST) remains the 'gold-standard' method for confirmation of AI diagnosis, although salivary cortisol is a promising tool.
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Affiliation(s)
- Vasiliki Siampanopoulou
- Endocrinology Unit, First Department of Internal Medicine, Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens
| | - Elisavet Tasouli
- First Department of Internal Medicine, Thriasio General Hospital of Elefsina, Elefsina, Greece
| | - Anna Angelousi
- Endocrinology Unit, First Department of Internal Medicine, Laiko General Hospital of Athens, National and Kapodistrian University of Athens, Athens
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11
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Zheng W, Duan Y, Xia Y, Liang L, Gong Z, Wang R, Lu D, Zhang K, Yang Y, Sun Y, Zhang H, Han L, Gong Z, Xiao B, Qiu W. Clinical and genetic characteristics of 42 Chinese paediatric patients with X-linked adrenal hypoplasia congenita. Orphanet J Rare Dis 2023; 18:126. [PMID: 37237297 DOI: 10.1186/s13023-023-02737-y] [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: 07/12/2022] [Accepted: 05/18/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND X-linked adrenal hypoplasia congenita (AHC) is a rare disorder characterized by primary adrenal insufficiency (PAI) and hypogonadotropic hypogonadism (HH), with limited clinical and genetic characterization. METHODS The clinical, biochemical, genetic, therapeutic, and follow-up data of 42 patients diagnosed with X-linked AHC were retrospectively analysed. RESULTS Hyperpigmentation (38/42, 90%), vomiting/diarrhoea (20/42, 48%), failure to thrive (13/42, 31%), and convulsions (7/42, 17%) were the most common symptoms of X-linked AHC at onset. Increased adrenocorticotropic hormone (ACTH) (42/42, 100%) and decreased cortisol (37/42, 88%) were the most common laboratory findings, followed by hyponatremia (32/42, 76%) and hyperkalaemia (29/42, 69%). Thirty-one patients presented with PAI within the first year of life, and 11 presented after three years of age. Three of the thirteen patients over the age of 14 exhibited spontaneous pubertal development, and ten of them experienced delayed puberty due to HH. Six patients receiving human chorionic gonadotropin (hCG) therapy exhibited a slight increase in testicular size and had rising testosterone levels (both P < 0.05). The testicular volumes of the three patients with pulsatile gonadotropin-releasing hormone (GnRH) therapy were larger than those of the six patients undergoing hCG therapy (P < 0.05), and they also exhibited some growth in terms of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone. Of the 42 patients, three had an Xp21 deletion, and 39 had an isolated DAX1 defect. Most patients (9/10) with entire DAX1 deletion accounting for 23.8% (10/42) of the total variants had early onset age of less than one year. CONCLUSIONS This study details the clinical features and genetic spectra of X-linked AHC. Patients with X-linked AHC show a bimodal distribution of the age of onset, with approximately 70% presenting within the first year of life. Pulsatile GnRH may be recommended for HH when hCG therapy is not satisfactory, although it is difficult to achieve normal testicular volume. The combination of clinical features and molecular tests provides information for an accurate diagnosis.
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Affiliation(s)
- Wanqi Zheng
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Ying Duan
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Yu Xia
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Lili Liang
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Zhuwen Gong
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Ruifang Wang
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Deyun Lu
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Kaichuang Zhang
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Yi Yang
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Yuning Sun
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Huiwen Zhang
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Lianshu Han
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Zizhen Gong
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China
| | - Bing Xiao
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China.
| | - Wenjuan Qiu
- Department of Paediatric Endocrinology and Genetic Metabolism, Xinhua Hospital, Shanghai Institute of Paediatric Research, School of Medicine, Shanghai Jiao Tong University, 1665 Kongjiang Road, Shanghai, 200092, China.
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12
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Hasenmajer V, Ferrigno R, Minnetti M, Pellegrini B, Isidori AM, Lenzi A, Salerno M, Cappa M, Chan L, De Martino MC, Savage MO. Rare forms of genetic paediatric adrenal insufficiency: Excluding congenital adrenal hyperplasia. Rev Endocr Metab Disord 2023; 24:345-363. [PMID: 36763264 PMCID: PMC10023752 DOI: 10.1007/s11154-023-09784-7] [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] [Accepted: 01/03/2023] [Indexed: 02/11/2023]
Abstract
Adrenal insufficiency (AI) is a severe endocrine disorder characterized by insufficient glucocorticoid (GC) and/or mineralocorticoid (MC) secretion by the adrenal glands, due to impaired adrenal function (primary adrenal insufficiency, PAI) or to insufficient adrenal stimulation by pituitary ACTH (secondary adrenal insufficiency, SAI) or tertiary adrenal insufficiency due to hypothalamic dysfunction. In this review, we describe rare genetic causes of PAI with isolated GC or combined GC and MC deficiencies and we also describe rare syndromes of isolated MC deficiency. In children, the most frequent cause of PAI is congenital adrenal hyperplasia (CAH), a group of adrenal disorders related to steroidogenic enzyme deficiencies, which will not be included in this review. Less frequently, several rare diseases can cause PAI, either affecting exclusively the adrenal glands or with systemic involvement. The diagnosis of these diseases is often challenging, due to the heterogeneity of their clinical presentation and to their rarity. Therefore, the current review aims to provide an overview on these rare genetic forms of paediatric PAI, offering a review of genetic and clinical features and a summary of diagnostic and therapeutic approaches, promoting awareness among practitioners, and favoring early diagnosis and optimal clinical management in suspect cases.
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Affiliation(s)
- Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rosario Ferrigno
- UOSD Auxology and Endocrinology, Department of Pediatric, AORN Santobono-Pausilipon, Naples, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Bianca Pellegrini
- Dipartimento Di Medicina Clinica E Chirurgia, Federico II University, Naples, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Marco Cappa
- Endocrinology Unit, Pediatric University Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Li Chan
- Endocrinology Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | | | - Martin O Savage
- Endocrinology Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
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13
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Duan Y, Xia Y, Gong Z, Liu H, Liang L, Zhang K, Yang Y, Wang R, Xiao B, Qiu W. A Novel Mutation in Melanocortin Receptor 2 and a Reported Mutation in Melanocortin Receptor 2 Accessory Protein: Three Chinese Cases with Familial Glucocorticoid Deficiency. Mol Syndromol 2023; 14:71-79. [PMID: 36777708 PMCID: PMC9911991 DOI: 10.1159/000526320] [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: 09/14/2021] [Accepted: 07/31/2022] [Indexed: 11/19/2022] Open
Abstract
Background Familial glucocorticoid deficiency (FGD) is a rare autosomal recessive disease characterized by glucocorticoid deficiency without mineralocorticoid deficiency. We report 3 Chinese patients with MRAP or MC2R mutations. Case Reports Patient 1 presented with hyperpigmentation. Endocrine investigations revealed low serum cortisol levels and elevated adrenocorticotropic hormone (ACTH) levels. Furthermore, low serum sodium was evident. She was diagnosed with FGD type 2 due to a homozygous mutation in MRAP (c.106+1delG), revealed through exome sequencing (ES). After 2-year treatment with hydrocortisone, skin hyperpigmentation was improved. Patient 2 initially presented with hyponatremia. Low cortisol levels and high levels of ACTH were subsequently detected; he was subjected to a hydrocortisone treatment during which he experienced repeated hypoglycemic attacks and pigmentation. ES revealed the same mutation as in patient 1 in MRAP (c.106+1delG), thus he was diagnosed with FGD type 2. After 6 years of age, his symptoms remarkably improved, and there was no episode of hypoglycemia. Patient 3 mainly presented with hyperpigmentation, hypoglycemic attack, and tall stature. Laboratory findings were normal except for low serum cortisol levels and high ACTH levels. She was diagnosed with FGD type 1 as ES revealed a novel homozygous mutation in MC2R (c.712C>A, p.His238Tyr). After nearly 2 years of hydrocortisone replacement therapy, the excessive growth was reduced to near normal, and the skin color returned to normal. Conclusions Three patients were diagnosed with FGD (one with FGD type 1 and two with FGD type 2). They all presented with hyperpigmentation and hypoglycemia; however, compared with patient 1, the clinical manifestations of patient 2 were more complicated. Patient 3 had later onset and taller stature than patients 1 and 2. A novel mutation in patient 3 expands the mutation spectrum of MC2R.
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14
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Miller WL, White PC. History of Adrenal Research: From Ancient Anatomy to Contemporary Molecular Biology. Endocr Rev 2023; 44:70-116. [PMID: 35947694 PMCID: PMC9835964 DOI: 10.1210/endrev/bnac019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 01/20/2023]
Abstract
The adrenal is a small, anatomically unimposing structure that escaped scientific notice until 1564 and whose existence was doubted by many until the 18th century. Adrenal functions were inferred from the adrenal insufficiency syndrome described by Addison and from the obesity and virilization that accompanied many adrenal malignancies, but early physiologists sometimes confused the roles of the cortex and medulla. Medullary epinephrine was the first hormone to be isolated (in 1901), and numerous cortical steroids were isolated between 1930 and 1949. The treatment of arthritis, Addison's disease, and congenital adrenal hyperplasia (CAH) with cortisone in the 1950s revolutionized clinical endocrinology and steroid research. Cases of CAH had been reported in the 19th century, but a defect in 21-hydroxylation in CAH was not identified until 1957. Other forms of CAH, including deficiencies of 3β-hydroxysteroid dehydrogenase, 11β-hydroxylase, and 17α-hydroxylase were defined hormonally in the 1960s. Cytochrome P450 enzymes were described in 1962-1964, and steroid 21-hydroxylation was the first biosynthetic activity associated with a P450. Understanding of the genetic and biochemical bases of these disorders advanced rapidly from 1984 to 2004. The cloning of genes for steroidogenic enzymes and related factors revealed many mutations causing known diseases and facilitated the discovery of new disorders. Genetics and cell biology have replaced steroid chemistry as the key disciplines for understanding and teaching steroidogenesis and its disorders.
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Affiliation(s)
- Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Perrin C White
- Division of Pediatric Endocrinology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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15
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Bodoni AF, Coeli-Lacchini FB, Gebenlian JL, Sobral LM, Garcia CB, Silva WA, Peronni KC, Ramalho LNZ, Ramalho FS, Moreira AC, de Castro M, Leopoldino AM, Antonini SRR. Nicotinamide Nucleotide Transhydrogenase (NNT) is essential for adrenal steroidogenesis: clinical and in vitro lessons. J Clin Endocrinol Metab 2022; 108:1464-1474. [PMID: 36478070 DOI: 10.1210/clinem/dgac705] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/20/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nicotinamide nucleotide transhydrogenase (NNT) acts as an antioxidant defense mechanism. NNT mutations cause familial glucocorticoid deficiency (FGD). How impaired oxidative stress disrupts adrenal steroidogenesis remains poorly understood. OBJECTIVE To ascertain the role played by NNT in adrenal steroidogenesis. METHODS The genotype-phenotype association of a novel pathogenic NNT variant was evaluated in a boy with FGD. Under basal and oxidative stress (OS) induced conditions, transient cell cultures of the patient's and controls wild type (WT) mononuclear blood cells were used to evaluate antioxidant mechanisms and mitochondrial parameters [reactive oxygen species (ROS) production, reduced glutathione (GSH), and mitochondrial mass]. Using CRISPR/Cas9, a stable NNT gene knockdown model was built in H295R adrenocortical carcinoma cells to determine the role played by NNT in mitochondrial parameters and steroidogenesis. NNT immunohistochemistry was assessed in fetal and post-natal human adrenals. RESULTS The homozygous NNT p.G866D variant segregated with the FGD phenotype. Under basal and OS conditions, p.G866D homozygous mononuclear blood cells exhibited increased ROS production, and decreased GSH levels and mitochondrial mass when compared to WT NNT cells. In line, H295R NNT knocked-down cells presented impaired NNT protein expression, increased ROS production, decreased the mitochondrial mass, as well as the size and the density of cholesterol lipid droplets. NNT knockdown affected steroidogenic enzyme expression, impairing cortisol and aldosterone secretion. In human adrenals, NNT is abundantly expressed in the transition fetal zone and in zona fasciculata. CONCLUSION Together, these studies demonstrate the essential role of NNT in adrenal redox homeostasis and steroidogenesis.
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Affiliation(s)
- Aline Faccioli Bodoni
- Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | | | - Juliana Lourenço Gebenlian
- Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Lays Martin Sobral
- Department of Clinical Analysis, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Cristiana Bernadelli Garcia
- Department of Clinical Analysis, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
| | - Wilson Araújo Silva
- Department of Genetics, Ribeirao Preto Medical School, University of Sao Paulo (USP), Ribeirao Preto, Brazil
- Center for Cell Based Therapy, Ribeirao Preto Medical School, University of Sao Paulo (USP), Ribeirao Preto, Brazil
- Center for Medical Genomics at Clinical Hospital of the Ribeirao Preto Medical School, University of São Paulo, Brazil
| | - Kamila Chagas Peronni
- Department of Genetics, Ribeirao Preto Medical School, University of Sao Paulo (USP), Ribeirao Preto, Brazil
- Center for Cell Based Therapy, Ribeirao Preto Medical School, University of Sao Paulo (USP), Ribeirao Preto, Brazil
- Center for Medical Genomics at Clinical Hospital of the Ribeirao Preto Medical School, University of São Paulo, Brazil
| | - Leandra Náira Zambelli Ramalho
- Department of Pathology and Forensic Medicine, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Fernando Silva Ramalho
- Department of Pathology and Forensic Medicine, School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Ayrton C Moreira
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Margaret de Castro
- Department of Internal Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Andreia Machado Leopoldino
- Department of Clinical Analysis, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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16
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McGlacken-Byrne SM, Achermann JC, Conway GS. Management of a Girl With Delayed Puberty and Elevated Gonadotropins. J Endocr Soc 2022; 6:bvac108. [PMID: 35935072 PMCID: PMC9351373 DOI: 10.1210/jendso/bvac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Indexed: 11/19/2022] Open
Abstract
A girl presenting with delayed puberty and elevated gonadotropins may have a range of conditions such as Turner syndrome (TS), primary ovarian insufficiency (POI), and 46,XY disorders of sexual development (DSD). An organized and measured approach to investigation can help reach a timely diagnosis. Management of young people often requires specialist multidisciplinary input to address the endocrine and nonendocrine features of these complex conditions, as well as the psychological challenges posed by their diagnosis. Next-generation sequencing within the research setting has revealed several genetic causes of POI and 46,XY DSD, which may further facilitate an individualized approach to care of these young people in the future. Pubertal induction is required in many and the timing of this may need to be balanced with other issues specific to the condition (eg, allowing time for information-sharing in 46,XY DSD, optimizing growth in TS). Shared decision-making and sign-posting to relevant support groups from the outset can help empower young people and their families to manage these conditions. We describe 3 clinical vignettes of girls presenting with delayed puberty and hypergonadotropic amenorrhea and discuss their clinical management in the context of current literature and guidelines.
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Affiliation(s)
- Sinéad M McGlacken-Byrne
- Institute for Women’s Health, University College London, London WC1E 6AU, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- Department of Paediatric Endocrinology, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - John C Achermann
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Gerard S Conway
- Institute for Women’s Health, University College London, London WC1E 6AU, UK
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17
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Suntharalingham JP, Ishida M, Del Valle I, Stalman SE, Solanky N, Wakeling E, Moore GE, Achermann JC, Buonocore F. Emerging phenotypes linked to variants in SAMD9 and MIRAGE syndrome. Front Endocrinol (Lausanne) 2022; 13:953707. [PMID: 36060959 PMCID: PMC9433874 DOI: 10.3389/fendo.2022.953707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background Heterozygous de novo variants in SAMD9 cause MIRAGE syndrome, a complex multisystem disorder involving Myelodysplasia, Infection, Restriction of growth, Adrenal hypoplasia, Genital phenotypes, and Enteropathy. The range of additional clinical associations is expanding and includes disrupted placental development, poor post-natal growth and endocrine features. Increasingly, milder phenotypic features such as hypospadias in small for gestational age (SGA) boys and normal adrenal function are reported. Some children present with isolated myelodysplastic syndrome (MDS/monosomy 7) without MIRAGE features. Objective We aimed to investigate: 1) the range of reported SAMD9 variants, clinical features, and possible genotype-phenotype correlations; 2) whether SAMD9 disruption affects placental function and leads to pregnancy loss/recurrent miscarriage (RM); 3) and if pathogenic variants are associated with isolated fetal growth restriction (FGR). Methods Published data were analyzed, particularly reviewing position/type of variant, pregnancy, growth data, and associated endocrine features. Genetic analysis of SAMD9 was performed in products of conception (POC, n=26), RM couples, (couples n=48; individuals n=96), children with FGR (n=44), SGA (n=20), and clinical Silver-Russell Syndrome (SRS, n=8), (total n=194). Results To date, SAMD9 variants are reported in 116 individuals [MDS/monosomy 7, 64 (55.2%); MIRAGE, 52 (44.8%)]. Children with MIRAGE features are increasingly reported without an adrenal phenotype (11/52, 21.2%). Infants without adrenal dysfunction were heavier at birth (median 1515 g versus 1020 g; P < 0.05) and born later (median 34.5 weeks versus 31.0; P < 0.05) compared to those with adrenal insufficiency. In MIRAGE patients, hypospadias is a common feature. Additional endocrinopathies include hypothyroidism, hypo- and hyper-glycemia, short stature and panhypopituitarism. Despite this increasing range of phenotypes, genetic analysis did not reveal any likely pathogenic variants/enrichment of specific variants in SAMD9 in the pregnancy loss/growth restriction cohorts studied. Conclusion MIRAGE syndrome is more phenotypically diverse than originally reported and includes growth restriction and multisystem features, but without adrenal insufficiency. Endocrinopathies might be overlooked or develop gradually, and may be underreported. As clinical features including FGR, severe infections, anemia and lung problems can be non-specific and are often seen in neonatal medicine, SAMD9-associated conditions may be underdiagnosed. Reaching a specific diagnosis of MIRAGE syndrome is critical for personalized management.
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Affiliation(s)
- Jenifer P. Suntharalingham
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Miho Ishida
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Ignacio Del Valle
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Susanne E. Stalman
- Department of Pediatrics, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Nita Solanky
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Emma Wakeling
- North East Thames Regional Genetic Service, Great Ormond Street Hospital, London, United Kingdom
| | - Gudrun E. Moore
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - John C. Achermann
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Federica Buonocore
- Genetics and Genomic Medicine Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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18
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Tong Y, Yue D, Xin Y, Zhang D. GNAS mutation is an unusual cause of primary adrenal insufficiency: a case report. BMC Pediatr 2022; 22:472. [PMID: 35927642 PMCID: PMC9351131 DOI: 10.1186/s12887-022-03517-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 07/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background Primary adrenal insufficiency in children has non-specific and extensive clinical features, so the diagnosis of its etiology is complex and challenging. Although congenital adrenal hyperplasia is the most common cause, more and more other genetic causes have been identified. GNAS mutation is easily overlooked as a rare cause of primary adrenal insufficiency. Here we firstly report a neonatal case of primary adrenal insufficiency caused by GNAS mutation. Case presentation A boy was diagnosed with congenital hypothyroidism 10 days post-partum and treated immediately. He also had persistent hyperkalaemia and hyponatraemia with elevated adrenocorticotropic hormone. At 70 days after birth, he was transferred to our hospital on suspicion of congenital adrenal hyperplasia. Physical examination found no other abnormalities except for growth retardation. Laboratory examination revealed increased aldosterone and normal cortisol, 17-hydroxyprogesterone, and androstenedione levels. Abnormally elevated parathyroid hormone was accompanied by normal blood calcium. Genetic assessment found a de novo, heterozygous c.432 + 1G > A variant in GNAS. Conclusions We report this case to highlight that GNAS mutation is an unusual cause of primary adrenal insufficiency. The combination of primary hypothyroidism and /or pseudohypoparathyroidism will provide diagnostic clues to this condition.
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Affiliation(s)
- Yajie Tong
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, P. R. China
| | - Dongmei Yue
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, P. R. China
| | - Ying Xin
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, P. R. China
| | - Dan Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, 110004, P. R. China.
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19
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Seven Menevse T, Kendir Demirkol Y, Gurpinar Tosun B, Bayramoglu E, Yildiz M, Acar S, Erisen Karaca S, Orbak Z, Onder A, Sobu E, Anık A, Atay Z, Bugrul F, Derya Bulus A, Demir K, Dogan D, Cihan Emeksiz H, Kirmizibekmez H, Ozcan Murat N, Yaman A, Turan S, Bereket A, Guran T. Steroid Hormone Profiles and Molecular Diagnostic Tools in Pediatric Patients With non-CAH Primary Adrenal Insufficiency. J Clin Endocrinol Metab 2022; 107:e1924-e1931. [PMID: 35028661 DOI: 10.1210/clinem/dgac016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT There is a significant challenge of attributing specific diagnoses to patients with primary adrenal insufficiency of unknown etiology other than congenital adrenal hyperplasia (non-CAH PAI). Specific diagnoses per se may guide personalized treatment or may illuminate pathophysiology. OBJECTIVE This work aimed to investigate the efficacy of steroid hormone profiles and high-throughput sequencing methods in establishing the etiology in non-CAH PAI of unknown origin. METHODS Pediatric patients with non-CAH PAI whose etiology could not be established by clinical and biochemical characteristics were enrolled. Genetic analysis was performed using targeted-gene panel sequencing (TPS) and whole-exome sequencing (WES). Plasma adrenal steroids were quantified by liquid chromatography-mass spectrometry and compared to that of controls. This study comprised 18 pediatric endocrinology clinics with 41 patients (17 girls, median age: 3 mo, range: 0-8 y) with non-CAH PAI of unknown etiology. RESULTS A genetic diagnosis was obtained in 29 (70.7%) patients by TPS. Further molecular diagnosis could not be achieved by WES. Compared to a healthy control group, patients showed lower steroid concentrations, most statistically significantly in cortisone, cortisol, and corticosterone (P < .0001, area under the receiver operating characteristic curve: .96, .88, and .87, respectively). Plasma cortisol of less than 4 ng/mL, cortisone of less than 11 ng/mL, and corticosterone of less than 0.11 ng/mL had a greater than 95% specificity to ensure the diagnosis of non-CAH PAI of unknown etiology. CONCLUSION Steroid hormone profiles are highly sensitive for the diagnosis of non-CAH PAI of unknown etiology, but they are unlikely to point to a specific molecular diagnosis. TPS is an optimal approach in the molecular diagnosis of these patients with high efficacy, whereas little additional benefit is expected from WES.
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Affiliation(s)
- Tuba Seven Menevse
- Department of Pediatric Endocrinology and Diabetes, Marmara University, School of Medicine, 34899, Ustkaynarca/Pendik Istanbul, Turkey
| | - Yasemin Kendir Demirkol
- Department of Pediatric Genetics, Umraniye Research and Training Hospital, University of Health Sciences, 34764 Istanbul, Turkey
| | - Busra Gurpinar Tosun
- Department of Pediatric Endocrinology and Diabetes, Marmara University, School of Medicine, 34899, Ustkaynarca/Pendik Istanbul, Turkey
| | - Elvan Bayramoglu
- Department of Pediatric Endocrinology, Haseki Training and Research Hospital, 34096 Istanbul, Turkey
| | - Melek Yildiz
- Department of Pediatric Endocrinology and Diabetes, Istanbul University, School of Medicine, 34093 Istanbul, Turkey
| | - Sezer Acar
- Department of Pediatric Endocrinology and Diabetes, Behcet Uz Education and Research Hospital, 35210 Izmir, Turkey
| | - Seda Erisen Karaca
- Department of Pediatric Pediatrics, Duzce University, School of Medicine, 81620 Bolu, Turkey
| | - Zerrin Orbak
- Department of Pediatric Endocrinology and Diabetes, Ataturk University, School of Medicine, 25030 Erzurum, Turkey
| | - Asan Onder
- Department of Pediatric Endocrinology and Diabetes, Medeniyet University, School of Medicine, 34722 Istanbul, Turkey
| | - Elif Sobu
- Department of Pediatric Endocrinology, Kartal Training and Research Hospital, 34865 Istanbul, Turkey
| | - Ahmet Anık
- Department of Pediatric Endocrinology, Aydin Adnan Menderes University, School of Medicine, 09010 Aydin, Turkey
| | - Zeynep Atay
- Department of Pediatric Endocrinology and Diabetes, Istanbul Medipol University, School of Medicine, 34810 Istanbul, Turkey
| | - Fuat Bugrul
- Department of Pediatric Endocrinology and Diabetes, Selcuk University, School of Medicine, 42250 Konya, Turkey
| | - Ayse Derya Bulus
- Department of Pediatric Endocrinology and Diabetes, Ankara Kecioren Research and Training Hospital, University of Health Sciences, 06000 Ankara, Turkey
| | - Korcan Demir
- Department of Pediatric Endocrinology and Diabetes, Dokuz Eylul University, School of Medicine, 35340 Izmir, Turkey
| | - Durmus Dogan
- Department of Pediatric Endocrinology and Diabetes, Onsekiz Mart University, School of Medicine, 17110 Canakkale, Turkey
| | - Hamdi Cihan Emeksiz
- Department of Pediatric Endocrinology and Diabetes, Medeniyet University, School of Medicine, 34722 Istanbul, Turkey
| | - Heves Kirmizibekmez
- Department of Pediatric Endocrinology and Diabetes, Umraniye Research and Training Hospital, University of Health Sciences, 34764 Istanbul, Turkey
| | - Nurhan Ozcan Murat
- Department of Pediatric Endocrinology and Diabetes, Derince Research and Training Hospital, 41900 Kocaeli, Turkey
| | - Akan Yaman
- Department of Pediatrics, Gungoren Hospital, 34164 Istanbul, Turkey
| | - Serap Turan
- Department of Pediatric Endocrinology and Diabetes, Marmara University, School of Medicine, 34899, Ustkaynarca/Pendik Istanbul, Turkey
| | - Abdullah Bereket
- Department of Pediatric Endocrinology and Diabetes, Marmara University, School of Medicine, 34899, Ustkaynarca/Pendik Istanbul, Turkey
| | - Tulay Guran
- Department of Pediatric Endocrinology and Diabetes, Marmara University, School of Medicine, 34899, Ustkaynarca/Pendik Istanbul, Turkey
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20
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An Update on Genetics of Adrenal Gland and Associated Disorders. ENDOCRINES 2022. [DOI: 10.3390/endocrines3020017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The intricacies of human adrenal development have been under scrutiny for decades. Each year marks the identification of new genes and new interactions between gene products that ultimately will act to produce the fully functioning adult gland. Due to the complexity of this process, genetic missteps may lead to a constellation of pathologies. Recent years have identified several novel genetic causes of adrenal dysgenesis and provided new insights into previously delineated processes. SF1, DAX1 (NR0B1), CDKN1C, SAMD9, GLI3, TPIT, MC2R, MRAP, NNT, TXNRD2, AAAS, and MCM4 are among the genes which have had significant contributions to our understanding of the development and function of both adrenals and gonads. Collection and elucidation of these genetic and clinical insights are valuable tools for clinicians who diagnose and manage cases of adrenal dysfunction.
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21
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Arriba M, Ezquieta B. Molecular Diagnosis of Steroid 21-Hydroxylase Deficiency: A Practical Approach. Front Endocrinol (Lausanne) 2022; 13:834549. [PMID: 35422767 PMCID: PMC9001848 DOI: 10.3389/fendo.2022.834549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/28/2022] [Indexed: 11/18/2022] Open
Abstract
Adrenal insufficiency in paediatric patients is mostly due to congenital adrenal hyperplasia (CAH), a severe monogenic disease caused by steroid 21-hydroxylase deficiency (21-OHD, encoded by the CYP21A2 gene) in 95% of cases. CYP21A2 genotyping requires careful analyses that guaranty gene-specific PCR, accurate definition of pseudogene-gene chimeras, gene duplications and allele dropout avoidance. A small panel of well-established disease-causing alterations enables a high diagnostic yield in confirming/discarding the disorder not only in symptomatic patients but also in those asymptomatic with borderline/positive results of 17-hydroxyprogesterone. Unfortunately, the complexity of this locus makes it today reluctant to high throughput techniques of massive sequencing. The strong relationship existing between the molecular alterations and the degree of enzymatic deficiency has allowed genetic studies to demonstrate its usefulness in predicting/classifying the clinical form of the disease. Other aspects of interest regarding molecular studies include its independence of physiological variations and analytical interferences, its usefulness in the diagnosis of simple virilizing forms in males and its inherent contribution to the genetic counseling, an aspect of great importance taking into account the high carrier frequency of CAH in the general population. Genetic testing of CYP21A2 constitutes an irreplaceable tool to detect severe alleles not just in family members of classical forms but also in mild late-onset forms of the disease and couples. It is also helpful in areas such as assisted reproduction and preimplantation diagnosis. Molecular diagnosis of 21-OHD under expert knowledge definitely contributes to a better management of the disease in every step of the clinical course.
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Affiliation(s)
- María Arriba
- Molecular Diagnostics Laboratory, Department of Laboratory Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
| | - Begoña Ezquieta
- Molecular Diagnostics Laboratory, Department of Laboratory Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IiSGM), Madrid, Spain
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22
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Ali N, Maharaj AV, Buonocore F, Achermann JC, Metherell LA. Can Digenic, Tri-Allelic Inheritance of Variants in STAR and CYP11A1 Give Rise to Primary Adrenal Insufficiency? A Case Report. Front Endocrinol (Lausanne) 2022; 13:860055. [PMID: 35418949 PMCID: PMC8995429 DOI: 10.3389/fendo.2022.860055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 02/21/2022] [Indexed: 11/28/2022] Open
Abstract
An eight-year old South Asian boy presenting with progressive hyperpigmentation was found to have primary adrenal insufficiency (PAI) in the form of isolated glucocorticoid deficiency. Follow up of this boy for nine years, until the age of 17 years showed normal pubertal onset and progression. Molecular evaluation, by targeted next generation sequencing of candidate genes linked to PAI revealed changes in two genes that are intricately linked in the early stages of steroid biosynthesis: compound heterozygous variants in STAR, c.465+1G>A and p.(E99K), plus a heterozygous rs6161 change in CYP11A1. No variants in other known causal genes were detected. The proband's mother was heterozygous for the c.465+1G>A STAR and rs6161 CYP11A1 variants, while the father was homozygous for the p.(E99K) alteration in STAR but wild-type for CYP11A1. Both parents had normal adrenal cortical function as revealed by short Synacthen tests. The STAR variant c.465+1G>A will lead to abnormal splicing of exon 4 in mRNA and the addition of the p.(E99K) variant, predicted damaging by SIFT and CADD, may be sufficient to cause PAI but this is by no means certain given that the unaffected father is homozygous for the latter change. The rs6161 CYP11A1 variant [c.940G>A, p.(E314K)] has recently been demonstrated to cause PAI in conjunction with a severe rare disruptive change on the other allele, however sequencing of the coding region of CYP11A1 revealed no further changes in this subject. We wondered whether the phenotype of isolated glucocorticoid deficiency had arisen in this child due to tri-allelic inheritance of a heterozygous CYP11A1 change along with the two STAR variants each of which contribute a partial loss-of-function burden that, when combined, is sufficient to cause PAI or if the loss-of-function c.465+1G>A combined with the presumed partial loss-of-function p.(E99K) in STAR could be causative.
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Affiliation(s)
- Naseer Ali
- Department of Endocrinology and Metabolism, Meitra Hospital, Calicut, India
| | - Avinaash Vickram Maharaj
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London, London, United Kingdom
| | - Federica Buonocore
- Genetics & Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - John C. Achermann
- Genetics & Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Louise A. Metherell
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary, University of London, London, United Kingdom
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23
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Nisticò D, Bossini B, Benvenuto S, Pellegrin MC, Tornese G. Pediatric Adrenal Insufficiency: Challenges and Solutions. Ther Clin Risk Manag 2022; 18:47-60. [PMID: 35046659 PMCID: PMC8761033 DOI: 10.2147/tcrm.s294065] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/28/2021] [Indexed: 01/19/2023] Open
Abstract
Adrenal insufficiency is an insidious diagnosis that can be initially misdiagnosed as other life-threatening endocrine conditions, as well as sepsis, metabolic disorders, or cardiovascular disease. In newborns, cortisol deficiency causes delayed bile acid synthesis and transport maturation, determining prolonged cholestatic jaundice. Subclinical adrenal insufficiency is a particular challenge for a pediatric endocrinologist, representing the preclinical stage of acute adrenal insufficiency. Although often included in the extensive work-up of an unwell child, a single cortisol value is usually difficult to interpret; therefore, in most cases, a dynamic test is required for diagnosis to assess the hypothalamic-pituitary-adrenal axis. Stimulation tests using corticotropin analogs are recommended as first-line for diagnosis. All patients with adrenal insufficiency need long-term glucocorticoid replacement therapy, and oral hydrocortisone is the first-choice replacement treatment in pediatric. However, children that experience low cortisol concentrations and symptoms of cortisol insufficiency can take advantage using a modified release hydrocortisone formulation. The acute adrenal crisis is a life-threatening condition in all ages, treatment is effective if administered promptly, and it must not be delayed for any reason.
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Affiliation(s)
| | | | | | | | - Gianluca Tornese
- Department of Pediatrics, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
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24
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Liu Z, Liu Y, Gao K, Chen X. The etiology and clinical features of non-CAH primary adrenal insufficiency in children. Front Pediatr 2022; 10:961268. [PMID: 36061374 PMCID: PMC9437356 DOI: 10.3389/fped.2022.961268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The most common cause of primary adrenal insufficiency (PAI) in children is congenital adrenal hyperplasia; however, other genetic causes occur. There is limited epidemiological and clinical information regarding non-CAH PAI. METHODS Data for patients diagnosed from January 2015 to December 2021 at a tertiary hospital in northern China were retrospectively analyzed. We excluded those with CAH, which is the most common pathogenic disease among PAI patients. Next-generation sequencing was used for genetic analysis. RESULTS This retrospective study included 16 children (14 males and 2 females) with PAI. A genetic diagnosis was obtained for 14/16 (87.5%) individuals. Pathogenic variants occurred in 6 genes, including ABCD1 (6/16, 37.5%), NR0B1 (4/16, 25.0%), NR5A1/steroidogenic factor-1 (2/16; 12.5%), AAAS (1/16, 6.25%), and NNT (1/16, 6.25%). No genetic cause of PAI diagnosis was found in 2 girls (2/16, 12.5%). CONCLUSIONS Causes of PAI in children are diverse and predominantly affect males. Most PAI in children is congenital, and ABCD1 gene defects account for the largest proportion of PAI cases. Whole-exome sequencing is a tool for diagnosis. However, diagnoses are unclear in some cases.
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Affiliation(s)
- Ziqin Liu
- Department of Endocrinology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Yi Liu
- Department of Endocrinology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Kang Gao
- Department of Endocrinology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Xiaobo Chen
- Department of Endocrinology, Children's Hospital Capital Institute of Pediatrics, Beijing, China
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25
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Almeida MQ. Genetic Diagnosis of Primary Adrenal Insufficiency in Children: A Paradigm Change. J Endocr Soc 2021; 5:bvab117. [PMID: 34278182 PMCID: PMC8279073 DOI: 10.1210/jendso/bvab117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Madson Q Almeida
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Unidade de Oncologia Endocrinologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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