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Pitsava G, Maria AG, Faucz FR. Disorders of the adrenal cortex: Genetic and molecular aspects. Front Endocrinol (Lausanne) 2022; 13:931389. [PMID: 36105398 PMCID: PMC9465606 DOI: 10.3389/fendo.2022.931389] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Adrenal cortex produces glucocorticoids, mineralocorticoids and adrenal androgens which are essential for life, supporting balance, immune response and sexual maturation. Adrenocortical tumors and hyperplasias are a heterogenous group of adrenal disorders and they can be either sporadic or familial. Adrenocortical cancer is a rare and aggressive malignancy, and it is associated with poor prognosis. With the advance of next-generation sequencing technologies and improvement of genomic data analysis over the past decade, various genetic defects, either from germline or somatic origin, have been unraveled, improving diagnosis and treatment of numerous genetic disorders, including adrenocortical diseases. This review gives an overview of disorders associated with the adrenal cortex, the genetic factors of these disorders and their molecular implications.
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Affiliation(s)
- Georgia Pitsava
- Division of Intramural Research, Division of Population Health Research, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda MD, United States
| | - Andrea G. Maria
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda MD, United States
| | - Fabio R. Faucz
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda MD, United States
- Molecular Genomics Core (MGC), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda MD, United States
- *Correspondence: Fabio R. Faucz,
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Guarnotta V, Niceta M, Bono M, Marchese S, Fabiano C, Indelicato S, Di Gaudio F, Garofalo P, Giordano C. Clinical and hormonal characteristics in heterozygote carriers of congenital adrenal hyperplasia. J Steroid Biochem Mol Biol 2020; 198:105554. [PMID: 31805392 DOI: 10.1016/j.jsbmb.2019.105554] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/24/2019] [Accepted: 11/24/2019] [Indexed: 10/25/2022]
Abstract
Non-classical congenital adrenal hyperplasia (NC-CAH) includes a group of genetic disorders due to a broad class of CYP21A2 variants identifying a disease-causing 'C' genotype. The heterozygous carriers of CYP21 mutations are at increased risk of developing clinically evident hyperandrogenism, even though clinical and laboratory characteristics are still underestimated. With the aim of obtaining a more accurate delineation of the phenotype of heterozygous carrier of CAH, we analyzed clinical, biochemical and molecular characteristics in a cohort of Sicilian subjects. Fifty-seven females with biallelic and monoallelic CYP21A2 variants classifying NC-CAH (24) and heterozygous carriers of CAH (33), respectively were selected. Forty-four females age-matched healthy controls were also enrolled and genotyped for CYP21A2. Clinical, hormonal and genetic data were collected. CYP21A2 monoallelic mutations, defining the heterozygous carriers state, were identified in subjects with clinical features including hirsutism, oligomenorrhoea, overweight and a PCO-like phenotype, particularly occurring in the age of adolescence. Consistently, levels of 17OHP and cortisol were found to be significantly different from NC-CAH. Overall, some clinical and laboratory findings including oligomenorrhea and 17OHP/cortisol ratio were observed as independent markers associated with carriers of CAH. Here we report a high prevalence of late-onset signs of polycystic ovary syndrome (PCOS) and hyperandrogenism in heterozygous carriers. The 17OHP/cortisol ratio may be a predictive tool to identify the carriers of CAH, even though specific cut-off values have not yet been identified.
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Affiliation(s)
- Valentina Guarnotta
- Dipartimento di Promozione Della Salute, Materno-Infantile, Medicina Interna e Specialistica Di Eccellenza "G. D'Alessandro" (PROMISE), Sezione Di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Italy
| | - Marcello Niceta
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Marianna Bono
- UOC Endocrinology, Ospedale Villa Sofia-Cervello, Palermo, Italy
| | - Serena Marchese
- UOC Pediatria d'Urgenza e Pronto Soccorso Pediatrico, ARNAS Ospedali Civico-Di Cristina, Benfratelli-ISMEP, Palermo, Italy
| | - Carmelo Fabiano
- UOS Laboratory of Molecular Genetics, AO Villa Sofia-Cervello, Palermo, Italy
| | - Serena Indelicato
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Università degli Studi di Palermo, Via del Vespro, Palermo, I-90127, Italy
| | - Francesca Di Gaudio
- Dipartimento di Scienze e Tecnologie Biologiche, Chimiche e Farmaceutiche, Università degli Studi di Palermo, Via Archirafi 32, Palermo, I-90123, Italy
| | | | - Carla Giordano
- Dipartimento di Promozione Della Salute, Materno-Infantile, Medicina Interna e Specialistica Di Eccellenza "G. D'Alessandro" (PROMISE), Sezione Di Malattie Endocrine, del Ricambio e della Nutrizione, Università di Palermo, Italy.
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Jayakrishnan R, Lao Q, Adams SD, Ward WW, Merke DP. Revisiting the association of HLA alleles and haplotypes with CYP21A2 mutations in a large cohort of patients with congenital adrenal hyperplasia. Gene 2019; 687:30-34. [PMID: 30419250 DOI: 10.1016/j.gene.2018.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/03/2018] [Accepted: 11/08/2018] [Indexed: 11/20/2022]
Abstract
The CYP21A2 gene encoding 21‑hydroxylase is on chromosome 6p21.3 within the human leukocyte antigen (HLA) class III major histocompatibility complex and an association between congenital adrenal hyperplasia (CAH) due to 21‑hydroxylase deficiency and HLA class I and II alleles has been shown in genetically isolated populations. One-third of CAH causing alleles are 30-kb deletions due to homologous recombination events between active and pseudogenes resulting in chimeric genes. The aim of this study was to re-visit the association between the CYP21A2 variants and HLA polymorphisms in a large ethnically diverse cohort of patients with CAH who underwent comprehensive CYP21A2 genotyping, including specification of chimeric gene subtypes (CAH CH-1 through CH-9 of CYP21A1P/CYP21A2 chimeras; CAH-X CH-1 through CH-3 of TNXA/TNXB chimeras) in alleles with 30-kb deletions. The study population included 201 patients (86 males, 115 females, age 3-75 years) with CAH due to 21‑hydroxylase deficiency (159 classic, 42 nonclassic) and 194 parents. Based on the availability of parental genotype, we determined the haplotypes of CYP21A2 mutations and HLA types in 95 probands (190 alleles). Five prevalent haplotype associations were found: p.V281L and B*14-C*08 (P < 0.0001); p.I172N and DQB1*03 (P = 0.035); and of the chimeric genes caused by 30-kb deletions: CH-1 and A*03 (P = 0.033); CH-5 and C*06-DRB1*07 (P < 0.0001); and CAH-X CH-1 and DQB1*03 (P = 0.004). Our findings show that a number of associations between HLA alleles and haplotypes and CYP21A2 mutations, including large 30-kb deletions, exist commonly across ethnicities. These HLA associations may have clinical implications for patients with CAH and may provide insight into the genetics of this highly complex region of the human genome.
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Affiliation(s)
| | - Qizong Lao
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Sharon D Adams
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - William W Ward
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA; Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
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Papadakis G, Kandaraki EA, Tseniklidi E, Papalou O, Diamanti-Kandarakis E. Polycystic Ovary Syndrome and NC-CAH: Distinct Characteristics and Common Findings. A Systematic Review. Front Endocrinol (Lausanne) 2019; 10:388. [PMID: 31275245 PMCID: PMC6593353 DOI: 10.3389/fendo.2019.00388] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 05/30/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Twenty-one-hydroxylase-deficient non-classic adrenal hyperplasia (NC-CAH) is a very common autosomal recessive syndrome with prevalence between 1:1,000 and 1:2,000 individuals and the frequency varies according to ethnicity. On the other hand, polycystic ovary syndrome has a familial basis and it is inherited under a complex hereditary trait. This syndrome affects 6 to 10% of women in reproductive age and it is the most common endocrine disorder in young women. Our aim was to investigate, through a systematic review, the distinct characteristics and common findings of these syndromes. Methods: The search period covered January 1970 to November 2018, using the scientific databases PubMed. Inclusion criteria were adult women patients with PCOS or NC-CAH. Search terms were "polycystic ovary syndrome," "PCOS," "non-classical adrenal hyperplasia," "NC-CAH," "21-hydroxylase deficiency." From an initial 16,255 titles, the evaluations led to the final inclusion of 97 papers. Results: The clinical features of NC-CAH are hirsutism and ovulatory and menstrual dysfunction therefore; differentiation between these two syndromes is difficult based on clinical grounds only. Additionally, NC-CAH and PCOS are both associated with obesity, insulin resistance, and dyslipidaemia. Reproductive abnormalities are also common between these hyperandrogenemic disorders since in patients with NC-CAH polycystic ovarian morphology and subfertility are present as they are in women with PCOS. The diagnosis of PCOS, is confirmed once other disorders that mimic PCOS have been excluded e.g., conditions that are related to oligoovulation or anovulation and/or hyperandrogenism, such as hyperprolactinaemia, thyroid disorders, non-classic congenital adrenal hyperplasia, and androgen-producing neoplasms. Conclusions: The screening tool to distinguish non-classic adrenal hyperplasia from PCOS is the measurement of 17-hydroxyprogesterone levels. The basal levels of 17-hydroxyprogesterone may overlap, but ACTH stimulation testing can distinguish the two entities. In this review these two common endocrine disorders are discussed in an effort to unveil their commonalities and to illuminate their shadowed distinctive characteristics.
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Affiliation(s)
| | - Eleni A. Kandaraki
- Department of Endocrinology and Diabetes, HYGEIA Hospital, Athens, Greece
| | - Ermioni Tseniklidi
- Department of Endocrinology and Diabetes, HYGEIA Hospital, Athens, Greece
| | - Olga Papalou
- Department of Endocrinology and Diabetes, HYGEIA Hospital, Athens, Greece
| | - Evanthia Diamanti-Kandarakis
- Department of Endocrinology and Diabetes, HYGEIA Hospital, Athens, Greece
- *Correspondence: Evanthia Diamanti-Kandarakis
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Carmina E, Dewailly D, Escobar-Morreale HF, Kelestimur F, Moran C, Oberfield S, Witchel SF, Azziz R. Non-classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency revisited: an update with a special focus on adolescent and adult women. Hum Reprod Update 2017; 23:580-599. [DOI: 10.1093/humupd/dmx014] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 05/12/2017] [Indexed: 01/29/2023] Open
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Grubic Z, Maskalan M, Stingl Jankovic K, Zvecic S, Dumic Kubat K, Krnic N, Zunec R, Ille J, Kusec V, Dumic M. Association of HLA alleles and haplotypes with CYP21A2 gene p. V282L mutation in the Croatian population. HLA 2016; 88:239-244. [PMID: 27709802 DOI: 10.1111/tan.12907] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/07/2016] [Accepted: 09/15/2016] [Indexed: 11/28/2022]
Abstract
The CYP21A2 mutations that are in linkage disequilibrium with particular HLA-A, -B, -DRB1 alleles/haplotypes, cause deficiency of the 21-hydroxylase enzyme (21-OHD) and account for the majority of congenital adrenal hyperplasia (CAH) cases. The aim of this study was to investigate those associations with the p.V282L mutation linked to the non-classical (NC) form of CAH among Croatians. The study included parents of patients with the NC form of CAH, positive for the p.V282L mutation (N = 55) and cadaveric donor samples (N = 231). All subjects were HLA-A, -B, and -DRB1 typed and tested for the presence of the p.V282L mutation. Among parents of patients, 92.73% of subjects were positive for the B*14:02 allele and almost half of them carried the HLA-A*33:01-B*14:02-DRB1*01:02 haplotype. Among cadaveric samples 77 out of 96 subjects positive for the B*14:02 allele had the p.V282L mutation. Among them, 37 were positive for the HLA-A*33:01-B*14:02-DRB1*01:02 haplotype, 23 had the HLA-A*33:01-B*14:02-DRB1*03:01 haplotype, 8 had the B*14:02-DRB1*01:02 combination and 5 were carrying the HLA-A*68:02-B*14:02-DRB1*13:03 haplotype. Only 4 of these subjects were positive for the B*14:02 allele. HLA-B*14:02 was the only single allele with association that reached statistically significant P value (RR = 12.00; P = 0.0024). Haplotypes B*14:02-DRB1*01:02 (P < 0.001) and HLA-A*68:02-B*14:02-DRB1*13:03 (P < 0.001) as well as HLA-A*33:01-B*14:02-DRB1*01:02 and HLA-A*33:01-B*14:02-DRB1*03:01 showed high relative risks (RR = 45.00, RR = 41.63 and RR = 36.96, respectively). Our data support the previously documented association of the HLA-A*33:01-B*14:02-DRB1*01:02 haplotype with the p.V282L mutation, but also point out a high frequency of the p.V282L mutation among Croatians with HLA-A*33:01-B*14:02-DRB1*03:01 and HLA-A*68:02-B*14:02-DRB1*13:03 haplotypes.
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Affiliation(s)
- Z Grubic
- Tissue Typing Centre, Department of Transfusion Medicine and Transplantation Biology, Clinical Hospital Centre Zagreb, Zagreb, Croatia.
| | - M Maskalan
- Tissue Typing Centre, Department of Transfusion Medicine and Transplantation Biology, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - K Stingl Jankovic
- Tissue Typing Centre, Department of Transfusion Medicine and Transplantation Biology, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - S Zvecic
- Tissue Typing Centre, Department of Transfusion Medicine and Transplantation Biology, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - K Dumic Kubat
- Department of Pediatrics, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - N Krnic
- Department of Pediatrics, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - R Zunec
- Tissue Typing Centre, Department of Transfusion Medicine and Transplantation Biology, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - J Ille
- Department of Pediatrics, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - V Kusec
- Department of Laboratory Diagnosis, Clinical Hospital Centre Zagreb, Zagreb, Croatia
| | - M Dumic
- Department of Pediatrics, School of Medicine, Zagreb, Croatia
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Ambroziak U, Kępczyńska-Nyk A, Kuryłowicz A, Małunowicz EM, Wójcicka A, Miśkiewicz P, Macech M. The diagnosis of nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency, based on serum basal or post-ACTH stimulation 17-hydroxyprogesterone, can lead to false-positive diagnosis. Clin Endocrinol (Oxf) 2016; 84:23-9. [PMID: 26331608 DOI: 10.1111/cen.12935] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 07/20/2015] [Accepted: 08/24/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE As nonclassic congenital adrenal hyperplasia (NCCAH) needs to be taken into account in women with hyperandrogenism, we aimed to assess whether the recommended level of poststimulated 17OHP ≥30 nmol/l confirms NCCAH. PATIENTS AND METHODS Forty, consecutive women with biochemical and/or clinical hyperandrogenism (aged 25·4, 18-38) suspected of having NCCAH were recruited to the study. In patients with 17OHP level between 5·1 and 29·9 nmol/l an ACTH stimulation test was performed. In patients with basal or poststimulated 17OHP ≥30 nmol/l, twenty-four-hour urinary steroid profile (USP) analysis was performed and CYP21A2 mutation was assessed. In selected patients with poststimulated 17OHP <30 nmol/l USP was also performed. RESULTS The group was divided into two subgroups with basal or poststimulated 17OHP ≥30 nmol/l (group A) and with poststimulated 17OHP <30 nmol/l (group B). Among 40 patients, basal or poststimulated 17OHP ≥30 nmol/l was found in 21, but NCCAH was confirmed by USP followed by genetic testing only in 5 (24%). Four patients were diagnosed as heterozygotes, and in twelve, no CYP21A2 mutation was detected. CONCLUSION The diagnosis of NCCAH based only on serum 17OHP measurements (basal or poststimulated) may lead to false-positive diagnosis when performed by immunoassay with a cut-off value of ≥30 nmol/l. The definitive diagnosis can be established based on USP and/or genetic testing.
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Affiliation(s)
- Urszula Ambroziak
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Kępczyńska-Nyk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Alina Kuryłowicz
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
- Department of Human Epigenetics, Mossakowski Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland
| | - Ewa Maria Małunowicz
- Department of Biochemistry, Radioimmunology and Experimental Medicine, Children's Memorial Health Institute, Warsaw, Poland
| | - Anna Wójcicka
- Genomic Medicine, Medical University of Warsaw, Warsaw, Poland
- Laboratory of Human Cancer Genetics, Centre of New Technologies, CENT, University of Warsaw, Warsaw, Poland
| | - Piotr Miśkiewicz
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Macech
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
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Binay C, Simsek E, Cilingir O, Yuksel Z, Kutlay O, Artan S. Prevalence of nonclassic congenital adrenal hyperplasia in Turkish children presenting with premature pubarche, hirsutism, or oligomenorrhoea. Int J Endocrinol 2014; 2014:768506. [PMID: 24778650 PMCID: PMC3981121 DOI: 10.1155/2014/768506] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 11/25/2022] Open
Abstract
Background. Nonclassic congenital adrenal hyperplasia (NCAH), caused by mutations in the gene encoding 21-hydroxylase, is a common autosomal recessive disorder. In the present work, our aim was to determine the prevalence of NCAH presenting as premature pubarche (PP), hirsutism, or polycystic ovarian syndrome (PCOS) and to evaluate the molecular spectrum of CYP21A2 mutations in NCAH patients. Methods. A total of 126 patients (122 females, 4 males) with PP, hirsutism, or PCOS were included in the present study. All patients underwent an ACTH stimulation test. NCAH was considered to be present when the stimulated 17-hydroxyprogesterone plasma level was >10 ng/mL. Results. Seventy-one of the 126 patients (56%) presented with PP, 29 (23%) with PCOS, and 26 (21%) with hirsutism. Six patients (4,7%) were diagnosed with NCAH based on mutational analysis. Four different mutations (Q318X, P30L, V281L, and P453S) were found in six NCAH patients. One patient with NCAH was a compound heterozygote for this mutation, and five were heterozygous. Conclusion. NCAH should be considered as a differential diagnosis in patients presenting with PP, hirsutism, and PCOS, especially in countries in which consanguineous marriages are prevalent.
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Affiliation(s)
- Cigdem Binay
- Division of Paediatric Endocrinology, Department of Paediatrics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
- *Cigdem Binay:
| | - Enver Simsek
- Division of Paediatric Endocrinology, Department of Paediatrics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
| | - Oguz Cilingir
- Department of Medical Genetics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
| | - Zafer Yuksel
- Department of Medical Genetics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
| | - Ozden Kutlay
- Department of Medical Genetics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
| | - Sevilhan Artan
- Department of Medical Genetics, Osmangazi University, School of Medicine, 26480 Eskisehir, Turkey
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Erdogan G, Pabuccu R, Ertek S, Israel S, Yilmaz B, Yilmaz H, Caglar G. Late-onset congenital adrenal hyperplasia with Cushing syndrome. Intern Med 2014; 53:1955-9. [PMID: 25175129 DOI: 10.2169/internalmedicine.53.0654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Although hirsutism is classically part of the clinical presentation of polycystic ovarian syndrome (PCOS), congenital adrenal hyperplasia and Cushing's syndrome (CS), CS associated with underlying late-onset congenital adrenal hyperplasia (LCAH) in an adult has not been previously reported. We herein present the case of a 25-year-old woman who was followed for PCOS for seven years. After undergoing detailed tests described within the text, she received the diagnosis of LCAH and was found to have point mutations. Interestingly, she later had diagnosis of endogenous CS that regressed folowing excision of an adrenal adenoma found on MRI. The present patient thus exhibited the coexistence of two paradoxical endocrine pathologies.
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Affiliation(s)
- Gurbuz Erdogan
- Department of Endocrinology and Metabolic Diseases, Ufuk University Medical Faculty, Turkey
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Abstract
Congenital adrenal hyperplasia consists of a heterogenous group of inherited disorders
due to enzymatic defects in the biosynthetic pathway of cortisol and/or aldosterone. This
results in glucocorticoid deficiency, mineralocorticoid deficiency, and androgen excess.
95% of CAH cases are due to 21-hydroxylase deficiency. Clinical forms range from the
severe, classical CAH associated with complete loss of enzyme function, to milder,
non-classical forms (NCAH). Androgen excess affects the pilosebaceous unit, causing
cutaneous manifestations such as acne, androgenetic alopecia and hirsutism. Clinical
differential diagnosis between NCAH and polycystic ovary syndrome may be difficult. In
this review, the evaluation of patients with suspected CAH, the clinical presentation of
CAH forms, with emphasis on the cutaneous manifestations of the disease, and available
treatment options, will be discussed.
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Affiliation(s)
- Cleo Dessinioti
- Department of Dermatology; Andreas Sygros Hospital; University of Athens; Athens, Greece
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Witchel SF, Azziz R. Nonclassic congenital adrenal hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:625105. [PMID: 20671993 PMCID: PMC2910408 DOI: 10.1155/2010/625105] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 04/05/2010] [Indexed: 11/26/2022]
Abstract
Nonclassic congenital adrenal hyperplasia (NCAH) due to P450c21 (21-hydroxylase deficiency) is a common autosomal recessive disorder. This disorder is due to mutations in the CYP21A2 gene which is located at chromosome 6p21. The clinical features predominantly reflect androgen excess rather than adrenal insufficiency leading to an ascertainment bias favoring diagnosis in females. Treatment goals include normal linear growth velocity and "on-time" puberty in affected children. For adolescent and adult women, treatment goals include regularization of menses, prevention of progression of hirsutism, and fertility. This paper will review key aspects regarding pathophysiology, diagnosis, and treatment of NCAH.
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Affiliation(s)
- Selma Feldman Witchel
- Division of Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Ricardo Azziz
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Department of Obstetrics and Gynecology, and Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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Unluhizarci K, Kula M, Dundar M, Tanriverdi F, Israel S, Colak R, Dokmetas HS, Atmaca H, Bahceci M, Balci MK, Comlekci A, Bilen H, Akarsu E, Erem C, Kelestimur F. The prevalence of non-classic adrenal hyperplasia among Turkish women with hyperandrogenism. Gynecol Endocrinol 2010; 26:139-43. [PMID: 19718570 DOI: 10.3109/09513590903215466] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The prevalence of non-classic adrenal hyperplasia (NCAH) among Turkish women with hirsutism has not been established so far. Thus, we aimed to evaluate the prevalence of 21-hydroxylase (21-OH) deficiency by ACTH stimulation test among hirsute women. The study population consisted of 285 premenopousal women, aged 16-46 years (mean: 23.2 ± 0.3). All were hirsute and hyperandrogenic. Androgen secreting tumors of the ovaries and the adrenal glands were excluded as well as thyroid dysfunction and hyperprolactinemia. All the patients were evaluated by 0.25 mg (i.v.) ACTH stimulation test and 17-OHP responses were obtained at 30 and 60 min. The diagnosis of NCAH due to 21-OH deficiency was considered in patients with the poststimulation 17-OHP level exceed 10 ng/ml. Six (2.1%) of the patients had NCAH due to 21-OH deficiency confirmed by genotyping. The rest of the patients were polycystic ovary syndrome (n = 166, 58.2%) and idiopathic hyperandrogenemia (n = 113, 39.7%). There were no patients with idiopathic hirsutism because patients with normal serum androgen levels were excluded. This first and most extensive national study investigating NCAH prevalence among Turkish population showed that NCAH is not prevalent in this population.
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Affiliation(s)
- Kursad Unluhizarci
- Department of Endocrinology, Erciyes University Medical School, Kayseri, Turkey
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Witchel S, Azziz R. NonClassic Congenital Adrenal Hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010. [DOI: 10.1186/1687-9856-2010-625105] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Weghofer A, Brill H, Feichtinger R, Barad D, Gleicher N. Does autoimmunity play a role in the pathophysiology of premature ovarian ageing? Reprod Biomed Online 2008; 16:830-4. [PMID: 18549693 DOI: 10.1016/s1472-6483(10)60149-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To determine a possible causative association between autoimmunity and premature ovarian ageing (POA), 394 women undergoing IVF at an academically affiliated private IVF centre were retrospectively evaluated for the presence of autoimmune-related diseases. Out of 162 POA women, 13 (8.0%) demonstrated a history of autoimmune disease(s), while autoimmunity was present in 28 (12.1%) of 232 controls. POA women with poor response (four oocytes or fewer) despite high-dose treatment presented autoimmunity in 7.9%, compared with 12.1% control subjects without autoimmune diseases. When family history was considered (patient and/or first-degree relatives), at least one autoimmune disease was reported in 14 (8.6%) POA and 31 (13.4%) controls with comparable distributions of autoimmune diseases among both groups. Infertile women with premature ovarian ageing and age-appropriate ovarian function show high but comparable prevalences of autoimmune-related diseases. These findings support the assumption that aetiologies other than autoimmune disease lead to POA.
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Affiliation(s)
- Andrea Weghofer
- Department of Obstetrics and Gynecology, Medical University Vienna, Austria.
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Trakakis E, Rizos D, Loghis C, Chryssikopoulos A, Spyropoulou M, Salamalekis E, Simeonides G, Vagopoulos V, Salamalekis G, Kassanos D. The prevalence of non-classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency in Greek women with hirsutism and polycystic ovary syndrome. Endocr J 2008; 55:33-9. [PMID: 18187875 DOI: 10.1507/endocrj.k07-053] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
UNLABELLED The study was aimed to find out the prevalence of non-classical congenital adrenal hyperplasia (NC-CAH) due to 21-hydroxylase deficiency (21-OHdef) among Greek women with hirsutism and polycystic ovary syndrome (PCOS) and to compare the results of ACTH stimulated 17-hydroxyprogesterone 60 min (17-OHP60) values, with human leukocyte antigens (HLA) phenotypes, in any patient diagnosed as having NC-CAH. One hundred and seven women with hirsutism and PCOS were included in the study. All were presented at the Reproductive Endocrinology Outpatient Clinic with hirsutism and PCOS. After ACTH stimulation test, 10 women were diagnosed as having NC-CAH because of high 17-OHP60 values >or=36 nmol/l, and 97 as having PCOS. Ten (10.3%) of the 97 women presented hormonal findings compatible with adrenal hyper-response due to ACTH testing, because of hyperstimulated 17-OHP60 values >or=21 nmol/l and <32 nmol/l. The HLA typing of 10 patients with NC-CAH revealed the phenotypes B14, DR1, B35, B7 and B44 which present positively genetic linkage disequilibrium with 21-OHdef, as reported in the literature. IN CONCLUSION In Greek women with hirsutism and PCOS we have found that: a. The prevalence of NC-CAH among these women is relatively high and reaches at 10%. b. The HLA phenotypes B(14), DR(1), B(35), B(7) and B44 were found in high frequency in these NC-CAH patients. c. Adrenal NC-CAH due to 21-OHdef as well as adrenal hyperactivity, revealed after ACTH testing, constitutes an important reason of hirsutism and PCOS in these Greek women and both reach a rate of 20%.
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Affiliation(s)
- Eftihios Trakakis
- Second Department of Obstetrics and Gynecology, University of Athens, Aretaieion University Hospital, Greece
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Kaibe M, Takakuwa K, Murakawa H, Ishii K, Tamura M, Tanaka K. Studies on the human leukocyte antigens in patients with polycystic ovary syndrome in a Japanese population--possible susceptibility of HLA-A11 and -DRB1*0403 to patient population with polycystic ovary syndrome. ACTA ACUST UNITED AC 2006; 55:301-6. [PMID: 16533342 DOI: 10.1111/j.1600-0897.2006.00369.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PROBLEM The objective of this study was to identify the human leukocyte antigen (HLA) alleles that confer susceptibility or resistance to polycystic ovary syndrome (PCOS) in the Japanese population. METHOD OF STUDY HLA-A, -B and -C antigens were determined in 56 patients with PCOS using conventional serological method. HLA-DRB1 genotypes were determined using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method in 68 patients with PCOS. As a control population, 237 healthy individuals (males and females) were examined concerning HLA-A, -B and -C antigens, and 292 individuals were examined concerning HLA-DRB1 genotypes. The rate of possession of each antigen was compared between the two populations. RESULTS The rate of possession of the HLA-A11 and HLA-DRB1*0403 in the patients with PCOS was significantly higher compared with that in the control group. The rate of possession of HLA-B39 in the patients with PCOS was significantly lower compared with that in the general population group. CONCLUSION Human leukocyte antigen systems appear to be linked to PCOS.
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Affiliation(s)
- Mamiko Kaibe
- Department of Obstetrics and Gynecology, Niigata University School of Medicine, Niigata, Japan
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Claahsen-van der Grinten HL, Stikkelbroeck NMML, Sweep CGJ, Hermus ARMM, Otten BJ. Fertility in patients with congenital adrenal hyperplasia. J Pediatr Endocrinol Metab 2006; 19:677-85. [PMID: 16789634 DOI: 10.1515/jpem.2006.19.5.677] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is generally regarded as a paediatric endocrine disease, but nowadays nearly all patients reach adulthood as a result of improved diagnosis and treatment. It is now increasingly recognised that treatment goals shift during life: one of the major treatment goals in childhood and puberty, i.e. normal growth and development, is no longer relevant after childhood, whereas other aspects, such as fertility and side effects of long-term glucocorticoid treatment, become more important in adulthood. This paper focuses on fertility in male and female adult patients with CAH. In males with CAH the fertility rate is reduced compared with the normal population, the most frequent cause being testicular adrenal rest tumours. Development and growth of these tumours is assumed to be ACTH dependent and undertreatment may play an important role. If intensifying glucocorticoid treatment does not lead to tumour decrease, surgical intervention may be considered, but the effect on fertility is not yet known. In females with CAH the degree of fertility depends on the phenotype of the CAH. Most fertility problems are seen in the classic salt-wasting type. Age of menarche and regularity of the menstrual cycle depends on the degree of adrenal suppression. Not only adrenal androgens have to be normalised but also the levels of adrenal progestins (progesterone and 17-OH-progesterone) that interfere with normal ovulatory cycles. The regularity of menstrual cycles can be considered as an important measure of therapeutic control in adolescent females with CAH and therefore as a therapeutic goal from (peri)pubertal years on. Other factors that contribute to impaired fertility in females with CAH are ovarian hyperandrogenism (polycystic ovary syndrome), ovarian adrenal rest tumours, genital surgery and psychological factors. Subfertility in CAH can have its origin already in the peripubertal years and is therefore of interest to the paediatric endocrinologist.
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