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Concolino P. Challenging Molecular Diagnosis of Congenital Adrenal Hyperplasia (CAH) Due to 21-Hydroxylase Deficiency: Case Series and Novel Variants of CYP21A2 Gene. Curr Issues Mol Biol 2024; 46:4832-4844. [PMID: 38785559 PMCID: PMC11119849 DOI: 10.3390/cimb46050291] [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: 04/14/2024] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive genetic defects in cortisol synthesis and shows elevated ACTH concentrations, which in turn has downstream effects. The most common variant of CAH, 21-hydroxylase deficiency (21OHD), is the result of pathogenic variants in the CYP21A2 gene and is one of the most common monogenic disorders. However, the genetics of 21OHD is complex and challenging. The CYP21A2 gene is located in the RCCX copy number variation (CNV), a complex, multiallelic, and tandem CNV in the major histocompatibility complex (MHC) class III region on chromosome 6 (band 6p21.3). Here, CYP21A2 and its pseudogene CYP21A1P are located 30 kb apart and share a high nucleotide homology of approximately 98% and 96% in exons and introns, respectively. This high-sequence homology facilitates large structural rearrangements, copy number changes, and gene conversion through intergenic recombination. There is a good genotype-phenotype correlation in 21OHD, and genotyping can be performed to confirm the clinical diagnosis, predict long-term outcomes, and determine genetic counseling. Thus, genotyping in CAH is clinically relevant but the interpretations can be challenging for non-initiated clinicians. Here, there are some concrete examples of how molecular diagnosis can sometimes require the use of multiple molecular strategies.
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Affiliation(s)
- Paola Concolino
- Dipartimento di Scienze di Laboratorio ed Ematologiche, UOC Chimica, Biochimica e Biologia Molecolare Clinica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
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Concolino P, Perrucci A, Carrozza C, Urbani A. Genetic Characterization of a Cohort of Italian Patients with Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency. Mol Diagn Ther 2023; 27:621-630. [PMID: 37548905 DOI: 10.1007/s40291-023-00666-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Defects in the steroid 21-hydroxylase gene (CYP21A2) cause 21-hydroxylase deficiency (21OHD), the main cause of congenital adrenal hyperplasia (CAH). The disease shows a broad spectrum of clinical forms, ranging from severe or classical (salt wasting, SW, and simple virilizing, SV), to mild late onset or nonclassical (NC). 21OHD affects 1 in 15,000 in its severe classic form and 1 in 200-1000 in its mild NC form. There are many studies reporting the frequency of CYP21A2 pathogenic variants in different populations; however, few of them provide comprehensive information about Italian patients. Here, we present genetic results from a cohort of 245 unrelated Italian individuals with clinical diagnosis of CAH due to 21OHD. METHODS A specific polymerase chain reaction (PCR) protocol combined with Sanger sequencing was used for CYP21A2 analysis. The multiplex ligation-dependent probe amplification (MLPA) assay was employed for copy number variation (CNV) determination. RESULTS One hundred fourteen (46.5%) of the index cases had the NC form, 57 (23.3%) had the SV form, and 74 (30.2%) presented the SW form of the disease. The most prevalent variant found in NC patients was the p.Val282Leu (51.3%), while the most frequent variants in the classical form were p.Ile173Asn (8.6%) and c.293-13C>G (26.0%). In our study, the frequency of large rearrangements was 15.3%, with CAH-X alleles representing 40% of all DEL/CONV. In addition, 12 alleles carried rare variants, and 1 had a novel variant p.(Arg342Gln). We observed phenotype-genotype correlation in 94.7% of cases. A complete concordance was observed in Groups 0 (enzyme activity completely impaired) where all patients had the SW form as expected. In Group A (0-1% residual enzyme activity), 78.4% of patients had the anticipated SW form while 21.6% were diagnosed with the SV form. Within Group B (~ 2% residual enzyme activity), 93.4% of patients exhibited SV form and 6.5% SW disease. Finally, 92.6% and 7.4% of patients belonging to Group C (enzyme partially impaired to ~ 20-60% residual activity) exhibited NC and SV phenotypes, respectively. CONCLUSION This work, representing a comprehensive genetic study, expanded the CYP21A2 variants spectrum of Italian patients with 21OHD and could be helpful in prenatal diagnosis and genetic counseling.
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Affiliation(s)
- Paola Concolino
- Clinical Chemistry, Biochemistry and Molecular Biology Operations (UOC), Agostino Gemelli Foundation University Hospital IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Alessia Perrucci
- Clinical Chemistry, Biochemistry and Molecular Biology Operations (UOC), Agostino Gemelli Foundation University Hospital IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Cinzia Carrozza
- Clinical Chemistry, Biochemistry and Molecular Biology Operations (UOC), Agostino Gemelli Foundation University Hospital IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
- Department of Basic Biotechnological Sciences, Intensivological and Perioperative Clinics, Catholic University of Sacred Heart, Rome, Italy
| | - Andrea Urbani
- Clinical Chemistry, Biochemistry and Molecular Biology Operations (UOC), Agostino Gemelli Foundation University Hospital IRCCS, Largo A. Gemelli 8, 00168, Rome, Italy
- Department of Basic Biotechnological Sciences, Intensivological and Perioperative Clinics, Catholic University of Sacred Heart, Rome, Italy
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Dumic KK, Grubic Z, Kusec V, Braovac D, Gotovac K, Vinkovic M, Vucinic M, Dumic M. The prevalence and genotype of 21-hydroxylase deficiency in the Croatian Romani population. Front Endocrinol (Lausanne) 2023; 14:1170449. [PMID: 37324261 PMCID: PMC10266231 DOI: 10.3389/fendo.2023.1170449] [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: 02/20/2023] [Accepted: 04/20/2023] [Indexed: 06/17/2023] Open
Abstract
Objective Congenital adrenal hyperplasia (CAH) owing to 21-hydroxylase deficiency (21-OHD) is a rare autosomal recessive disorder caused by pathological variants in the CYP21A2 gene. After a high prevalence of classic 21-OHD CAH in the Romani population was reported in the Republic of North Macedonia, we decided to estimate the prevalence of 21-OHD in Croatia and, if high, assess the possible causes and estimate the frequency of particular CYP21A2 variants. Design Cross-sectional study. Methods Data from a Croatian 21-OHD genetic database was reviewed, and only Romani patients were included in the study. CYP21A2 genotyping was performed using allele-specific PCR, MLPA, and Sanger sequencing. Results According to a survey conducted in 2017, Croatia had 22,500 Romani people and six of them had a salt-wasting (SW) form of 21-OHD. All were homozygous for the c.IVS2-13A/C-G pathological variant in intron 2 and descended from consanguineous families belonging to different Romani tribes. The calculated prevalence of 21-OHD in Croatian Romani is 1:3,750, while in the Croatian general population, it is 1:18,000. Three of the six Romani patients originated from two neighboring villages in North-western Croatia (Slavonia County), as well as the seventh patient who is of mixed Romani/Croatian descent and heterozygous for the c.IVS2-13A/C-G pathological variant (not included in the prevalence calculation). Conclusion A high prevalence of SW 21-OHD in the Croatian Romani population caused by the homozygous cIVS2-13A/C-G pathological variant was found. In addition to isolation and consanguinity, other possible reasons could be the heterozygous advantage of the CYP21A2 gene pathological variant and the bottleneck effect as a result of the Romani Holocaust in World War II.
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Affiliation(s)
- Katja K. Dumic
- Department of Paediatric Endocrinology and Diabetes, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Zorana Grubic
- Tissue Typing Centre, Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Vesna Kusec
- Department of Laboratory Medicine, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Duje Braovac
- Department of Paediatric Endocrinology and Diabetes, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Kristina Gotovac
- Department for Functional Genomics, Center for Translational and Clinical Research, University of Zagreb School of Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Maja Vinkovic
- Department of Paediatric Endocrinology and Diabetes, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Maja Vucinic
- Department of Pediatrics, General Hospital Našice, Našice, Croatia
| | - Miroslav Dumic
- Department of Paediatric Endocrinology and Diabetes, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
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Tang P, Zhang J, Peng S, Wang Y, Li H, Wang Z, Zhang Y, Huang Y, Xu J, Zhang D, Liu Q, Wang L, Lan W, Jiang J. Genotype-phenotype correlation in patients with 21-hydroxylase deficiency. Front Endocrinol (Lausanne) 2023; 14:1095719. [PMID: 36992809 PMCID: PMC10042299 DOI: 10.3389/fendo.2023.1095719] [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: 11/11/2022] [Accepted: 01/26/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION 21-hydroxylase deficiency (21OHD) is the most common cause of congenital adrenal hyperplasia (CAH). However, patients with 21OHD manifest various phenotypes due to a wide-spectrum residual enzyme activity of different CYP21A2 mutations. METHODS A total of 15 individuals from three unrelated families were included in this study. Target Capture-Based Deep Sequencing and Restriction Fragment Length Polymorphism was conducted on peripheral blood DNA of the three probands to identify potential mutations/deletions in CYP21A2; Sanger sequencing was conducted with the DNA from the family members of the probands. RESULTS Dramatically different phenotypes were seen in the three probands of CAH with different compound heterozygous mutations in CYP21A2. Proband 1 manifested simple virilizing with mutations of 30-kb deletion/c.[188A>T;518T>A], the latter is a novel double mutants classified as SV associated mutation. Although both probands carry the same compound mutations [293-13C>G]:[518T>A], gonadal dysfunction and giant bilateral adrenal myelolipoma were diagnosed for proband 2 and proband 3, respectively. CONCLUSION Both gender and mutations contribute to the phenotypes, and patients with the same compound mutations and gender could present with different phenotypes. Genetic analysis could help the etiologic diagnosis, especially for atypical 21OHD patients.
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Affiliation(s)
- Peng Tang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Jun Zhang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Song Peng
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yapeng Wang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Haoyang Li
- Fifteen Squadron Five Brigade, School of Basic Medical Science, Army Medical University, Chongqing, China
| | - Ze Wang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yao Zhang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yiqiang Huang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Jing Xu
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Dianzheng Zhang
- Department of Bio-Medical Sciences, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States
| | - Qiuli Liu
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Luofu Wang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
| | - Weihua Lan
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
- *Correspondence: Jun Jiang, ; Weihua Lan,
| | - Jun Jiang
- Department of Urology, Daping Hospital, Army Medical University, Chongqing, China
- *Correspondence: Jun Jiang, ; Weihua Lan,
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Nordenström A, Lajic S, Falhammar H. Long-Term Outcomes of Congenital Adrenal Hyperplasia. Endocrinol Metab (Seoul) 2022; 37:587-598. [PMID: 35799332 PMCID: PMC9449109 DOI: 10.3803/enm.2022.1528] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/11/2022] Open
Abstract
A plethora of negative long-term outcomes have been associated with congenital adrenal hyperplasia (CAH). The causes are multiple and involve supra-physiological gluco- and mineralocorticoid replacement, excess adrenal androgens both intrauterine and postnatal, elevated steroid precursor and adrenocorticotropic hormone levels, living with a congenital condition as well as the proximity of the cytochrome P450 family 21 subfamily A member 2 (CYP21A2) gene to other genes. This review aims to discuss the different long-term outcomes of CAH.
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Affiliation(s)
- Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Corresponding author: Henrik Falhammar. Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden Tel: +46-851776411, Fax: +46-851773096, E-mail:
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