Genetic Analysis Reveals Complete Androgen Insensitivity Syndrome in Female Children Surgically Treated for Inguinal Hernia

Background: Complete androgen insensitivity syndrome (CAIS) is a congenital condition caused by genetic defects in the androgen receptor (AR) gene located on the X chromosome, which lead to a phenotypical female individual with a 46, XY karyotype. Early diagnosis of CAIS is essential for proper clinical management, allows assessment of familial risk and contributes to healthcare decisions. However, diagnosis of CAIS can be overlooked in girls with inguinal hernia, resulting in inappropriate management. Methods: Five female patients from three unrelated families presented to our genetic clinic with primary amenorrhea. Each patient had been diagnosed with inguinal hernia in childhood and had undergone hernia repair without further investigation into what was contained in the hernial sac. We carried out physical examination, cytogenetic studies, hormonal evaluation, and molecular analysis to establish a comprehensive diagnosis. Family history and pedigree were collated to identify at-risk family members. Results: All patients presented with female external genitalia. Cytogenetic studies revealed a 46, XY karyotype and hormonal analysis suggested a diagnosis of CAIS. Sequencing of the AR gene in all patients and suspected family members revealed pathogenic variants in the AR gene and confirmed the molecular diagnosis of CAIS. Conclusions: We report the delayed diagnosis of CAIS in female Indonesian patients with a history of inguinal hernia in childhood. An early diagnosis of CAIS is essential for appropriate clinical management, as well as assessing familial risk. Increasing awareness among clinicians is paramount, and we encourage a CAIS diagnosis to be considered in any patient presenting with female appearance and inguinal hernia.

Virilization due to androgen hypersecretion in a patient with ovarian leydig cell tumor: diagnostic and psychosocial implications

Virilization due to hyperandrogenism in women causes male signs and symptoms such as swelling of the clitoris, deepening of the voice, facial hair and increase in body hair. Virilization is caused by less than 0.5% of all ovarian tumors. Here we report a case of virilizing Leydig cell tumor of the left ovary in a 36 year old woman. Misinterpretation of symptoms, conflicting medical information and advice from previous doctors had confused the patient. We performed a diagnostic evaluation including clinical, hormonal parameters, imaging, anatomical pathology examinations, and psychological assessment. Blood analysis showed a high testosterone level. The presence of an ovarian tumor was confirmed by laparoscopy. Since the patient refused ovariectomy, a biopsy of the left ovary was performed. Pathology showed a Leydig cell tumor without histological signs of malignancy. In spite of extensive explanation and psychological counseling, cultural barriers prevented appropriate treatment. An ovarian Leydig cell tumor should always be considered for a woman in the reproductive age with symptoms of virilization. The diagnosis is suspected on the basis of an ovarian mass on examination and further investigation and should be proven by biopsy.

Correlation between androstenedione and 17-hydroxyprogesterone levels in the saliva and plasma of patients with congenital adrenal hyperplasia

INTRODUCTION

Congenital adrenal hyperplasia (CAH) or adrenogenital syndrome is the most common cause of female ambiguous genitalia. Management of such patients involves medical treatment using glucocorticoids such as hydrocortisone, prednisone or dexamethasone. Monitoring is done by measurement of 17-hydroxyprogesterone (17-OHP) or androstenedione in serum, plasma or saliva. The aim of this study was to develop a system of monitoring steroid treatment in CAH patients using only saliva.

METHODS

We studied the saliva of 24 CAH patients who received glucocorticoid replacement therapy. The patients were asked to collect saliva upon awakening, and in the afternoon and evening. The levels of 17-OHP and androstenedione in the saliva as well as in serum were then measured by immunoassay.

RESULTS

There was a significant positive correlation between 17-OHP in serum and in saliva (R equals 0.929, p-value less than 0.01). A significant positive correlation between androstenedione level in saliva and serum was also found (R equals 0.611, p-value less than 0.01). This study also revealed a significant positive correlation between androstenedione and 17-OHP in serum (R equals 0.647, p-value less than 0.01) and saliva (R equals 0.799, p-value less than 0.01). All patients showed increased level of 17-OHP and androstenedione in the sample collected upon awakening.

CONCLUSION

Determination of salivary androstenedione and 17-OHP in CAH patients could be a useful alternative to the measurement of these hormones in serum.

Lack of correlation between phenotype and genotype in untreated 21-hydroxylase-deficient Indonesian patients

BACKGROUND

Mutations in CYP21A2 lead to deficiency of 21-hydroxylase and can have either severe or moderate effects on phenotype, which can be prevented by early treatment. We studied long-term effects of this deficiency on phenotype in patients who had not been treated for prolonged periods and correlated these phenotypes with the mutations found in our patients.

OBJECTIVE

To assess the correlation between genotype and phenotype in untreated patients with 21-hydroxylase deficiency.

DESIGN

Subjects with 21-hydroxylase deficiency were selected from a large population of Indonesian patients with disorders of sexual differentiation. CYP21A2 mutations in these patients were correlated with their phenotype in terms of genital development and steroid hormone levels.

PATIENTS

Fifteen 46,XX patients with ages between 1 and 33 years, of whom 12 had never been treated before.

MEASUREMENTS

Mutations in CYP21A2, genital phenotype and steroid hormone levels.

RESULTS

We found in all patients CYP21A2 mutations which affect enzyme activity, with a relatively high allele frequency of R356W (40%), I172N (20%) and IVS2 - 1A > G (13%). Clitoris length was directly correlated with levels of testosterone, but not with age. The phenotype was not always concordant with the genotype: different phenotypes (mild to severe virilization) were found in sibling pairs with the mutations IVS2 - 13A > G or I172N. The high frequency of homozygous mutants for R356W in patients aged from 1 to 11 years old is remarkable, as this mutation has been described only in salt-wasting patients. In our study, this mutation caused a urogenital sinus in three out of seven cases, whereas in the remaining cases the labia were at least partially fused. This mutation caused severe virilization with remarkably high serum levels of renin. We found one novel substitution in intron 2 (IVS2 - 37A > G), containing the branch site, which is likely to affect the CYP21-enzyme. Two additional intron 2 substitutions were discovered, which are supposed to affect the 21-hydroxylase (i.e. IVS2 + 33A > C and IVS2 + 67C > T).

CONCLUSION

We conclude that a correlation exists between the concentration of androgens and the extent of virilization. However, there was no clear correlation between genotype and phenotype, except for the mutation R356W.