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Ahmad J, Ahmad A, Hadid L. Restoration of reproductive capacity in a male patient with congenital adrenal hyperplasia and bilateral testicular adrenal rest tumors (TARTs) after six months of glucocorticoid intensification: A case report. Medicine (Baltimore) 2023; 102:e36061. [PMID: 38065885 PMCID: PMC10713158 DOI: 10.1097/md.0000000000036061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/20/2023] [Indexed: 12/18/2023] Open
Abstract
RATIONALE Congenital adrenal hyperplasia (CAH) is considered one of the most common inherited disorders. In about more than 95% of all CAH cases, the deficient enzyme is 21-hydroxylase. Infertility is an important complication of this disease, and although this topic has been studied more frequently in females, cases, and literature reviews of the causes of infertility in male patients are constantly increasing. PATIENT CONCERNS A 28 old male with congenital adrenal hyperplasia (we assume to be a nonclassical type) presented to our institution with infertility and suspected bilateral testicular masses after 4 years of stopping dexamethasone. DIAGNOSIS Testicular adrenal rest tumors. INTERVENTIONS Dexamethasone was reapplied in a supraphysiologic dose (1.5 mg before bedtime) with periodic monitoring of the patient. OUTCOMES Treatment with supraphysiologic dose of dexamethasone led to regression of these tumors and significant improvement in sperm count, resulting in being capable of having a child. LESSONS There are many suspected causes of reduced male fertility in male CAH patients and the presence of testicular adrenal rest tumors is the main cause of infertility in this population. These benign tumors are believed to arise from ectopic adrenal cells in the testes, that grow under adrenocorticotropic hormone stimulation in poorly controlled patients. Annual scrotal ultrasound is recommended in all males with CAH for detection and treatment of these tumors as early as possible before they cause permanent damage to the seminiferous tubules and irreversible infertility.
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Affiliation(s)
- Jihan Ahmad
- Department of Endocrinology, Al-Assad University Hospital, Damascus University, Damascus, Syria
| | - Adnan Ahmad
- Department of Urology, Al-Assad University Hospital, Damascus University, Damascus, Syria
| | - Lama Hadid
- Department of Endocrinology, Al-Assad University Hospital, Damascus University, Damascus, Syria
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Zhang Q, Zang L, Zhang CY, Gu WJ, Li B, Jia XF, Chen K, Pei Y, Du J, Guo QH, Ba JM, Lyu ZH, Dou JT, Mu YM. [Diagnosis and treatment of 21-hydroxylase deficiency with testicular adrenal rest tumors:a report of three cases and literature review]. Zhonghua Nei Ke Za Zhi 2022; 61:72-76. [PMID: 34979773 DOI: 10.3760/cma.j.cn112138-20210718-00488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Objective: To provide insight into the diagnosis for clinicians, the clinical characteristics, diagnosis and treatment history of 3 patients with 21-hydroxylase deficiency (21-OHD) and testicular adrenal rest tumors (TART) were analyzed. Methods: The clinical, laboratory and imaging data of 3 male patients with 21-OHD and TART, confirmed with CYP21 gene sequencing, from May 2010 to May 2021 in the First Medical Center of Chinese PLA General Hospital were analyzed retrospectively. The treatment strategy and clinical outcome were followed up. Results: All the 3 patients were first diagnosed with bilateral adrenal mass at the age of 27-42 years old. They were 145-162 cm tall. The levels of progesterone, 17-hydroxyprogesterone, and adrenocorticotropic hormone (ACTH) of the 3 patients were relatively high, and that of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) of the 3 patients were low. Testosterone level of 1 patient was significantly elevated, and that of the other 2 patients was below the lower limit of normal range. Testicular ultrasound showed heterogeneous hyperechoic masses in both testes. CT of the adrenal glands showed bilateral adrenal enlargement with mass. All 3 patients were treated with dexamethasone. After 4-96 months of follow-up, 17-hydroxyprogesterone level was kept above the median normal level. One of the patients got married and had a baby after treatment. The sizes of adrenal hyperplasia and testicular masses reduced to various degrees with the change of the testicular masses being proportional to that of adrenal hyperplasia. Conclusions: Patients with 21-OHD are prone to have TART, leading to the impaired testicular function. Early glucocorticold therapy is beneficial to the reduction of TART and restoration of testicular function.
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Affiliation(s)
- Q Zhang
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - L Zang
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - C Y Zhang
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - W J Gu
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - B Li
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - X F Jia
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - K Chen
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Y Pei
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - J Du
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Q H Guo
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - J M Ba
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Z H Lyu
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - J T Dou
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Y M Mu
- Department of Endocrinology, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
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Bachelot A, Lapoirie M, Dulon J, Leban M, Renard Penna R, Touraine P. Effects of mitotane on testicular adrenal rest tumors in congenital adrenal hyperplasia due to 21-hydroxylase deficiency: a retrospective series of five patients. Eur J Endocrinol 2021; 184:365-371. [PMID: 33444225 DOI: 10.1530/eje-20-0787] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 01/12/2021] [Indexed: 11/08/2022]
Abstract
We conducted a retrospective study on the long-term effect of mitotane treatment on testicular adrenal rest tumors (TARTs) in five adult patients with classic 21-hydroxylase deficiency. After 60 months of mitotane treatment, a decrease in adrenal steroids was observed in four patients. Testicular ultrasonography showed complete disappearance of TART in two patients, stabilization in two patients and a halving of TART volume in the remaining patient. Sperm count improved notably in two patients who had normal baseline inhibin B levels and small inclusions, thus enabling cryopreservation of the subjects' semen. Four years of follow-up of these two patients after the withdrawal of mitotane showed no recurrence of TART and persistent normal testicular function. In conclusion, mitotane could be used as a last resort in CAH patients in the cases of azoospermia associated with TARTs but normal inhibin B levels, as it can improve long-term endocrine and exocrine testicular function.
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Affiliation(s)
- Anne Bachelot
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Paris, France
- Sorbonne Université, Paris, France
| | - Marion Lapoirie
- Department of Endocrinology, Hospices Civils de Lyon, Fédération d'Endocrinologie, Bron, France
| | - Jérôme Dulon
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Paris, France
| | - Monique Leban
- AP-HP, Hôpital Pitié-Salpêtrière, Department of Hormonal Biochemistry
| | - Raphaële Renard Penna
- Sorbonne Université, Paris, France
- AP-HP, Hôpital Pitié-Salpêtrière, Department of Radiology, Paris, France
| | - Philippe Touraine
- AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Paris, France
- Sorbonne Université, Paris, France
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Karen Leong SW, Wu LL. Case series of testicular adrenal rest tumours in boys with congenital adrenal hyperplasia: A single centre experience. Med J Malaysia 2019; 74:92-93. [PMID: 30846672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Testicular adrenal rest tumours (TART) are aberrant adrenal tissue within the testes (1). Although benign, they can lead to obstruction of the seminiferous tubules and infertility in patients with congenital adrenal hyperplasia (CAH). We report six boys who developed TART, a complication of CAH. Diagnosis was confirmed by ultrasound and testicular vein sampling of elevated 17-hydroxyprogesterone (17-OHP) levels. Glucocorticoids dosages were increased 1½-2 folds to suppress size of the aberrant adrenal tissues. Despite reductions in 17-OHP, the lesions remained unchanged. Three patients had testis-sparing surgery to excise the TART and to preserve normal testicular tissues.
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Affiliation(s)
- S W Karen Leong
- University Kebangsaan Malaysia Medical Centre, Department of Paediatrics, Kuala Lumpur, Malaysia.
| | - L L Wu
- University Kebangsaan Malaysia Medical Centre, Department of Paediatrics, Kuala Lumpur, Malaysia
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Ozisik H, Yurekli BS, Simsir IY, Altun I, Soyaltin U, Guler E, Onay H, Sarsik B, Saygili F. Testicular Adrenal Rest Tumor (TART) in congenital adrenal hyperplasia. Eur J Med Genet 2017; 60:489-493. [PMID: 28676275 DOI: 10.1016/j.ejmg.2017.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia is one of the most common autosomal recessive genetic disorders. Testicular adrenal tumors are significant complications of congenital adrenal hyperplasia. We would like to present two patients of testicular adrenal rest tumors. Patient 1 24 year-old male, he was diagnosed with congenital adrenal hyperplasia at the age of 8 due to precocious puberty. He received hydro-cortisone treatment until the age of 18. Testicular mass had been detected and right radical orchiectomy had been applied 6 months ago and reported as testicular adrenal rest tumor. In scrotal ultrasound, a mixed type mass lesion (6 × 4x3 cm) covering a large part of left testis was observed. The imaging findings were consistent with adrenal rest tumor. The patient took adrenocorticotropic hormone supressive therapy with dexamethasone 0.75 mg once a day. Patient 2, 38 year-old male, he had been followed-up as adrenal insufficiency for 35 years. He underwent right orchiectomy operation due to the testicular mass in 2010 and the pathological examination revealed Leydig cell tumor. In scrotal ultrasound, small multifocal lesions were detected on the left testis and resection was done. It was reported as testicular adrenal rest tumor. He is being followed-up with glucocorticoid treatment according to androgen and adrenocorticotropic hormone levels. Early diagnosis of testicular adrenal rest tumor is significant in preventing irreversible testicular damage and infertility. In the differential diagnosis, we should keep in mind that testicular adrenal rest tumor can mimic other testicular tumors such as primary germ cell tumors.
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Affiliation(s)
- Hatice Ozisik
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey.
| | - Banu Sarer Yurekli
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Ilgin Yildirim Simsir
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Ilker Altun
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Utku Soyaltin
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Ezgi Guler
- Ege University, Faculty of Medicine, Department of Radiology, Turkey
| | - Huseyin Onay
- Ege University, Faculty of Medicine, Department of Medical Genetics, Turkey
| | - Banu Sarsik
- Ege University, Faculty of Medicine, Department of Pathology, Turkey
| | - Fusun Saygili
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
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Hershkovitz E, Arafat M, Loewenthal N, Haim A, Parvari R. Combined adrenal failure and testicular adrenal rest tumor in a patient with nicotinamide nucleotide transhydrogenase deficiency. J Pediatr Endocrinol Metab 2015; 28:1187-90. [PMID: 25879317 DOI: 10.1515/jpem-2015-0075] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 02/26/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The nicotinamide nucleotide transhydrogenase (NNT) enzyme is the main generator of nicotinamide adenine dinucleotide phosphate-oxidase in the mitochondrion. Mutations of the NNT gene have been recently implicated in familial glucocorticoid deficiency. We describe the long-term clinical course of a NNT-deficient 20-year-old patient with combined adrenal failure who had developed a testicular adrenal rest tumor and precocious puberty. METHODS The patient's medical records were reviewed. Whole-exome sequencing was performed on DNA obtained from the patient and family members. RESULTS The patient experienced Addisonian crisis at 10 months of age. Enlarged testicular volume and precocious puberty, accompanied by increased testosterone levels, were noted at 6 years. Testicular biopsy revealed a adrenal rest tumor, which regressed after intensification of glucocorticoid treatment. Genetic studies disclosed a c.1163A>C, p.Tyr388Ser substitution on the NNT gene. This mutation is predicted to be damaging to NNT function. CONCLUSION We demonstrated for the first time that the clinical spectrum of NNT deficiency may consist of mineralocorticoid deficiency and testicular involvement as well.
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Corica D, Santucci S, Pitrolo E, Romeo M, Wasniewska M, De Luca F. Testicular adrenal rest tumor in an adolescent with congenital adrenal hyperplasia, resolved by therapy doses adjustment. Minerva Pediatr 2014; 66:233-235. [PMID: 24826980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- D Corica
- Department of Pediatrics, University of Messina, Messina, Italy -
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Abstract
PURPOSE OF REVIEW Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is one of the most common autosomal recessive disorders. In the past, pregnancy was considered to be unlikely for women with CAH, particularly the classical forms. The purpose of this review is to provide current information regarding the pathophysiology of CAH, factors relevant for female and male fertility, and recommendations for management during pregnancy. RECENT FINDINGS Individuals with CAH, both female and male, have reduced fertility. For women, chronic anovulation, elevated progestin levels, and aberrant endometrial implantation have been identified as reasons for the subfertility. Testicular adrenal rest tumors, oligospermia, and hypogonadotropic hypogonadism are frequently associated with subfertility in men with all forms of CAH. SUMMARY Adequate suppression of progesterone appears to be an essential aspect of preconception management for women. Most importantly, treatment needs to be individualized. Awareness of these factors and appropriate therapeutic interventions can lead to successful outcome defined as a healthy live born infant.
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Affiliation(s)
- Selma Feldman Witchel
- Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania 15224, USA.
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Affiliation(s)
- Tinh-Hai Collet
- Service of Internal Medicine, Department of Internal Medicine, University Hospital, Bugnon 46, 1011 Lausanne, Switzerland
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Tiryaki T, Aycan Z, Hücümenoğlu S, Atayurt H. Testis sparing surgery for steroid unresponsive testicular tumors of the congenital adrenal hyperplasia. Pediatr Surg Int 2005; 21:853-5. [PMID: 16180005 DOI: 10.1007/s00383-005-1547-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2005] [Indexed: 11/29/2022]
Abstract
The association between testicular tumors/nodules and congenital adrenal hyperplasia (CAH) has been recognized for many years. Tumors are considered to be an aberrant adrenal tissue that has descended with the testes and has become hyperplastic due to ACTH stimulation. The recommended treatment consists of increasing the glucocorticoid dose to suppress ACTH secretions. If the testicular size is not reduced after suppression therapy or a side effect of glucocorticoid dose is noted, surgical intervention should be considered. We diagnosed steroid unresponsive testicular tumors of the CAH in two patients who were treated by testicular sparing tumor enucleation. We believe that testis sparing surgery is the procedure of choice for all patients with testicular adrenal rest tumor, since it maximizes future fertility potential.
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Affiliation(s)
- Tuğrul Tiryaki
- Pediatric Surgery Clinic, Social Security Institution Children's Hospital, Ankara, Turkey.
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Bercovici JP, Fiet J, Gibault L, Volant A, Abalain JH, Floch HH, Sonnet E, Fournier G. Testicular adrenal rest tumours in salt wasting congenital adrenal hyperplasia (in vivo and in vitro studies). J Steroid Biochem Mol Biol 2005; 93:67-72. [PMID: 15748834 DOI: 10.1016/j.jsbmb.2004.10.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2003] [Accepted: 10/28/2004] [Indexed: 11/30/2022]
Abstract
We describe the case of a 20-year-old patient with salt-wasting congenital adrenal hyperplasia (CAH) related to 21-hydroxylase deficiency. Bilateral craggy testicular tumours were found, requiring histological evaluation. Prior to the surgical procedure, the patient was treated with dexamethasone (he presented cortisol deficiency) and was stimulated with ACTH. High levels of 11beta-OH steroids measured in the gonadal vein, compared with peripheral blood samples suggested the presence of adrenal rests. Incubation of the tumours (which could not be differentiated histologically, from Leydig tissue), with radioactive steroid precursors was carried out. The results revealed the testicular tumours were of adrenal tissue origin, associated with 21-hydroxylase deficiency. The patient's non-compliance to glucocorticoid treatment was the main cause of his hypogonadotropic hypogonadism.
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Affiliation(s)
- Jean Pierre Bercovici
- Department of Endocrinology, Université de Bretagne Occidentale (UBO), 29200 Brest, France
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Affiliation(s)
- Ieuan Hughes
- Department of Paediatrics, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK.
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Cunnah D, Perry L, Dacie JA, Grant DB, Lowe DG, Savage MO, Besser GM. Bilateral testicular tumours in congenital adrenal hyperplasia: a continuing diagnostic and therapeutic dilemma. Clin Endocrinol (Oxf) 1989; 30:141-7. [PMID: 2612016 DOI: 10.1111/j.1365-2265.1989.tb03735.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Bilateral testicular tumours are a rare but well described complication of congenital adrenal hyperplasia (CAH). It can be extremely difficult to distinguish histologically between Leydig cell tumours and adrenocortical rest hyperplasia which may lead in some cases to unnecessary orchidectomy in young men. A 26-year-old male in whom CAH had been diagnosed neonatally, was referred for further investigation of a craggy mass in the left testis. Six months earlier, right orchidectomy had been performed after presentation with bilateral enlarged, hard testes and azoospermia. The tumour was interpreted to be a malignant interstitial cell tumour of the testis. Our investigations revealed that his CAH was inadequately controlled and that the hormonal secretion from the remaining left testicular mass was ACTH dependent. Percutaneous venous sampling revealed high concentrations of cortisol and other adrenocortical hormones coming from the gonadal vein. Dexamethasone suppressed these adrenal hormones and reduced the size and softened the consistency of the testicular mass. Total disappearance of the mass was achieved by using dexamethasone, given in a reverse circadian rhythm regimen. Spermatogenesis returned and the patient's wife became pregnant after 6 months; she gave birth to a normal male infant. To our knowledge, this is the first time in this clinical setting that fertility has been achieved. This case highlights the need for both a functional and histological assessment of such 'tumours' in CAH prior to orchidectomy.
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Affiliation(s)
- D Cunnah
- Department of Endocrinology, St Bartholomew's Hospital, London, UK
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Horký K, Küchel O, Gregorová I, Jiránková J, Matys Z. [Clinical experiences with aminoglutethimide (Elipten), a new inhibitor of steroid biosynthesis in the adrenal gland]. Schweiz Med Wochenschr 1968; 98:1843-51. [PMID: 4236505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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