'Exaggerated adrenarche' in children presenting with premature adrenarche

OBJECTIVE

Previous reports of endocrinological profiles in children presenting with premature adrenarche have not shown consistent abnormalities. We therefore aimed to review the clinical and biochemical aspects of a large number of patients presenting with premature adrenarche without virilization and determine the relation between clinical and biochemical characteristics and the frequency of adrenal steroid disorders.

DESIGN AND PATIENTS

Eighty-eight patients presenting with adrenarche without virilization during 1985-1992 were retrospectively reviewed. There were 72 girls and 16 boys. All were normotensive and had either prepubertal breasts or testes < 4 ml. In patients with high adrenal androgen levels, adrenal tumours had been excluded by either adrenal ultrasound or CT scan.

MEASUREMENT

We recorded clinical manifestations, auxological data, bone age, biochemical results including basal 17OH-progesterone (b17OHP), dehydroepiandrosterone sulphate (DHEAS), androstenedione (delta 4A), testosterone, cortisol and stimulated 17OHP and cortisol. ACTH stimulation tests (using soluble Synacthen 250 micrograms intramuscularly and collecting blood at 0, 30 and 60 minutes) were performed when clinically indicated. 17OH-Pregnenolone (17OHPreg) was also measured during ACTH stimulation tests in 13 individuals to look for abnormalities of 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD).

RESULTS

The age of onset ranged from 3 to 9.5 years (mean 6.8 +/- 1.3). There were no significant differences by sex for height SDS, weight SDS or % ideal body weight, but bone age advancement was greater in males (P < 0.02). The most common presenting clinical manifestation was premature appearance of pubic hair in 93.8%, the other 6.2% presenting with body odour, acne and/or hirsutism. Twelve patients had b17OHP > 6 nmol/l of whom 5 were diagnosed as having congenital adrenal hyperplasia (CAH) resulting from 21-hydroxylase deficiency after ACTH stimulation tests. A further 33 patients who had b17OHP < 6 nmol/l had normal 17OHP and cortisol responses to ACTH stimulation. Patients, after excluding those with CAH, were divided on the basis of their DHEAS levels into prepubertal (< 1.5 mumol/l), pubertal (1.5-6 mumol/l) and above pubertal range (> 6 mumol/l). The 8 patients with DHEAS values above the pubertal range were described as having 'exaggerated adrenarche'. There were no significant clinical differences between these 3 groups, but significant differences were found for bone age advancement and the steroids, b17OHP, delta 4A and testosterone. There was a strong correlation between DHEAS and delta 4A (r = 0.623, P < 0.001). The 'exaggerated adrenarche' group had higher 17 OHPreg/17OHP ratios at 60 minutes after stimulation but these were not diagnostic for 3 beta-HSD deficiency.

CONCLUSION

The value of assessing basal steroids in children presenting with premature adrenarche is demonstrated in this series with 5.7% being diagnosed with 21-hydroxylase deficiency and 9.1% with 'exaggerated adrenarche'. No relation was found between adrenal steroids and clinical features except for the acceleration of bone age. The relation between 'exaggerated adrenarche' and future ovarian hyperandrogenism needs further evaluation.

Congenital adrenal hyperplasia family studies using the short ACTH test

Because of the increasing use of 17-hydroxyprogesterone (17OHP) levels with the short adrenocorticotrophic hormone (ACTH) test in the detection of 21-hydroxylase deficiency, the diagnostic efficiency of the test was evaluated in patient and family studies of congenital adrenal hyperplasia due to 21-hydroxylase deficiency and of congenital adrenal hyperplasia due to 11-hydroxylase (11OH) deficiency (the latter disorder now overlaps basally with the milder non-classical 21-hydroxylase deficiency [NC-CAH]). Stimulated 17-hydroxyprogesterone level (17OHP30), 17-hydroxyprogesterone increase (delta 17 OHP) and the ratio 17-hydroxyprogesterone increase to cortisol increase (delta 17OHP/delta cortisol) were the parameters from the short ACTH test derived for assessment. 17-OHP30 provided complete differentiation of NC-CAH from the controls and heterozygotes, but overlap between NC-CAH and 11-OH occurred. Complete differentiation of NC-CAH from 11-OH was achieved using delta 17OHP. The heterozygotes showed best differentiation from the controls using delta 17OHP/delta cortisol with a diagnostic accuracy of 70%, however marked overlap of heterozygotes and NC-CAH with 11-OH was found. The short ACTH test proved to be a valuable technique with the further detection of homozygotes (n = 3) and heterozygotes (n = 5) in the 13 families studied. However, when interpreting the short ACTH test a careful choice of parameters should be made. It should be kept in mind that mild NC-CAH patients can only be differentiated from 11OH patients by using delta 17OHP.

Determination of 17-oxosteroid glucuronides and sulphates in urine by liquid chromatography using 2,4-dinitrophenylhydrazine as a prelabelling reagent for spectrophotometric detection

A direct, convenient method using high-performance liquid chromatography with spectrophotometric detection has been developed for the determination of conjugated 17-oxosteroids in urine without hydrolysis. Conjugated 17-oxosteroids are extracted with a Sep-Pak C18 cartridge, prelabelled with 2,4-dinitrophenylhydrazine in trichloroacetic acid-benzene solution and then separated by high-performance liquid chromatography on a reversed-phase C18 column using a mobile phase of 70% methanol in a buffer consisting of 50 mM sodium acetate in 2% (v/v) acetic acid. The eluate is monitored by a spectrophotometer at 380 nm and a linear response was found for absorbance readings (peak heights) from amounts of various conjugated oxosteroids between 25 and 250 ng. The method provides a sensitive, reliable technique for the analysis of urinary 17-oxosteroid conjugates.

Celite multi-column chromatography for the simultaneous separation of progesterone, deoxycorticosterone and 17 alpha-hydroxyprogesterone from small plasma or tissue samples

A rapid, inexpensive and reliable chromatographic method has been developed for the simultaneous separation of progesterone, deoxycorticosterone and 17 alpha-hydroxyprogesterone on 15-cm Celite columns using n-heptane-benzene-methanol-water (100:35:80:20) as mobile phase. Six columns can be run in parallel within an hour with the assistance of nitrogen pressure. There is negligible column-to-column or batch-to-batch variation with consistent high recoveries. Columns are easily and quickly prepared and being inexpensive are disposable which is important when working with radioactivity. Using this method three important corticosteroids can be rapidly and reliably isolated from 20-30 small plasma or tissue samples per day.