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Tampubolon KAG, Sibarani J. Unusual morphology of isolated male epispadia: A rare case report. Urol Case Rep 2024; 54:102707. [PMID: 38559702 PMCID: PMC10978465 DOI: 10.1016/j.eucr.2024.102707] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
In less than 10% of cases, males may have isolated epispadias, which is caused by failure in the urethral tubularization process, leading to dorsal urethral defect. This case report presents a unique instance where epispadias was associated with ambiguous genitalia. A 5-year-old boy diagnosed with epispadias. The penis resembled external female genitalia, with scrotal skin covering it. He underwent a two-stage operation without complications. The aim of the surgical techniques is to correct these anomalies and restore urinary continence and sexual function. Long-term outcomes of the surgery can vary, which highlights the need for further research.
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Affiliation(s)
| | - Jupiter Sibarani
- Department of Urology, Hasan Sadikin Academic Medical Center, Universitas Padjadjaran, Indonesia
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2
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Li O, Gabrielson A, Wang MH. When to address form and when to address function: Timing of surgical reconstruction for a patient with 46 XY DSD. Urol Case Rep 2023; 51:102572. [PMID: 37818409 PMCID: PMC10561031 DOI: 10.1016/j.eucr.2023.102572] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 10/12/2023] Open
Abstract
Differences of sexual development (DSD) refers to congenital conditions characterized by discordant appearances of external genitalia with respect to sex chromosomes. We present a case of a 46 XY DSD adolescent with bilateral undescended testes and severe scrotolabial anomalies who was lost to follow-up for several years who recently presented with "recurrent UTIs." Although the patient desired immediate reconstruction to void while standing, shared-decision making was used to first address his bilateral cryptorchidism, with plans to delay other reconstruction until the patient is older. Pediatric patients with DSD have complicated medical and surgical problems and require a collaborative multidisciplinary team.
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Affiliation(s)
- Oscar Li
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew Gabrielson
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ming-Hsien Wang
- James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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3
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Levy B, Teplitsky S, Kalaitzoglou E, Kahler S, Matheny JP, Saltzman AF. "Exogenous" 5 Alpha Reductase Deficiency: A Case Report. Urology 2023; 178:147-150. [PMID: 37178876 DOI: 10.1016/j.urology.2023.05.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023]
Abstract
Testosterone and dihydrotestosterone are significant drivers of male external genital development, and therefore teratogens that alter these hormone profiles have been hypothesized to cause aberrations in development. Here, we present the first case report of genitalia anomalies after prenatal exposure to spironolactone and dutasteride through 8-weeks of gestation. The patient was born with abnormal male external genitalia which was surgically managed. Long-term outcomes such as gender identity, sexual function, hormonal maturation through puberty, and fertility remain unknown. These numerous considerations necessitate multi-disciplinary management with close follow-up to address sexual, psychological, and anatomic concerns.
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Affiliation(s)
- Brittany Levy
- Department of Surgery, University of Kentucky, Lexington, KY
| | - Seth Teplitsky
- Department of Urology & Pediatrics, Division of Pediatric Urology, University of Kentucky, Lexington, KY
| | - Evangelia Kalaitzoglou
- Department of Pediatrics, Division of Endocrinology and Barnstable Brown Diabetes Center, University of Kentucky, Lexington, KY
| | - Stephen Kahler
- Department of Pediatrics, Division of Genetics, University of Kentucky, Lexington, KY
| | - Juliann Paige Matheny
- Department of Pediatrics, Division of Genetics, University of Kentucky, Lexington, KY
| | - Amanda F Saltzman
- Department of Urology & Pediatrics, Division of Pediatric Urology, University of Kentucky, Lexington, KY.
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Dineva S, Gaydarski L, Landzhov B. Disorder of sexual development, urinary bladder duplication, pancake kidney and neural tube defect. Radiol Case Rep 2023; 18:2354-2358. [PMID: 37179802 PMCID: PMC10172636 DOI: 10.1016/j.radcr.2023.03.049] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 05/15/2023] Open
Abstract
Congenital malformations of the urogenital system with fully developed duplications, such as urinary bladder, are sporadic. They are often present in the setting of endogenous molecular disbalance, such as steroid metabolism disturbances. Other rare manifestations of hormonal disbalance present as intersex conditions in which the individual has karyotype-specific internal genital organs with opposite-sex signs of the external genitalia, known as ambiguous genitalia. Congenital variations and malformations are often fully recognized and understood during radiological exams. Herein we present a unique case of a 2-month-old baby with female chromosomal sex and ambiguous genitalia together with the manifestation of several anatomical malformations: urinary bladder duplication in the coronal plane, pancake kidney with supernumerary renal arteries, 2 ureters and neural tube defect. Despite their low incidence rate, knowledge of such malformations is paramount for correct diagnosis and treatment in such cases.
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Affiliation(s)
- Svetla Dineva
- Radiology Department, National Cardiology Hospital, “Konyovitsa” 65 Str, Sofia, 1309, Bulgaria
- Corresponding author.
| | - Lyubomir Gaydarski
- Department of Anatomy, Histology and Embryology, Medical University of Sofia, Sofia, Bulgaria
| | - Boycho Landzhov
- Department of Anatomy, Histology and Embryology, Medical University of Sofia, Sofia, Bulgaria
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López Soto Á, Bueno González M, Urbano Reyes M, Carlos Moya Jiménez L, Beltrán Sánchez A, Garví Morcillo J, Velasco Martínez M, Luis Meseguer González J, Martínez Rivero I, García Izquierdo O. Imaging in fetal genital anomalies. Eur J Obstet Gynecol Reprod Biol 2023; 283:13-24. [PMID: 36750003 DOI: 10.1016/j.ejogrb.2023.01.035] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/15/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
Genital anomalies are a heterogeneous group of congenital pathologies that have become increasingly relevant since the Chicago Consensus of 2005. Their postnatal diagnosis has developed significantly in the last two decades, while prenatal diagnosis seems to be underdeveloped, with few protocols available, fragmented scientific literature, and low diagnostic rates. This review aims to examine the current status of this subspecialty from the perspective of prenatal imaging. Indications for the evaluation of fetal genitalia can be divided into medical and non-medical reasons. Medical reasons include sex-linked disorders, detection of other anomalies, relevant family history, or multiple pregnancy. Non-medical reasons include parental request for sex disclosure. Disclosure of fetal sex may be associated with ethical, legal, and medical issues. The main imaging technology used is 2D ultrasound, although there are other complementary techniques such as 3D, MRI, or Color Doppler. Regarding working methodology, several authors have drawn attention to the lack of standardized protocols and guidelines. Most guidelines tend to limit their recommendations to study indications and ethical issues. Technical proposals, measurements, or working methods have not yet been standardized. Fetal sex determination is usually divided into early and late gestation. Early gestation is based on the sagittal sign. Late gestation is based on direct visualization. There are several measurements to describe male and female genitalia, such as penile length, bilabial diameter, or scrotal diameter. Prenatal diagnosis of genital pathologies presents some particularities such as the wide spectrum of phenotypes, the high frequency of associated deformities, or the time of diagnosis. Some of the most frequent pathologies are ambiguous genitalia, fetal sex discordance, hypospadias, micropenis, clitoromegaly, ovarian cysts, hydro(metro)colpos, and cloacal anomalies. Higher-quality studies and direction from scientific societies through the implementation of clinical guidelines are needed.
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Affiliation(s)
- Álvaro López Soto
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain.
| | | | - Maribel Urbano Reyes
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
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Vicentin JP, de Souza El Beck M, Germano CW, Andrade JGR, Barros BA, de Paive E Silva RB, Miranda ML, Viguetti-Campos NL, Vieira TAP, Mazzola TN, Guaragna MS, Fabbri-Scallet H, Mello MP, Marques-de-Faria AP, Maciel-Guerra AT, Guerra-Junior G. Trends in Time Regarding Sex Assignment of Patients with Disorders of Sex Development: Experience of an Interdisciplinary Service. Sex Dev 2023; 16:236-241. [PMID: 35172315 DOI: 10.1159/000520704] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 11/04/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The aim of this retrospective study was to verify the association between the time of diagnosis and initial and final sex assignment in a disorder of sex development (DSD) diagnostic group, looking at the age of the patients at first visit, severity of genital ambiguity, and karyotype. METHODS The time of diagnosis was divided into 3 groups: before 2000, between 2000 and 2006, and after 2006. Data were categorized and analyzed using the χ2 test with α < 0.05. RESULTS A total of 567 cases were analyzed; 307 were assigned as male, 135 as female, and 125 remained undefined at the first visit. After clinical and laboratory evaluations, 369 patients were male and 198 were female. Neither initial nor final sex assignment proportions changed over time, but there were significant differences in the age at first visit, with referral occurring at an earlier age, as well as more severe genital ambiguity presentations, a higher proportion of sex chromosome aberrations, and a lower frequency of 46,XX DSD cases. This occurred both in the sample as a whole (567 cases) and in the group of 125 patients without definitive sex assignment at the first visit. The results were similar when only 284 patients aged less than 12 months at the first visit were analyzed. DISCUSSION/CONCLUSION Over time, there were no changes in sex assignment proportions, but there was an increased awareness of the need for early referral and changes in clinical, cytogenetic, and diagnostic aspects.
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Affiliation(s)
- Julia P Vicentin
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Mayra de Souza El Beck
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Carlos W Germano
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Juliana G R Andrade
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Beatriz A Barros
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Roberto B de Paive E Silva
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Marcio L Miranda
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Nilma L Viguetti-Campos
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Tarsis A P Vieira
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Tais N Mazzola
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Mara S Guaragna
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Helena Fabbri-Scallet
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Maricilda P Mello
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Antonia P Marques-de-Faria
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Andrea T Maciel-Guerra
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Gil Guerra-Junior
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), School of Medical Sciences and Clinical Hospital, State University of Campinas (UNICAMP), Campinas, Brazil
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Hanna CA, Cummins A, Fox D. Babies born with ambiguous genitalia: Developing an educational resource for Australian midwives. Women Birth 2023; 36:e142-e149. [PMID: 35697608 DOI: 10.1016/j.wombi.2022.05.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/02/2022] [Accepted: 05/30/2022] [Indexed: 01/25/2023]
Abstract
PROBLEM AND BACKGROUND The birth of a baby with ambiguous genitalia is rare and usually unexpected. Parents often receive inconsistent language from health-professionals after the birth. Initial interaction with the birth team has long-term consequences for families with babies born with ambiguous genitalia. AIM Understand the current practices on the day of birth and explore knowledge gaps for midwives regarding babies born with ambiguous genitalia. Develop educational content that can enable midwives to respond appropriately when the sex of a baby is unclear. METHODS This study included two phases, utilising qualitative descriptive research design with semi-structured interviews to understand the experiences of midwives caring for babies with ambiguous genitalia and their families. The findings informed the development a midwifery educational resource using these qualitative findings. FINDINGS Our analysis of 14 interviews with Australian midwives identified that they had no formal education to support families with a baby with ambiguous genitalia. Emotional support, advocacy and medical information translation were areas midwives perceived as essential skills to support these families. DISCUSSION Midwives provide a unique role in parental birth experiences. Themes that arose emphasised their psychosocial support role but lacked formal education and guidance on this topic. Midwives had learnt from the media about babies born with ambiguous genitalia and wanted evidence-based education to support parents. Midwife education focusing on both psychosocial and clinical care for parents and their baby with ambiguous genitalia is crucial. CONCLUSION Midwives can play a pivotal role in supporting parents with a baby with ambiguous genitalia. Themes from this qualitative study informed the development of a midwifery education digital resource.
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Affiliation(s)
- Chloe A Hanna
- Department of Gynaecology, Royal Children's Hospital, Melbourne, Australia; Reproductive Development Laboratory, Murdoch Children's Research Institute Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia.
| | - Allison Cummins
- Department of Midwifery, School of Nursing and Midwifery, College of Medicine, Health and Wellbeing, University of Newcastle, Australia
| | - Deborah Fox
- Centre for Midwifery, Child and Family Health, University of Technology Sydney, Australia
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8
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Witchel SF, Mazur T, Houk CP, Lee PA. The Long Path to Our Current Understanding Regarding Care of Children with Differences/Disorders of Sexual Development. Horm Res Paediatr 2022; 95:608-618. [PMID: 36446331 DOI: 10.1159/000527042] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 12/02/2022] Open
Abstract
Testes were associated with maleness from antiquity, and ancient societies had fanciful myths about the origins of the sexes and about fetal sexual development. 17th century anatomists developed the concept that mammals developed from eggs and discovered sperm in semen; in 1878, Hertwig observed sperm entering eggs (of sea urchins), establishing the cellular basis of sex development. Individuals with atypical genitalia were known clinically in the 17th century, with much debate about their origins, but by the late 19th century it was generally accepted that gonads determined sex, and that sex determined gender role. Testosterone was isolated in 1935, and Alfred Jost showed that both circulating testosterone and diffusible anti-Mullerian hormone were needed for male development. Patients with apparent androgen insensitivity were reported in 1937 and shown to be unresponsive to exogenous androgen by Lawson Wilkins in 1957; androgen receptor mutations were reported in 1989. Steroidogenic errors were associated with differences in sex development (DSDs) starting in the 1940s, and finding mutations in the responsible enzymes explained many forms of hyper- and hypo-androgenism in both sexes. Sex chromosomes were identified in the early 20th century; Y was associated with maleness, and the responsible SRY gene was identified in 1991. Early efforts to manage patients with DSDs were confounded by philosophical perspectives on the relative roles of prenatal biology versus postnatal environment. Approaches to natal sex assignment evolved in the later 20th century and now emphasize a team approach based on data, not guessing, parental involvement, cultural considerations, and the acknowledgement of uncertainty.
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Affiliation(s)
- Selma F Witchel
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tom Mazur
- The Center for Psychosexual Health, Jacobs School of Medicine and Biomedical Sciences, State of New York at Buffalo, Buffalo, New York, USA
| | | | - Peter A Lee
- Pennsylvania State University, Hershey, Pennsylvania, USA
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Profeta G, Micangeli G, Tarani F, Paparella R, Ferraguti G, Spaziani M, Isidori AM, Menghi M, Ceccanti M, Fiore M, Tarani L. Sexual Developmental Disorders in Pediatrics. Clin Ter 2022; 173:475-488. [PMID: 36155734 DOI: 10.7417/ct.2022.2466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Disorders of sex development (DSD) are a heterogeneous group of pathologies that result in an alteration in sex determination or differentiation. DSD are estimated to affect 1: 4,500 newborns and according to the 2006 Chicago Consensus classification, DSD can be divided into three categories: those with a 46 XX karyotype, those with a 46 XY karyotype and those relating to sex chromosomes. It is crucial to correctly identify the pathology already in the first days of life to direct the patient and his family to the best path of care. For this reason, the role of the pediatrician is fundamental in the correct identification of the clinical picture and in supporting the family during the long process that involves the management of these patients. To make a diagnosis, it is necessary to follow a path led by a multidisciplinary team that includes several steps such as the execution of the genetic analysis, the evaluation with diagnostic imaging methods and laboratory evaluations. The therapeutic management, on the other hand, is still very complex even if in recent years we have moved from an attitude of early gender reassignment to an approach of watchful waiting to let the patient choose when she/he is mature enough to do so, which gender she/he feels to belong. It should not be forgotten that throughout this process the pediatrician must be both supportive and clinically active in the management of the child and his family.
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Affiliation(s)
- G Profeta
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - G Micangeli
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - F Tarani
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - R Paparella
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - G Ferraguti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - M Spaziani
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - M Menghi
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - M Ceccanti
- SITAC, Società Italiana per il Trattamento dell'Alcolismo e le sue Complicanze, Rome, Italy
| | - M Fiore
- Institute of Biochemistry and Cell Biology, IBBC-CNR, Rome, Italy
| | - L Tarani
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
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Kumar S, Ghorai RP, Navriya S, Usha P, Ranjan SK. Persistent Urogenital Sinus with Ambiguous Genitalia and Urethral Duplication in a Pubertal Female. J Indian Assoc Pediatr Surg 2022; 27:610-612. [PMID: 36530829 PMCID: PMC9757777 DOI: 10.4103/jiaps.jiaps_150_21] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/21/2022] [Accepted: 03/06/2022] [Indexed: 06/17/2023] Open
Abstract
Urogenital sinus (UGS) and cloacal malformations are the spectra of disease affecting mainly females, resulting in an unusual confluence of the genital and urinary tract with or without the involvement of the gastrointestinal tract. Successful reconstruction of these anomalies depends on the accurate preoperative delineation of abnormal anatomy with the help of cross-sectional and other contrast studies like genitourogram along with cystourethroscopy wherever indicated. We hereby report a case of a 14-year-old female who presented with irregular cyclical hematuria and was diagnosed with persistent UGS with urethral duplication. After a thorough evaluation, the patient was successfully managed with surgical reconstruction, described in this study. Persistent UGS is a complex developmental anomaly. Complete characterization of anomaly requires a thorough evaluation such as hormonal assessment, endoscopy, cross-sectional, and radiological contrast study. Surgical reconstruction needs individualization and may need clitoroplasty, labioplasty, and urethral and vaginal mobilization. Morphological and functional outcome is satisfactory in a well-planned surgical reconstruction.
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Affiliation(s)
- Sunil Kumar
- Department of Urology, AIIMS, Rishikesh, Uttarakhand, India
| | | | | | - Preeti Usha
- Department of Community and Family Medicine, AIIMS, Rishikesh, Uttarakhand, India
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de Omena Filho RL, Petroli RJ, Soardi FC, de Paula Michelatto D, Mazzola TN, Fabbri-Scallet H, de Mello MP, Zanotti SV, Gubert IC, Monlleo I. So, and if it is not congenital adrenal hyperplasia? Addressing an undiagnosed case of genital ambiguity. Ital J Pediatr 2022; 48:89. [PMID: 35689291 PMCID: PMC9188102 DOI: 10.1186/s13052-022-01284-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background The Congenital Adrenal Hyperplasia due to 21 hydroxylase deficiency is the most common cause of genital ambiguity in persons with XX sexual chromosomes. Genital ambiguity among persons with XY sexual chromosomes comprises diverse and rare etiologies. The deficiency of 17-beta-hydroxysteroid dehydrogenase type 3 enzyme (HSD17B3) is a rare autosomal recessive disorder due to functionally altered variants of the HSD17B3 gene. In this disorder/difference of sex development, the conversion of androstenedione into testosterone is impaired. The appearance of external genitalia of 46,XY individuals varies from typically male to almost female. Case presentation We report on a child presenting severe ambiguous genitalia. Due to access constraints, specialized care did not start until the child was 10 months old. Parents are consanguineous and were born in an area of high isonymy that is a cluster for rare recessive diseases. A new homozygous missense variant c.785G > T was found in exon 10 of the HSD17B3 gene. Conclusions Researchers-clinicians and researchers-researchers collaborative efforts to elucidate the genetic basis of this disease were critical since this etiologic investigation is not available through the public health system. This case exemplifies the families’ pilgrimage in cases of genital ambiguity due to a rare genetic condition. Recognizing the etiology was the baseline to provide information on prognosis and treatment options, and to shelter family and child doubts and hopes in order to better support their decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s13052-022-01284-9.
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Affiliation(s)
- Reinaldo Luna de Omena Filho
- Maternal, Child and Adolescent Health Center, State University of Health Sciences of Alagoas, Postgraduate Program in Health Sciences of the Institute of Biological and Health Sciences of the Federal University of Alagoas, Maceió, Brazil
| | - Reginaldo José Petroli
- Medical Genetics Sector, Faculty of Medicine, Federal University of Alagoas, Maceió, Brazil
| | - Fernanda Caroline Soardi
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering, State University of Campinas, Campinas, Brazil
| | | | - Taís Nitsch Mazzola
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering, State University of Campinas, Campinas, Brazil
| | - Helena Fabbri-Scallet
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering, State University of Campinas, Campinas, Brazil
| | - Maricilda Palandi de Mello
- Laboratory of Human Molecular Genetics, Center of Molecular Biology and Genetic Engineering, State University of Campinas, Campinas, Brazil
| | | | | | - Isabella Monlleo
- Clinical Genetics Service, Medical Genetics Sector, Faculty of Medicine, University Hospital, Federal University of Alagoas, Avenida Lourival Melo Mota, S/N, Tabuleiro 23 do Martins, 57072-970, Maceió, Alagoas, Brasil.
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12
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Hryhorczuk AL, Phelps AS, Yu RN, Chow JS. The radiologist's role in assessing differences of sex development. Pediatr Radiol 2022; 52:752-764. [PMID: 34355264 DOI: 10.1007/s00247-021-05147-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/26/2021] [Accepted: 06/28/2021] [Indexed: 12/29/2022]
Abstract
When infants are identified with a difference of sex development (DSD), a thoughtful approach to imaging is essential to appropriate clinical management. This review provides a comprehensive guide for radiologists who are tasked with performing this critical assignment. We review the embryologic basis of DSDs, with attention to the imaging findings that can indicate specific diagnoses. We also discuss techniques for optimal imaging, including strategies for identifying the gonads by US, tactics for performing genitograms with fluoroscopy and contrast-enhanced US, and the appropriate utilization of MRI. Finally, we review the clinical data and imaging findings that characterize some of the most common DSDs, including congenital adrenal hyperplasia, complete androgen insensitivity syndrome and gonadal dysgenesis.
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Affiliation(s)
- Anastasia L Hryhorczuk
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Department of Radiology, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-4252, USA.
| | - Andrew S Phelps
- Department of Radiology, Oregon Health & Science University, Portland, OR, USA
| | - Richard N Yu
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Jeanne S Chow
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
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13
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Sato T, Nakano S, Ichihashi Y, Kobayashi H, Hida M, Ishii T, Hasegawa T. Less-Invasive Diagnostic Approaches for Infants with Suspected Differences of Sex Development: A Case Report of a 297-g Neonate with Ambiguous Genitalia. Neonatology 2022; 119:785-789. [PMID: 36273444 DOI: 10.1159/000527065] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
Less-invasive diagnostic approaches for low-birthweight preterm neonates with suspected differences of sex development have not been established. Herein, we describe our diagnostic approaches for a 297-g neonate with ambiguous genitalia. Using a fiberscope, the external genitalia were inspected in an incubator to minimize the risk of hypothermia and infection. Endotracheal aspirate, collected during routine care, was used for genetic testing to avoid anemia and vital signs fluctuations caused by peripheral blood sampling. Array comparative genomic hybridization indicated a 46,XY karyotype. No pathogenic variants of AR and SRD5A2 were found. Endocrinological data could not be evaluated owing to the absence of reference data. Identification and structural evaluation of the internal genitalia and gonads were difficult. On postnatal day 42, the parents assigned their baby's sex as male. Our less-invasive diagnostic approaches of inspection and genetic testing are useful for management, including sex assignment in extremely low-birthweight preterm neonates with ambiguous genitalia.
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Affiliation(s)
- Takeshi Sato
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan, .,The Center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan,
| | - Satsuki Nakano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The Center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
| | - Yosuke Ichihashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The Center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
| | - Hisato Kobayashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Mariko Hida
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The Center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The Center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
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14
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Abstract
Background 49XXXXY syndrome is the rarest X chromosome aneuploidy, with approximate incidence of 1:85,000–100,000 male births. Worldwide, around 100 cases have been reported. In this report, we describe one such case seen in Sri Lanka. Case presentation A 10-day-old Sri Lankan neonate born in a tertiary care center was referred to the pediatric endocrinology unit of Lady Ridgeway Hospital due to detection of ambiguous genitalia at birth. He was the first child born to nonconsanguineous healthy parents following an uncomplicated antenatal period. He was born at term via normal vaginal delivery, with a birth weight of 2.385 kg. The baby was active, and there was no documented hypoglycemia or alteration in basic biochemical investigations. On examination, the child had hypertelorism, upslanting palpebral fissures, flat occiput, and mild webbing of the neck. System examination was normal. Genitalia examination revealed bifid scrotum, perineal urethra, 2 cm phallus, and bilateral testis in situ. Hormonal analysis, including dehydroepiandrosterone sulfate, testosterone, and 17-OH progesterone levels, was normal except for an elevated level of follicle-stimulating hormone, indicating gonadal dysgenesis. Ultrasound of the abdomen detected testis located at bilateral inguinal canal, and no Müllerian structures were visible. Echocardiography showed a small patent foramen ovale with otherwise normal heart. Chromosome analysis revealed 49XXXXY syndrome. Conclusion 49XXXXY syndrome should be entertained as a rare possibility for ambiguous genitalia, and karyotyping is an essential investigation for evaluation of such patients.
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Affiliation(s)
- N P G C R Naotunna
- Endocrinology and Diabetic Unit, Lady Ridgeway Hospital, Colombo, Sri Lanka.
| | - C Liyanage
- Paediatric Unit, Provincial General Hospital, Badulla, Sri Lanka
| | - N Atapattu
- Endocrinology and Diabetic Unit, Lady Ridgeway Hospital, Colombo, Sri Lanka
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15
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Markantes GK, Stamou MI, Barouti K, Georgakopoulou D, Vasileiou V, Georgopoulos NA. A manless adultery: the story of Bassa as related in a Marcus Valerius Martialis' epigram. Hormones (Athens) 2021; 20:825-829. [PMID: 34297347 DOI: 10.1007/s42000-021-00310-5] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/12/2021] [Indexed: 11/26/2022]
Abstract
During the Golden Age of the Roman Empire, Rome was transformed into a magnificent city where architecture, the arts, and commerce flourished. An inconceivable amount of wealth was accumulated by a handful of noble families, while the masses starved. In such a context, moral values inevitably decline, while sexual mores are liberalized and ever more veer towards salacity. This reality was elegantly illustrated in short, often sarcastic poems known as epigrams. Herein, we present a case of a woman with enigmatic appearance of the external genitalia, exhibiting unrestrained homosexual activity, as described in an epigram by Marcus Valerius Martialis (a contemporary poet who lived in the 1st century AD). Based on the information provided in the ancient text, we formulate a differential diagnosis and deduce that this woman was, in fact, a case of congenital adrenal hyperplasia (CAH). To our knowledge, this is the earliest literary description worldwide of a case of CAH as a cause of homosexuality and unquenchable lust.
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Affiliation(s)
- Georgios K Markantes
- Division of Endocrinology, Department of Internal Medicine, University of Patras School of Health Sciences, Patras, Greece
| | - Maria I Stamou
- Harvard Reproductive Sciences Center, Massachusetts General Hospital, Boston, MA, USA
- Mount Auburn Hospital, Harvard Medical School Teaching Hospital, Cambridge, MA, USA
| | - Konstantina Barouti
- Division of Endocrinology, Department of Internal Medicine, University of Patras School of Health Sciences, Patras, Greece
| | - Danai Georgakopoulou
- Division of Endocrinology, Department of Internal Medicine, University of Patras School of Health Sciences, Patras, Greece
| | - Vasiliki Vasileiou
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos General Hospital, Athens, Greece
| | - Neoklis A Georgopoulos
- Division of Endocrinology, Department of Internal Medicine, University of Patras School of Health Sciences, Patras, Greece.
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16
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Zidoune H, Martinerie L, Tan DS, Askari M, Rezgoune D, Ladjouze A, Boukri A, Benelmadani Y, Sifi K, Abadi N, Satta D, Rastari M, Seresht-Ahmadi M, Bignon-Topalovic J, Mazen I, Leger J, Simon D, Brauner R, Totonchi M, Jauch R, Bashamboo A, McElreavey K. Expanding DSD Phenotypes Associated with Variants in the DEAH-Box RNA Helicase DHX37. Sex Dev 2021; 15:244-252. [PMID: 34293745 DOI: 10.1159/000515924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/16/2021] [Indexed: 11/19/2022] Open
Abstract
Missense variants in the RNA-helicase DHX37 are associated with either 46,XY gonadal dysgenesis or 46,XY testicular regression syndrome (TRS). DHX37 is required for ribosome biogenesis, and this subgroup of XY DSD is a new human ribosomopathy. In a cohort of 140 individuals with 46,XY DSD, we identified 7 children with either 46,XY complete gonadal dysgenesis or 46,XY TRS carrying rare or novel DHX37 variants. A novel p.R390H variant within the RecA1 domain was identified in a girl with complete gonadal dysgenesis. A paternally inherited p.R487H variant, previously associated with a recessive congenital developmental syndrome, was carried by a boy with a syndromic form of 46,XY DSD. His phenotype may be explained in part by a novel homozygous loss-of-function variant in the NGLY1 gene, which causes a congenital disorder of deglycosylation. Remarkably, a homozygous p.T477H variant was identified in a boy with TRS. His fertile father had unilateral testicular regression with typical male genital development. This expands the DSD phenotypes associated with DHX37. Structural analysis of all variants predicted deleterious effects on helicase function. Similar to all other known ribosomopathies, the mechanism of pathogenesis is unknown.
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Affiliation(s)
- Housna Zidoune
- Human Developmental Genetics Unit, CNRS UMR 3738, Institut Pasteur, Paris, France.,Department of Animal Biology, Laboratory of Molecular and Cellular Biology, University Frères Mentouri Constantine 1, Constantine, Algeria.,Department of Medicine, Laboratory of Biology and Molecular Genetics, University Salah Boubnider Constantine 3, Constantine, Algeria
| | - Laetitia Martinerie
- Assistance Publique-Hôpitaux de Paris Université de Paris, Robert Debré University Hospital, Endocrinology-Diabetology Department, Reference Center for Growth and Development Endocrine Diseases, Paris, France
| | - Daisylyn S Tan
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Masomeh Askari
- Department of Genetics, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Djalila Rezgoune
- Department of Animal Biology, Laboratory of Molecular and Cellular Biology, University Frères Mentouri Constantine 1, Constantine, Algeria.,Department of Medicine, Laboratory of Biology and Molecular Genetics, University Salah Boubnider Constantine 3, Constantine, Algeria
| | | | - Asma Boukri
- Department of Endocrinology and Diabetology, CHU Ibn Badis Constantine, Constantine, Algeria
| | - Yasmina Benelmadani
- Department of Medicine, Laboratory of Biology and Molecular Genetics, University Salah Boubnider Constantine 3, Constantine, Algeria
| | - Karima Sifi
- Department of Medicine, Laboratory of Biology and Molecular Genetics, University Salah Boubnider Constantine 3, Constantine, Algeria
| | - Noureddine Abadi
- Department of Medicine, Laboratory of Biology and Molecular Genetics, University Salah Boubnider Constantine 3, Constantine, Algeria
| | - Dalila Satta
- Department of Animal Biology, Laboratory of Molecular and Cellular Biology, University Frères Mentouri Constantine 1, Constantine, Algeria.,Department of Medicine, Laboratory of Biology and Molecular Genetics, University Salah Boubnider Constantine 3, Constantine, Algeria
| | - Mandana Rastari
- Department of Genetics, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Mehrshad Seresht-Ahmadi
- Department of Genetics, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | | | - Inas Mazen
- Genetics Department, National Research Center, Cairo, Egypt
| | - Juliane Leger
- Assistance Publique-Hôpitaux de Paris Université de Paris, Robert Debré University Hospital, Endocrinology-Diabetology Department, Reference Center for Growth and Development Endocrine Diseases, Paris, France
| | - Dominique Simon
- Assistance Publique-Hôpitaux de Paris Université de Paris, Robert Debré University Hospital, Endocrinology-Diabetology Department, Reference Center for Growth and Development Endocrine Diseases, Paris, France
| | - Raja Brauner
- Fondation Ophtalmologique Adolphe de Rothschild and Université Paris Descartes, Paris, France
| | - Mehdi Totonchi
- Department of Genetics, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
| | - Ralf Jauch
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Anu Bashamboo
- Human Developmental Genetics Unit, CNRS UMR 3738, Institut Pasteur, Paris, France
| | - Kenneth McElreavey
- Human Developmental Genetics Unit, CNRS UMR 3738, Institut Pasteur, Paris, France
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17
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Ali MA, Maalman RSE, Donkor YO, Mensah JE. Ambiguous genitalia: clinical management of adult female with male assigned gender: a case report. J Med Case Rep 2021; 15:362. [PMID: 34253226 PMCID: PMC8273980 DOI: 10.1186/s13256-021-02914-2] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Disorders of sex development are anomalies in which the development of urogenital ridge is undifferentiated for the male and female child. Imaging plays a vital role in investigating the gross anatomy and associated anomalies. Ultrasonography, such as genitography and magnetic resonance, is the primary modality for demonstrating internal gonads and genitalia. Early multidisciplinary approach in the management of ambiguous genitalia including early surgical intervention is the predominant practice, with few current considerations on deferral of genital reconstruction until adolescent age. CASE PRESENTATION We report the rare case of a 24-year-old adult female from a majority ethnic group of the Volta region, Ghana who was diagnosed and raised as male, now requiring surgical restoration to the female gender. The surgical team decided to assign external genitalia to correspond with the already intact internal organs, thus constructing the vulva. Consent was given by the client and her family members for management and surgical intervention. The surgery was scheduled and duly performed with a successful outcome. Understanding and consent was sought from the patient for the purpose of using her images for teaching, scientific publication, and demonstrations. CONCLUSION The advantages of deferring surgical reconstruction with psychological counseling after early assessment need to be considered to prevent inappropriate gender assignment.
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Affiliation(s)
- Mahamudu Ayamba Ali
- Department of Basic Medical Sciences, School of Medicine, University of Health and Allied Sciences, Ho, Volta Region, Ghana.,Consultant Urologist, Department of Surgery, School of Medicine, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Raymond Saa-Eru Maalman
- Department of Basic Medical Sciences, School of Medicine, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Yaw Otchere Donkor
- Department of Basic Medical Sciences, School of Medicine, University of Health and Allied Sciences, Ho, Volta Region, Ghana.
| | - James Edward Mensah
- Consultant Urologist, Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana.,School of medicine and Dentistry, University of Ghana, College of Health Sciences, Accra, Ghana
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18
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Lin R, Liu N, Wang X, Zhu X, Huang D, Shi B. Rupture and hemorrhage of a seminoma mixed with yolk sac tumors in 46XY partial gonadal dysgenesis: a case report and literature review. BMC Surg 2021; 21:307. [PMID: 34217242 PMCID: PMC8254990 DOI: 10.1186/s12893-021-01302-3] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background 46XY partial gonadal dysgenesis (PGD) is a rare subtype of disorder of sex development (DSD). 46YY PGD is a congenital disease with atypical chromosomal, gonadal, or anatomical sex development. The patient in this case report had male and female genitalia simultaneously. We created a flowchart of the differential diagnosis for clinicians. Case presentation A 41-year-old male was admitted to the hospital complaining of lower quadrant abdominal pain for 1 day. Physical examination revealed that his penis size was normal, but a urethral orifice was located in the perineum area between the scrotum and anus. One small testicle was in the left scrotum, but no testicle was present on the right. The patient’s abdomen was bulging, and he had lower abdominal pain. According to the emergency CT scan, a lesion (74*65 mm) was found in the right pelvis between the bladder and rectum. The lesion showed an unclear boundary and hematocele appearance. The lesion was removed by emergency surgery, and the pathology report indicated a mixed germ cell tumor with a seminoma and yolk sac tumors. Conclusion This article is a case report of germ cell tumors in 46XY PGD patients. The literature review summarizes the clinical diagnosis, and a flowchart is provided for physicians in future practice. The importance of this report is that it will help acquaint physicians with this rare disease and make the right initial clinical decision quickly through the use of this flowchart. However, the variants of special subtypes of 46XY DSD are myriad, and all the diagnoses could not be covered in one flowchart.
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Affiliation(s)
- Rui Lin
- General Surgery Department, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China
| | - Nanbin Liu
- General Surgery Department, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China
| | - Xiuyan Wang
- Ultrasound Department, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China
| | - Xuyou Zhu
- Pathology Department, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China
| | - Daojing Huang
- General Surgery Department, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China.
| | - Baomin Shi
- General Surgery Department, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China.
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19
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Akbulut S, Ceylan SD, Tuncali T, Sogutcu N. Coexistence of Ovarian Granulose Cell Tumor, Congenital Adrenal Hyperplasia, and Triple Translocation: Is a Consequence or Coincidence? J Gastrointest Cancer 2021; 52:508-514. [PMID: 32388791 DOI: 10.1007/s12029-020-00408-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Indexed: 02/07/2023]
Abstract
PURPOSE Congenital adrenal hyperplasia (CAH) is rare autosomal recessive disease. CAH due to 21-hydroxylase deficiency accounts for 95% of cases. We aimed to share the first case of coexistence of simple virilizing-type congenital adrenal hyperplasia [I172N mutation in the CYP21A], triple translocation [t(9;11;12)], and ovarian granulose cell tumor. METHODS A 59-year-old female patient was presented to our clinic, complaining with abdominal pain and distension. Physical examination revealed palpable abdominal mass, virilism, ambiguous genitalia, clitoramegaly, and hyperpigmentation. Contrast-enhanced abdominal computed tomography showed a giant mass originating from the right tubo-ovarian structure. RESULTS The patient was operated in the light of the clinico-radiological features mentioned above. A giant mass weighing 3500 g was detected on the right tubo-ovarian structure during laparotomy, and mass was excised with right tubo-ovarian structure. Immunohistochemical examination revealed ovarian granulosa cell tumor. The high serum concentration of 17-OH progesterone was measured at baseline and after 250-μg bolus of synthetic ACTH. In genetic analysis, we screened for six-point mutations, large deletions, and non-common mutations using restriction fragment length polymorphism (RFLP) methods, PCR, and sequencing of CYP21 gene respectively. The patient was detected to be homozygous for the I172N mutation. In addition, 50% of the metaphases examined had triple translocation [t(9;11;12)]. CONCLUSION The coexistence of congenital adrenal hyperplasia, triple chromosomal translocations, and ovarian granulosa cell tumor has not been described previously. This coexistence may be a sign of a new syndrome.
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Affiliation(s)
- Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Elazig Yolu 10. Km, 44280, Malatya, Turkey.
| | - Senay Durmaz Ceylan
- Department of Endocrinology, Kirikkale University Faculty of Medicine, 71450, Kirikkale, Turkey
| | - Timur Tuncali
- Department of Genetics, Ankara University Faculty of Medicine, 06100, Ankara, Turkey
| | - Nilgun Sogutcu
- Department of Pathology, Diyarbakir Education and Research Hospital, 21400, Diyarbakir, Turkey
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20
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AbouZeid AA, Mohammad SA, Shokry SS, El-Naggar O. Posterior cloaca: A urogenital rather than anorectal anomaly. J Pediatr Urol 2021; 17:410.e1-410.e7. [PMID: 33549475 DOI: 10.1016/j.jpurol.2021.01.014] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/04/2021] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND 'Persistent Cloaca' refers to one of the major groups of anorectal anomalies in the female when a single perineal orifice is located at the normal site of the urethra draining both urogenital and alimentary tracts. However, 'posterior cloaca' is a new term developed by Pena to describe a unique defect in females in which a common urogenital sinus is deviated posteriorly to open into normally located anorectum (type A) or in the perineum slightly anterior to the anus (type B). METHODS The study included seven girls diagnosed as posterior cloaca. Their age at presentation ranged from 1 to 108 months (median 12 months). The main presentation was abnormal external genitalia, while two cases underwent colostomy (±vaginostomy) at birth. Surgical reconstruction varied according to the degree of deviation from normal anatomy. Partial urogenital sinus mobilization (PUM) was used to correct minor forms; while at the other end of the spectrum (absent urinary bladder), continent urinary diversion was performed. Due to the high incidence of renal and urological anomalies, regular follow up at paediatric nephrology/urology clinics was advised for affected cases. RESULTS All seven cases had a common urogenital confluence characteristically deviated posteriorly. The degree of backward deviation of the common urogenital orifice was variable ranging from mild to severe posterior displacement. In six cases (85%), the common urogenital orifice was shifted backwards in the perineum approaching the anal verge (type B). In one case, the common urogenital orifice opened internally into the anorectum (type A). Major urinary tract anomalies were quite common (5 of 7 cases; 71%): absent urinary bladder (2 cases); single kidney (2 cases); crossed ectopic kidney (1 case); hydroureteronephrosis (2 cases). CONCLUSION Posterior cloaca is a rare anomaly in the female essentially affecting the lower urogenital tract with a high incidence of associated renal anomalies. Management should be tailored according to the degree of developmental defect.
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Affiliation(s)
| | | | - Shady S Shokry
- Pediatric Surgery Department, Faculty of Medicine, Ain Shams University, Egypt
| | - Osama El-Naggar
- Pediatric Surgery Department, Faculty of Medicine, Ain Shams University, Egypt
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21
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Lampalzer U, Briken P, Schweizer K. 'That decision really was mine…'. Insider perspectives on health care controversies about intersex/diverse sex development. Cult Health Sex 2021; 23:472-483. [PMID: 33754954 DOI: 10.1080/13691058.2021.1892828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/16/2021] [Indexed: 06/12/2023]
Abstract
After 20 years of debate on intersex care, there has been a slight movement away from the paradigm of 'optimal gender' including early genital modification to conform to predicted gender identity towards a paradigm of 'full consent' including the provision of full information about the risks, benefits and alternatives to interventions and the postponement of irreversible interventions on minors too young to give informed consent. However, controversy continues. Against this background, the aim of this study was to analyse core aspects of current debates in intersex care. Focus was placed on controversies about surgery on external genitalia; gonadectomies; the expressed wishes of patients under the age of consent; and how to deal with intersex within the family. Eight guideline-based interviews were conducted with two people with intersex/diverse sex development conditions who had been subjected to surgery, two parents of children with an intersex/dsd condition, two medical doctors, and two psychologists. Data were analysed thematically. Findings indicate that while 'full consent' influenced actions and debate, the persons involved held differing opinions about how this policy can or should be achieved. In addition, the data illustrated how concepts such as normalcy, identity and sexuality are relevant when dealing with intersex issues.
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Affiliation(s)
- Ute Lampalzer
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katinka Schweizer
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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22
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Alswailem M, Alsagheir A, Abbas BB, Alzahrani O, Alzahrani AS. Molecular genetics of disorders of sex development in a highly consanguineous population. J Steroid Biochem Mol Biol 2021; 208:105736. [PMID: 32784047 DOI: 10.1016/j.jsbmb.2020.105736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 11/15/2022]
Abstract
UNLABELLED Consanguinity increases the risk of hereditary diseases including disorders of sex development (DSD). There are minimal data on DSD in the highly consanguineous population of Saudi Arabia. This study reports the molecular genetics of a series of patients with different types of DSD. METHODS We enrolled 77 patients from 47 families with DSD. DNA was isolated from peripheral leucocytes. Genes of interest were amplified by polymerase chain reaction and subsequently sequenced. RESULTS Overall, 77 patients from 47 families (44 of them are consanguineous) had a total of 29 mutations; 16 of them were described before and 13 were novel mutations. The most common condition was 5-α reductase (SRD5A2) deficiency (25 patients from 18 families) and the most common mutation was a splice site mutation in intron 1 (c.282-2A>G). The next most common condition was 11-β hydroxylase (CYP11B1) deficiency where 19 patients from 10 families had 8 mutations (7 of them are novel). Other mutations affected CYP17A1 with 2 novel and 2 known mutations in 7 patients; HSD3B2 with 2 known mutations in 11 patients of 4 families; StAR with 1 novel and 1 known mutations in 4 patients; NR0B1 with 1 novel mutation in 2 siblings; HSD17B3 with 1 known mutation in 3 siblings; LHCGR with 1 novel mutation in 2 siblings; and AR with 1 novel and 3 known mutations in 4 unrelated patients. CONCLUSION In the highly consanguineous and homogeneous population of Saudi Arabia, SRD5A2 and CYP11B1 deficiencies are common causes of DSDs. Other DSDs occur less frequently but often with novel mutations.
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Affiliation(s)
- Meshael Alswailem
- Department of Molecular Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Afaf Alsagheir
- Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Bassam Ben Abbas
- Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ohoud Alzahrani
- Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ali S Alzahrani
- Department of Molecular Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia; Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.
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23
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Khan S, Tafweez R, Haider A, Yaqoob M. Spectrum of external genital anomalies in disorders of Sex Development at Children Hospital & Institute of Child Health, Lahore, Pakistan. Pak J Med Sci 2020; 37:244-249. [PMID: 33437285 PMCID: PMC7794156 DOI: 10.12669/pjms.37.1.2991] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To describe the mode of presentation and frequency of external genital anomalies in disorder of sex development (DSD) Methods: This cross-sectional study was conducted at Children Hospital & Institute of Child Health, Lahore from January to December, 2016 on Children with DSD above 10 years of age. A detailed history and physical examination were done. Positive findings were recorded on a predesigned proforma and analyzed by SPSS 21. Karyotyping on blood samples was done to determine their genetic sex. Results: Out of 83 DSD children, 67% (n=56) were assigned a female sex at birth of which 9% (n=5) had ambiguous genitalia. Male sex at birth was given to 33% (n=27) of which 96% (n=26) had genital ambiguity. Mode of presentation other than ambiguous genitalia were delayed puberty, amenorrhea, hirsuitism, gynaecomastia, cyclic hematuria etc. Clitoromegaly was the main finding in 62.5% (n=5) and micropenis in 45% (n=9). Karyotypic sex of 56 female sex of rearing was 46XX 80% (n=45), 45X0 13% (n=7), XXX 2% (n=1) and 46 XY in 5% (n=3). Karyotypic sex of 27 male sex of rearing was 46XY in 78% (n=21), 46XX in 15% (n=4) and 47XXY in 7% (n=2). Conclusion: Disorders of sex development presented with a wide spectrum of external genital anomalies ranging from clitoromegaly in females to micropenis and hypospadias in males. There was also an extreme diversity in mode of presentation of these cases including pubertal delay, amenorrhea in females and gender confusion disorders.
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Affiliation(s)
- Sarah Khan
- Dr. Sarah Khan, MBBS, M-Phil Anatomy Assistant Professor of Anatomy, Department of Anatomy, King Edward Medical University, Lahore, Pakistan
| | - Raafea Tafweez
- Dr. Raafea Tafweez, MBBS, M-Phil, FCPS, PhD. Professor of Anatomy, Department of Anatomy, King Edward Medical University, Lahore, Pakistan
| | - Areiba Haider
- Dr. Areiba Haider, MBBS, M-Phil. Anatomy, Assistant Professor of Anatomy, Department of Anatomy, King Edward Medical University, Lahore, Pakistan
| | - Muhammad Yaqoob
- Dr. Muhammad Yaqoob, MBBS, MCPS, PhD. Associate Professor of Genetics, Department of Genetics, The Children's Hospital & Institute of Child Health, Lahore, Pakistan
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Zainuddin AA, Grover SR, Soon CH, Ghani NAA, Mahdy ZA, Manaf MRA, Shamsuddin K. A Multicenter Cross-Sectional Study of Malaysian Females With Congenital Adrenal Hyperplasia: Their Body Image and Their Perspectives on Feminizing Surgery. J Pediatr Adolesc Gynecol 2020; 33:477-483. [PMID: 32376362 DOI: 10.1016/j.jpag.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To explore the impact of congenital adrenal hyperplasia (CAH) on body image in Malaysian females with CAH and to understand the perspectives of these young women and their parents toward feminizing genitoplasty (FG). DESIGN Multi-center cross-sectional study. SETTING Two tertiary medical centers in Malaysia. PARTICIPANTS A total of 59 patients with CAH who were raised as females and more than 10 years old, and their parents. METHODS The CAH respondents completed the validated and translated Body Image Disturbance Questionnaires (BIDQ). All CAH respondents and their parents underwent semi-structured interviews to explore their views on FG. MAIN OUTCOME MEASURES Body image disturbance score and perspectives on FG. RESULTS The 59 CAH respondents consisted of 12 children, 29 adolescents, and 18 adults. The majority were of Malay ethnicity (64.4%) with classical CAH (98.3%) and had undergone FG (n = 55, 93.2%). For the BIDQ scores, the median score (interquartile range) for general body image was 1.29 (0.71), range 1.00-3.29, whereas the genital appearance score was 1.07 (0.39), range 1.00-4.29, revealing a greater concern for general body parts over genitalia. With regards to FG, it was perceived as necessary. Infancy and early childhood were perceived as the best timing for first FG by both respondents and parents, most preferring single-stage over 2-stage surgery. CONCLUSIONS General body appearance concerns were greater than for genital appearance, with more impact on the patients' lives. Contrary to much international opinion, feminizing surgery was perceived as necessary and appropriate by CAH respondents and their families, and should be offered in infancy or early childhood. Future qualitative studies are recommended.
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Affiliation(s)
- Ani Amelia Zainuddin
- Department of Obstetrics and Gynecology, UKM Medical Center, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia.
| | - Sonia Regina Grover
- Department of Pediatric Adolescent Gynecology, Royal Children's Hospital Melbourne, University of Melbourne, Melbourne, Australia
| | - Chong Hong Soon
- Department of Obstetrics and Gynecology, UKM Medical Center, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
| | - Nur Azurah Abdul Ghani
- Department of Obstetrics and Gynecology, UKM Medical Center, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
| | - Zaleha Abdullah Mahdy
- Department of Obstetrics and Gynecology, UKM Medical Center, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
| | - Mohammad Rizal Abdul Manaf
- Department of Community Health, UKM Medical Center The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
| | - Khadijah Shamsuddin
- Department of Community Health, UKM Medical Center The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
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Choi JH, Lee Y, Oh A, Kim GH, Yoo HW. Molecular Characteristics of Sequence Variants in GATA4 in Patients with 46,XY Disorders of Sex Development without Cardiac Defects. Sex Dev 2020; 13:240-245. [PMID: 32992319 DOI: 10.1159/000511258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 08/26/2020] [Indexed: 11/19/2022] Open
Abstract
A GATA4 haploinsufficiency has been well described in patients with congenital heart defects (CHDs), whilst only a few studies have reported mutations related to a 46,XY disorder of sex development (DSD) phenotype. This study investigated the clinical phenotypes and molecular characteristics of two 46,XY DSD patients harboring GATA4 variants. Mutation analysis was performed using a targeted gene panel or whole-exome sequencing. The transactivation activity of each variant protein was examined by in vitro luciferase reporter assay using the AMH and SRY promoters. Subject 1 presented with a micropenis and hypospadias. Subject 2 showed complete female external genitalia with a 46,XY karyotype. Both patients were responsive to hCG stimulation tests and did not manifest CHD. A novel heterozygous variant, c.643A>G (p.R215G), in GATA4 was identified in Subject 1, whereas Subject 2 harbored a previously reported variant, c.1220C>A (p.P407Q), in GATA4 and a previously known pathogenic mutation, i.e., c.226C>T (p.Q76*) in the AR gene. The reporter assays using the SRY and AMH promoters revealed decreased transcriptional activity of both p.P407Q and p.R215G. However, the GATA4 p.P407Q variant was classified as likely benign. In conclusion, it is essential to integrate clinical features and endocrine findings when interpreting sequence variants.
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Levy-Khademi F, Zeligson S, Lavi E, Klopstock T, Chertin B, Avnon-Ziv C, Abulibdeh A, Renbaum P, Rosen T, Perlberg-Bengio S, Zahdeh F, Behar DM, Levy-Lahad E, Zangen D, Segel R. The novel founder homozygous V225M mutation in the HSD17B3 gene causes aberrant splicing and XY-DSD. Endocrine 2020; 69:650-654. [PMID: 32372306 DOI: 10.1007/s12020-020-02327-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Mutations in the gene HSD17B3 encoding the 17-beta hydroxysteroid dehydrogenase 3 enzyme cause testosterone insufficiency leading to XY disorders of sex development. In this study the clinical and molecular characteristics of three patients from consanguineous families are elucidated. METHODS We identified three patients from two unrelated families with XY DSD and a novel homozygous HSD17B3:c. 673G>A mutation. The effect of the mutation on splicing was determined in RNA extracted from the testis of one patient. RESULTS Three patients presented at ages 0.1, 8 and 0.7 years with ambiguous genitalia and an XY Karyotype. Endocrine workup showed normal cortisol and mineralocorticoid levels with a low testosterone/androstenedione ratio. Whole-exome sequencing, carried out in the first family, revealed a homozygous novel mutation in the HSD17B3 gene: c. 673G>A, p. V225M. The same mutation was found by Sanger sequencing in the third unrelated patient. Haplotype analysis of a 4 Mb region surrounding the HSD17B3 gene on chromosome 9 revealed that the mutation resides on the same allele in all three patients. The mutation, being the first nucleic acid on exon 10, affects splicing and causes exon 10 skipping in one of our patients' testes. CONCLUSION The novel homozygous c. 673G>A, p. V225M mutation in the 17HSDB3 gene is likely a founder mutation and causes severe XY-DSD. It changes a conserved amino acid residue, and also alters 17HSDB3 gene transcription by causing skipping of exon 10, thereby contributing to an imbalance in the relevant protein isoforms and consequently, significant decreased 17HDSB3 enzymatic activity.
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Affiliation(s)
- Floris Levy-Khademi
- Division of Pediatric Endocrinology, Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel.
- The Hebrew University School of Medicine, Jerusalem, Israel.
| | - Sharon Zeligson
- The institute of Medical Genetics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Eran Lavi
- The Hebrew University School of Medicine, Jerusalem, Israel
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tehila Klopstock
- The Hebrew University School of Medicine, Jerusalem, Israel
- The institute of Medical Genetics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Boris Chertin
- The Hebrew University School of Medicine, Jerusalem, Israel
- Department of Pediatric Urology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Carmit Avnon-Ziv
- Division of Pediatric Endocrinology, Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Abdulsalam Abulibdeh
- The Hebrew University School of Medicine, Jerusalem, Israel
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Paul Renbaum
- The institute of Medical Genetics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Tzvia Rosen
- The institute of Medical Genetics, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Fouad Zahdeh
- The institute of Medical Genetics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Doron M Behar
- Gene by Gene, Genomic Research Center, Houston, Texas, USA
| | - Ephrat Levy-Lahad
- The Hebrew University School of Medicine, Jerusalem, Israel
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - David Zangen
- The Hebrew University School of Medicine, Jerusalem, Israel.
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Reeval Segel
- The Hebrew University School of Medicine, Jerusalem, Israel
- The institute of Medical Genetics, Shaare Zedek Medical Center, Jerusalem, Israel
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Das S, Saikia UK, Saikia KK, Sarma D, Choudhury BK, Bhuyan AK, Baro A, Das DV, Appaiah S. "Spectrum of 46 XY Disorders of Sex Development": A Hospital-based Cross-sectional Study. Indian J Endocrinol Metab 2020; 24:360-365. [PMID: 33088761 PMCID: PMC7540835 DOI: 10.4103/ijem.ijem_98_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/25/2020] [Accepted: 06/26/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Disorders of sex development (DSD) are a wide range of relatively rare conditions having diverse pathophysiology. Identification of an underlying cause can help in treating any coexisting hormone deficiencies and can help with anticipating any other immediate or long-term health concerns. OBJECTIVE To study the clinical and biochemical profile of patients with 46 XY DSD along with androgen receptor (AR) gene mutation status in selected group of patients. METHODS A cross-sectional study was conducted after enrolling the eligible DSD patients. Thorough elicitation of history and detailed clinical examination was done. Assays for luteinizing hormone, follicle-stimulating hormone, testosterone, dihydrotestosterone, androstenedione, AMH & Inhibin B (where indicated), and human chorionic gonadotropin stimulation were done as per protocol. RESULTS In total, 48 patients were included in the study. Ambiguous genitalia (58.3%) followed by hypospadias (33.3%) were common presentation. Androgen biosynthetic defect were the most commonly encountered diagnosis followed by androgen insensitivity syndrome (AIS). Swyer syndrome was diagnosed in 4.2% of cases; partial gonadal dysgenesis, ovotesticular DSD, and vanishing testis syndrome contributed to 2% of cases each. Eight cases (16.7%) who presented with isolated proximal and midshaft hypospadias for whom no diagnosis was found were categorized in the "etiology unclear" group. AR gene mutation analysis designed against specific exons did not yield any results. CONCLUSION 46 XY DSD is a heterogeneous group of patients with a varying age of presentation and a diverse clinical profile. Most patients are reared as males and maintained the same gender identity except in isolated cases. Diagnosis of AIS remains a clinical challenge as a definite hormonal criterion does not exist and genetic mutations in AR gene may be negative. Flanking region sequencing, whole genome sequencing, and promoter region sequencing may reveal pathogenic variants. Variations in other genes regulating AR pathway may also be candidates to be studied.
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Affiliation(s)
- Samiran Das
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Uma K. Saikia
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Kandarpa K. Saikia
- Department of Bioengineering and Technology, GUIST, Gauhati University, Assam, India
| | - Dipti Sarma
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | | | - Ashok K. Bhuyan
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Abhamoni Baro
- Department of Endocrinology, Gauhati Medical College, Guwahati, India
| | - Darvin V. Das
- Department of Endocrinology, Trivandrum Medical College, Thiruvananthapuram, Kerala, India
| | - Sonali Appaiah
- Department of Endocrinology, St Johns Medical College, Banglore, Karnataka, India
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Lee PA, Fuqua JS, Houk CP, Kogan BA, Mazur T, Caldamone A. Individualized care for patients with intersex (disorders/differences of sex development): part I. J Pediatr Urol 2020; 16:230-237. [PMID: 32249189 DOI: 10.1016/j.jpurol.2020.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 02/20/2020] [Indexed: 12/16/2022]
Abstract
The care of individuals with disorders/differences of sex development aims to enable affected individuals and their families to have the best quality of life, particularly those born with severe genital ambiguity. Two of the biggest concerns for parents and health professionals are: (1) making a gender assignment and (2) the decisions of whether or not surgery is indicated, and if so, when is best for the patient and parents. These decisions, which can be overwhelming to families, are almost always made in the face of uncertainties. Such decisions must involve the parents, include multidisciplinary contributions, have an underlying principle of full disclosure, and respect familial, philosophical, and cultural values. Assignment as male or female is made with the realization that gender identity cannot be predicted with certainty. Because of the variability among those with the same diagnosis and complexity of phenotype-genotype correlation, the use of algorithms is inappropriate. The goal of this article is to emphasize the need for individualized care to make the best possible decisions for each patient's unique situation.
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Affiliation(s)
- Peter A Lee
- Penn State College of Medicine, Hershey, PA 17033, USA.
| | - John S Fuqua
- Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | | | | | - Tom Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, John R. Oishei Children's Hospital, Buffalo, NY 14222, USA.
| | - Anthony Caldamone
- Hasbro Children's Hospital, Warren Alpert School of Medicine at Brown University, Providence, RI 02903, USA.
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Hougen HY, Seideman CA, Adam MP, Amies Oelschlager AM, Fechner PY, Ramsell L, Shnorhavorian M, Squire A, Austin JC. Congenital virilization of female infants recognized after pregnancies with retained levonorgestrel intrauterine devices. J Pediatr Urol 2020; 16:241-243. [PMID: 32265103 DOI: 10.1016/j.jpurol.2020.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/12/2020] [Indexed: 11/25/2022]
Abstract
The Mirena intrauterine device (IUD) is a hormone-secreting contraceptive device. Pregnancy with the Mirena is rare and effects to the fetus are unknown. Here we present four females with genital virilization after pregnancy with persistent Mirena IUD. All patients had a 46, XX karyotype and normal hormone evaluation. All underwent exam under anesthesia, demonstrating posterior labial fusion and short urogenital sinus with normal bladder, urethra, vagina, and cervix. Three of four patients underwent flap vaginoplasty without complications and good cosmetic outcomes. This series suggests that persistent levonorgestrel-secreting IUD during pregnancy is associated with genital virilization in female fetuses.
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Affiliation(s)
- Helen Y Hougen
- Department of Urology, Oregon Health and Sciences University, 3303 SW Bond Ave. CH10U. Portland, OR, 97239, USA.
| | - Casey A Seideman
- Division of Pediatric Urology, Department of Urology, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Rd. Portland, OR, 97239, USA.
| | - Margaret P Adam
- Division of Genetic Medicine, Department of Pediatrics, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
| | - Anne-Marie Amies Oelschlager
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Patricia Y Fechner
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; Division of Endocrinology, Department of Pediatrics, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Linda Ramsell
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Margarett Shnorhavorian
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; Division of Pediatric Urology, Department of Urology, University of Washington School of Medicine, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA.
| | - Audrey Squire
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - J Christopher Austin
- Division of Pediatric Urology, Department of Urology, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Rd. Portland, OR, 97239, USA.
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Acimi S. Preservation of vagina or perineal utricle in perineal hypospadias repair. J Pediatr Urol 2020; 16:258-259. [PMID: 31948803 DOI: 10.1016/j.jpurol.2019.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Smail Acimi
- Department of Visceral Surgery, Children's Hospital Canastel, University of Oran, Oran, Algeria.
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Kim YM, Oh A, Kim KS, Yoo HW, Choi JH. Pubertal outcomes and sex of rearing of patients with ovotesticular disorder of sex development and mixed gonadal dysgenesis. Ann Pediatr Endocrinol Metab 2019; 24:231-236. [PMID: 31905442 PMCID: PMC6944855 DOI: 10.6065/apem.2019.24.4.231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/29/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with ovotesticular disorder of sex development (DSD) and mixed gonadal dysgenesis (MGD) usually present with asymmetric gonads and have wide phenotypic variations in internal and external genitalia. The differential diagnosis of these conditions is based on karyotype and pathological findings of the gonads. This study investigated the clinical features at presentation, karyotype, sex of rearing, and pubertal outcomes of patients with ovotesticular DSD and MGD. METHODS The study comprised 23 patients with DSD who presented with asymmetric gonads. The presenting features, karyotype, sex of rearing, and pubertal outcomes were reviewed retrospectively. RESULTS All 23 patients presented with ambiguous genitalia at a median age of 1 month (range, 1 day-1.6 years). Müllerian duct remnants were identified in 15 of 23 patients (65.2%). Fourteen patients were diagnosed with ovotesticular DSD, whereas the other 9 were diagnosed with MGD. Eight of 14 patients (57.1%) with ovotesticular DSD were raised as males, while 7 of 9 patients with MGD (77.8%) were assigned as males. One male-assigned patient with ovotesticular DSD changed to female sex at age 20 years. CONCLUSION Patients with ovotesticular DSD and MGD manifest overlapping clinical presentations and hormonal profiles. It is difficult to determine the sex of rearing and predict long-term pubertal outcomes. Therefore, long-term follow-up is required to monitor spontaneous puberty, sex outcome, and urological and gynecological complications.
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Affiliation(s)
- Yoon Myung Kim
- Department of Pediatrics, GangNeung Asan Hospital, Gangneung, Korea
| | - Arum Oh
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kun-Suk Kim
- Department of Urology, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, Seoul, Korea,Address for correspondence: Jin-Ho Choi, MD Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-Gil, Songpa-Gu, Seoul 05505, Korea Tel: +82-2-3010-3991 Fax: +82-2-473-3725 E-mail:
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Abstract
AIM OF THE STUDY Misdiagnosing a cloaca as a disorder of sex development may lead to inappropriate testing, treatment, and negative emotional consequences to families. We were impressed by the fact that a significant number of patients suffering from a cloaca were referred to us with the diagnosis of a "disorder of sex development" previously referred as "ambiguous genitalia" or "intersex". On re-evaluation, none of them truly had a disorder of sex differentiation. This prompted us to conduct the following retrospective review to try to find the cause of the misdiagnosis and the way to prevent it. METHODS A retrospective review of our colorectal database was performed to identify the total number of patients with cloacas and the number initially diagnosed as "ambiguous genitalia, intersex"/disorder of sex development. The external appearance of their genitalia and unnecessary testing or treatment received were recorded. MAIN RESULTS A total of 605 patients with cloacas were identified. Of these, 77 (12.7%) were referred to us with the diagnosis of "ambiguous genitalia" and 13 of them (17%) went on to receive an intervention that was not indicated: karyotyping (10), steroids (3), and ovarian biopsy (1). The karyotype result in all patients was XX. The misdiagnosis was triggered by the external appearance of the perineum, simulating a case of virilization with a hypertrophic clitoris, but was simply prominent labial skin. Careful examination of the perineal structure allowed us to determine that it consisted of folded skin with no evidence of corpora. CONCLUSION Patients born with a cloaca are at risk for mismanagement from being erroneously labeled as disorders of sex development. The diagnosis of a cloacal anomaly is a clinical one. The practitioner must distinguish between phallus-like clitoral hypertrophy and a normal clitoris with prominent labial skin.
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van Zoest M, Bijker EM, Kortmann BBM, Kempers M, van Herwaarden AE, van der Velden J, Claahsen-van der Grinten HL. Sex Assignment and Diagnostics in Infants with Ambiguous Genitalia - A Single-Center Retrospective Study. Sex Dev 2019; 13:109-117. [PMID: 31466074 DOI: 10.1159/000502074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2019] [Indexed: 12/20/2022] Open
Abstract
Ambiguous genitalia affect 1 in 5,000 live births. Diagnostic procedures can be time-consuming, and often the etiology cannot be established in this group of individuals with differences/disorders of sex development (DSD). We aimed to evaluate the clinical presentation, sex assignment, and diagnostic workup in these patients. In this retrospective observational study, we included infants who presented with ambiguous genitalia from 2006 to 2016 at the Radboudumc (Radboud University Medical Center) DSD expert center. Relevant data were collected from patient records. Sixty-two 46,XY and fourteen 46,XX individuals were included. Sex was assigned in the first days of life and based on the combination of presence or absence of a uterus on ultrasound, AMH level, palpable gonads, and the karyotype (corresponded in 96% of the patients). In 86% of the 46,XX DSD subjects, a diagnosis was made, whereas in only 15/62 (24%) of the 46,XY DSD individuals, etiology was determined. In 52 individuals, genetic testing was performed resulting in a diagnosis in 24 patients (46%). AMH, hCG-stimulated testosterone, and dihydrotestosterone levels contributed to determining etiology, whilst basal testosterone and basal dihydrotestosterone did not. Establishing a diagnosis in infants with ambiguous genitalia is complex and challenging; this study aids to enhance this process and improve current practice.
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Bruni V, Roppa K, Scionti F, Apa R, Sestito S, Di Martino MT, Pensabene L, Concolino D. A 46,XY Female with a 9p24.3p24.1 Deletion and a 8q24.11q24.3 Duplication: A Case Report and Review of the Literature. Cytogenet Genome Res 2019; 158:74-82. [PMID: 31141803 DOI: 10.1159/000500619] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2018] [Indexed: 12/11/2022] Open
Abstract
Deletion of distal 9p is associated with a rare clinical condition characterized by dysmorphic features, developmental delay, and ambiguous genitalia. The phenotype shows variable expressivity and is related to the size of the deletion. 8q24 duplication has been reported in only few cases to date, all showing dysmorphic features and mild psychomotor developmental delay. A case of chromosomal aberration involving a 9p terminal deletion with an 8q duplication has never been reported. Here, we describe a child with a female phenotype, male karyotype, dysmorphic features, ambiguous genitalia, and developmental delay. In order to assess the cause of the patient's phenotype, conventional karyotyping, FISH, and a chromosomal microarray analysis were performed on the patient and her parents. The cytogenetic and molecular analysis revealed an unbalanced chromosomal aberration with a duplication in the long arm of chromosome 8 at 8q24.11q24.3 associated with a distal deletion in the short arm of chromosome 9 at 9p24.3p24.1, derived from a maternal balanced translocation. We compared the clinical picture of our patient with other similar cases reported in the literature and found that some clinical findings, such as strabismus, symphalangism of the first finger, and cubitus valgus, have never been previously associated with 9p deletion or 8q duplication expanding the phenotypic range of this condition. This study is aimed to better define the clinical history and prognosis of patients with this rare chromosomal aberration.
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Bose HS, Rice AM, Marshall B, Gebrail F, Kupshik D, Perry EW. Deficient pregnenolone synthesis associated with congenital adrenal hyperplasia and organelle dysfunction. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190009. [PMID: 31051467 PMCID: PMC6499912 DOI: 10.1530/edm-19-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/11/2019] [Indexed: 12/01/2022] Open
Abstract
Steroid hormones are essential for the survival of all mammals. In adrenal glands and gonads, cytochrome P450 side chain cleavage enzyme (SCC or CYP11A1), catalyzes conversion of cholesterol to pregnenolone. We studied a patient with ambiguous genitalia by the absence of Müllerian ducts and the presence of an incompletely formed vagina, who had extremely high adrenocorticotropic hormone (ACTH) and reduced pregnenolone levels with enlarged adrenal glands. The testes revealed seminiferous tubules, stroma, rete testis with interstitial fibrosis and reduced number of germ cells. Electron microscopy showed that the patient's testicular mitochondrial size was small with little SCC expression within the mitochondria. The mitochondria were not close to the mitochondria-associated ER membrane (MAM), and cells were filled with the microfilaments. Our result revealed that absence of pregnenolone is associated with organelle stress, leading to altered protein organization that likely created steric hindrance in testicular cells. Learning points: Testes revealed seminiferous tubules, stroma, rete testis with interstitial fibrosis and reduced number of germ cells; Testicular mitochondrial size was small with little SCC expression within the mitochondria; Absence of pregnenolone is associated with organelle stress.
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Affiliation(s)
- Himangshu S Bose
- Laboratory of Biochemistry, Biomedical Sciences, Mercer University School of Medicine, Savannah, Georgia, USA
- Memorial University Medical Center, Savannah, Georgia, USA
| | - Alan M Rice
- Laboratory of Biochemistry, Biomedical Sciences, Mercer University School of Medicine, Savannah, Georgia, USA
- Pediatric Endocrinology and Diabetes Center, Kalispell Regional Medical Center, Kalispell, Montana, USA
| | - Brendan Marshall
- Anatomy and Pathology, Augusta State University, Augusta, Georgia, USA
| | - Fadi Gebrail
- Laboratory of Biochemistry, Biomedical Sciences, Mercer University School of Medicine, Savannah, Georgia, USA
- Laboratory of Pathology, Memorial University Medical Center, Savannah, Georgia, USA
| | - David Kupshik
- Laboratory of Biochemistry, Biomedical Sciences, Mercer University School of Medicine, Savannah, Georgia, USA
| | - Elizabeth W Perry
- Anatomy and Pathology, Augusta State University, Augusta, Georgia, USA
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Patil UA, Patil PU, Devdikar MS, Patil SU. Reduction Clitoroplasty by Ventral Approach: Technical Refinement. J Obstet Gynaecol India 2019; 69:48-52. [PMID: 30956492 DOI: 10.1007/s13224-017-1062-8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Background Aesthetic alteration of the genitalia is increasingly sought by women who are unhappy about the size, shape or overall appearance of their vulva. Clitoral hypertrophy is usually seen in congenital malformations, specifically in intersexual stages of hormonal expression. A large clitoris has an appearance of a small penis, is psychologically disturbing and interferes in sexual activity. Purpose Clitoral reduction surgery has evolved over the years. Total clitorectomy, clitoral recession and neuro-vascular pedicle sparing clitoroplasty can be considered as three major milestones in its evolution. In nerve sparing clitoroplasty, earlier dorso-lateral approach was challenged by ventral approach, which is establishing itself as the approach of choice by its own merits. Clitoral reduction surgery being not a very commonly performed surgery, demands refinements in its technique to improve its results and particularly the aesthetic outcome, which is gaining more importance in recent years. Methods An adult case of late onset congenital adrenal hyperplasia (CAH) with clitoromegaly underwent nerve sparing reduction clitoroplasty by ventral approach under moderate magnification. We present key points of the preoperative anatomic evaluation. Technical refinements planned and executed step wise during the procedure resulted in satisfactory outcome. Result Patient now has normal appearing genitalia, a small clitoris nicely covered by skin hood and very well preserved sensation to light touch. Conclusions Preservation of sensation in the glans clitoris is of paramount importance during clitoral reduction surgery. Knowledge of the anatomy of the neurovascular supply to the glans clitoris gives us freedom from not isolating it in order to preserve it. In fact a deliberate attempt to dissect it can prove detrimental particularly when operating on a smaller organ during childhood. A ventral approach with refined technique proves safe and gives satisfactory result. Moderate degree of magnification eases dissection. A component-based detailed preoperative planning improves the overall aesthetic appearance of the female genitalia.
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Affiliation(s)
- Uddhav A Patil
- Department of Plastic Surgery, D. Y. Patil Medical College and Hospital, Kolhapur, Maharashtra 416006 India.,LakshyaKiran Cosmetic Laser Centre, 10-11, First Floor, Trade Center, Station Road, Kolhapur, Maharashtra 416001 India
| | - Paddmaja U Patil
- Prakriti Hospital, East of Pavilion Ground, Kasba Bavada, Kolhapur, Maharashtra 416006 India
| | - Manasi S Devdikar
- Devdikar Medical Center, Near New ST Stand, Sahakarnagar, Akluj, Maharashtra 413101 India
| | - Shreyasi U Patil
- Prakriti Hospital, East of Pavilion Ground, Kasba Bavada, Kolhapur, Maharashtra 416006 India
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Pesmatzoglou M, Kanaka-Gantenbein C, Dermentzoglou V, Voutetakis A, Nikaina I, Skiathitou AV, Siahanidou T. The Dilemma of Sex of Rearing: A Case of a 45,X/46,XY Neonate with Hydrocolpos. J Pediatr Adolesc Gynecol 2019; 32:70-3. [PMID: 30205160 DOI: 10.1016/j.jpag.2018.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/25/2018] [Accepted: 09/01/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND A rare disorder of sex development is 45,X/46,XY mosaicism, which is phenotypically very heterogenous, ranging from normal male (or female) to that of genital ambiguity of varying degrees. CASE We report a case of a neonate with 45,X/46,XY mosaicism and hydrocolpos, and we point out the dilemma and the difficulty in gender assignment. SUMMARY AND CONCLUSION Gender assignment of cases with frank genital ambiguity is often difficult to be determined, because several factors have to be taken into consideration, such as genital appearance, anticipated urological and sexual function, capacity for future fertility, gonadal malignancy risk, and psychosocial factors. A multidisciplinary approach is definitely needed in the management of such cases.
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Nasir AA, Abdur-Rahman LO, Adesiyun OO, Bamigbola KT, Adegboye MB, Raji HO, Adesiyun OAM, Adeniran JO. Analysis of Presentations and Outcomes of Care of Children with Disorders of Sexual Development in a Nigerian Hospital. J Pediatr Adolesc Gynecol 2019; 32:21-26. [PMID: 30149125 DOI: 10.1016/j.jpag.2018.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/13/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE To describe the presentation, diagnosis, management, and short-term outcome of children with disorders of sexual development (DSD) in the context of multidisciplinary team care. DESIGN Prospective descriptive study. SETTING University Teaching Hospital. PARTICIPANTS All children who presented with genital ambiguity. INTERVENTIONS AND MAIN OUTCOME MEASURES Records of all patients diagnosed and managed for DSD between January 2011 and December 2016 were reviewed. The care pathway included clinical, laboratory, internal genitalia evaluation, and panel (including parents) meeting. RESULTS Fifteen children presented with DSD at a median age of 20 months. Only 5/15 (33.3%) presented in the neonatal period. Ten of fifteen patients (66.7%) presented with genital ambiguity. Ovotesticular DSD was the most common diagnosis (9/15; 60%). Seven of the patients were genetically female (46, XX), 1 was genetically male (46, XY) and 1 without genetic diagnosis. Six patients were assigned male gender and they underwent male genitoplasty. Five of them had excision of Müllerian structures with gonadectomy. Three of fifteen patients (20%) were diagnosed as 46, XX DSD, at a median age of 7 years. All of them were due to congenital adrenal hyperplasia and underwent female genitoplasty. Two patients were diagnosed as XY, DSD. They were both raised as female at presentation and were reassigned male sex. Both had urethroplasty done. Four patients had postoperative urethrocutaneous fistula and 1 had partial wound dehiscence. The median follow-up period was 21 months (interquartile range, 2-26 months). CONCLUSION The frequency of ovotesticular DSD is high in our setting. The decision of sex assignment was finally made at a median age of 7.5 months in most of our patients with satisfactory short-term surgical outcome.
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Affiliation(s)
- Abdulrasheed A Nasir
- Division of Paediatric Surgery, Department of Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria.
| | - Lukman O Abdur-Rahman
- Division of Paediatric Surgery, Department of Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Omotayo O Adesiyun
- Department of Paediatrics, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Kayode T Bamigbola
- Division of Paediatric Surgery, Department of Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Majeed B Adegboye
- Department of Anaesthesia, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Hadijat O Raji
- Department of Obstetrics and Gynaecology, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Olusola A M Adesiyun
- Department of Radiology, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - James O Adeniran
- Division of Paediatric Surgery, Department of Surgery, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
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Manzoor J, Aftab S, Yaqoob M. Ambiguous genitalia: An overview of 7 years experience at the Children's Hospital & Institute of Child Health, Lahore, Pakistan. Pak J Med Sci 2019; 35:151-155. [PMID: 30881414 PMCID: PMC6408627 DOI: 10.12669/pjms.35.1.289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To determine the classification and etiological diagnosis of children presented with ambiguous genitalia/atypical genitalia according to the newer classification system of Disorder of Sex Development (DSD). Methods: This observational, cross-sectional study was conducted at the Department of Pediatric Endocrinology and Diabetes at The Children’s Hospital &Institute of Child Health, Lahore from January, 2007 to December; 2014. Files of all the children with ambiguous genitalia were retrospectively analyzed and relevant data was retrieved. All the information was recorded on predesigned proforma and analyzed accordingly. Results: A total of 300 cases of ambiguous genitalia classified according to the new DSD classification. 46, XX DSD were 54.3% (n=163), 46, XY DSD were 43.7% (n=131), sex chromosome DSD were 2% (n=6). Among 46, XX DSD cases, the most common cause was congenital adrenal hyperplasia (97%, n=158). However, in 46, XY DSD partial androgen insensitivity/5α-reductase deficiency (62%. n=81) constituted the most commonest disorder. Other causes of 46XY DSD include testosterone synthesis defect(23%), congenital adrenal hyperplasia (CAH,12%), testis regression syndrome (1.5%) and persistent mullerian duct syndrome (PMDS,1.5%). Sex chromosome disorder constituted one case of iso-chromosome X turner syndrome, mixed gonadal dysgenesis (n=3), ovotesticular DSD/chimerism (n=2). Conclusion: Ambiguous genitalia have varied etiologies, 46; XXDSD found being the commonest of all, showing predominance of CAH especially salt loosing type. The early detection and prompt treatment of cases of ambiguous genitalia plays a pivotal role in the management of acute life threatening condition and gender assignment.
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Affiliation(s)
- Jaida Manzoor
- Dr. Jaida Manzoor, MBBS, FCPS. Associate Professor (Pediatric Endocrinology), Department of Pediatric Endocrinology and Diabetes, The Children's Hospital & Institute of Child Health, Lahore, Pakistan
| | - Sommayya Aftab
- Dr. Sommayya Aftab, MBBS, FCPS. Senior Registrar (Pediatric Endocrinology), Department of Pediatric Endocrinology and Diabetes, The Children's Hospital & Institute of Child Health, Lahore, Pakistan
| | - Muhammad Yaqoob
- Dr. Muhammad Yaqoob, MBBS, MCPS, PhD. Assistant Professor (Clinical Genetics), Department of Genetics, The Children's Hospital & Institute of Child Health, Lahore, Pakistan
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Çetinkaya M, Özen S, Uslu S, Gönç N, Acunas B, Akıncı A, Satar M, Berberoğlu M. Diagnostic and therapeutic approach in newborns with ambiguous genitale with disorder of sex development: consensus report of Turkish Neonatal and Pediatric Endocrinology and Diabetes Societies. Turk Arch Pediatr 2018; 53:S198-S208. [PMID: 31236033 PMCID: PMC6568300 DOI: 10.5152/turkpediatriars.2018.01818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Disorders of sex development are defined as conditions in which the chromosomal, gonadal, and anatomic sex is discordant. Patients usually present with atypical appearing genitalia. In the assessment of neonates with disorders of sex development, first, it is important to determine whether this situation requires prompt evaluation, and then the karyotype, hormone levels, and underlying etiology should be determined as soon as possible. All these procedures should be performed in the guidance of a multidisciplinary team in reference centers. As the physical examination of the infant is extremely important, the physcian should suspect and then perform a detailed history and physical examinationi and lastly plan the required laboratory and imaging procedures for the definite diagnosis. It is important not to be hurried in the choice of sex. The aim of this article, which includes the diagnostic and therapeutic approaches in infants with ambiguous genitalia, was to provide a common practice for all pediatricians.
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Affiliation(s)
- Merih Çetinkaya
- Division of Neonatology, Health Sicences University, İstanbul Kanuni Sultan Süleyman Training and Research Hospital, İstanbul, Turkey
| | - Samim Özen
- Division of Pediatric Endocrinology, Department of Pediatrics, Ege University, Faculty of Medicine, İzmir, Turkey
| | - Sinan Uslu
- Division of Neonatology Health Sicences University, İstanbul Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Nazlı Gönç
- Division of Pediatric Endocrinology, Department of Pediatrics, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Betül Acunas
- Division of Neonatology, Department of Pediatrics, Trakya University, Faculty of Medicine, Edirne, Turkey
| | - Ayşehan Akıncı
- Division of Pediatric Endocrinology, Department of Pediatrics, İnönü University, Faculty of Medicine, Malatya, Turkey
| | - Mehmet Satar
- Division of Neonatology, Department of Pediatrics, Çukurova University, Faculty of Medicine, Adana, Turkey
| | - Merih Berberoğlu
- Division of Pediatric Endocrinology, Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
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Acimi S, Bessahraoui M, Acimi MA, Abderrahmane N, Debbous L. Vaginoplasty and creating labia minora in children with disorders of sex development. Int Urol Nephrol 2019; 51:395-9. [PMID: 30547360 DOI: 10.1007/s11255-018-2058-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE To report current results of vaginoplasty using the mucosa of the prepuce, and creating labia minora by penile skin in children with disorders of sex development (DSD). METHODS In 10 years, we have performed 22 vaginoplasties using the described technique of vaginoplasty, 21 patients with 46, XX DSD and 1 ovotesticular DSD. The assessment of the results of this technique of vaginoplasty was undertaken in several stages: (a) The evaluation of the cosmetic result. (b) The research for a urinary incontinence and urethrovaginal fistulas. (c) The research for a vaginal stenosis by the introduction of a lubricated feeding tube into the vaginal cavity. The labia minora was evaluated by three criteria: its skin should be thin and very supple, it should have a free edge which partially or totally covers the clitoris, urethral meatus, and vaginal orifice; and it is preferable that its color be darker than the rest of the skin. RESULTS The cosmetic outcome was considered by parents and the surgeon as very satisfactory in 11 patients (50% of cases), satisfactory in 4 patients (18.2%), and unsatisfactory in 7 patients (31.8%). The postoperative complications were five cases of proximal stenosis (22.7%), one distal stenosis (stenosis of introitus) and two necrosis of the preputial flap. No urethrovaginal fistula and urinary incontinence were reported. CONCLUSIONS In infant and young child, when it is difficult to make use of complete urogenital mobilization, the mucosa of the prepuce can be an alternative to create a neovagina, its histological constitution is identical to a vaginal wall, and it does not prevent to have a good labia minora.
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Nazer II, Alhashmi G, Sharief SN, Hefni NA, Ibrahim A, El-Desoky SM, Alsayyad AJ, Safdar OY, Kari JA. A case of urinary bladder agenesis and bilateral ectopic ureters: a case report. BMC Urol 2018; 18:83. [PMID: 30257657 PMCID: PMC6158848 DOI: 10.1186/s12894-018-0396-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 09/19/2018] [Indexed: 11/27/2022] Open
Abstract
Background Urinary bladder agenesis is a very rare congenital anomaly with very few cases reported in the literature. Case presentation We report a one-month-old baby presenting with ambiguous genitalia and recurrent urinary tract infections. Her clinical course was complicated by renal impairment. Magnetic resonant imaging (MRI) revealed a diagnosis of bladder agenesis with bilateral ectopic insertion of the ureters into the vagina, associated with several other anomalies. The patient underwent bilateral high anterior ureterostomies in an hospital abroad at 5.5 months of age. She then developed ureteral necrosis that had to be corrected with left pyeloplasty and by placing a left nephrostomy tube for drainage. Eventually, the patient’s renal function declined, and she developed chronic kidney disease (CKD).The case with its imaging findings and pathogenesis as well as a review of the literature are presented. Conclusions Urinary bladder agenesis is a rare congenital condition that can be associated with multiple anomalies. Early diagnosis and therapeutic intervention can prevent progression to chronic kidney disease.
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Affiliation(s)
| | | | | | | | | | - Sherif M El-Desoky
- Pediatric department and Pediatric Nephrology Center of Excellence, King Abdulaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia.,Department of Pediatrics, Jeddah, Kingdom of Saudi Arabia
| | | | - Osama Yousef Safdar
- Pediatric department and Pediatric Nephrology Center of Excellence, King Abdulaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia. .,Department of Pediatrics, Jeddah, Kingdom of Saudi Arabia.
| | - Jameela A Kari
- Pediatric department and Pediatric Nephrology Center of Excellence, King Abdulaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia.,Department of Pediatrics, Jeddah, Kingdom of Saudi Arabia
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Seranio N, Darge K, Canning DA, Back SJ. Contrast enhanced genitosonography (CEGS) of urogenital sinus: A case of improved conspicuity with image inversion. Radiol Case Rep 2018; 13:652-654. [PMID: 30023034 PMCID: PMC6046367 DOI: 10.1016/j.radcr.2018.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/16/2018] [Indexed: 11/10/2022] Open
Abstract
Imaging plays a pivotal role in evaluating the urogenital anatomy in children with ambiguous genitalia. Contrast enhanced genitosonography (CEGS) represents a low-cost and radiation-free alternative to the traditional techniques of fluoroscopic genitography and magnetic resonance imaging. We report a case of a child with ambiguous genitalia whose urogenital sinus anomaly is clearly demonstrated using CEGS and the postprocessing technique of image inversion. This case report shows the utility of CEGS in this patient population and the enhanced conspicuity with image inversion.
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Affiliation(s)
- Nicolas Seranio
- Department of Radiology, Children's Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104, USA.,Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kassa Darge
- Department of Radiology, Children's Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104, USA.,Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas A Canning
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan J Back
- Department of Radiology, Children's Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104, USA.,Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Heeley JM, Hollander AS, Austin PF, Merritt DF, Wesevich VG, Amarillo IE. Risk association of congenital anomalies in patients with ambiguous genitalia: A 22-year single-center experience. J Pediatr Urol 2018; 14:153.e1-153.e7. [PMID: 29157626 DOI: 10.1016/j.jpurol.2017.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 09/22/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ambiguous genitalia refers to a form of differences of sex development (DSD) wherein the appearance of the external genitalia is atypical. This rare condition presents challenges in decision-making and clinical management. Review of historical data may reveal areas for clinical research to improve care for patients with ambiguous genitalia. OBJECTIVE This chart review was performed to identify patients with ambiguous genitalia, and to classify them as having 46,XX DSD, 46,XY DSD, or sex chromosome DSD. Within these categories, we looked at establishment of specific diagnoses, type and frequency of other congenital anomalies and neoplasms, and gender assignment, as well as incidence of gender reassignment and transition. METHODS We performed a retrospective chart review of patients diagnosed with DSD conditions from 1995 to 2016 using ICD9 codes. For the purpose of this study, review was limited to individuals assessed to have neonatal "ambiguous genitalia" or "indeterminate sex." RESULTS Review identified 128 patients evaluated for ambiguous genitalia from 22 years of experience (Figure). Approximately half of these (53%) had 46,XY karyotype, 35% had 46,XX, and the remaining 12% had sex chromosome aberrations. Diagnostic rate for 46,XX DSD was higher at 64%, all of which were congenital adrenal hyperplasia, while diagnostic rate for 46,XY DSD was 11.7% for a molecularly confirmed diagnosis and 24% if clinical diagnoses were included. The most common anomalies included cardiac anomalies in 28/128 (22%), skeletal anomalies in 19/128 (15%), and failure to thrive or growth problems in 19/128 (15%). Additional congenital anomalies were found in 53 out of 128 patients (41%). There were three reported neoplasms in this group: gonadoblastoma, hepatoblastoma, and myelodysplastic syndrome with monosomy 7. Gender assignment was consistent with chromosomes in approximately 90% of XX and XY patients. There were three recorded gender reassignments or transitions. DISCUSSION Diagnostic rate for ambiguous genitalia is low, especially in 46,XY DSD. Most neonates were assigned gender consistent with their chromosomes. Given the high rate of associated anomalies, screening for cardiac or other anomalies in patients with ambiguous genitalia may be beneficial. CONCLUSION Patients with ambiguous genitalia often have additional congenital anomalies. Establishment of a specific diagnosis is uncommon in 46,XY patients. A few patients have gender reassignment outside of the newborn period. Ongoing collection of clinical data on this population may reveal new information regarding long-term health, quality of life, and establishment of more diagnoses with improved molecular techniques.
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Affiliation(s)
- Jennifer M Heeley
- Division of Genetics and Genomics, Department of Pediatrics, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Abby S Hollander
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Paul F Austin
- Division of Urology, Department of Surgery, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | - Diane F Merritt
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St Louis, MO, USA
| | | | - Ina E Amarillo
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St Louis, MO, USA.
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Abstract
Normal sex development depends on the precise spatio-temporal sequence and coordination of mutually antagonistic activating and repressing factors. These factors regulate the commitment of the unipotential gonad into the binary pathways governing normal sex development. Typically, the presence of the SRY gene on the Y chromosome triggers the cascade of molecular events that lead to male sex development. Disorders of sex development comprise a heterogeneous group of congenital conditions associated with atypical development of internal and external genitalia. These disorders are generally attributed to deviations from the typical progression of sex development. Disorders of sex development can be classified into several categories including chromosomal, gonadal, and anatomic abnormalities. Genetic tools such as microarray analyses and next-generation sequencing techniques have identified novel genetic variants among patients with disorders of sexual development. Most importantly, patient management needs to be individualized, especially for decisions related to sex of rearing, surgical interventions, hormone treatment, and potential for fertility preservation.
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Affiliation(s)
- Selma Feldman Witchel
- Division of Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
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Jesus VM, Buriti F, Lessa R, Toralles MB, Oliveira LB, Barroso U Jr. Total urogenital sinus mobilization for ambiguous genitalia. J Pediatr Surg 2018; 53:808-12. [PMID: 28917585 DOI: 10.1016/j.jpedsurg.2017.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 08/11/2017] [Accepted: 08/11/2017] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Genital ambiguity is a very common phenomenon in disorders of sex development (DSD). According to the Chicago Consensus 2006, feminizing genitoplasty, when indicated, should be performed in the most virilized cases (Prader III to V). Advances in the knowledge of genital anatomy in DSD have enabled the development and improvement of various surgical techniques. Mobilization of the urogenital sinus (MUS), first described by Peña, has become incorporated by most surgeons. However, the proximity of the urethral sphincter prompts concern over urinary incontinence, especially for full mobilization of the urogenital sinus. OBJECTIVE To retrospectively evaluate the short-term surgical results of feminizing genitoplasty with total mobilization of the urogenital sinus in patients with DSD. METHODS Review of medical records of all patients undergoing feminizing genitoplasty with mobilization of the urogenital sinus. We evaluated the rates of complications from surgery and of urinary incontinence, as well as cosmetic results, according to the opinion of the surgeon and the family. RESULTS A total of 8 patients were included in the study. The mean age at surgery was 51months. Congenital adrenal hyperplasia (CAH) was diagnosed in six patients, and gonadal dysgenesis in the other two. The vagina was separated from the urethra, with suitable distance in all cases. No patient had urinary incontinence after surgery. The mean follow-up of patients was. 20months (3-56months). In all cases, surgeons recorded being satisfied with the aesthetic result of post-surgical genitalia. The family was recorded as satisfied with the aesthetic result of the genitalia after surgery. In every case, there was no need for a second surgical procedure. CONCLUSION The total mobilization of the urogenital sinus is a feasible and safe technique. The technique permits good cosmetic results, and urinary incontinence is absent. TYPE OF STUDY Therapeutic study. LEVEL OF EVIDENCE Level III.
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Çakmaklı S, Çankaya T, Gürsoy S, Koç A, Kırbıyık Ö, Kılıçarslan ÖA, Özer E, Erçal D, Bozkaya ÖG. Two Cases with Ring Chromosome 13 at either End of the Phenotypic Spectrum. Cytogenet Genome Res 2018. [PMID: 29518772 DOI: 10.1159/000486775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Ring chromosome 13 is a rare genetic condition with an incidence of 1/58,000 in live births. Major clinical features of patients with ring chromosome 13 include growth and developmental retardation, microcephaly, facial dysmorphism, ambiguous genitalia, anal atresia, eye malformations, retinoblastoma, and hand, foot, and toe abnormalities. The severity of the phenotype depends on the amount of genetic material lost during ring chromosome formation. Here, we report 2 cases with ring chromosome 13 at either end of the phenotypic spectrum.
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Affiliation(s)
- Seda Çakmaklı
- Department of Medical Genetics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Acimi S, Acimi MA, Debbous L, Bessahraoui M, Bouanani I. Clitoroplasty: A variant of the technique by Acimi. Arab J Urol 2018; 16:232-7. [PMID: 29892488 DOI: 10.1016/j.aju.2017.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/12/2017] [Accepted: 12/23/2017] [Indexed: 11/30/2022] Open
Abstract
Objectives To evaluate the mid-term results of clitoroplasty through the reduction of the length and diameter of the corpus cavernosum, as well as the volume of the glans. Patients and methods From October 2003 to July 2015, we performed 29 clitoroplasties using the described procedure. The median (range) age of the patients was 18 (3–47) months. After surgery we evaluated the volume of the clitoris, the appearance of glans, and its sensitivity to light touch, pressure, and pain. Results The length of the apparent part of the glans remained large (>10 mm) in four patients (14%), was an average size (between 5 and 10 mm) in 11 (39%), and small (<5 mm) in 13 (46%). The length of the corpus cavernosum was <20 mm and its diameter <5 mm in all cases. The sensitivity of the reduced clitoris to touch, pressure and pain seemed normal in all patients. In addition, we never found the circumflex arteries and nerves of the penis (on histological examination of excised pieces of corpus cavernosum) in all children operated on during the first 3 years of life. The circumflex arteries of the penis begin to develop, only after the fourth year. This anatomical finding is an argument for performing clitoroplasty at an early age to avoid any risk of intraoperative and postoperative bleeding. Conclusions The sensitivity of the clitoral glans appeared to be normal in all cases, with a good cosmetic appearance of the external genitalia in most patients.
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Alswailem MM, Alzahrani OS, Alhomaidah DS, Alasmari R, Qasem E, Murugan AK, Alsagheir A, Brema I, Abbas BB, Almehthel M, Almeqbali A, Alzahrani AS. Mutational analysis of rare subtypes of congenital adrenal hyperplasia in a highly inbred population. Mol Cell Endocrinol 2018; 461:105-111. [PMID: 28870780 DOI: 10.1016/j.mce.2017.08.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/30/2017] [Accepted: 08/31/2017] [Indexed: 11/16/2022]
Abstract
CONTEXT Apart from 21 Hydroxylase deficiency, other subtypes of congenital adrenal hyperplasia (CAH) are rare. We studied the clinical features and molecular genetics of a relatively large series of patients with CYP17A1, HSD3β2 and StAR deficiencies. PATIENTS AND METHODS We studied 21 patients including 7 patients with CYP17A1, 10 patients with HSD3β2 and 4 patients with StAR deficiencies. For mutation detection, we isolated DNA from peripheral leucocytes, amplified genes of interest using polymerase chain reaction and directly sequenced the amplicons using Dideoxy Chain Termination method. RESULTS Regardless of their karyotype, patients with CYP17A1 deficiency presented with normally looking external female genitalia and were raised as females. Hypertension and hypokalemia were prominent features in 4 of 7 patients. Two missense (p.R416H, p.R239Q) and 2 non-sense (p.Y329X, p.Y329X) mutations were found in these 7 cases. In 3 unrelated families with 10 affected siblings with HSD3β2 mutations, two non-sense mutations were found (p.Q334X, p.R335X). 46XY patients with HSD3β2 deficiency presented with ambiguous genitalia while 46XX patients presented with normal female external genitalia. Adrenal crisis was common in patients with both karyotypes. In the 4 patients with StAR deficiency, both genetic male and female patients presented with normally looking female external genitalia and adrenal crisis. One previously reported missense mutation (p.R182H) was found in 3 unrelated patients and a novel non-sense mutation (p.Q264X) in the fourth patient. CONCLUSIONS These cases of rare subtypes of CAH illustrate the heterogeneous phenotypic and genetic features of these subtypes and add unique novel mutations to the previously known ones.
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Affiliation(s)
- Meshael M Alswailem
- Department of Molecular Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ohoud S Alzahrani
- Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Doha S Alhomaidah
- Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Rahma Alasmari
- Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ebtesam Qasem
- Department of Molecular Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | | | - Afaf Alsagheir
- Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Imad Brema
- Department of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Bassam Ben Abbas
- Department of Pediatrics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Mohammed Almehthel
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Ali Almeqbali
- National Diabetic and Endocrine Center, Muscat, Oman
| | - Ali S Alzahrani
- Department of Molecular Oncology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia; Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.
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Chowdhury MAK, Anwar R, Saha A. Ambiguous genitalia-A social dilemma in Bangladesh: A case report. Int J Surg Case Rep 2017; 42:98-101. [PMID: 29232631 PMCID: PMC5730421 DOI: 10.1016/j.ijscr.2017.11.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Ambiguous Genitalia is a form of birth defect in which sex of the newborn cannot be readily distinguishable because of atypical appearance of the external genitalia. CASE REPORT-CLINICAL FINDINGS The patient, an 8 months old baby, was identified as a female baby since birth; but, some senior members of their neighborhood raised confusion regarding sex differentiation of the child. On examination, there was enlarged clitoris or micropenis, bifid scrotum or labioscrotal fold, and separate presence of urethral and vaginal orifices. Right testis was found in the middle of right inguinal canal and left testis was found near the deep inguinal ring. CASE REPORT-DIAGNOSIS, THERAPEUTIC INTERVENTION AND OUTCOME The ultrasonogram showed a rudimentary uterus measuring 26.7×7.27mm with no ovary and the right testis was found in the mid inguinal canal while the left testis was in the deep inguinal ring. Diagnostic endoscopic procedure showed normal appearing testes in deep inguinal ring, about 2cm vaginal remnant with normal urethra and bladder. Hormonal study revealed low serum testosterone with normal DHT and high oestradiol while the karyotyping revealed 46XY. After 3 months of hormonal treatment, multiple surgical interventions were taken to correctly determine the sex of the child. Later on the patient was discharged with follow up advices. CONCLUSION 'Ambiguous genitalia' is considered as a taboo in Bangladesh; hence, the social awareness regarding this curable disorder is a timely need in Bangladesh.
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Affiliation(s)
| | - Rashidul Anwar
- International Centre for Diarrhoeal Diseases Research, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Arnab Saha
- Interfaith Medical Center, 1545 Atlantic Ave, Brooklyn, NY 11213, United States
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