Major immunophenotypic abnormalities in patients with primary adrenal insufficiency of different etiology

Introduction

Patients with primary adrenal insufficiency (PAI) suffer from increased risk of infection, adrenal crises and have a higher mortality rate. Such dismal outcomes have been inferred to immune cell dysregulation because of unphysiological cortisol replacement. As the immune landscape of patients with different types of PAI has not been systematically explored, we set out to immunophenotype PAI patients with different causes of glucocorticoid (GC) deficiency.

Methods

This cross-sectional single center study includes 28 patients with congenital adrenal hyperplasia (CAH), 27 after bilateral adrenalectomy due to Cushing's syndrome (BADx), 21 with Addison's disease (AD) and 52 healthy controls. All patients with PAI were on a stable GC replacement regimen with a median dose of 25 mg hydrocortisone per day. Peripheral blood mononuclear cells were isolated from heparinized blood samples. Immune cell subsets were analyzed using multicolor flow cytometry after four-hour stimulation with phorbol myristate acetate and ionomycin. Natural killer (NK-) cell cytotoxicity and clock gene expression were investigated.

Results

The percentage of T helper cell subsets was downregulated in AD patients (Th1 p = 0.0024, Th2 p = 0.0157, Th17 p < 0.0001) compared to controls. Cytotoxic T cell subsets were reduced in AD (Tc1 p = 0.0075, Tc2 p = 0.0154) and CAH patients (Tc1 p = 0.0055, Tc2 p = 0.0012) compared to controls. NKCC was reduced in all subsets of PAI patients, with smallest changes in CAH. Degranulation marker CD107a expression was upregulated in BADx and AD, not in CAH patients compared to controls (BADx p < 0.0001; AD p = 0.0002). In contrast to NK cell activating receptors, NK cell inhibiting receptor CD94 was upregulated in BADx and AD, but not in CAH patients (p < 0.0001). Although modulation in clock gene expression could be confirmed in our patient subgroups, major interindividual-intergroup dissimilarities were not detected.

Discussion

In patients with different etiologies of PAI, distinct differences in T and NK cell-phenotypes became apparent despite the use of same GC preparation and dose. Our results highlight unsuspected differences in immune cell composition and function in PAI patients of different causes and suggest disease-specific alterations that might necessitate disease-specific treatment.

Gender role behaviour in prenatally dexamethasone-treated children at risk for congenital adrenal hyperplasia--a pilot study

AIM

To investigate the effects of prenatal dexamethasone (DEX) exposure on gender role behaviour.

METHODS

The participants were 25 of the 40 children (62%, mean age 11 years) at risk for CAH treated with DEX prenatally during the years 1985-1995 in Sweden. The control group consisted of 35 sex- and age-matched healthy children. A new inventory, the Karolinska Inventory of Gender Role Behaviour (KI-GRB), was developed to assess directly school-age children's behaviour, and was evaluated using a separate sample of 160 school-age children.

RESULTS

DEX-treated CAH-unaffected boys showed more neutral behaviours than the controls (p = 0.04), while the DEX-treated CAH-unaffected girls did not differ from the controls after adjusting for the site of residence. There was a larger variation in the behaviour of the DEX-treated boys (p < 0.05) and a tendency for less-masculine behaviours in the DEX-treated CAH-unaffected children (p = 0.13). There were no between-group differences in the feminine behaviours. Recalculation of the analyses including the CAH-affected children showed analogous results.

CONCLUSIONS

This pilot study indicates that the gender role behaviour may be affected in boys as an effect of DEX exposure in early pregnancy. Larger retrospective studies are needed for more conclusive results.

Prenatal dexamethasone use for the prevention of virilization in pregnancies at risk for classical congenital adrenal hyperplasia because of 21-hydroxylase (CYP21A2) deficiency: a systematic review and meta-analyses

CONTEXT

Prenatal treatment with dexamethasone to prevent virilization in pregnancies at risk for classical congenital adrenal hyperplasia (CAH) remains controversial.

OBJECTIVE

To conduct a systematic review and meta-analyses of studies that evaluated the effects of dexamethasone administration during pregnancies at risk for classical CAH because of 21-hydroxylase deficiency (CYP21A2).

DATA SOURCES

We searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception through August 2009. Review of reference lists and contact with CAH experts further identified candidate studies.

STUDY SELECTION

Reviewers working independently and in duplicate determined trial eligibility. Eligible studies reported the effects on either foetal or maternal outcomes of dexamethasone administered during pregnancy compared to a control group that did not receive any treatment.

DATA EXTRACTION

Reviewers working independently and in duplicate determined the methodological quality of studies and collected data on patient characteristics, interventions, and outcomes.

DATA SYNTHESIS

We identified only four eligible observational studies (325 pregnancies treated with dexamethasone). The methodological quality of the included studies was overall low. Meta-analysis demonstrates a reduction in foetus virilization measured by Prader score in female foetuses treated with dexamethasone initiated early during pregnancy (weighted mean difference, -2.33, 95% CI, -3.38, -1.27). No deleterious effects of dexamethasone on stillbirths, spontaneous abortions, foetal malformations, neuropsychological or developmental outcomes were found although these data are quite sparse. There was increased oedema and striae in the mothers treated with dexamethasone. There were no data on long-term follow-up of physical and metabolic outcomes in children exposed to dexamethasone.

CONCLUSIONS

The observational nature of the available evidence and the overall small sample size of the whole body of the literature significantly weaken inferences about the benefits and harms of dexamethasone in this setting. Dexamethasone seems to be associated with reduction in foetus virilization without significant maternal or foetal adverse effects. However, this review underscores the current uncertainty and further investigation is clearly needed. The decision about initiating treatment should be based on patients' values and preferences and requires fully informed and consenting parents.

Prenatal exposure to sex steroid hormones and behavioral/cognitive outcomes

Experimental studies in animals indicate that androgen exposure in fetal or neonatal life largely accounts for known sex differences in brain structure and behavior. Clinical research in humans suggests similar influences of early androgen concentrations on some behaviors that show sex differences, including play behavior in childhood and sexual orientation in adulthood. Available research also suggests that sex steroid hormone exposure may contribute to sex differences in the risk of autism and affective disorders in schizophrenia. However, findings have been inconsistent for other characteristics that show sex differences, including aggression and spatial ability. Moreover, social and environmental factors may modulate some of the associations observed. This article reviews the evidence that early-life exposure to sex steroid hormones contributes to sexually dimorphic behavior and cognitive abilities in humans.

The effects of manipulation of puberty on growth

Short stature in adulthood can be considered as a disability because it can be associated with many difficulties including those of a psychological and social nature. Many factors can influence final adult height such as genetics, the magnitude of growth hormone (GH) secretion, height before puberty, and the onset and duration of puberty. A crucial factor affecting final adult height, however, is the total height achieved during puberty. The combination of GH and gonadotropin-releasing hormone analogues greatly enhances growth and their separate and combined use for the treatment of GH deficiency, central precocious puberty and other diagnoses in children and adolescents is discussed in this article.

Transient adrenogenital syndrome due to exposure to danazol in utero

We describe a premature female infant exposed in utero to danazol during the first trimester of pregnancy. She was first observed in the newborn period with marked degree virilization and clinical findings suggestive of salt-losing congenital adrenal hyperplasia. This was supported by the high plasma levels of 17 alpha-hydroxyprogesterone and adrenocorticotropic hormone and low plasma cortisol level. Levels of testosterone, androstenedione, 11-deoxycortisol, and renin were also elevated. An excessive increase in the levels of 17 alpha-hydroxyprogesterone and 11-deoxycortisol to corticotropin administration associated with impaired increase in plasma cortisol level strongly suggests a partial block in the 21-hydroxylation of 17 alpha-hydroxyprogesterone. However, the high levels of 11-deoxycortisol also suggest a block of the steroid 11 beta-monooxygenase. A year later she was found to have normal basal levels of the adrenal steroids and normal response to corticotropin administration, pointing out the transitory nature of these abnormalities. It may be hypothesized that danazol produced a transitory block of the steroid 21- and 11 beta-monooxygenases in this child.