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Tresoldi AS, Betella N, Hasenmajer V, Pozza C, Vena W, Fiamengo B, Negri L, Cappa M, Lania AGA, Lenzi A, Isidori AM, Pizzocaro A. Bilateral testicular masses and adrenal insufficiency: is congenital adrenal hyperplasia the only possible diagnosis? First two cases of TARTS described in Addison-only X-linked adrenoleukodystrophy and a brief review of literature. J Endocrinol Invest 2021; 44:391-402. [PMID: 32691371 DOI: 10.1007/s40618-020-01362-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 05/11/2020] [Accepted: 07/12/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Testicular adrenal rest tumors (TARTs) are benign masses deemed to originate from pluripotent testicular steroidogenic cells that grow under chronic ACTH stimulation. These lesions, occasionally misdiagnosed as Leydig cell tumors (LCTs), are typically described in patients with congenital adrenal hyperplasia (CAH). X-linked adrenoleukodystrophy (X-ALD) is an inherited disorder of beta-oxidation with accumulation of very long chain fatty acids (VLCFAs) in various tissues, and a rare cause of primary adrenal insufficiency (PAI). TARTs have never been associated with X-ALD. CASE 1 DESCRIPTION: A 19-year old male, who had previously undergone bilateral enucleation of presumed LCTs, was referred to our unit. Follow-up scans showed persistent bilateral lesions compatible with TARTs. Biochemical exams revealed PAI but excluded CAH. A serum VLCFAs panel was consistent with X-ALD, with gene testing confirming the diagnosis. Histological revision of the previously resected testicular lesions was compatible with TARTs. Start of glucocorticoid replacement therapy was associated with a reduction of testicular masses. CASE 2 DESCRIPTION: A 26-year old X-ALD male was diagnosed with bilateral testicular lesions compatible with TARTs. These lesions increased after ACTH elevation following switch to modified-release hydrocortisone. Clinical and sonographic findings allowed for a "watchful-waiting" approach, avoiding unnecessary surgery. CONCLUSION These are the first cases reported of TARTs in patients with X-ALD-associated PAI. Testicular lesions in patients with an early onset of ACTH elevation, regardless of the cause, should always be thoughtfully investigated, as they may reveal themselves as TARTs. We suggest that all patients affected from chronic ACTH elevation of a young age of onset should undergo testicular ultrasound in order to evaluate the presence of these lesions. GRT in these patients might also help preserving fertility.
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Affiliation(s)
- A S Tresoldi
- Endocrinology, Diabetology and Medical Andrology Unit, Humanitas Clinical and Research Center - IRCCS -, Via Manzoni, 56, 20089, Rozzano, MI, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - N Betella
- Endocrinology, Diabetology and Medical Andrology Unit, Humanitas Clinical and Research Center - IRCCS -, Via Manzoni, 56, 20089, Rozzano, MI, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - V Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - C Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - W Vena
- Endocrinology, Diabetology and Medical Andrology Unit, Humanitas Clinical and Research Center - IRCCS -, Via Manzoni, 56, 20089, Rozzano, MI, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
| | - B Fiamengo
- Pathology, Humanitas Clinical and Research Center - IRCCS -, Rozzano, MI, Italy
| | - L Negri
- Division of Gynecology and Reproductive Medicine, Humanitas Fertility Center, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy
| | - M Cappa
- Endocrinology Unit, IRCCS "Bambino Gesù" Children's Hospital, Rome, Italy
| | - A G A Lania
- Endocrinology, Diabetology and Medical Andrology Unit, Humanitas Clinical and Research Center - IRCCS -, Via Manzoni, 56, 20089, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, MI, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A Pizzocaro
- Endocrinology, Diabetology and Medical Andrology Unit, Humanitas Clinical and Research Center - IRCCS -, Via Manzoni, 56, 20089, Rozzano, MI, Italy
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Abstract
We are presenting a monozygotic twin brothers presented at different ages with different presentations. Twin-A presented at age of 18 days with salt losing crisis. Investigations revealed high plasma renin with low-normal aldosterone. Adrenocorticotropic hormone, stimulation test revealed low 17-OH progesterone at 0 and 60 minutes. Adrenocorticotropic hormone level and serum cortisol were normal, which excluded initial impression of congenital adrenal hyperplasia. He was diagnosed to have isolated primary hypoaldosteronism. At age of 18 months, he was noticed to have hyperpigmentation of lips and gum. Adrenal failure was suspected, and hydrocortisone was added. Twin-B presented at 9 years and 6 months of age with adrenal crisis. Both were having unilateral undescended testes. Adrenal hypoplasia congenita (AHC) was suspected after his twin's presentation. Molecular analysis for gene study for both of them revealed adrenal insufficiency, NR0B1 (DAX1) gene mutation. In conclusion, gene analysis is important for the diagnosis of AHC and for genetic counseling.
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Affiliation(s)
- Alia M Al Amer
- Unit of Pediatric Endocrinology and Diabetes, Maternity and Children Hospital, Dammam, Kingdom of Saudi Arabia. E-mail.
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Zheng ZQ, Wu BB, Zhang MY, Lu W, Luo FH. [Recurrent anorexia and pigmentation of skin for more than two months in an infant]. Zhongguo Dang Dai Er Ke Za Zhi 2017; 19:926-929. [PMID: 28774370 PMCID: PMC7390047 DOI: 10.7499/j.issn.1008-8830.2017.08.015] [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] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/12/2017] [Indexed: 06/07/2023]
Abstract
A 2-month-old boy presented with adrenal insufficiency, impaired liver function, hypertriglyceridemia, significantly elevated creatine kinase and electrolyte disturbance. Microarray comparative genomic hybridization (aCGH) analysis test showed a pathogenic 8.7 Mb deletion in the short arm of chromosome X (Xp21.3 - p21.1) and confirmed the diagnosis of complex glycerol kinase deficiency (cGKD). He was treated with hydrocortisone, coenzyme Q10 and L-carnitine and was subsequently followed up for 4 years. His serum cortisol levels returned to normal one week later after treatment, but the serum creatine kinase, triglyceride and aminotransferase levels were progressively increased along with mental retardation and decreased muscular strength. cGKD is also named as Xp21 contiguous gene syndrome. The clinical manifestations of this disease include hypertriglyceridemia, congenital adrenal hypoplasia (AHC), Duchenne muscular dystrophy, and mental retardation. This case highlights the necessity to screen the serum triglyceride and creatine kinase levels in infants with suspected adrenal insufficiency.
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Affiliation(s)
- Zhang-Qian Zheng
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai 201102, China.
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