Identification of nonclassical 21-hydroxylase deficiency in girls with precocious pubarche

Premature Pubarche: Time to Revise the Diagnostic Approach?

Premature pubarche (PP) could represent the first manifestation of non-classic congenital adrenal hyperplasia caused by 21 hydroxylase deficiency (NC21OHD) (10–30% of cases). In the last 20 years, the necessity of performing an ACTH test to diagnose NC21OHD in all cases with PP has been questioned, with conflicting results. This study aims to retrospectively evaluate the predictive value of the basal androgens, 17-OHP levels, and auxological features in suggesting the presence of NC21OHD and, thus, the need for a standard ACTH test to confirm the diagnosis. In all, 111 consecutive patients (87 females) with PP and advanced bone age underwent an ACTH test. Of these, 6/111 cases (1 male) were diagnosed with NC21OHD. The mean baseline 17 hydroxyprogesterone (17-OHP), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEA-S), delta 4 androstenedione (Δ4A), and testosterone serum levels were higher in NC21OHD patients than in the others (p < 0.05). We found three predictive features for NC21OHD: basal 17 OHP of >200 ng/mL, bone age advance of >2 years, and DHEA-S levels of >228 ng/mL with sensitivity and specificity of 83.3% and 97.1%, 83.3% and 65.7%, and 83.3% and 96.2%, respectively. Our data confirm that the prevalence of NC21OHD is low among patients with PP. Serum 17-OHP of >200 ng/mL could be helpful to decide, in most cases, which patients should undergo the ACTH test. Bone age advance represented an inadequately specific predictive marker of NC21OHD.

Role of Body Weight in the Onset and the Progression of Idiopathic Premature Pubarche

BACKGROUND

The term premature pubarche (PP) refers to the appearance of pubic hair before age 8 in girls and before age 9 in boys. Although idiopathic PP (often associated with premature adrenarche) is considered an extreme variation from the norm, it may be an initial sign of persistent hyperandrogenism. Factors contributing to PP onset and progression have not been identified to date.

AIMS

The objectives of this study are to describe a group of Italian children with PP, to identify potential factors for its onset, and to define its clinical and biochemical progression.

METHODS

We retrospectively enrolled all infants born between 2001 and 2014 with PP. Children with advanced bone age (BA) underwent functional tests to determine the cause of PP. Hormonal analysis and BA determination were performed annually during a 4-year follow-up period.

RESULTS

A total of 334 children with PP were identified: idiopathic PP (92.5%, associated with premature adrenarche in some cases); related to precocious puberty (6.6%); late-onset 21-hydroxylase deficiency (0.9%). Low birth weight was associated with premature adrenal activation. Body mass index (BMI) was the only factor that influenced the progression of BA during follow-up.

CONCLUSIONS

Low birth weight is a predisposing factor for premature adrenal activation. The increase in BMI in patients with idiopathic PP during the 4-years of follow-up was responsible for BA acceleration. We recommend prevention of excessive weight gain in children with PP and strict adherence to follow-up in order to prevent serious metabolic consequences.

Children with premature pubarche: is an alterated neonatal 17-Ohp screening test a predictive factor?

BACKGROUND

Neonatal screening for 21 hydroxylase deficiency is designed to detect classical form of congenital adrenal hyperplasia (CAH). It is still unclear whether newborns who result false positives at neonatal screening might later develop signs of androgen excess. The aim of this study is to verify whether a slightly elevated 17-OHP at newborn screening is a predictive factor for premature pubarche.

METHODS

We evaluated all infants born between 2001 and 2014 with premature pubarche. In case of increased bone age, they were submitted to functional tests to find out the cause of their symptoms. Their 17-OHP values at newborn screening for CAH were reconsidered.

RESULTS

We identified 330 patients (269 females, 61 males) with premature pubarche. All these children had a normal 17-OHP at newborn screening with the exception of a child, born preterm and not affected by CAH.

CONCLUSIONS

An elevated 17-OHP at newborn screening is not a predictive factor for premature pubarche. A likely cause of increased 17-OHP level at screening is an immaturity of adrenal gland or a neonatal stress. Therefore a strict follow up of these neonates during childhood is not necessary.

Characteristics and prevalence of non-classical congenital adrenal hyperplasia with a V2811 mutation in patients with premature pubarche

We aimed to determine the prevalence and clinical characteristics of non-classical congenital adrenal hyperplasia (NCCAH) with V281L mutation in patients with premature pubarche. An adrenocorticotrophic hormone (ACTH) stimulation test was performed in 14 of the 159 patients with premature pubarche (PP). Patients whose stimulated 17alpha-hydroxyprogesterone (17-OHP) level on the ACTH test was > or =10 ng/mL underwent a mutational analysis of the CYP21 gene. NCCAH was defined in nine (5.7%) patients, all of whom had the V281L mutation. Four of the NCCAH patients were homozygote and four of them were heterozygote. One other patient was compound heterozygote for V281L mutation and the I2 splice mutation. One of the patients with V281L heterozygous mutation developed true precocious puberty and the other one had rapid progressive early puberty and developed polycystic ovary syndrome. ACTH stimulated 17-OHP > or = 10 ng/mL in PP patients is load star to mutation analysis and heterozygote patients should be followed for clinical and biological hyperandrogenism up to completion of the whole 'genome sequence'.

Precocious pubarche: distinguishing late-onset congenital adrenal hyperplasia from premature adrenarche

CONTEXT

Because precocious pubarche (PP) reveals late-onset congenital adrenal hyperplasia (LO-CAH) in 5 to 20% of cases, an adrenal stimulation test is recommended in all patients presenting with it. This test is stressful and expensive, and results are normal in more than 80% of cases.

OBJECTIVE

Our objective was to identify clinical and plasma predictors of LO-CAH among patients presenting with PP.

DESIGN, SETTING, AND PATIENTS

We conducted a retrospective cohort study that included all patients seen for PP at our hospital between 1999 and 2006 (n = 238). All had undergone an ACTH test.

MAIN OUTCOME MEASURE

LO-CAH was defined by a post-ACTH 17-hydroxyprogesterone (17-OHP) plasma level greater than 10 ng/ml and confirmed by mutational analysis of the CYP21 gene. The association of standard clinical and laboratory indicators with LO-CAH was assessed.

RESULTS

Ten (4%) of 238 patients had LO-CAH. Basal 17-OHP, Delta4-androstenedione, and testosterone plasma levels were significantly higher in these patients. A 2-ng/ml threshold for basal 17-OHP plasma levels offered 100% (95% CI, 69-100) sensitivity for the diagnosis of LO-CAH and 99% (95% CI, 96-100) specificity.

CONCLUSION

We identified three plasma predictors of LO-CAH in patients presenting with PP. A selective strategy based on a 2-ng/ml basal 17-OHP plasma level threshold would have safely avoided 99% of the unnecessary ACTH tests among our patients.

Premature adrenarche--normal variant or forerunner of adult disease?

Adrenarche is the puberty of the adrenal gland. The descriptive term pubarche indicates the appearance of pubic hair, which may be accompanied by axillary hair. This process is considered premature if it occurs before age 8 yr in girls and 9 yr in boys. The chief hormonal product of adrenarche is dehydroepiandrosterone (DHEA) and its sulfated product DHEA-S. The well documented evolution of adrenarche in primates and man is incompatible with either a neutral or harmful role for DHEA and implies most likely a positive role for some aspect of young adult pubertal maturation and developmental maturation. Premature adrenarche has no adverse effects on the onset and progression of gonadarche in final height. Both extra- and intraadrenal factors regulate adrenal androgen secretion. Recent studies have shown that premature adrenarche in childhood may have consequences such as functional ovarian hyperandrogenism, polycystic ovarian syndrome, and insulin resistance in later life, sometimes already recognizable in childhood or adolescence. Premature adrenarche may thus be a forerunner of syndrome X in some children. The association of these endocrine-metabolic abnormalities with reduced fetal growth and their genetic basis remain to be elucidated.

Pubarca precoce: estudo retrospectivo clínico e laboratorial

Analisaram-se 109 prontuários de pacientes atendidos no período de janeiro de 1990-2000, cujo diagnóstico era pubarca precoce, com o objetivo de se avaliar a etiologia e evolução destes pacientes. Os mesmos foram divididos em 4 grupos: G1, n=41 (35F/6M, idades entre 11 meses e 7anos e 11 meses, mediana: 7anos e 1 mês), nos quais foram dosados: 17-OH progesterona (17OHP), DHEA, DHEA-S, androstenediona, testosterona total e/ou livre, e feito teste de estímulo do LH e FSH com GnRH (Relisorm®, 100mig iv); no grupo G2, n=28 (20F/8M, idades entre 9meses e 8anos e 11 meses, mediana: 7anos e10meses), além dos exames mencionados, investigou-se a deficiência da 21-hidroxilase através da dosagem de 17OHP sob estímulo agudo com ACTH (Cortrosina®, 250mig iv), O grupo G3, n=23 (19F/4M, idades entre 1ano e 2meses e 8anos e 10meses, mediana: 7anos e 6meses), além dos exames anteriores, foi investigado para deficiências de 11 beta-hidroxilase e 3beta-hidroxi-esteróide desidrogenase pelas dosagens de 11-deoxicortisol, e relação DHEA/androstenediona, respectivamente. As dosagens de testosterona total e/ou livre, DHEA-S e estradiol (em meninas) foram feitas nos 3 grupos. No grupo G4, n=14 (12F/2M, idades entre 1ano e 1 mês e 8anos e 9meses, mediana: 6anos e 5meses) o diagnóstico foi feito apenas com dados clínicos. Três meninas (6meses, 2anos e 1 mês e 2anos e 7meses) foram consideradas à parte; tiveram puberdade precoce associada a hiperandrogenismo, como primeira manifestação de adenocarcinoma adrenal. A investigação demonstrou níveis muito elevados de DHEA-S e massas adrenais ressecadas posteriormente. Um grupo controle de 18 crianças normais pré-púberes (8F/10M) foi submetido ao teste agudo do ACTH. No estímulo com GnRH, um delta LH > ou = 7,0 foi considerado indicativo de resposta púbere. Andrógenos e estradiol foram dosados por RIE e kits comerciais DPC; LH e FSH foram dosados por métodos imunométricos. As respostas entre pacientes e grupo controle foram comparadas pelo teste de Mann-Whitney. Nos grupos G1, G2 e G3 apenas 4 pacientes responderam com um delta LH > ou = 7,0 e 2 evoluíram com puberdade precoce verdadeira. A resposta da 17OHP ao ACTH (G2 e G3, n=51) diagnosticou 2 casos de deficiência da 21-hidroxilase, forma não-clássica. Nos outros, as respostas não diferiram do grupo controle. Não houve acúmulo de outros precursores testados pelo ACTH no G3. Concluímos que uma minoria de crianças com adrenarca precoce evoluem para puberdade precoce ou têm hiperplasia adrenal congênita na forma não clássica, o que mostra que, após avaliação dos níveis de esteróides basais, o seguimento apenas clínico seria mais prático e econômico, deixando a realização de testes para quando houvesse algum dado inicial ou evolutivo que o indicasse.

Adrenal insufficiency in a man with non-classical 21-hydroxylase deficiency: consequence or coincidence?

Deficiency of the adrenal enzyme 21-hydroxylase, which is required for cortisol synthesis, appears in two forms: a rare classical variant with severe enzyme deficiency, usually presenting in neonates with ambiguous genitalia (from androgen overproduction) or adrenal crisis (from glucocorticoid and mineralocorticoid underproduction), and a common (1% of the general population) non-classical variant with mild enzyme deficiency, usually presenting in young adults with findings of androgen excess but without clinical evidence of decreased steroid hormone production. We describe a 22-year-old man who had clinical and biochemical findings consistent with adrenal insufficiency, including a favorable response to hydrocortisone replacement, in whom elevated serum levels of the cortisol precursor 17-hydroxyprogesterone were diagnostic of non-classical 21-hydroxylase deficiency and in whom no other cause of adrenal insufficiency could be identified. These findings raise the possibility that non-classical 21-hydroxylase deficiency, an extremely frequent disorder which is generally thought to be without significant morbidity, might cause or contribute to adrenal insufficiency in adults.